Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Canyon Springs Post-acute during CMS and state inspections, most recent first.
A resident was administered Ivermectin based on a physician's order that lacked an indication for use. An LVN, uncertain about the medication's purpose, added 'for parasite infection' to the MAR without confirming a diagnosis or clarifying the order with the prescriber. The facility's policy requires all medication orders to include a clinical indication, and assigning a diagnosis is not within the LVN's scope of practice.
Licensed nurses did not consistently document the application of BiPAP therapy at bedtime for a resident with chronic respiratory and cardiac conditions, as required by physician order and facility policy. The DON confirmed that missing documentation meant the procedure was not considered completed, resulting in a failure to provide respiratory care according to professional standards.
Staff failed to follow infection prevention protocols, including not performing hand hygiene between glove changes during wound care, allowing a urine drainage bag to touch the floor without a protective cover, and storing unlabeled used basins and bed pans improperly. Additional lapses included using contaminated gloves for medication administration, placing IV supplies on soiled surfaces, improper disinfection of equipment, feeding multiple residents without hand hygiene, and not adhering to contact precaution signage and PPE requirements.
Three residents received psychotropic medications, including anti-anxiety, antidepressant, and antipsychotic drugs, without documentation of attempted non-pharmacological interventions or appropriate behavior monitoring. The DON confirmed the absence of required documentation and monitoring, despite facility policy mandating these practices.
A resident with a history of stroke, aphasia, and dysphagia was admitted with a gastrostomy tube and received enteral nutrition as ordered. Despite this, five MDS assessments failed to document the presence of the feeding tube and the proportion of nutrition and fluids provided by tube feeding. The MDS nurse and RD confirmed the omission, and observations verified the ongoing use of a feeding pump at the bedside.
Two residents were affected when an LVN administered the wrong nutritional supplement, giving Boost Plus instead of the ordered Ensure Plus, and an RN failed to use the push-pause method while flushing a PICC line with normal saline. Both actions did not follow physician orders or professional standards, as confirmed by staff interviews and record reviews.
Nursing staff failed to consistently document the administration and removal of controlled medications, such as hydrocodone-acetaminophen and tramadol, on both the Controlled Substance Accountability Sheet (CSAS) and Medication Administration Record (MAR). In several cases, medications were signed out but not recorded as given, or recorded as given but not signed out, leading to discrepancies in medication counts. The DON and nursing staff confirmed these documentation lapses during interviews and record reviews.
Surveyors observed a medication error rate of 9.68% when three errors occurred during medication administration: a resident received two puffs of an inhaler without the required interval, another self-administered an extra puff of a prescribed inhaler without staff instruction, and a third received multiple medications via G-tube without water flushes between doses. Nursing staff were unaware or unsure of proper procedures, and facility policies requiring correct intervals, instructions, and water flushes were not followed.
Surveyors found that medications, including inhalers, eyedrops, and controlled substances, were not properly labeled or stored, with expired and discontinued drugs remaining in medication rooms and carts. Staff confirmed that medications lacking resident names, open dates, or correct expiration dates were present, and that expired or discontinued medications were not consistently removed as required by facility policy.
Two residents had delays in the documentation of discharge orders and interdisciplinary team (IDT) meeting notes. In both cases, required entries such as physician notifications, ombudsman notifications, and IDT meeting notes were recorded days or months after the actual events, contrary to facility policy requiring timely charting of care and services.
Two residents were not provided with a dignified dining experience when staff stood while feeding them, contrary to facility policy. One resident with severe cognitive impairment and another with a cognitive communication deficit were both assisted with meals by staff who remained standing, despite the residents' needs and facility expectations that staff should be seated during meal assistance.
A resident with a diagnosis of schizophrenia and an active order for Aripiprazole did not have a comprehensive care plan developed to address their mental health needs. The DON confirmed that no care plan was in place for this active diagnosis, despite facility policy requiring person-centered care plans for all resident needs.
A resident with severe cognitive impairment and multiple medical conditions did not receive the prescribed amount of enteral feeding, and required oral care was not performed. Staff failed to document and monitor the amount of tube feeding administered, and oral care supplies were not available or used as ordered. These actions were inconsistent with physician orders and facility policy.
A resident with COPD, asthma, and CHF was given oxygen therapy at a higher flow rate than ordered by the physician, as confirmed by an LVN and the DON. The facility's policy requires adherence to physician orders for oxygen administration, but the resident received 1.5 lpm instead of the prescribed 1 lpm via nasal cannula.
A resident with Alzheimer's disease was found using bilateral quarter upper bed rails without a physician's order, timely care plan, or informed consent prior to installation. Staff confirmed that required assessments and documentation were completed only after the bed rails were already in use, contrary to facility policy.
A resident with intact cognition did not receive the planned menu meal or the correct food alternative on multiple occasions. The resident was served repeated meals not matching the posted menu and, when requesting an alternative, was given an unlisted item instead. The dietary manager confirmed these errors and that the facility's policy requiring adherence to planned menus was not followed.
Two residents who were fully dependent on staff for activities of daily living were found without accessible call lights; in one case, the call light was on a feeding tube pole, and in another, it was clipped to privacy curtains. Both a CNA and an RN confirmed the call lights were not within reach, contrary to facility policy.
A resident with a history of pneumonia and UTI experienced symptoms such as vomiting and decreased intake, prompting a physician's order for repeat CBC and CMP tests. Although the lab results, which included multiple abnormal findings, were received by the facility, there was no documentation that these results were communicated to the physician as required by facility policy.
The facility failed to maintain proper infection control in four out of six shower rooms, with issues such as feces on the floor, used personal items left behind, and unclean conditions confirmed by the Maintenance Director and Director of Nursing. Facility policies require daily cleaning and disinfection to prevent infection.
A facility failed to notify a responsible party about a resident's elbow injury, despite obtaining a physician's order for treatment. The clinical record lacked documentation of notification, and the DON confirmed this oversight. The facility's policy required notification of significant changes in a resident's status, which was not followed.
A resident with diabetes and malnutrition experienced delayed wound care and inadequate documentation at an LTC facility. Physician's orders for MRSA-infected leg wounds were obtained and implemented late, and no order was obtained for a toe wound. A STAT lab revealed severe dehydration, but the change in condition was not documented. Additionally, documentation for an elbow wound was insufficient, lacking weekly skin status updates and change of condition notes, contrary to facility policies.
A resident prescribed Lasix, a diuretic with a black box warning, was not monitored for potential side effects, such as dehydration, as required. The consultant pharmacist failed to report drug irregularities, and the resident's clinical records lacked documentation for monitoring these side effects. The resident was later hospitalized with severe dehydration and hypernatremia, highlighting the oversight in monitoring.
A resident at risk for dehydration experienced a delay in receiving STAT lab results, which revealed a critical high sodium level. The results were obtained a day after the order, leading to a delay in hospital transfer. Interviews indicated that the lab specimen took 9 hours to reach the lab, exceeding the facility's policy of 4 to 6 hours for STAT results.
A resident with diabetes had an elevated A1c level, but the facility failed to promptly notify the physician, delaying medication adjustment. The facility's policy required notification, but there was no documentation of compliance, confirmed by the DON.
Medication Order Lacked Indication and Was Inappropriately Modified by LVN
Penalty
Summary
A deficiency occurred when a resident was prescribed Ivermectin without an indication for use identified in the physician's order. The order, dated 6/24/25, specified the dosage and duration but did not state the clinical reason for prescribing the medication. Upon review, the Medication Administration Record (MAR) reflected the medication was to be given for a 'parasite infection,' but this indication was not present in the original order. During interviews, the Licensed Vocational Nurse (LVN) who processed the order admitted to not knowing the intended use of Ivermectin and stated she added 'for parasite infection' to the MAR after searching for information online, without confirming a diagnosis or indication with the prescriber. Further review and interviews with the Assistant Director of Nursing (ADON) confirmed that the facility's process requires clarification of any medication order lacking an indication, and that assigning a diagnosis is outside the LVN's scope of practice. The facility's policy mandates that medication orders must include the clinical condition or symptoms for which the medication is prescribed. The failure to clarify the order and the unauthorized addition of an indication by the LVN resulted in care and treatment not being provided in accordance with professional standards of practice.
Failure to Document BiPAP Application for Resident on Oxygen Therapy
Penalty
Summary
Licensed nurses failed to consistently document the application of BiPAP therapy at bedtime for a resident with multiple respiratory and cardiac diagnoses, including chronic respiratory failure with hypoxia, congestive heart failure, chronic obstructive pulmonary disease, obstructive sleep apnea, chronic pulmonary edema, and dependence on supplemental oxygen. The physician's order specified that BiPAP should be applied at bedtime, and the facility's policy required documentation of the time BiPAP was started and notification of the physician if the resident refused the procedure. Record review revealed multiple dates over several months where there was no documentation of BiPAP application in the resident's Respiratory Administration Record. During an interview, the DON confirmed that if the application was not documented, it was considered not done, and acknowledged that licensed nurses were expected to initial the record to confirm BiPAP application as ordered. The lack of documentation indicated a failure to provide respiratory care consistent with professional standards of practice.
Infection Control Lapses in Multiple Care and Environmental Practices
Penalty
Summary
Staff failed to implement proper infection prevention and control practices in several instances throughout the facility. During a wound dressing change for a resident with a non-pressure chronic ulcer and local skin infection, two nurses changed gloves multiple times without performing hand hygiene between glove changes, contrary to facility policy and infection prevention standards. In another case, a resident with a suprapubic catheter had their urine drainage bag touching the floor and not covered with a protective bag, despite staff acknowledging that this practice increases infection risk. Multiple observations revealed that used basins, bed pans, and urinals belonging to residents were unlabeled and improperly stored on top of toilet tanks or under sinks in shared bathrooms. Staff confirmed these items were not labeled with resident identifiers and cited lack of storage space as the reason for improper storage. Additionally, a nurse used contaminated gloves to administer eye drops to a resident after touching various surfaces, and another nurse placed IV supplies on a visibly soiled overbed table without cleaning it or using a protective barrier. Further deficiencies included improper disinfection practices, such as using the same germicidal wipe to clean both contaminated and uncontaminated surfaces, and staff donning and doffing gloves without performing hand hygiene. A staff member was observed feeding two residents simultaneously without hand hygiene between residents. There were also lapses in transmission-based precautions: signage indicating contact precautions was missing from a resident's door, and a staff member entered the room of a resident on contact isolation without wearing required PPE, despite facility policy and physician orders.
Failure to Document Non-Pharmacological Interventions and Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that three residents were free from chemical restraints and that psychotropic medications were used appropriately. For one resident with diagnoses including chronic subdural hemorrhage, dementia, and anxiety disorder, lorazepam and trazodone were administered for anxiety and depression without any clinical documentation that non-pharmacological interventions were attempted or provided. Nursing progress notes and medication administration records over several months did not indicate any such interventions, and the DON confirmed the absence of this documentation. Another resident with type 2 diabetes, dementia, and depression continued to receive mirtazapine and sertraline for depression, again without documentation of non-pharmacological interventions being attempted or provided. Review of nursing progress notes and medication administration records for multiple months confirmed this lack of documentation, which was also acknowledged by the DON. The facility's own policy required the use of behavioral interventions unless contraindicated and proper documentation of the clinical need for psychotropic medications. A third resident, diagnosed with Alzheimer's disease, was prescribed quetiapine for psychosis manifested by paranoia. However, there was no monitoring of the target behavior for which the medication was prescribed. The DON confirmed that behavior monitoring should have been in place for this medication, and the facility's policy required ongoing evaluation of the effectiveness of psychotropic medications and assessment for adverse consequences, including periodic reevaluation of behavioral symptoms.
Failure to Accurately Code MDS for Tube Feeding
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for one resident who had a feeding tube in place. Despite clear documentation in the clinical record and physician orders indicating the resident was receiving enteral nutrition via a gastrostomy tube, five separate MDS assessments did not reflect the presence of the feeding tube or the percentage of nutritional and fluid intake provided by this artificial route. Observations confirmed the presence of a feeding pump at the resident's bedside, and interviews with the MDS nurse and registered dietitian (RD) revealed that the relevant MDS sections were either left blank or not coded, which was acknowledged as an error by the RD responsible for completing those sections. The resident in question had diagnoses including aphasia and dysphagia following a cerebral infarction, and had been on tube feeding since admission. The facility's documentation and staff interviews confirmed that the resident was receiving a prescribed formula via enteral pump for a specified number of hours each day. However, the MDS assessments failed to capture this information in Section K0520B (nutritional approaches), K0710A (proportion of total calories received through tube feeding), and K0710B (average fluid intake per day by tube feeding), resulting in inaccurate assessments that did not reflect the resident's actual nutritional status.
Failure to Follow Physician Orders and Proper Technique in Medication Administration
Penalty
Summary
A licensed vocational nurse (LVN) administered the wrong nutritional supplement to a resident by providing Boost Plus instead of the physician-ordered Ensure Plus. The LVN prepared and gave the entire carton of Boost Plus to the resident, despite the clinical record and registered dietitian's note specifying Ensure Plus as the required supplement to address the resident's weight loss and variable oral intake. The LVN later confirmed the error upon review of the resident's order summary report. In a separate incident, a registered nurse (RN) failed to use the push-pause method when flushing another resident's peripherally inserted central catheter (PICC) line with normal saline. The RN flushed the line quickly without the recommended technique, which was confirmed during a follow-up interview. The director of nursing (DON) stated that the push-pause method should be used to maintain the patency of the PICC line, and this was supported by a referenced clinical article.
Failure to Accurately Document and Reconcile Controlled Substances
Penalty
Summary
The facility failed to maintain accurate and complete records for controlled substances for four of six randomly selected residents. In one instance, nursing staff signed out a controlled medication from the Controlled Substance Accountability Sheet (CSAS) for a resident but did not document its administration on the Medication Administration Record (MAR). This discrepancy was confirmed by the Director of Nursing (DON) during a review of the records, where a dose of hydrocodone-acetaminophen was signed out but not recorded as administered on the MAR. In other cases, nursing staff documented the administration of controlled medications on the MAR for three residents but did not sign out the medications on the CSAS. For example, doses of hydrocodone-acetaminophen and tramadol were recorded as given on the MAR but were not reflected on the CSAS, indicating a lack of reconciliation between the two records. The DON confirmed that there were no additional CSAS records to account for these discrepancies and acknowledged that the medications were dispensed from the Automated Dispensing Unit (ADU), but the required documentation was not completed. Additionally, during a controlled substance count, a nurse confirmed that the physical count of a resident's medication did not match the CSAS, as one tablet was removed and administered but not signed out. The facility's policy requires that all controlled substances be properly documented on both the CSAS and MAR, and that inventory counts be reconciled at the end of each shift. These failures in documentation and reconciliation were observed and confirmed through interviews and record reviews.
Medication Error Rate Exceeds Acceptable Threshold Due to Administration Failures
Penalty
Summary
A medication error rate of 9.68% was identified during medication administration observations, with three errors noted out of 31 opportunities involving three residents. In the first instance, a resident prescribed albuterol sulfate inhalation received the second puff only 10 seconds after the first, rather than waiting the recommended one minute between puffs. The nurse administering the medication was unaware of the required interval, and the facility's policy and national guidelines both specify a one-minute wait between inhalations. In the second case, a resident self-administered three puffs of budesonide-formoterol fumarate dihydrate inhaler instead of the two puffs ordered by the physician. The nurse did not provide instructions or verify the correct dosage with the resident before allowing self-administration. The facility's policy requires staff to explain the procedure and verify the correct medication, dosage, and administration method prior to administration. The third error involved a resident receiving five different medications via gastrostomy tube without water flushes between each medication. The nurse administered each medication sequentially without flushing the tube, contrary to facility policy, which requires a water flush between medications to ensure safe administration. The nurse stated that she was taught to mix medications with extra water but was not instructed to flush between medications, and the DON was unsure of the correct procedure.
Medication Labeling and Storage Deficiencies Identified
Penalty
Summary
Surveyors identified multiple failures in the facility’s medication management practices, specifically regarding the labeling and storage of drugs and biologicals. During inspections of medication rooms and carts, numerous instances were observed where medications, including inhalers, nasal sprays, eyedrops, and topical solutions, lacked appropriate labeling with resident names or usage instructions. Additionally, several multi-dose vials and insulin vials were found without open dates or with incorrect expiration dates, and some were being used past their discard dates. Expired over-the-counter medications and expired home medications were also found stored alongside current medications in resident bins and medication rooms. Controlled substances and antibiotics that had been discontinued were still present in narcotic boxes within medication carts, rather than being removed and secured as required. In one instance, a medication refrigerator contained discontinued eye drops for a resident, despite facility policy stating that such medications should be removed and discarded. Staff interviews confirmed that these medications should not have remained in storage and that regular checks were expected to prevent such occurrences. The facility’s own policies require that all medications be properly labeled with at least the medication name, dose, strength, expiration date, and resident’s name, and that discontinued or expired medications be removed and either returned or destroyed according to pharmacy instructions. Despite these policies, surveyors found that expired, discontinued, and unlabeled medications were not consistently identified or removed from storage, and that staff were aware of but did not always follow the required procedures.
Late Documentation of Discharge and IDT Notes
Penalty
Summary
The facility failed to ensure timely and accurate documentation in the clinical records for two residents. For one resident, the discharge order and related progress notes, including physician notification, ombudsman notification, and interdisciplinary team (IDT) meeting notes, were documented several days after the actual discharge and associated events. The case manager confirmed that the discharge order was given and the ombudsman was notified on earlier dates, but the documentation was not completed until later due to being behind on paperwork. For another resident, the IDT meeting notes were also documented late, with the meeting having occurred months prior to the actual documentation. The social services director acknowledged that IDT meeting documentation was typically completed after the meeting. The facility's policy requires that all services provided, progress toward care plan goals, and any changes in the resident's condition be documented in the medical record, but this was not followed in these cases.
Staff Failed to Maintain Dignity During Meal Assistance
Penalty
Summary
Staff failed to maintain respect and dignity for two residents during meal assistance. In the first instance, a certified nursing assistant (CNA) was observed standing while feeding a resident with severe cognitive impairment, dementia, dysphagia, and adult failure to thrive. The resident was sitting up in bed, and the privacy curtain was not drawn. The CNA admitted to preferring to stand to see the resident's face and acknowledged that the resident had requested the CNA to sit, but the CNA refused, citing a lack of available chairs. The CNA then sat on the resident's bed to continue feeding, which was also not in accordance with facility expectations. The Director of Staff Development (DSD) confirmed that staff should be seated in front of residents during meal assistance and should not sit on residents' beds. In the second instance, a restorative nurse assistant (RNA) was observed standing at the bedside while feeding another resident who was sitting on the bed. This resident had a cognitive communication deficit and dysphagia but was cognitively intact. The RNA stated it was acceptable to stand while feeding, but both the DSD and the Director of Nursing (DON) later confirmed that staff are required to sit while feeding residents. The facility's policy on dignity, revised in 2021, specifies that residents are to be treated with dignity and respect at all times, including being provided with a dignified dining experience.
Lack of Comprehensive Care Plan for Schizophrenia Diagnosis
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident diagnosed with schizophrenia. The resident was admitted with a diagnosis of schizophrenia and had a physician's order for Aripiprazole to treat the condition. Upon review of the clinical record, it was found that there was no care plan addressing the resident's schizophrenia, including target symptoms, measurable objectives, or interventions. During an interview and record review, the DON confirmed the absence of a care plan for this active diagnosis. The facility's policy requires a comprehensive, person-centered care plan with measurable objectives and timetables for each resident's needs.
Failure to Administer and Document Enteral Feeding and Oral Care as Ordered
Penalty
Summary
A deficiency was identified when a resident with a history of dysphagia, hemiplegia, aphasia, and type 2 diabetes mellitus was not administered enteral feeding in accordance with the physician's order. The resident was prescribed a continuous tube feeding of Jevity 1.2 at 75 ml/hr for 20 hours per day, totaling 1500 ml, and was also ordered to receive oral care every shift. Observations revealed that the feeding tube was disconnected, and the amount of feeding solution administered was insufficient compared to the prescribed amount. Staff interviews confirmed that the feeding was stopped prematurely and that there was no documentation of the specific amount of enteral feeding given. Further observations showed that the resident had whitish buildup and tartar in the mouth, indicating that oral care had not been performed as ordered. The CNA responsible for the resident stated that oral care had not yet been provided that morning, and there was no toothbrush available at the bedside. Instead, lemon glycerin swab sticks and foam-tipped swab sticks were used for oral care, but these were not utilized during the observed period. Record reviews and staff interviews confirmed that there was no hourly, per shift, or daily documentation and monitoring of the resident's enteral feeding intake. The DON, RN, and dietician all verified the lack of accurate monitoring and documentation, and acknowledged that the resident did not receive the prescribed amount of enteral feeding. Facility policy required documentation of the amount and type of enteral feeding, as well as monitoring for adequate nutrition, but these procedures were not followed.
Failure to Administer Oxygen Therapy at Physician-Ordered Flow Rate
Penalty
Summary
A deficiency was identified when a resident receiving oxygen therapy was administered oxygen at a flow rate of 1.5 liters per minute (lpm) via nasal cannula, instead of the physician-ordered rate of 1 lpm. This discrepancy was observed during multiple visits to the resident's room, and was confirmed by a licensed vocational nurse (LVN) who acknowledged that the oxygen flow rate being delivered did not match the physician's order. The LVN stated that the correct procedure would have been to follow the doctor's order for oxygen therapy. The resident involved had a medical history including chronic obstructive pulmonary disease (COPD), asthma, and congestive heart failure (CHF). The facility's policy on oxygen administration requires verification and adherence to physician orders, as well as proper adjustment of the oxygen delivery device. The director of nursing (DON) confirmed that nurses are expected to review and follow physician orders for oxygen therapy and to ensure accurate flow rate administration.
Failure to Obtain Order, Consent, and Care Plan Prior to Bed Rail Use
Penalty
Summary
The facility failed to ensure proper procedures were followed prior to the installation and use of bilateral quarter upper bed rails for a resident diagnosed with Alzheimer's disease. Specifically, the bed rails were observed in use without a physician's order, and there was no timely development of a care plan addressing their use. Additionally, informed consent for the bed rails was not obtained from the resident's representative before the rails were installed. These actions were confirmed through observation, record review, and staff interviews, which revealed that the required assessment, order, care plan, and consent were all completed only after the bed rails had already been put in place. The resident's clinical record indicated that the bed rails were in use at all times while the resident was in bed to enhance mobility, but documentation showed that the necessary physician's order, care plan, and informed consent were not present at the time of installation. Staff interviews further confirmed that facility policy requires these steps to be completed prior to bed rail use, but they were not followed in this instance. The facility's own policies also specify that residents or their representatives must be informed of the risks and benefits and alternatives to bed rails, and that a comprehensive care plan must be developed, neither of which occurred before the bed rails were put in use.
Failure to Provide Planned Menu Meals and Alternatives According to Resident Preferences
Penalty
Summary
A resident with intact cognition, as indicated by a BIMS score of 15, did not receive the planned menu meal or the appropriate food alternative on multiple occasions. During a dining observation, the resident received a beef patty and salad, which was the same meal served the previous day, despite the posted menu listing soft tacos and salad. The resident confirmed he had not requested an alternative for that meal and expressed a preference for the soft tacos, which he did not receive. Additionally, the resident reported that on a previous occasion, after requesting barbecue chicken from the alternative menu, he was instead served chicken nuggets, which were not listed as an alternative option. Review of the resident's tray ticket showed a documented dislike of all pork, and the dietary manager confirmed that the soft tacos were made with beef, not pork, indicating the planned menu item was appropriate for the resident's preferences. The dietary manager acknowledged that the resident received a vegetable patty instead of the planned menu item and that the requested alternative meal was not provided as listed. The facility's policy requires that menus be prepared in advance and followed, but these requirements were not met in this instance.
Call Light System Not Accessible to Dependent Residents
Penalty
Summary
Surveyors observed that the facility failed to ensure that the call light system was within reach for two residents who were dependent on staff for activities of daily living. In one instance, a resident with cerebral palsy, who was cognitively intact but fully dependent for mobility and self-care, was found lying in bed without the call light within reach; it was instead hanging on a feeding tube pole. A Certified Nursing Assistant confirmed that the call light was not accessible to the resident and acknowledged it should not have been placed on the feeding tube pole. The Director of Nursing also confirmed that the resident was dependent on staff and that the call light should always be within reach. In another case, a resident with hemiplegia and hemiparesis, and moderate cognitive impairment, was observed lying in bed with the call light clipped to the privacy curtains, out of reach. A Registered Nurse confirmed the call light was not accessible and stated it should not have been placed on the curtains. Both residents' clinical records indicated they were dependent on staff for all activities of daily living, including mobility and personal care. The facility's policy required that each resident have a means to call staff for assistance from their bed, but this was not followed in these instances.
Failure to Communicate Lab Results to Physician
Penalty
Summary
The facility failed to ensure that laboratory results were communicated to the physician for one of three sampled residents. The resident in question had a history of pneumonia and urinary tract infection and was admitted with symptoms including vomiting, decreased appetite, reduced fluid intake, and low urine output. A physician's order was placed for a repeat CBC and CMP, and the blood was collected and results received the same day, with multiple abnormal findings noted. Despite the receipt of these lab results, there was no documentation in the resident's medical record that the results were communicated to the physician as required. During an interview, a registered nurse confirmed that the results had not been documented as reported to the physician. Facility policy requires that such communication be documented in the Progress Notes section of the medical record, but this was not done in this instance.
Inadequate Infection Control in Shower Rooms
Penalty
Summary
The facility failed to implement proper infection control practices in four out of six shower rooms, as observed during a survey. In shower room [ROOM NUMBER], a brown substance identified as feces was found on the floor, which the Maintenance Director (MD) confirmed should have been cleaned and disinfected by staff after use. In another shower room, cotton swabs and a shaver cover were left on the floor drain, which the MD acknowledged should have been disposed of after use. Additionally, a used white towel was found on the shower handlebar in a different shower room, and the MD confirmed that the room should have been cleaned for the next resident. Further observations revealed a used shaver, toilet tissue, wheelchair footrests, and socks in the bathtub of another shower room, which the MD confirmed should have been removed to maintain cleanliness for subsequent use. The Director of Nursing (DON) acknowledged these observations and stated that shower rooms should not be left dirty to prevent infection. The facility's policies and procedures, which were reviewed, indicated that environmental surfaces should be cleaned and disinfected according to CDC recommendations and OSHA standards, and that bathrooms should be cleaned daily to maintain a safe and sanitary environment.
Failure to Notify Responsible Party of Resident's Injury
Penalty
Summary
The facility failed to notify a responsible party regarding a change in condition when a resident sustained an injury to his left elbow. A physician's order was obtained to treat the injury, but the clinical record lacked documentation that the responsible party was informed of the wound. During an interview, the director of nurses reviewed the resident's clinical record and confirmed the absence of documentation for notifying the responsible party. The facility's policy required a nurse to notify the resident's representative when there was a significant change in the resident's status, which was not adhered to in this case.
Failure to Provide Timely Wound Care and Documentation
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards for Resident 1, who was admitted with diagnoses including diabetes mellitus and malnutrition, and was at risk for dehydration. The resident had a wound on the left lower leg infected with MRSA, for which physician's orders for treatment were obtained late and implemented three days after admission. Additionally, there was a failure to obtain a physician's order for a wound on the right third toe, which was noted to have 10% slough and 90% granulation, and the resident was not seen by a podiatrist. The facility also failed to document a change in condition for Resident 1 when a STAT lab was ordered, which revealed a critically high sodium level, leading to a diagnosis of severe dehydration. Furthermore, there was a lack of documentation regarding a left elbow wound, for which a physician's order was obtained to cleanse and dress the wound. However, there was no corresponding change of condition note, despite a surgical procedure being performed to remove necrotic tissue from the wound. The facility's documentation practices were inadequate, as evidenced by the lack of weekly skin status documentation and failure to record changes in the resident's condition. The facility's policies required documentation of all services provided and communication between the interdisciplinary team regarding the resident's condition and response to care, which was not adhered to in this case.
Failure to Monitor Lasix Side Effects
Penalty
Summary
The deficiency involved a failure by the consultant pharmacist (CP) to report drug irregularities for a resident who was prescribed Lasix, a diuretic with a black box warning (BBW) from the FDA due to its potential serious side effects. The CP did not address the need for monitoring the side effects of Lasix, such as signs and symptoms of dehydration, in the resident's clinical record. This oversight was identified during a review of the resident's medication orders and clinical records, which lacked documentation indicating that the side effects of Lasix were being monitored. The resident had been admitted to the hospital with severe dehydration and hypernatremia, conditions that could be related to the side effects of Lasix. Despite the critical nature of these conditions, the Medication Record Review (MRR) conducted shortly after the prescription of Lasix did not result in any recommendations for monitoring. Interviews with the CP and the director of nurses (DON) confirmed the absence of documentation and monitoring for Lasix's side effects. Additionally, the facility's policy on Medication Regiment Review, which should have guided the monitoring of adverse consequences, was not adhered to, and the specific policy for handling medications with black box warnings was not provided upon request.
Delay in STAT Lab Results Leads to Hospitalization
Penalty
Summary
The facility failed to ensure timely acquisition of a STAT laboratory result for a resident, which led to a delay in necessary medical intervention. The resident, who was at risk for dehydration, had a STAT lab order placed for a comprehensive metabolic panel. However, the results were not obtained until the following day, revealing a critical high sodium level that required immediate medical attention. This delay resulted in the resident being sent to the hospital with a diagnosis of severe dehydration. Interviews with facility staff and the lab company revealed that the lab specimen took approximately 9 hours to reach the lab, which was considered too long for a STAT order. The facility's policy indicated that STAT results should be released within 4 to 6 hours from the time of the blood draw. The director of nurses and the administrator acknowledged ongoing issues with obtaining timely lab results, which contributed to the delay in addressing the resident's critical condition.
Failure to Notify Physician of Abnormal Lab Result
Penalty
Summary
The facility failed to promptly notify a physician or nurse practitioner of an abnormal lab result for one of the residents, leading to a delay in the adjustment of the resident's diabetic medication. The resident, who was admitted with a diagnosis of diabetes mellitus, had a lab test drawn on December 29, 2022, which showed an elevated A1c level of 9.1%. This result was not documented as reviewed by licensed nurses, nor was there any indication that the physician or nurse practitioner was notified in a timely manner. The facility's policy required nursing staff to review test results and notify the physician if the results met certain criteria. However, there was no documentation to show that the nursing staff followed this protocol. The director of nurses confirmed the lack of documentation during an interview, indicating a failure in the facility's process for handling lab results. This oversight resulted in a delay in the resident's medication adjustment, as changes were only made after the physician was eventually informed of the elevated A1c level.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 329 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.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near San Jose
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Vista Manor Nursing Center | 0.2 mi | ★★★★★ | 0 | 0 |
| Inspire Behavioral Health | 1.5 mi | ★★★★★ | 16 | 1 |
| San Jose Healthcare & Wellness Center | 2.1 mi | ★★★★★ | 0 | 0 |
| The Ridge Post Acute | 2.2 mi | ★★★★★ | 26 | 0 |
| Mission De La Casa | 3.2 mi | ★★★★★ | 0 | 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.