Below average — CMS composite of the measures below.
The next survey window likely opens around March 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 Casa Coloma Health Care Center during CMS and state inspections, most recent first.
The facility failed to maintain a safe environment and properly implement safety measures for three residents. A resident with cognitive impairment ingested chemical preservatives from an unsecured urine specimen tube left at the bedside, contrary to policy requiring specimens to be kept in a secluded location. Another resident with epilepsy had a physician order and care plan for padded side rails and seizure precautions, yet observations showed unpadded side rails, CNAs were unaware of the need for pads, and there was no documentation of refusal despite MAR entries indicating padding. A third resident with severe cognitive impairment had a bed remote with frayed, exposed wires accessible at the bedside; both a CNA and the maintenance director confirmed the condition, which conflicted with policies requiring the environment and equipment to be maintained free of accident hazards.
Failure to Report and Investigate Resident-to-Resident Abuse Allegation: The facility did not properly operationalize its abuse policy when a resident reported that her roommate hit her on the forearm. The record showed the allegation was labeled fabricated, there was no documented investigation, and the DON and ADM acknowledged it was not reported to the State licensing agency. The SSD said she did not report because the resident was cognitively intact and declined, and six nurses did not know suspected abuse had to be reported to the State. The posted State agency phone number was also inaccurate.
Controlled medication records did not reconcile for four residents receiving PRN or scheduled opioid pain meds. MARs and CDRs for Norco and oxycodone showed mismatched sign-outs and administration entries, and the ADON and DON confirmed the discrepancies, stating the records should match and that the issue could reflect a med error, overgiving of narcotics, or possible diversion.
A medication pass observation found a 7.69% error rate when an LPN omitted scheduled insulin glargine and Glycolax for one resident and gave glipizide to another resident after breakfast instead of 30 minutes before the meal. The LPN confirmed the insulin was delayed because she did not want to give it with two other injections, and the DON confirmed the insulin was administered more than two hours late and that meds should be given within the ordered timeframe.
Expired meds and supplies were found in the med storage room, including docusate liquid, a catheter stabilization device, and an IV administration set. In addition, a packet of zinc oxide ordered for a resident with hemiplegia, hemiparesis, and CHF was left on the resident’s bedside table; the resident said a nurse left it there, and an LPN and the TN confirmed it should not be left at bedside.
Improper hand hygiene and food handling practices were observed in the dietary area. The kitchen handwashing sink had no hot water on two occasions, the CDM picked up ice from the floor and then touched food thermometers without washing hands, and dietary staff placed wet reusable lids on residents’ nutritional drinks, allowing liquid to drip into the drinks.
Failure to follow EBP requirements for two residents. One resident with a Foley catheter and MDRO history had physician orders and a care plan for EBP, but no EBP/PPE signage was posted in the room during multiple observations. Another resident with ESRD, dialysis dependence, and MDRO history had EBP ordered, but a CNA provided high-contact care while wearing a mask and gloves without a gown, despite stating a gown was required.
POLST and physician orders did not match for two residents. One resident with severe cognitive impairment had conflicting POLST documents in the chart, with the scanned POLST showing CPR and full treatment while the physician order showed DNR and comfort-focused care; the DON later found a matching DNR POLST in the hospice binder. Another resident with intact cognition had a physician order for Full Code and Full Treatment, but the POLST stated DNR and selective treatment. Staff, including the ADON, LPN, and DON, confirmed the mismatches and that the orders were not aligned with the residents’ documented wishes.
Failure to Investigate and Report Resident-to-Resident Abuse Allegation: A cognitively intact resident reported that a roommate hit her, and nursing documentation noted the allegation and that staff were notified. The DON, ADM, and SSD were aware of the report, but the allegation was not thoroughly investigated or reported because the resident allegedly refused to report it. The roommate had psychiatric diagnoses and mild cognitive impairment, and staff interviews confirmed the incident was treated as unwitnessed despite the resident’s repeated statements that she had been hit.
A resident with hemiplegia and hemiparesis after a stroke, and with intact cognition per BIMS, was dependent on staff for personal hygiene and had a care plan for daily grooming and cleanliness. Staff and record review showed the resident was scheduled for showers or bed baths twice weekly, but documentation was missing for some scheduled baths, and there were no recorded refusals. During observation, the resident had greasy hair and stated she had not had a good bed bath or hair wash for 2-3 weeks, while CNA and DON interviews confirmed the inconsistency in bathing documentation and care delivery.
A resident with an indwelling urinary catheter and nephrostomy tube had both drainage bags placed together in the same privacy bag on the floor next to the bed. An LPN confirmed the bags should be separate, hanging off the side of the bed, and not on the floor, and the DON stated the same. The resident had diagnoses including UTI, hydronephrosis, and moderate cognitive impairment, and the facility’s catheter care and CAUTI prevention policies required drainage bags to be kept off the floor.
Respiratory care orders were not followed for three residents. One resident with asthma and OSA had oxygen set above the ordered range and the NC was off her nostrils. Another resident with respiratory failure and cognitive impairment had unlabeled oxygen tubing and no oxygen-in-use sign at the room. A third resident with COPD and respiratory failure had a titration order to keep SpO2 at 88-92%, but staff repeatedly documented oxygen saturations above the ordered range and did not adjust the oxygen.
A resident with osteoarthritis and inflammatory radiculopathy had an order for PRN Tylenol and a care plan for chronic pain, but staff did not assess pain every shift, did not offer non-pharmacological interventions, and did not administer pain medication. The resident was repeatedly observed grimacing, moaning, and rubbing her knees or lower legs, and stated that nobody asked about pain or offered medication. The DON acknowledged the resident had not been assessed or treated for pain as expected, and the MAR did not show pain assessments, non-pharmacological interventions, or pain meds.
Incorrectly Sized Bed Rail: A resident with cognitive impairment, weakness, and a history of falls had a physician order for quarter-length side rails for bed mobility and repositioning, but observations showed a half-length right side rail in place. The care plan did not specify the rail size or type to match the order, and the ADON and DON both confirmed the installed rail did not align with the physician order or quarterly bed rail assessments.
Late Administration of Scheduled Insulin Glargine: A resident with Type 2 DM and intact cognition did not receive scheduled Insulin Glargine on time. During med pass, an LN omitted the insulin from the initial administration and later gave it more than two hours after the ordered 8:00 a.m. time, stating she delayed it because she did not want to give it with two other injections. The DON confirmed the dose was scheduled twice daily and was administered outside the facility’s required timeframe.
Therapeutic diet orders were not followed for three residents. Kitchen staff served the wrong entree to a resident on a 2 gm sodium diet, gave a resident on a soft and bite sized diet a dessert with wafers instead of the ordered item without wafers, and placed graham crackers on a tray for a resident ordered a mechanical soft ground texture. The CDM, AD, and RD each confirmed the items did not match the ordered diets, and the facility policy required food to be prepared to meet individual needs.
Uninterrupted Power Supply for Life-Sustaining Equipment: During a power outage, staff observed that the emergency outlets were not working and used extension cords, flashlights, and power cords to try to power oxygen concentrators in Station 2. The SSD confirmed the emergency outlets were not working, and the emergency power did not kick in for 24 minutes. The DM stated the generator should transfer within 6-9 seconds, but it was shut down when the switch was pushed in near the kitchen back door, and he had to reset it before power was restored.
Resident rooms in multiple 3-bed rooms did not meet the required 80 sq. ft. per resident. The ADM provided measurements showing the rooms ranged from about 217.2 to 230.2 sq. ft. total, which equaled roughly 72.4 to 76.7 sq. ft. per resident. Surveyors observed no complaints or space concerns, and residents and staff stated care could be provided and privacy was maintained with curtains.
The facility failed to ensure accurate accountability of controlled medications, including tramadol, due to procedural lapses. An LPN disposed of tramadol without a second nurse to cosign, and medication cart-controlled drug sign-in/sign-out sheets had missing signatures. Additionally, the narcotic destruction process was not properly documented, with only the pharmacist's signature on the logs.
A facility was found to have an 8.82% medication error rate during a medication pass, exceeding the acceptable threshold. Errors included a nurse administering acarbose after breakfast instead of with the first bite, and another nurse failing to prime a Humalog KwikPen before injection. The Director of Nursing confirmed the lack of specific training on medication delivery devices.
The facility failed to label multi-dose medications with open and discard dates, risking the use of expired medications. Inspections revealed unlabeled inhalers and improperly stored ampules, contrary to manufacturer instructions and facility policies. The DON misunderstood labeling requirements, leading to non-compliance with medication storage protocols.
The facility failed to ensure food safety by allowing expired food items and improper storage conditions, including expired beverages in the refrigerator and a box soaked with cooking oil in the dry storage area. Additionally, there were physical environment issues such as a cracked light cover and missing light covers, posing contamination risks. The facility also lacked air gaps in sinks, increasing the risk of backflow contamination, and could not provide relevant policies or guidelines.
A LTC facility failed to maintain effective infection control, as staff did not use proper PPE for residents on droplet precautions, and residents were not offered hand hygiene before meals. Additionally, enteral feeding equipment was not labeled or changed as required, and a glucometer was improperly disinfected, increasing infection risks.
The facility failed to provide hot water in bathroom sinks for several residents and an entire hall due to a malfunctioning water heater pump. Residents, including those with rheumatoid arthritis, reported discomfort and difficulty washing with cold water. Staff were aware and reported the issue, but it remained unresolved for over 20 days. The Director of Maintenance confirmed the need for pump replacement, and the Administrator acknowledged the issue, but residents did not consistently receive alternative solutions.
The facility failed to respond to call lights in a timely manner for two residents, one with heart and kidney disease and another with irritable bowel syndrome, due to a muted call system at a nursing station. This resulted in significant delays in assistance, with one resident experiencing a fall. The facility's policy required call lights to be answered within five minutes, but the muted system and staff unawareness led to prolonged response times.
The facility failed to follow physician orders and medication administration protocols for several residents. A resident had conflicting orders for a knee brace, another had incorrect oxygen therapy settings, and a third was monitored for a discontinued medication. Additionally, loose pills were found at a resident's bedside, contrary to policy.
A resident with sensorineural hearing loss was not assisted with their hearing aids, leading to frustration and communication difficulties. Despite repeated requests for help, staff failed to address the malfunctioning hearing aids, and inaccurate documentation was noted. The facility's policy on assistive devices was not followed, impacting the resident's psychosocial well-being.
A resident with a feeding tube was not properly positioned with the head of bed elevated at 30-45 degrees during feedings, as required by physician orders and care plans. Observations showed the resident lying almost flat, increasing the risk of aspiration. Despite reminders and posted signs, staff failed to adhere to the prescribed positioning, compromising the resident's safety.
Two residents with COPD received oxygen at higher rates than prescribed, despite documentation indicating otherwise. Observations showed discrepancies in oxygen delivery, which were acknowledged by an LPN. The facility's policy on oxygen administration was not followed, leading to incorrect therapy.
A resident was administered quetiapine without adequate indication or non-pharmacological interventions. The facility failed to document the necessity of the medication or attempt non-drug interventions, leading to unnecessary medication use.
A resident with multiple health conditions did not receive restorative nursing services after being discharged from PT/OT due to insurance limitations. Despite being cognitively intact and expressing a desire for therapy, the necessary orders were not entered into the EHR, and the referral process was not completed. This failure resulted in the resident not maintaining her highest practicable level of well-being.
A resident in the facility was found without an accessible call light, as it was bundled and out of reach. The resident, who required assistance due to multiple health issues, was unable to call for help, increasing the risk of falls. The issue was confirmed by staff, who acknowledged the call light should have been reported for maintenance. The facility's policy mandates that call systems remain functional and accessible, which was not followed in this case.
The facility failed to meet the required 80 square feet per resident in 32 rooms, affecting residents' privacy and mobility. Interviews revealed residents' discomfort with crowded conditions and staff challenges in providing care efficiently due to limited space.
A resident with chronic pain and morbid obesity received lidocaine patches applied by a CNA, which is outside the CNA's scope of practice. Interviews revealed that CNAs were not permitted to apply such patches, a task reserved for licensed nurses. Despite this, a CNA admitted to applying the patches, and a nurse acknowledged leaving them with CNAs. The facility's policy stated only licensed personnel could administer medications, leading to a deficiency in professional standards.
The facility failed to maintain a secure environment for residents, as sliding glass doors in two residents' rooms could not be locked. A resident, admitted with depression and cognitively intact, felt unsafe due to the non-functional lock, which had been an issue for three years despite requests for repair. Observations confirmed the doors could not be locked, posing a security risk. The DON was unaware of the issue, which violated the facility's maintenance policy.
A CNA failed to follow infection control practices by handling soiled linen without gloves and neglecting hand hygiene before handling clean linen. The DON acknowledged the lapse, which violated the facility's policies on laundry handling and hand hygiene.
Failure to Maintain Safe Environment, Implement Seizure Precautions, and Maintain Equipment
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe environment and provide adequate supervision and equipment maintenance for multiple residents. For one resident with moderate cognitive impairment, anxiety, hearing deficit, and macular degeneration, staff left a urine specimen collection pack containing preservative additives (Boric Acid, Sodium Borate, and Sodium Formate) unsecured at the bedside. According to the SBAR dated 3/18/26, during morning rounds a CNA observed this resident opening the biohazard specimen kit, removing the tube’s lid, and ingesting an unknown amount of the white material inside, which was then seen on the resident’s lips and tongue, along with increased confusion. An IDT note later documented that the nurse had inadvertently left the urine specimen collection pack near the bedside cabinet instead of securing it in the designated storage area, contrary to the facility’s policy that cultures and specimens be kept in a secluded location. The deficiency also includes the facility’s failure to implement a physician’s order for seizure precautions for a resident with epilepsy and intact cognition. A physician order directed nursing staff to monitor placement of padded side rails every shift, and the resident’s care plan identified risk for injury related to seizure disorder with an intervention to monitor side rail placement every shift. Observations on two separate days showed the resident in bed with side rails that were not padded. During interviews, CNAs familiar with the resident’s care needs stated they had not seen foam side rail pads used for this resident and were not aware they were needed, despite foam pads being used for other residents. The resident reported a history of epilepsy and seizures and stated awareness that side rails should be padded to prevent injuries in case of a seizure, but that nobody had placed the pads. The DON confirmed that foam side rail pads are used for residents on seizure precautions, that the side rails must be padded for safety, and that there was no documentation of the resident refusing side rail padding, despite MAR entries indicating side rails were padded. A further deficiency was identified in relation to equipment maintenance for another resident with severe cognitive impairment, encephalopathy, dementia, epilepsy, and diabetes. During observation, this resident’s bed remote control was seen next to the resident in bed, with frayed and exposed wires at the junction of the remote and cord and where the cord was wrapped around the bed rail. The resident stated he was able to use the bed remote and was observed picking it up. A CNA confirmed the presence of frayed and exposed wires and stated that this should not be and that it could shock the resident if he touched the frayed wire. The Director of Maintenance also confirmed the frayed and exposed wires on the bed remote control cord, acknowledged that the remote still worked but needed to be changed, and stated this was the first time he had been notified of the issue. These conditions were inconsistent with the facility’s policies requiring the environment to be as free from accident hazards as possible and requiring maintenance of equipment in a safe and operable manner at all times. Collectively, these events show that the facility did not follow its own policies on securing specimens, implementing seizure safety measures, and maintaining equipment, resulting in one resident ingesting chemical preservatives from a specimen tube, placing another resident at risk for injuries during seizure activity due to lack of padded side rails, and creating an electrical safety hazard for a resident with access to a bed remote with frayed, exposed wiring.
Failure to Report and Investigate Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to ensure its abuse policy was operationalized and implemented to prohibit and prevent abuse, ensure timely reporting, and complete a thorough investigation of an allegation of resident-to-resident physical abuse. The facility’s policies stated that abuse prevention included protecting residents from abuse by other residents, requiring staff training on abuse identification and reporting, and investigating and reporting all altercations that may represent resident-to-resident abuse. The abuse investigation and reporting policy also stated that reports of resident abuse or mistreatment were to be promptly reported to local, state, and federal agencies and thoroughly investigated by facility management. Resident 2 was admitted in 2024 with diagnoses including heart disease and polyarthritis. The resident’s MDS dated 3/13/26 indicated intact cognition and intact ability to think, rationalize, and recall. On 1/23/26 at 8:30 p.m., an SBAR communication form documented that Resident 2 reported to a nurse that her roommate’s fist landed on her left forearm. The note classified the report as a fabricated statement toward the roommate, and the resident declined to report it as a SOC 341. The clinical record contained no documented evidence that the allegation of physical abuse by another resident was investigated by the facility. During interviews, the DON acknowledged the incident was not reported to the State licensing agency and stated there was no redness or injury and that the incident was not witnessed by staff. The ADM stated he was the abuse coordinator and said he talked to both residents, but he did not ask Resident 2 if she had been hit or injured and validated there was no documented evidence that the allegation was investigated or reported. The SSD stated she was informed of the allegation and told Resident 2 she would report it to appropriate agencies, but then stated that because Resident 2 was alert, oriented, and cognitively intact and declined, she did not report it. Six nurses interviewed did not know that suspected or alleged abuse allegations were to be reported to the State licensing agency, and the posted emergency contact list containing the State agency phone number was found to be inaccurate.
Controlled Medication Records Did Not Reconcile for Four Residents
Penalty
Summary
The facility failed to ensure accurate accountability of controlled medications for four sampled residents when random audits of the MAR and CDR did not reconcile. For Resident 32, physician orders included Norco 5-325 mg two tablets by mouth twice daily for chronic pain and Norco 5-325 mg one tablet by mouth every 6 hours as needed for moderate pain, but the CDR showed Norco signed out on 4/14/26 at 4:30 a.m. and 4/23/26 at 4:30 a.m. without corresponding MAR documentation that the doses were not administered. For Resident 27, an order for oxycodone 5 mg 1/2 tablet every 6 hours as needed for pain management was in place, but the CDR showed doses signed out on 3/16/26 at 12:06 p.m., 4/13/26 at 3 a.m., 4/13/26 at 10:45 a.m., and 4/22/26 at 5:03 a.m. without MAR documentation that they were not administered, and the MAR also showed oxycodone administered on 3/20/26 at 12:06 p.m. without a matching CDR entry. For Resident 21, an order for Norco 5-325 mg one tablet by mouth every 8 hours as needed for moderate to severe pain was documented, but the CDR showed Norco signed out on 3/22/26 at 1:25 p.m. without MAR documentation that it was not administered, and the MAR showed Norco administered on 3/23/26 at 1:24 p.m. without a matching CDR entry. For Resident 114, an order for Norco 5-325 mg one tablet by mouth every 6 hours as needed for moderate to severe pain was documented, but the CDR showed Norco signed out on 4/21/26 at 8:11 p.m. without MAR documentation that it was administered. During interview, the ADON and DON confirmed the discrepancies and stated the MAR and CDR should reconcile; they also stated that mismatches could indicate medication error, overgiving of narcotics, or possible drug diversion. The facility policy stated controlled substances are to be reconciled upon receipt, administration, disposition, and at the end of each shift, and discrepancies are to be documented and reported immediately.
Medication Administration Errors During Pass Observation
Penalty
Summary
Medication administration errors occurred during a medication pass observation for two residents, resulting in a 7.69% error rate based on three errors out of 39 opportunities. For one resident, the nurse administered multiple scheduled medications but omitted Insulin Glargine 28 units SQ twice daily and Glycolax Powder 17 grams daily during the observed pass. The resident’s record showed the insulin glargine was scheduled for 8 a.m., but it was not given at that time during the observation. The same resident’s insulin glargine was later documented as administered at 10:42 a.m., more than two hours after the scheduled time. During interview, the nurse confirmed the insulin glargine was not given at 8 a.m. and stated it was delayed because she did not want to give it at the same time as two other injections. The nurse also confirmed Glycolax was not administered during the medication pass, although the MAR later showed it as signed as administered at 8 a.m. and the administration history showed an entry that was later striked out as incorrect and coded as refused. For the second resident, the nurse administered Glipizide 10 mg by mouth after breakfast even though the physician’s order was for the medication to be given in the morning 30 minutes before breakfast. The resident had already eaten breakfast and no meal tray was at bedside during the observation. The nurse confirmed the medication was given after breakfast and stated it was already late to give it when the shift started. The DON confirmed the insulin glargine was scheduled twice daily at 8 a.m. and 8 p.m., that it was administered at 10:42 a.m., and that medications should be given within one hour before or after the scheduled time unless there was an emergency.
Expired Medications and Bedside Topical Medication Storage
Penalty
Summary
The facility failed to ensure medications and medical supplies were stored safely when expired and discontinued items were found in the Station 3 Medication Storage Room during a concurrent observation and interview with the ADON. The items identified included a bottle of Docusate Sodium Liquid expired 7/2025, a StatLock Catheter Stabilization Device expired 2/28/26, and an IV Administration Set expired 3/4/26. The ADON confirmed the items were expired and should have been removed from facility stock. The facility policy titled Storage of Medications, revised 11/2020, stated that drugs and biologicals are to be stored in a safe, secure, and orderly manner and that discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. The facility also failed to ensure Resident 63's topical zinc oxide was not left at bedside. Resident 63 was admitted with diagnoses including hemiplegia, hemiparesis following cerebral infarction affecting the left non-dominant side, and CHF. A physician order dated 4/14/26 directed treatment to the coccyx superficial skin tear and application of zinc paste every shift and as needed after incontinent brief changes. During observation in the resident's room, a packet of zinc oxide was found on top of the resident's table, and the resident stated a nurse had left it there the day before. LN 8 confirmed the packet was in the room and stated it was not acceptable to leave it at bedside because it contained medication and should be applied by nurses. The Treatment Nurse later confirmed the zinc oxide packet was the same product used by the facility and stated staff cannot leave it at the bedside.
Improper Hand Hygiene and Food Handling in Dietary Services
Penalty
Summary
The facility failed to use proper personal hygiene practices to prevent contamination of food during kitchen operations. During observation, no hot water was available at the kitchen handwashing sink after the faucet was allowed to run for approximately 60 seconds on two separate occasions. The Certified Dietary Manager stated the water was only warm when she checked the sink. The facility’s handwashing policy stated hand hygiene is the primary means to prevent the spread of infections and included washing hands before and after handling food. During another observation, the Certified Dietary Manager picked up a piece of ice from the floor with a bare hand and then touched both food thermometers without performing hand hygiene. She also did not sanitize the thermometers before staff used them. In a separate observation, dietary staff were preparing nutritional drinks for residents and placed multiple wet reusable lids onto the cups, causing liquid to drop into the drinks. The Certified Dietary Manager stated the lids should not be used while wet and that it was not sanitary.
Failure to Follow Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection control program for two residents who were on Enhanced Barrier Precautions (EBP). Resident 99 was admitted with diagnoses including urinary tract infection, acute kidney failure, and obstructive and reflux uropathy. The resident’s MDS indicated intact cognition, and physician orders dated 4/8/26 and 4/9/26 directed use of an indwelling urinary catheter and EBP due to the presence of a Foley catheter and a history of MDRO in urine. The care plan also directed use of EBP for the indwelling urinary catheter and education of the resident and family on EBP needs. During observations in Resident 99’s room, no signage was posted indicating EBP or any PPE requirements before entering the room on multiple occasions. The resident was observed in bed with the Foley catheter bag hanging on the left side of the bed. The Assistant Director of Nursing stated EBP signage was important so staff would know whether PPE was needed before entering the room. Later, the Infection Preventionist observed EBP signage posted and stated that residents with devices such as a Foley catheter should have EBP signage posted; the Infection Preventionist confirmed the room had not had EBP signage earlier and that it was posted later in the afternoon. Resident 89 was admitted with end stage renal disease and dependence on renal dialysis. A physician order dated 1/9/26 indicated EBP due to a history of MDRO in the blood and a tunneled internal jugular port for hemodialysis access. During observation, CNA 4 entered the room and provided care including cleaning up and helping the resident get dressed. The CNA was observed wearing a mask and gloves but no gown, and the CNA stated she was supposed to use gown, gloves, and mask for EBP but forgot the gown. The Infection Preventionist reviewed the order and care plan and stated the resident should have been on EBP and that staff were expected to use the correct PPE for high-contact activities such as changing clothes and briefs.
POLST and Physician Orders Did Not Match Resident Wishes
Penalty
Summary
The facility failed to provide POLST orders that matched residents’ documented treatment wishes for 2 residents. Resident 19 was admitted and later readmitted with multiple diagnoses including failure to thrive, left above-the-knee amputation, dysphagia, mood disorder, and protein-calorie malnutrition. The resident had severe cognitive impairment with a BIMS score of 0, and the record identified the family member as the responsible party. The clinical record contained conflicting POLST documents: one scanned POLST indicated Attempt Resuscitation/CPR, Full Treatment, and long-term artificial nutrition, while another POLST indicated Do Not Attempt Resuscitation, Comfort-Focused Treatment, and no artificial means of nutrition. Resident 19’s physician order summary indicated DNR and Comfort-Focused treatment, but the POLST scanned into the clinical record did not match that order. During interview and record review, LN 6 stated the physician order and scanned POLST conflicted and could cause confusion in an emergency. The DON stated the resident had been on hospice, the POLST had been changed during hospice to reflect DNR and comfort-focused treatment, and after hospice discharge the responsible party wanted those same orders continued. The DON later produced a POLST located in the hospice binder that matched the DNR and comfort-focused treatment wishes, and acknowledged that the nursing staff would not have access to the binder while it was locked in the medical records office. Resident 13 was admitted with diagnoses including major depressive disorder and severe sepsis and had intact cognition on the MDS. The physician order listed Full Code and Full Treatment, while the POLST stated Do Not Attempt Resuscitation if the patient had no pulse and was not breathing, and Selective Treatment if the patient had a pulse and/or was breathing. During interviews, the ADON, LN 2, and DON all confirmed that the POLST and physician order did not match and that the physician order had not been updated to reflect the POLST. The DON stated the order should have been updated when the POLST was received, and the facility policy stated the resident’s documented treatment preferences and advance directive should be consistent with the plan of care.
Failure to Investigate and Report Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to ensure that an allegation involving verbal and physical abuse between two residents was identified, thoroughly investigated, and reported to the appropriate agencies. Resident 2, who had intact cognition with a BIMS score of 15/15 and diagnoses including heart disease and polyarthritis, reported that Resident 31 hit her with a closed fist. Resident 31 had diagnoses including anxiety, depression, and schizoaffective disorder, was documented as not capable of understanding rights, responsibilities, and informed consents, and had a BIMS score of 12/15 indicating mild cognitive impairment. The clinical record showed that on the evening of the incident, Resident 2 told nursing staff that Resident 31’s closed fist landed on her left forearm, and the nurse documented that there were no witnesses and no redness or swelling. The SBAR communication form documented the allegation and noted that the physician, ADM, SSD, and DON were notified. The SSD later documented that Resident 2 verbalized that her roommate hit her, that there was no witness and no bruising, and that Resident 2 refused to report it. Resident 2 later stated that she had reported the incident to nursing, that Resident 31 hit her in the shoulder, and that she was not told what happened afterward. During interviews, the DON stated she was aware of the incident and that Resident 31 denied hitting Resident 2, but the facility did not investigate the allegation and the DON stated the incident was not investigated because Resident 2 refused to report it. The Administrator stated there was no documented investigation because Resident 2 did not tell him she was hit and the nurse did not report physical contact, and he stated he did not read the SBAR or progress note addressing the incident. The SSD stated that because Resident 2 was alert, oriented, and cognitively intact and refused to have the report completed, she did not report it. Facility staff also stated that resident-to-resident altercations and allegations of abuse were to be investigated and reported, but the allegation was not documented as investigated or reported to the appropriate agencies.
Failure to Provide Scheduled Personal Hygiene Care
Penalty
Summary
The facility failed to ensure that Resident 7 received scheduled personal hygiene services, including showers or bed baths twice a week, as required. Resident 7 was admitted earlier in the year with diagnoses including hemiplegia and hemiparesis following a stroke affecting the left side. The MDS dated 2/27/26 showed a BIMS score of 13 out of 15, indicating intact cognition, and the resident was dependent on staff for personal hygiene, including showers. The care plan initiated 2/13/26 stated that Resident 7 required assistance with personal hygiene and that the goal was for the resident to be well groomed and clean daily. During observation on 4/22/26, Resident 7 was in bed with hair that appeared sticky and greasy, and the resident stated she felt smelly and not well cared for, adding that she had not had a good bed bath and hair wash for 2-3 weeks. Resident 7 stated she was scheduled for bathing twice a week, but it was inconsistent. CNA 2 acknowledged the resident's hair was greasy and stated she had bathed Resident 7 a week earlier, while Resident 7 said her hair had not been washed. Review of the shower schedule showed Resident 7 was due for showers on multiple dates in April 2026, but the weekly shower forms documented bed baths only on some of those dates and did not show bed baths on 4/4/26 or 4/11/26. The clinical record contained no documented refusals for those missed baths. The DSD and DON both confirmed the expectation for showers or bed baths twice weekly and could not find documentation showing that Resident 7 received care or refused care on the missed dates.
Catheter and Nephrostomy Drainage Bags Left on Floor
Penalty
Summary
The facility failed to provide catheter care in a manner to prevent catheter-related infections for one resident who had an indwelling urinary catheter and a nephrostomy tube. The resident was admitted in April 2026 with diagnoses including encephalopathy, tubulo-interstitial nephritis, urinary tract infection, and hydronephrosis. The resident’s MDS dated 4/11/26 indicated a BIMS score of 11 out of 15, showing moderate cognitive impairment. Orders in the record directed staff to monitor the Foley drainage bag for proper placement, no kinking or compression, and to keep it below the bladder at all times, and to monitor nephrostomy tubing placement every shift. During an observation on 4/22/26 at 8:40 a.m., the resident’s indwelling urinary catheter drainage bag and nephrostomy drainage bag were observed together in the same black mesh privacy bag laying on the floor. During a concurrent observation and interview, LN 1 confirmed the bags were in the same privacy bag and on the floor next to the bed, and stated they should be in separate privacy bags, hanging off the side of the bed, and not on the floor. The DON later stated urinary catheter drainage bags and nephrostomy drainage bags should be kept in privacy bags and should not be on the floor. The facility’s catheter care and CAUTI prevention policies also stated the drainage bag should be kept off the floor and should not be placed on the floor.
Respiratory Care Orders Not Followed
Penalty
Summary
Respiratory care was not provided in accordance with the physician’s orders for a resident with asthma and obstructive sleep apnea. The resident had an order for oxygen at 2-4 liters per minute via nasal cannula continuously to maintain oxygen saturation above 92%. During observation, the resident was lying in bed with the nasal cannula off her nostrils, and the oxygen concentrator was set at 5 liters per minute. A nurse confirmed the setting was 5 liters and stated it should have been between 2-3 liters. The ADON later reviewed the order and MAR and stated the order was not followed when the oxygen was set at 5 liters per minute, and the physician should have been notified when the resident removed the nasal cannula or was non-compliant. A second resident with diagnoses including epilepsy, respiratory failure with hypoxia, heart failure, and senile degeneration of the brain had an oxygen order for 1-4 liters per minute via nasal cannula continuously every shift. The resident also had an order for oxygen and nebulizer tubing to be changed weekly and labeled with the date changed. During observation, the resident was using oxygen at 4 liters per minute, but the tubing was not labeled with the date changed. A nurse confirmed the tubing was not labeled and stated it should be labeled when changed. The nurse also confirmed there was no oxygen-in-use sign at the resident’s room, and stated the room should have a sign indicating oxygen was being used. A third resident with acute and chronic respiratory failure with hypercapnia and hypoxia, COPD, acute pulmonary edema, and morbid obesity with alveolar hypoventilation had an order for oxygen at 2-4 liters per minute via nasal cannula continuously, titrated to keep oxygen saturation at 88-92% and no greater than 92%. During observation, the oxygen concentrator was set at 3.5 liters. Nurses documented oxygen saturations above the ordered range, including 96%, and stated that 3.5 liters was acceptable because it was within the order. Review of the MAR showed 64 instances from 4/1/26 through 4/22/26 where licensed nurses charted oxygen above the required range per the order. The DON stated the nurses did not follow the order and that the expectation was for licensed nurses to follow all orders.
Failure to Assess and Treat Resident Pain
Penalty
Summary
Safe, appropriate pain management was not provided for one resident with chronic pain conditions. Resident 74 was admitted with osteoarthritis and inflammatory radiculopathy of the lower back, and the physician had ordered Tylenol 500 mg every 6 hours as needed for pain. The resident’s care plan identified acute and chronic pain, with interventions to monitor and document signs of non-verbal pain, anticipate the need for pain relief, respond immediately to complaints of pain, and administer pain medications as ordered. The resident’s MDS indicated moderate cognitive impairment and showed that pain medications and non-pharmacological interventions were not offered or received. Review of the MAR for April 2026 showed that pain was not addressed, not assessed, non-pharmacological interventions were not offered, and pain medication was not given. During multiple observations, Resident 74 was seen in bed with facial expressions of pain, grimacing, moaning, and rubbing her knees or lower legs, and stated that her knees hurt, she had pain all over, and her left knee hurt when moved. Interviews with the resident and CNAs showed that the resident frequently complained of pain, especially during transfers and repositioning, and that staff reported pain complaints to nurses. The DON stated nurses were expected to assess pain every shift, use non-verbal cues when needed, offer non-pharmacological interventions such as heat, cold, repositioning, and distraction, and then offer medication if needed. The DON also acknowledged that Resident 74 had not been assessed for pain every shift, had not been offered non-pharmacological interventions, and had not received pain medication as reflected in the MARs reviewed for multiple months.
Incorrectly Sized Bed Rail
Penalty
Summary
The facility failed to provide services in accordance with a physician order, the plan of care, and resident assessment for one sampled resident, Resident 74, when the right-sided bed rail on the resident’s bed was not correctly sized. Resident 74 had been admitted in 2017 with diagnoses including cognitive impairment, weakness, and a history of falling. The physician order dated 1/4/26 specified side rails 1/4 x 2 for bed mobility and repositioning, and the resident’s MDS dated 3/27/26 showed moderate cognitive impairment with a Brief Interview for Mental Status score of 7 out of 15. Resident 74’s care plan, initiated 3/8/24, indicated the resident required staff assistance for bed mobility related to weakness and decreased strength and included education regarding the risks of using side rails, but it did not specify the size or type of side rails to match the physician order. Quarterly bed rail reviews dated 1/6/26 and 3/27/26 documented quarter-length left and right upper bed rails, yet observations on 4/21/26 and 4/22/26 showed a half-length right side rail in the middle of the bed in the upright and locked position. During an interview on 4/23/26, the ADON confirmed the installed right side rail was half-length and did not match the physician order, and the DON reviewed the order and assessments and validated that the installed right side rail was not in accordance with them.
Late Administration of Scheduled Insulin Glargine
Penalty
Summary
The facility failed to ensure that a resident with Type 2 DM and intact cognition received Insulin Glargine as ordered. The resident was admitted in April 2026, and the physician order dated 4/20/26 directed Insulin Glargine 28 units subcutaneously twice daily for DM 2. The care plan, initiated on 4/21/26, identified risk for hypo/hyperglycemia secondary to diabetes mellitus and directed that medications, including Insulin Glargine, be administered as ordered. During medication pass observation on 4/22/26, the resident’s Insulin Glargine was not included with the medications administered by LN 1. The administration history showed the insulin was scheduled for 8:00 a.m. but was given at 10:42 a.m. instead. LN 1 confirmed the insulin was not administered at the scheduled time and stated it was delayed because she did not want to give it at the same time as two other injections. The DON reviewed the record and confirmed the insulin was scheduled twice daily at 8:00 a.m. and 8:00 p.m. and that the 10:42 a.m. administration was over two hours late. The facility policy stated medications are to be administered in accordance with prescriber orders and within one hour of the prescribed time unless otherwise specified.
Therapeutic Diet Orders Not Followed for Three Residents
Penalty
Summary
The facility failed to follow prescribed therapeutic diets for three residents: Resident 95, Resident 99, and Resident 134. During a kitchen observation, Resident 99’s tray ticket showed a 2 gm sodium diet, but kitchen staff prepared the regular entree of country fried steak instead of the beef patty listed on the facility’s diet spreadsheet for that diet. The Certified Dietary Manager stated Resident 99 received the wrong entree item and should have received the beef patty. During the same observation, Resident 134’s tray ticket showed a soft and bite sized texture, but kitchen staff placed tiramisu pudding with wafers on the tray instead of the tiramisu without wafers listed on the diet spreadsheet. The Certified Dietary Manager stated Resident 134 received the wrong dessert item. Later, Resident 95’s tray ticket showed a mechanical soft ground texture, but kitchen staff placed graham crackers on the tray. The Assistant Dietary Manager stated Resident 95 should not have received graham crackers on a mechanical ground soft diet. The Registered Dietician stated it was her expectation that kitchen staff follow therapeutic diets for all residents and that incorrect texture was a safety concern. The facility’s policy stated each resident receives food prepared in a form designed to meet individual needs.
Uninterrupted Power Supply for Life-Sustaining Equipment
Penalty
Summary
The facility failed to ensure there was an uninterrupted power supply for life-sustaining equipment during a power outage for a census of 131. During an observation on 4/23/26 at 1:14 p.m., the facility experienced a power interruption, and staff were observed bringing out extension cords, flashlights, and power cords to plug oxygen concentrators into the red emergency outlets in Station 2. Staff stated the outlets were not working and that oxygen tanks were needed. During an interview at 1:35 p.m., the SSD stated the emergency outlets were not working, and at 1:38 p.m., 24 minutes later, the emergency power kicked in. The ADON stated at 1:43 p.m. that the emergency generator was on, and normal power was restored at 2:51 p.m. During a follow-up interview on 4/24/26, the DM stated the generator company installed the shutdown switch a year ago and that the generator should kick in within 6-9 seconds during a power outage. The DM stated the generator did not kick in within that time because the switch was pushed in, which shut the generator down, and that he had to pull the switch out when he checked it during the outage. He stated someone touched the switch, it was difficult to reset, and it took 10 minutes for the generator to kick in. The DM also stated this had happened in the past and that he had notified the AD and kitchen staff to be careful not to touch the switch. During observation, the generator switch was located to the right of the kitchen back door, and the DM demonstrated how easily the switch button could be pressed. The ADM later stated he had not been told the switch location was a bad spot and had not been notified of an incident related to the switch. The facility policy stated alternate energy sources would be used during a disruption in normal power, and that life-saving equipment and oxygen generating equipment were required to be restored to back-up power within 10 seconds of failure of the normal power source.
Resident Rooms Did Not Meet Required Square Footage
Penalty
Summary
The facility failed to ensure 32 resident rooms met the required 80 square feet per resident for multiple-occupancy rooms. The rooms identified were 21, 22, 23, 24, 25, 26, 27, 28, 29, 31, 32, 33, 34, 35, 36, 37, 38, 40, 42, 43, 44, 45, 46, 47, 48, 49, 53, 55, 56, 57, 58, and 59. The Administrator provided measurements showing these rooms were occupied by three residents and ranged from 217.2 to 230.2 square feet total, which calculated to approximately 72.4 to 76.7 square feet per resident, below the required minimum. During the initial tour and later observations, surveyors did not receive complaints from residents in the 20's hall and did not note space concerns in rooms 42, 44, and 51-59. Interviews with residents in several of the affected rooms showed they had no concerns with room size and stated staff provided privacy by pulling curtains. Staff interviewed, including an LN and CNAs assigned to the affected rooms, stated they were able to provide care in the rooms and had not received complaints about room size. Continued observations from 4/22/26 through 4/24/26 did not identify concerns with resident care space in the affected rooms.
Failure to Ensure Accurate Accountability of Controlled Medications
Penalty
Summary
The facility failed to ensure accurate accountability of controlled medications, specifically tramadol, due to several procedural lapses. Licensed Nurse 7 (LN 7) disposed of tramadol without a second nurse to cosign the destruction, as required by the facility's policy. LN 7 later requested another nurse, LN 2, to cosign the destruction without having witnessed it. Both nurses acknowledged the importance of following the facility's policy to prevent misuse of narcotic medications. The Director of Nursing (DON) admitted that the staff did not adhere to the policy because of their long-standing trust in each other. Additionally, the facility's medication cart-controlled drug sign-in/sign-out sheets were found to have missing signatures from outgoing and incoming nursing shifts, indicating a failure to properly reconcile the inventory of controlled medications. The DON confirmed that it was policy for nursing staff to count narcotics between shift changes and sign the sheets immediately. Furthermore, the narcotic destruction process conducted by the Consultant Pharmacist and the DON was not properly documented, as the destruction logs only contained the pharmacist's signature. The DON acknowledged that she should have signed the logs at the time of destruction.
Medication Administration Errors Observed
Penalty
Summary
The facility was found to have an 8.82% medication error rate during a medication pass observation, exceeding the acceptable threshold of 5%. This was observed when three medication errors occurred out of 34 opportunities. Specifically, Licensed Nurse 6 (LN 6) administered acarbose to Resident 138 after breakfast, contrary to the physician's order to administer it with the first bite of the meal. Additionally, LN 6 mistakenly administered ferrous sulfate instead of the prescribed ferrous gluconate. LN 6 acknowledged these errors during an interview, confirming the deviation from the prescribed orders. Another error was observed with Licensed Nurse 1 (LN 1) during the administration of Humalog KwikPen to Resident 101. LN 1 failed to prime the pen before injection, which is necessary to ensure the correct dosage is delivered. LN 1 was unaware of the specific handling instructions for the Humalog KwikPen, which were outlined in the manufacturer's labeling. The Director of Nursing (DON) confirmed that nursing staff were expected to follow the medication administration record and physician's orders, but acknowledged that staff had not received specific training on the use of delivery devices like the Humalog KwikPen.
Failure to Label Multi-Dose Medications with Open and Discard Dates
Penalty
Summary
The facility failed to ensure that multi-dose medications were properly labeled with open and discard dates, which could lead to the use of medications beyond their discard date. During an inspection of Medication Cart 5, a Stiolto Respimat inhaler and a fluticasone/salmeterol inhaler were found opened and unlabeled with open dates. Licensed Nurse 6 confirmed that the manufacturer's labeling indicated specific discard dates after the inhalers were first used, which were not adhered to. Similarly, an inspection of Medication Cart 1 revealed three budesonide ampules not stored in their foil pouch, and without an open date, contrary to the manufacturer's instructions. The Director of Nursing (DON) indicated a misunderstanding regarding the labeling and expiration dates, stating that she was instructed to follow the expiration date on the pharmacy label. The facility's policies and procedures (P&P) for administering and storing medications require that the expiration or beyond-use date be checked prior to administration and that the date opened be recorded on multi-dose containers. The nursing staff is responsible for maintaining medication storage in a safe and orderly manner, which was not followed in these instances.
Food Safety and Storage Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to ensure food safety by allowing expired food items and improper storage conditions in the kitchen. During an observation, a container of prepared apple juice and a container of iced tea concentrate were found expired in the walk-in refrigerator. The Dietary Aide confirmed these items should have been discarded the previous day. Additionally, a box soaked with cooking oil was found in the dry food storage area, which was not properly labeled or maintained. The Director of Dietary Services confirmed the expectation for staff to maintain a sanitary environment by labeling and dating items and ensuring cleanliness. Further deficiencies were noted in the facility's physical environment, including a cracked light cover between the steam table and food prep area, and missing light covers in the dry storage area. These issues pose a risk of physical debris contaminating food. Moreover, the facility lacked air gaps in the food production sink, the three-compartment sink, and the large sink next to the dishwasher, increasing the risk of backflow contamination. The facility could not provide any policy or guideline regarding air gaps, which is a requirement according to the 2022 Federal FDA Food Code.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by several deficiencies observed during a survey. Staff did not adhere to proper infection control protocols for residents on droplet precautions. Specifically, staff entered the rooms of two residents with confirmed influenza without donning the required personal protective equipment (PPE), such as gowns and gloves. Despite signs indicating droplet and contact precautions, staff members either misunderstood the requirements or neglected to follow them, increasing the risk of infection transmission. Additionally, the facility did not consistently offer hand hygiene opportunities to residents before meals. Several residents reported that they were not provided with the means to wash or sanitize their hands before eating, despite the presence of hand sanitizing supplies on food carts. Observations confirmed that staff sanitized their own hands but failed to offer the same to residents, which is a critical step in preventing the spread of infections. The facility also demonstrated lapses in the management of enteral feeding equipment and glucometer disinfection. Enteral feeding bags and syringes were not labeled or changed according to the facility's policy, and a glucometer was cleaned with a wipe not approved by the manufacturer. These oversights in equipment management further contributed to the potential for infection spread among the vulnerable resident population.
Facility Fails to Provide Hot Water in Bathroom Sinks
Penalty
Summary
The facility failed to provide hot water in the bathroom sinks for 5 out of 33 sampled residents, including Residents 3, 108, 137, 20, and 110, as well as the entire Hall 30, which housed 24 residents. This issue persisted for over 20 days due to a malfunctioning water heater pump that was turned off, resulting in residents not having comfortable water to wash their hands and faces. The deficiency was observed through interviews and direct observations, where residents and staff reported the prolonged time it took for water to become lukewarm, if at all. Resident 3, who has rheumatoid arthritis, expressed discomfort with the cold water, stating it was painful and difficult to wait for it to warm up. Other residents, such as Resident 108 and Resident 137, also reported similar issues, with Resident 108 noting it took 20-30 minutes for the water to become lukewarm. Staff, including CNAs, were aware of the problem and had reported it to maintenance and administration, but the issue remained unresolved for an extended period. The Director of Maintenance confirmed the water heater pump was leaking and needed replacement, which was identified 20 days prior. Despite the facility's policy requiring monthly monitoring of water temperatures, the logs showed that temperatures were not checked in the affected areas due to the broken equipment. The Administrator acknowledged the issue and stated that staff were instructed to provide warm water from the utility room, but residents reported not receiving this assistance consistently.
Delayed Call Light Response and Muted Call System
Penalty
Summary
The facility failed to ensure timely response to call lights for two residents, Resident 108 and Resident 3, which compromised their ability to receive necessary assistance. Resident 108, who was admitted with heart and kidney disease and was at high risk for falls, reported that call light responses were particularly delayed at night, leaving her without help when in pain or needing assistance to use the bathroom. Similarly, Resident 3, who had irritable bowel syndrome and muscle weakness, experienced significant delays in call light responses, sometimes waiting up to an hour for assistance, which led to a fall when she attempted to move from the commode to her bed without help. The facility's call system at nursing station 1 was found to be muted, preventing staff from being alerted to residents' calls for assistance. During an observation, call lights were on for several rooms, but there were no audible alerts from the phone system at the nursing station, and staff were unaware of the calls while they continued with their tasks. The Administrator confirmed the issue with the muted call system and acknowledged that the lack of audible alerts could delay response times to residents' needs. The facility's policy required that call lights be answered as soon as possible, but not later than five minutes. However, the muted call system and the staff's unawareness of the call lights resulted in significant delays in responding to residents' needs, as evidenced by the experiences of Resident 108 and Resident 3. This failure to respond promptly to call lights had the potential to jeopardize the health and safety of residents by not meeting their care needs in a timely manner.
Failure to Follow Physician Orders and Medication Administration Protocols
Penalty
Summary
The facility failed to ensure that physician orders were appropriate and followed as ordered for several residents, leading to potential adverse outcomes. Resident 94 had conflicting orders for a knee brace, with one order indicating a brace for the left knee and another for the right knee. Interviews with the resident and staff revealed confusion about which order was correct, and it was acknowledged that the order for the right knee brace was the correct one. Additionally, Resident 94 had an order for oxygen therapy at 2 liters per minute, but observations showed the oxygen concentrator set at higher levels without appropriate orders to adjust the flow rate. Resident 37's case involved the continuation of monitoring for a medication that had been discontinued. The medication Mirtazapine was no longer being administered, yet staff continued to document monitoring for its side effects and behavior as if it were still in use. This oversight was acknowledged by the Director of Nursing, who stated that all related orders should have been discontinued when the medication was stopped. Resident 109 was found to have loose pills in a medication cup at the bedside, which was against the facility's policy. The resident required assistance with medication administration due to coordination issues, and the medication should have been administered directly by the nurse. The Director of Nursing confirmed that leaving medication at the bedside was not compliant with the facility's procedures, highlighting a lapse in ensuring proper medication administration practices.
Failure to Assist Resident with Hearing Aids
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 87, received necessary assistance with their hearing aids, which were crucial for their communication and social interaction. Resident 87, who was admitted with sensorineural hearing loss and other medical conditions, expressed frustration and anger due to the inability to hear and communicate effectively. Despite the resident's repeated requests for assistance in getting an appointment to repair the hearing aids, staff did not provide the necessary help. Observations confirmed that the hearing aids were not in use, and staff interviews revealed a lack of action in addressing the resident's complaints. The facility's staff, including a CNA and a licensed nurse, acknowledged the importance of the hearing aids for Resident 87's communication and psychosocial well-being. However, the licensed nurse failed to report the malfunctioning hearing aids to Social Services, despite being aware of the issue for over a week. The nurse also inaccurately documented that the hearing aids were functioning and in use. The Director of Nursing confirmed that staff are expected to follow physician orders regarding assistive devices and report any malfunctions immediately. The facility's policy on assistive devices emphasizes the maintenance and supervision of such devices, but this was not adhered to in the case of Resident 87.
Failure to Maintain Proper Head of Bed Elevation for Tube Feeding
Penalty
Summary
The facility failed to ensure the safety of a resident with a feeding tube by not following the physician's order to keep the head of bed (HOB) elevated at 30-45 degrees during tube feeding. This deficiency was observed on multiple occasions, where the resident was found lying almost flat while receiving tube feeding, contrary to the physician's order and the care plan. The resident's medical history included conditions such as pneumonitis due to inhalation of food, lung disease, and dysphagia, which increased the risk of aspiration. Observations and interviews with licensed nurses and certified nursing assistants confirmed that the resident's HOB was not elevated as required, despite a sign posted above the bed indicating the need for elevation. The speech therapist also noted the improper positioning during therapy sessions and emphasized the importance of maintaining the correct HOB elevation to prevent aspiration. The facility's policy on enteral feedings required staff to be trained and competent in preventing aspiration by ensuring the HOB was elevated during and after feedings. The Director of Nursing acknowledged the risk of aspiration for residents receiving tube feeding and stated the expectation for staff to follow the physician's orders and speech therapist's instructions. Despite these expectations, the resident's improper HOB positioning was repeatedly observed, indicating a failure to adhere to the prescribed care plan and facility policy, potentially compromising the resident's safety.
Failure to Administer Oxygen Therapy as Prescribed
Penalty
Summary
The facility failed to ensure that two residents, both with chronic obstructive pulmonary disease (COPD), received oxygen therapy as prescribed by their physicians. Resident 78, admitted in the fall of 2024, was ordered to receive oxygen at 2 liters per minute via nasal cannula continuously. However, observations revealed that the oxygen concentrator was set to deliver 3.5 liters per minute. Similarly, Resident 93, who was admitted in 2022, was also prescribed 2 liters per minute of oxygen but was observed receiving 3 liters per minute. Both residents' medication administration records indicated that nurses had documented the administration of oxygen at the prescribed rate, despite the discrepancies observed. During interviews, Licensed Nurse 1 acknowledged the discrepancies in oxygen delivery rates for both residents, confirming that the rates were higher than the physician's orders. The Director of Nursing was informed of these issues and stated that the expectation was for nurses to follow physician orders. The facility's policy on oxygen administration, which emphasizes verifying physician orders and reviewing care plans, was not adhered to, leading to the incorrect administration of oxygen therapy.
Unnecessary Psychotropic Medication Administration
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 47, was free from unnecessary psychotropic medications. Resident 47 was administered quetiapine, an antipsychotic medication, without the implementation of non-pharmacological interventions and without adequate indication for its use. The resident's medical record did not contain documentation to support the necessity of the medication, and non-drug interventions were not attempted prior to or alongside the medication. Resident 47 was admitted with diagnoses including dementia with unspecified psychosis and recurrent urinary tract infections. Upon admission, the resident was described as agitated and difficult to manage, leading to the reintroduction of quetiapine, which had been used during a prior hospital stay. However, the facility did not have an order to continue the medication upon discharge from the hospital, and the documentation did not support the use of quetiapine for the resident's behavior, which was not persistent or adequately evaluated for underlying causes. The Director of Nursing confirmed that the facility's policy required documentation to support the use of antipsychotic medications and the implementation of non-pharmacological interventions. The facility's policy also indicated that antipsychotic medications should only be used after identifying and addressing medical, physical, and psychological causes of behavioral symptoms. Despite this, the facility did not adhere to these guidelines, resulting in the unnecessary administration of quetiapine to Resident 47.
Failure to Provide Restorative Nursing Services
Penalty
Summary
The facility failed to provide restorative nursing services (RNS) for a resident, identified as Resident 15, who was admitted with multiple diagnoses including primary osteoarthritis, heart failure, COPD, type 2 diabetes, and unspecified difficulty in walking. Despite being cognitively intact, Resident 15 reported not receiving physical or occupational therapy for several months and expressed a desire to regain some independence. The resident had initially received some therapy upon admission but had not been offered any restorative services after being discharged from PT/OT due to insurance limitations. The Director of Rehabilitation (DOR) claimed that Resident 15 refused treatment, but there was no documentation in the clinical record to support this claim. The resident was supposed to be referred to the RNS program after PT/OT discharge, but the process was not completed. The Director of Staff Development (DSD) and RNA 2 confirmed that the necessary orders were not entered into the electronic health record (EHR), and the referral form was not received by the DSD, resulting in a failure to initiate restorative services. The facility's policy indicated that residents should receive restorative nursing care to promote safety and independence, especially after being discharged from rehabilitative care. However, due to a breakdown in communication and process adherence, Resident 15 did not receive the necessary care to maintain her level of functioning, which could have impacted her physical, functional, and emotional well-being.
Inaccessible Call Light for Resident
Penalty
Summary
The facility failed to provide an accessible call light for one of the sampled residents, Resident 117. During an observation, it was noted that the call light was bundled up and attached to the call light plate, making it out of reach for Resident 117. This deficiency was confirmed during a joint observation and interview with two licensed nurses, who acknowledged that the call light was not accessible and that it should have been reported to maintenance for repair. The call light was eventually provided to Resident 117, but the delay in addressing the issue left the resident without a means to call for assistance. Resident 117 was admitted to the facility with multiple diagnoses, including protein calorie malnutrition, weakness, and abnormalities with gait and mobility. The resident was moderately cognitively impaired and required moderate assistance or supervision for various activities, including toileting and bathing. The care plan for Resident 117 emphasized the importance of having a call light within reach to prevent falls and ensure assistance could be requested when needed. The facility's policy also required that the resident call system remain functional at all times and be routinely maintained, which was not adhered to in this instance.
Deficiency in Room Size Requirements
Penalty
Summary
The facility failed to ensure that 32 resident rooms met the required 80 square feet per resident, as observed during a survey. The rooms in question housed three residents each, with measurements ranging from 72.4 to 76.7 square feet per resident, falling short of the regulatory requirement. The Administrator confirmed that there were no current room waivers in place for these rooms, and room measurements provided by the facility corroborated the deficiency. Interviews with residents revealed concerns about the lack of space affecting their quality of life. Residents reported issues such as compromised privacy, difficulty moving around due to crowded conditions, and challenges in accommodating personal belongings and equipment. Some residents expressed discomfort with the lack of privacy during personal conversations and the inconvenience of sharing a single television among three people. Staff interviews indicated that the room size occasionally hindered their ability to provide care efficiently. Licensed nurses and nursing assistants mentioned the need to reposition beds and move personal items to facilitate resident transfers, which sometimes slowed down their work. Despite these challenges, some staff members reported not hearing complaints from residents about room size, while others acknowledged the spatial limitations as a minor issue in their daily tasks.
Improper Medication Administration by CNA
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality when a Certified Nursing Assistant (CNA) administered medication to a resident, which was outside their scope of practice. The incident involved a resident who was admitted to the facility with chronic pain and morbid obesity. The resident's medication orders included the application of a lidocaine patch for pain management. During an observation, a lidocaine patch was found on the resident's bedside table, and the resident confirmed that CNAs applied the patches. Interviews with staff revealed that CNAs were not permitted to apply lidocaine patches, as this task was reserved for licensed nurses. Despite this, one CNA admitted to applying the patches, and a licensed nurse acknowledged leaving the patches with CNAs to apply later. The facility's policy clearly stated that only licensed personnel were authorized to administer medications, and the CNA job description specified that CNAs should provide non-pharmacological interventions for pain. This discrepancy between policy and practice led to a deficiency in the facility's adherence to professional standards.
Facility Fails to Maintain Secure Living Environment
Penalty
Summary
The facility failed to ensure a safe and functional living environment for residents, as evidenced by the inability to lock sliding glass doors in the rooms of two residents. Resident 1, who was admitted in 2021 with a diagnosis of depression and was cognitively intact, reported feeling unsafe due to the non-functional lock on her sliding glass door. Despite her repeated requests for repairs over three years, the issue remained unresolved. During an interview and observation, both Resident 1 and a Certified Nursing Assistant (CNA) confirmed the door could not be locked, posing a potential security risk as it allowed unauthorized access from outside. Similarly, the sliding glass door in Resident 3's room was also found to be non-lockable. A CNA confirmed the door was broken and acknowledged the safety issue it presented. The Director of Nursing (DON) was unaware of the problem until informed during the survey and recognized the safety concern, as it allowed potential entry from outside and access by other residents. The facility's policy mandates that the Maintenance Department is responsible for ensuring all equipment is safe and operable, which was not adhered to in this instance.
Infection Control Breach by CNA
Penalty
Summary
The facility failed to adhere to infection control practices when a Certified Nursing Assistant (CNA 1) did not use gloves while handling soiled linen and neglected proper hand hygiene after touching soiled linen. During an observation, CNA 1 was seen holding a soiled gown and linens with bare hands, transporting them from a resident's room to a soiled linen bin in the hallway. Subsequently, CNA 1 accessed the clean linen closet, retrieved two clean gowns, and proceeded to a resident's room without performing hand hygiene after handling the soiled items. The Director of Nursing (DON) confirmed that the staff should have used a bag for transporting soiled linen, worn gloves when handling soiled items, and performed hand hygiene afterward. The facility's policy on laundry and linen, dated January 2014, requires washing hands after handling soiled linen and before handling clean linen. Additionally, the handwashing/hand hygiene policy, dated August 2019, mandates that all personnel follow hand hygiene procedures to prevent the spread of infections.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Rancho Cordova
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| River City Post Acute | 1.8 mi | ★★★★★ | 48 | 0 |
| River Pointe Post-acute | 1.8 mi | ★★★★★ | 36 | 0 |
| Mountain Manor Senior Residence | 1.9 mi | ★★★★★ | 1 | 0 |
| American River Center | 3.4 mi | ★★★★★ | 11 | 0 |
| Whitney Oaks Care Center | 3.4 mi | ★★★★★ | 6 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.