Above average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Cedar Crest Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors identified multiple infection control deficiencies, including a dusty oxygen concentrator filter for a resident with COPD, failure by two LVNs to perform hand hygiene before administering eye and nasal medications, and the presence of unlabeled personal care items in a bathroom shared by four residents. Staff confirmed these practices were not in line with facility policies.
Cold drinks were served above the required temperature during tray line when milk and yogurt were observed at 56.7 F and 55.8 F. The DS stated cold drinks must be below 41 F and attributed the issue to the facility not having ice. Facility policy required cold food items to be held at 41 F or below and milk to remain refrigerated or be kept in an ice bath during meal service.
Ice bin sanitation was deficient when surveyors observed black substance in the ice chute, green substance on the corner, gray particles on the exterior, and discoloration on the rack. The DS, ESD, and ADM verified the upper ice maker and lower ice bin were separate models, but the facility only followed the 6-month cleaning schedule for the ice maker and did not have the manual for the ice bin, which required monthly cleaning. Staff reported residents, staff, and visitors accessed the ice machine and used ice for resident drinks and pitchers.
Unsafe and unclean equipment maintenance was identified when a bedside commode in a resident bathroom had rust, dark brown patches, and peeling paint, a bathroom sink overflow area had black, white, and dark brown spots with sharp edges from rotten porcelain, and laundry dryers had heavy lint buildup in the filter and lint compartment. The MA, MD/ESD, and DON confirmed the findings, and the MD/ESD stated dryers should be lint free and that lint buildup creates a fire concern.
A resident was observed in bed requesting help, but the call light was wrapped around the bed side rail and hanging off the bed instead of being within reach. The resident stated she needed her incontinent brief changed and could not reach the call light to ask for help. An CNA did not respond when asked how the call light should be positioned, then unwrapped it and gave it to the resident.
Resident care instructions were posted in plain view inside multiple resident rooms, including directions such as no straws, spoon sips, and bed positioning, and staff confirmed the postings were open and visible to visitors. In a separate event, an LVN left a laptop open at the nurse station with a resident’s MAR displayed on the screen before walking away.
A resident with atrial fibrillation, DM2, and CHF received ordered SQ enoxaparin for DVT prophylaxis, but the MDS section N0300 was coded as 0 injections despite EMAR documentation showing daily injections. The MDSC confirmed the coding error and stated the assessment should have reflected 4 injections.
Incomplete PRN Medication Orders: Two residents had physician orders for clonazepam and trazodone that did not include a frequency of administration. The DON reviewed both orders and confirmed the missing information, and the facility policy required medication orders to include dosage and frequency of administration.
A resident admitted with an F/C was observed with red-colored urine in the drain tube, and the chart contained no physician order to continue the catheter after admission. The LVN, DSD/IP consultant, DON, and PCP all confirmed the catheter should have had an order in place, and the facility’s catheter care policy required staff to note unusual urine appearance and notify the physician or supervisor for bleeding.
A resident had an IV in the right hand that was observed without a label, and the DON confirmed the site should have been labeled with the date it was changed. The resident still had the IV in place after the IV antibiotic order had ended, and the DON verified there was no current physician order for IV medications, no order to remove the IV, and no documentation that the nurse notified the physician that the IV was still needed.
Oxygen Therapy Documentation and Signage Deficiencies: Staff failed to post an Oxygen in Use/No Smoking sign outside one resident’s room and failed to date another resident’s NC. One resident had an order for O2 via NC as needed for hypoxia, SOB, and comfort, and was observed with O2 equipment at the bedside but no signage at the room entrance. Another resident with atrial fibrillation, acute respiratory failure with hypoxia, and CHF was observed receiving O2 via NC that was not labeled with the date, despite an order to change and date the tubing and bag weekly.
A resident had orders for morphine sulfate PRN for pain, but the clinical record did not show monitoring for side effects or a care plan for the opioid use. The DON reviewed the record and confirmed the resident was not monitored for adverse effects and was not care-planned for morphine sulfate, despite facility policy requiring monitoring for effectiveness, adverse effects, and potential overdose.
Medication Errors Exceeded Allowed Rate: Two medication errors were observed during med passes, resulting in an 8% error rate. An LVN did not have ordered artificial tears available for one resident, and another LVN gave tramadol to a resident from another resident’s bubble pack. The report also noted that the charge nurse job description requires meds for one resident not be given to another and that adequate floor stock be available.
An expired Ca-Rezz incontinent wash bottle was found in the central supply room during an observation with the CSC. The CSC confirmed the item was expired and stated he would put it away. Record review showed the facility policy addressed handling discontinued, outdated, or deteriorated medications or biologicals.
A resident with cerebral infarction and dysphagia had an order for a pureed diet with honey-thick liquids, but at lunch was served a pudding-thick mighty shake and flowing apple juice. The resident refused the pudding-thick drink and only drank part of the apple juice when assisted. CNA, dietary, and SP staff all confirmed the shake was thicker than ordered and that the resident should have received honey-thick liquids.
The facility failed to develop and implement comprehensive, resident-centered care plans for six residents. The care plans lacked specific activities and measurable objectives, despite known preferences. This was confirmed by both the AD and RNS during interviews and record reviews.
The facility failed to maintain kitchen utensils and equipment in good condition, as ten baking pans and a magnetic knife holder were found dirty and rusty. The dietary supervisor verified the condition and removed the baking pans, while the registered dietitian confirmed the need for cleanliness and maintenance according to the facility's sanitation policy.
The facility's QAPI program was found ineffective in identifying and preventing medication administration errors. Observations revealed multiple instances where LVNs deviated from prescribed dosages and manufacturer guidelines, leading to improper administration of Flonase, Alphagan, and MiraLAX. The Assistant Administrator was unaware of these issues, and no performance improvement projects were in place to address them.
A resident with dysphagia was fed by a CNA who was standing, contrary to facility policies requiring staff to sit at eye level to promote dignity. This was confirmed by both the CNA and an LVN present.
The facility failed to document a resident's advance directive, leaving section D of the POLST form blank and not including a care plan. Both the Social Service Director and Registered Nurse Supervisor verified the lack of documentation.
The facility failed to accurately complete the discharge MDS for a resident, who was discharged to home with home health services. The MDS incorrectly indicated that the resident was discharged to a short-term general hospital. This error was confirmed by the social service director, the MDS Coordinator, and the registered nurse supervisor.
A resident with chronic respiratory failure was prescribed oxygen at 2 LPM, but observations revealed the oxygen concentrator was set at 4 LPM. Staff confirmed the discrepancy and acknowledged the need to follow the physician's order.
The facility failed to consistently complete the dialysis communication form for a resident with end-stage renal disease, leading to incomplete documentation of vital signs and blood sugar levels. This failure was confirmed by the nurses involved and was against the facility's policy for the care of dialysis residents.
The facility reported a medication error rate of 13%, with errors observed in the administration of Flonase, Alphagan, and MiraLAX by LVNs. Errors included incorrect dosages, failure to follow manufacturer guidelines, and incomplete administration.
The facility failed to implement proper infection control practices when a laundry staff member did not perform hand hygiene before handling clean linens and a CNA did not change gloves or perform hand hygiene during a resident's wound treatment. These actions were confirmed by the maintenance director and the infection preventionist, as well as the CNA and LVN involved in the treatment.
Infection Control Lapses in Equipment Cleaning, Hand Hygiene, and Labeling of Personal Care Items
Penalty
Summary
The facility failed to implement proper infection prevention and control practices in several instances. The filter of a resident's oxygen concentrator was observed to be dusty, and both the licensed vocational nurse and the infection preventionist consultant confirmed that the filter should be kept clean and cleansed weekly, as per the user manual. Additionally, during medication administration, a licensed vocational nurse did not perform hand hygiene before donning gloves to administer eye drops to a resident, contrary to facility policy. In another instance, a different licensed vocational nurse did not cleanse her hands or change gloves before administering nasal spray to a resident after repositioning him, which was also against facility policy. Furthermore, during room rounds, multiple unlabeled personal care items, including wash basins, bed pans, urinals, and a kidney-shaped basin with a toothbrush and toothpaste, were found in a shared bathroom used by four residents. A certified nursing assistant confirmed that these items were in use and not labeled with resident names or room numbers, increasing the risk of cross-use. The infection preventionist consultant stated that these items should have been labeled before use, in accordance with facility policy requiring all bed pans and urinals to be marked for individual use.
Cold Drinks Served Above Safe Temperature
Penalty
Summary
The facility failed to ensure cold drinks were served at a safe and appetizing temperature when milk and yogurt were observed during the kitchen tray line at temperatures above 41 F. During the 12:03 p.m. tray line observation with the Dietary Supervisor, milk measured 56.7 F and yogurt measured 55.8 F. The drinks were being kept in a black bin on a movable shelf, and kitchen staff took one from the bin during tray line. The Dietary Supervisor stated cold drinks must be below 41 F and said the issue was due to the facility not having ice. The facility policy on meal serving temperatures stated cold food items shall be held at 41 degrees or below, and milk should not remain out of refrigeration during meal service if proper temperature cannot be maintained.
Ice Bin Not Properly Cleaned and Maintained
Penalty
Summary
The facility failed to ensure proper sanitation and maintenance of the ice bin used to store and dispense ice. During observation, surveyors found black substances in the ice chute, green substances on the upper left corner of the ice bin, fine grayish particles on the exterior front of the machine, and reddish-brown discoloration on the metal rack that catches the ice. The Dietary Supervisor and Environmental Services Director/Maintenance Director verified these conditions during the observation and stated the machine was not clean enough. The ice machine was located on the back patio, and staff reported that residents, staff, and visitors could access it. The Dietary Supervisor stated the kitchen department was responsible for checking the ice machine, but there was no log for checking its cleanliness. The Environmental Services Director/Maintenance Director stated maintenance staff cleaned only the exterior of the machine weekly, that an outside vendor cleaned the machine every six months, and that staff did not clean the area where the ice comes out of the machine. The Director of Nursing stated 41 residents preferred cold water or ice in their pitchers, and multiple CNAs and an LVN stated they routinely obtained ice from the machine for residents' drinks and pitchers. Record review and interviews showed the facility followed the manufacturer’s manual for the upper ice-making unit, Model KY0500A-161, which required cleaning every six months, but the lower ice bin, Model SPA310, had a separate manual requiring monthly cleaning. The Administrator and Environmental Services Director verified the facility did not have the manual for the ice bin. The outside vendor also verified the upper unit and lower ice bin were separate models, and the ice bin had been cleaned every six months. On observation, the Dietary Supervisor verified ice was touching the door of the dispenser that had the black substance.
Unsafe and Unclean Equipment Maintenance
Penalty
Summary
The facility failed to maintain equipment in safe operating and sanitary conditions when a bedside commode in a resident bathroom was observed with dark brown patches and peeling paint on the metal pipe below and behind the seat cover. The maintenance aide confirmed the commode was rusted and that the paint was coming off because it had been left outside for a long time. The aide stated it was not safe for residents to use a bedside commode with rust, and the DON stated it was not okay to use the rusted commode for residents and that it should be replaced with a new one. The facility also had a bathroom sink in a resident room with black, white, and dark brown spots and sharp edges around the overflow drain hole area. The maintenance director/environmental services director confirmed the spots and stated the porcelain was rotten, causing the sharp edges, and that the area needed cleaning. In addition, the laundry room dryers had lint buildup: the lint filter had a thick layer of white lint and there were patches of lint floating in the lint compartment for dryers 1 and 2. Laundry staff confirmed the lint should be cleaned every two hours, and the maintenance director/environmental services director confirmed the lint was present in both dryers.
Call Light Not Within Resident Reach
Penalty
Summary
The facility failed to ensure a call light was accessible and within reach for Resident 100. During observation and concurrent interview, Resident 100 was in bed and requesting help, and the resident stated that the incontinent brief needed to be changed. The resident’s call light was wrapped around the bed side rail and hanging off the bed, and the resident stated that she was not able to reach it to ask for help. During the same observation, CNA O was instructed to assist Resident 100 and did not respond when asked how the call light should be positioned. CNA O then unwrapped the call light from around the bed side rail and gave it to the resident. The facility’s undated policy stated that when a resident is in bed or confined to a chair, the call light should be within easy reach.
Resident privacy and medical information left visible
Penalty
Summary
The facility failed to keep resident personal care and medical information private and confidential when handwritten care instructions were posted in plain view inside the rooms of Resident 92, Resident 45, Resident 96, and Resident 26. During room rounds, surveyors observed open postings that included instructions such as “No straw please,” “Spoon sips please, no straw please,” “Position of bed in lowest position and extensive assistance with ambulation,” and “TSP only. No Straw Please,” all displayed on red cover pages or wooden bulletin boards near the head of the bed. The residents’ face sheets showed that Resident 92 was admitted on 7/23/2025, Resident 96 on 7/22/2025, Resident 26 on 7/5/2025, and Resident 45 on 10/3/2023. During a concurrent observation, the Administrator and an LVN confirmed that the postings were open, visible, and not covered, and the LVN stated that the residents often had visitors in their rooms, including daily visits. In a separate observation, after medication administration to Resident 10, an LVN parked a medication cart at the nurse station with a laptop open and Resident 10’s MAR displayed on the screen, then walked away into another resident’s room. The LVN later confirmed that Resident 10’s MAR had been left open and stated that he should have closed the MAR and laptop before walking away.
MDS Injection Coding Was Inaccurate
Penalty
Summary
The facility failed to accurately code the MDS for Resident 34 in section N0300 for injections. Resident 34 was admitted to the facility on 4/14/2021 and had diagnoses including atrial fibrillation, diabetes type 2, and congestive heart failure. The physician ordered enoxaparin 40 MG/0.4 ML SQ daily for DVT prophylaxis until ambulating well greater than 100 feet, and the EMAR showed the resident received the injection on 7/13/2025 and then daily from 7/14/2025 through 8/5/2025. The MDS assessment dated [DATE] recorded 0 injections received during the last 7 days or since admission/entry or reentry. During concurrent record review and interview on 8/11/2025, the MDS coordinator confirmed the resident received SQ injections every day starting 7/13/2025 and confirmed the MDS was coded inaccurately. The MDS coordinator stated the number of injections received during the assessment period should have been coded as 4 rather than 0.
Incomplete PRN Medication Orders
Penalty
Summary
Services provided by the facility did not meet professional standards of quality when physician orders for two residents lacked a frequency of administration. Resident 8, who was admitted to the facility, had a physician order dated 7/30/25 for clonazepam 0.5 mg as needed for anxiety, but the order did not include how often it could be administered. Resident 102, who was also admitted to the facility, had a physician order dated 7/29/25 for trazodone 50 mg as needed for depression, but the order likewise did not include a frequency of administration. During interviews on 8/11/25, the DON reviewed both orders and confirmed that each order was missing the frequency of administration. The facility policy, Medication and Treatment Orders, stated that medication orders must include dosage and frequency of administration.
Lack of Order to Continue Foley Catheter and Bloody Urine Observed
Penalty
Summary
Appropriate care for residents with bowel/bladder continence needs and catheter care was not provided for one sampled resident, Resident 26. During observation on 8/5/2025 at 3:20 p.m., Resident 26’s F/C drain tube was observed draining red-colored urine. Resident 26 was admitted to the facility on 7/5/2025 and had diagnoses including myocardial infarction, heart failure, atrial fibrillation, and benign prostatic hyperplasia. The nursing admission assessment indicated the resident was admitted with an F/C, and the care plan identified obstructive uropathy as the indication for catheter use. Review of the order summary report showed no documented physician order to continue the F/C after admission. During interview, the LVN confirmed the bloody urine and stated urine should be clear and amber in color. The DSD/IP consultant also confirmed the urine should be clear and amber and said she would find out why it was red. The DON later confirmed the resident was admitted with an F/C but there were no physician orders to continue it in the facility, and stated nursing staff should have received orders to continue the catheter upon admission. The PCP stated the catheter had been placed in the hospital and that the facility should have an order to continue the F/C after admission. The facility’s catheter care policy stated to check urine for unusual appearance, including blood, and notify the physician or supervisor in the event of bleeding.
Unlabeled IV Site and No Current IV Order
Penalty
Summary
Provide for the safe, appropriate administration of IV fluids when needed was not met for one resident who had an IV in the right hand. During observation and interview, the LVN verified the IV site had no label. The DON later stated the IV site must be labeled with the date it was changed. On a later observation, the resident still had the IV in place. During record review and interview, the DON verified there was no physician order for any medications to be administered through IV, the order for IV antibiotic ended on 8/8/25, and there was no physician order to remove the IV or documentation that the nurse informed the physician that the IV was still needed. The facility policy for peripheral and midline IV dressing changes stated the dressing should be labeled with initials and the date and time of the dressing change, and that the provider, supervisor, and/or oncoming shift should be notified of any complications or interventions.
Oxygen Therapy Documentation and Signage Deficiencies
Penalty
Summary
Facility staff failed to ensure proper respiratory care for two residents receiving oxygen therapy. Resident 29 had a physician order for oxygen at 2 to 3 liters per minute via nasal cannula as needed for hypoxia, shortness of breath, and comfort. During observation, the resident was awake and sitting up in bed with an oxygen concentrator and nasal cannula at the bedside, but there was no Oxygen in Use/No Smoking sign displayed at the entrance to the room. The DON later confirmed that signage for Oxygen in Use should be posted outside the rooms of all residents receiving oxygen. Resident 34 was observed receiving oxygen via nasal cannula, and the cannula was not dated or labeled. The resident’s record showed diagnoses including atrial fibrillation, acute respiratory failure with hypoxia, and congestive heart failure. The physician order directed staff to change oxygen tubing, including the nasal cannula and/or mask and storage bag, every week and as needed, and to date the tubing and bag. During interview, the LVN/CC verified the cannula was not labeled with a date and later stated it should be labeled when changed weekly; the DON also stated the nasal cannula should be labeled with the date when changed.
Failure to Monitor and Care-Plan Opioid Use
Penalty
Summary
Resident 6 had physician orders dated 7/17/25 for morphine sulfate 20 mg/ml, with instructions to give 0.125 ml every 4 hours as needed for moderate pain and 0.25 ml every 2 or 4 hours as needed for severe pain. Review of the clinical record showed that Resident 6 was not monitored for the side effects of the morphine sulfate and was not care-planned for its use. During an interview on 8/11/25 at 2:36 p.m., the DON reviewed the record and confirmed that Resident 6 was not monitored for side effects and was not care-planned on the use of morphine sulfate. The facility policy, Administering Pain Medications, stated that when opioids are used for pain management, the resident is monitored for medication effectiveness, adverse effects, and potential overdose.
Medication Errors Exceeded Allowed Rate
Penalty
Summary
The facility had a medication error rate of 8% after two medication errors were identified out of 25 medication administration opportunities during observation for two residents. During a medication pass observation, LVN G stated he did not have Artificial Tears Solution available to administer to Resident 60. Resident 60 had a physician order dated 8/8/21 for Artificial Tears Solution, one drop in both eyes four times daily at 9 a.m., 1 p.m., 5 p.m., and 9 p.m. During another medication pass observation, LVN L was preparing to administer tramadol 50 mg to Resident 98 for severe pain, but dispensed the tablet from Resident 7's bubble pack of tramadol 50 mg. In a concurrent observation and interview, LVN L reviewed Resident 7's tramadol bubble pack and counting sheet and confirmed that he dispensed the tablet from Resident 7's medication supply to give to Resident 98. The facility's charge nurse job description stated that prescribed medication for one resident is not to be administered to another and that an adequate supply of floor stock medications, supplies, and equipment is to be on hand to meet residents' nursing needs.
Expired Incontinent Wash Found in Central Supply
Penalty
Summary
The facility failed to ensure supplies were stored appropriately when an expired Ca-Rezz incontinent wash bottle was found in the central supply room. During an observation in the central supply room with the central supply coordinator, the bottle was observed to be expired on 3/2025, and the coordinator confirmed that it was expired and stated he would put it away. Record review of the facility's 2001 policy, Medication Labeling and Storage, indicated that if the facility has discontinued, outdated, or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items.
Incorrect Liquid Consistency Served to Resident with Dysphagia
Penalty
Summary
The facility failed to ensure that Resident 45 received liquids consistent with the resident’s ordered diet and swallowing needs. Resident 45 was admitted with diagnoses including cerebral infarction and dysphagia, and had an order for a no added salt pureed diet with moderately thick, honey-thick liquids. During the lunch meal observation, Resident 45 was served a thick white liquid in a plastic cup that did not pour when tilted, along with flowing apple juice. Resident 45 refused the thick white liquid and drank about 3/4 cup of the flowing apple juice when assisted by staff. During interview, CNA H confirmed the white liquid was a pudding-thick mighty shake and stated Resident 45 should have received honey-thick liquids, not pudding-thick liquids. The dietary supervisor also confirmed the mighty shake was pudding consistency and stated dietary staff may have added too much thickener, while the speech pathologist confirmed the resident had an order for honey-thick liquids and should have been served that consistency. The facility’s therapeutic diets policy stated thickened liquids are to be made with the consistency ordered by the attending physician and prepared according to the manufacturer’s instructions.
Failure to Develop Comprehensive, Resident-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, resident-centered care plans for six residents. For Resident 37, the care plan did not include specific activities that would be provided, such as daily room visits and watching television, despite the resident's preferences being known. This lack of detail in the care plan was confirmed by both the Activity Director (AD) and the Registered Nurse Supervisor (RNS) during interviews and record reviews. Similarly, Resident 1's care plan was found lacking in specific activities, such as watching television, going outside daily, and smoking outside, which were known preferences. The AD and RNS both verified that the care plan was not comprehensive and resident-centered, lacking measurable objectives and timetables to meet the resident's needs. This was also the case for Resident 53, whose care plan did not include activities like room visits, aroma therapy, blessings, and prayers, despite these being part of the resident's routine. The same deficiencies were observed for Residents 71, 41, and 2. Resident 71's care plan did not include specific activities like watching television and daily room visits. Resident 41's care plan missed activities such as talking to staff, socialization, and watching movies. Resident 2's care plan did not include activities like current events, watching television, and using an iPad. In all cases, the AD and RNS confirmed that the care plans were not comprehensive and resident-centered, lacking measurable objectives and timetables to meet the residents' physical, psychosocial, and functional needs.
Failure to Maintain Kitchen Utensils and Equipment in Good Condition
Penalty
Summary
The facility failed to ensure that kitchen utensils and equipment were maintained in good condition and stored in accordance with professional standards for safety. During an initial kitchen tour, ten baking pans were observed with brownish to dark colored spots that appeared dirty and rusty. Additionally, a magnetic knife holder with attached kitchen knives was found to have brownish discolorations that also looked dirty and rusty. These observations were made in the presence of the dietary supervisor (DS), who verified the condition of the items and removed the baking pans immediately. The DS also acknowledged the condition of the magnetic knife holder and stated that it would be cleaned. The registered dietitian (RD) later confirmed that baking pans and the magnetic knife holder should be kept clean and free of rust. The facility's undated policy and procedures on sanitation indicated that all utensils, counters, shelves, and equipment should be kept clean, maintained in good repair, and free from breaks, corrosion, open seams, cracks, and chipped areas that may affect their use or proper cleaning. The failure to maintain these items in good condition had the potential to cause the growth of microorganisms and cross-contamination of food, which could affect the 81 residents residing and consuming food at the facility.
Medication Administration Errors and Ineffective QAPI Program
Penalty
Summary
The Quality Assessment Performance Improvement (QAPI) program at the facility was found to be ineffective in identifying and preventing medication administration errors. During a medication pass observation, a 13% medication error rate was noted. Specifically, a Licensed Vocational Nurse (LVN A) administered Flonase to a resident but deviated from the prescribed dosage by spraying two sprays in each nostril instead of one. Additionally, LVN A did not follow the manufacturer's guidelines for administering the nasal spray, such as instructing the resident to blow their nose or closing the opposite nostril during administration. LVN A admitted to the errors and attributed them to initial confusion and forgetfulness about the proper guidelines. Further observations revealed that LVN A also improperly administered Alphagan ophthalmic solution to the same resident by allowing the tip of the eye drop bottle to contact the eyelashes, increasing the risk of contamination. LVN A did not instruct the resident to keep their eyes closed or press their index finger against the inner corner of the eye after administration, as recommended by the manufacturer. LVN A acknowledged these errors during an interview and expressed a commitment to improving their practices. Additional deficiencies were observed with other nurses. LVN B administered MiraLAX to a resident but did not mix it thoroughly, resulting in the resident not consuming the full dose. Similarly, LVN C administered MiraLAX to another resident, who only took a small sip, and LVN C left without ensuring the medication was fully consumed. The Assistant Administrator, involved with the QAPI program, was unaware of any medication administration issues and confirmed that the program had not identified or addressed such concerns. There was no documented evidence that medication administration errors were being reviewed or that performance improvement projects were in place to address these errors.
Failure to Maintain Resident Dignity During Feeding
Penalty
Summary
The facility failed to treat Resident 390 with respect and dignity when Certified Nurse Assistant E (CNA E) was observed standing while feeding the resident. Resident 390, who had been admitted with a diagnosis of dysphagia (difficulty swallowing), was being fed by CNA E while CNA E was standing over him. This observation was confirmed by both CNA E and Licensed Vocational Nurse J (LVN J), who was present in the room for medication administration. The facility's policies and procedures on dignity and assistance with meals explicitly state that residents should be fed in a manner that promotes their well-being and dignity, including not standing over them while feeding. However, these guidelines were not followed in this instance, leading to a deficiency in the care provided to Resident 390.
Failure to Document Resident's Advance Directive
Penalty
Summary
The facility failed to document the status of a resident's advance directive (AD) for one of seven residents investigated. Resident 2 was admitted with diagnoses including angioneurotic edema, unspecified heart failure, and unspecified hyperlipidemia. The clinical records for Resident 2 did not contain documentation verifying or obtaining an advance directive, nor was there a care plan regarding the advance directive. Additionally, the Physician Orders for Life-Sustaining Treatment (POLST) form for Resident 2 had all options in section D, which pertains to advance directives, left blank. During a concurrent record review and interview with the Social Service Director (SSD) and the Registered Nurse Supervisor (RNS), both verified that section D of Resident 2's POLST was left blank and that there was no documentation or care plan regarding the advance directive. The facility's policy and procedures on advance directives state that information about whether or not the resident has executed an advance directive should be prominently displayed in the medical record, which was not done in this case.
Incorrect Discharge MDS Coding
Penalty
Summary
The facility failed to accurately complete the discharge Minimum Data Set (MDS) for one resident, which had the potential to compromise the facility's ability to provide resident-centered discharge care planning and interventions. Specifically, Resident 79 was admitted with multiple diagnoses, including a displaced intertrochanteric fracture of the left femur, atrial fibrillation, and essential primary hypertension. The resident was discharged to home with home health services, but the MDS incorrectly indicated that the resident was discharged to a short-term general hospital. Interviews and record reviews confirmed the incorrect coding. The social service director, the Minimum Data Set Coordinator, and the registered nurse supervisor all verified that the discharge MDS was incorrectly coded. The error was identified during a review of the resident's face sheet, interdisciplinary team planned discharge summary report, and section A of the MDS. The coding error was acknowledged by the staff, who confirmed that the resident was indeed discharged to home with home health services, not to a short-term general hospital.
Failure to Administer Oxygen as Prescribed
Penalty
Summary
The facility failed to provide respiratory care in accordance with professional standards of practice for Resident 390. The resident, who had a diagnosis of chronic respiratory failure, was prescribed oxygen at 2 liters per minute (LPM) via a nasal cannula. However, during observations on two separate occasions on the same day, the oxygen concentrator was set at 4 LPM, which was confirmed by Licensed Vocational Nurse J. The nurse acknowledged that the oxygen should have been administered at the prescribed rate of 2 LPM as per the physician's order. Further interviews with the Registered Nurse Supervisor confirmed that staff should ensure oxygen is administered at the prescribed rate. A review of the facility's policies and procedures indicated that a physician's order is required for therapies and treatments, including oxygen administration. The failure to adhere to the physician's order for oxygen administration had the potential to compromise the resident's health and safety.
Failure to Complete Dialysis Communication Forms
Penalty
Summary
The facility failed to consistently complete the dialysis communication form for a resident who required dialysis services. The resident, who had end-stage renal disease and received dialysis on specific days, had incomplete documentation on the dialysis communication forms. Specifically, there was no documentation of vital signs on one occasion and no documentation of blood sugar on another occasion. These forms were supposed to be filled out by the licensed nurse receiving the resident from dialysis, but this was not done consistently, as confirmed by the nurses involved during interviews and record reviews. The facility's policy and procedure for the care of dialysis residents required that vital signs be taken upon the resident's return from dialysis. However, this policy was not followed, as evidenced by the incomplete forms. The nurses involved acknowledged that they should have completed the forms as required. This failure had the potential to compromise the facility's ability to identify and address potential complications after dialysis for the resident involved.
Medication Administration Errors
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, with a reported error rate of 13%. During a medication pass, four medication errors were observed out of thirty opportunities for three of seven residents. One incident involved a Licensed Vocational Nurse (LVN A) administering two sprays of Flonase in each nostril to a resident instead of the prescribed one spray, and not following the manufacturer's guidelines for proper administration. LVN A admitted to the discrepancy and acknowledged the error during an interview. Another incident involved LVN A administering Alphagan ophthalmic solution to the same resident but failing to follow the manufacturer's guidelines, including allowing the tip of the eye drop bottle to contact the eyelashes and not instructing the resident to keep their eyes closed for 1 to 2 minutes after administration. LVN A admitted to forgetting the proper procedure during the administration. Additionally, two separate incidents involved LVNs B and C administering MiraLAX to two different residents. LVN B did not thoroughly mix the MiraLAX solution, resulting in the resident consuming less than half of the mixture, while LVN C did not ensure that the resident fully consumed the MiraLAX mixture, leaving most of it in the glass. Both LVNs admitted to their respective oversights and acknowledged the need for improvement in their administration practices.
Failure to Implement Infection Control Practices
Penalty
Summary
The facility failed to implement proper infection control practices in two observed instances. In the first instance, a laundry staff member did not perform hand hygiene before handling clean linens and residents' personal clothing. This was observed during an interview with the maintenance director, who confirmed that all laundry staff should wash their hands before handling clean items. The infection preventionist emphasized the importance of hand hygiene in preventing the spread of infections. The facility's policy on hand hygiene was reviewed and indicated that hand hygiene is the primary means to prevent the spread of infections and should be performed before and after coming on duty. In the second instance, staff failed to perform hand hygiene during the treatment of a resident with a pressure ulcer and a surgical wound. The certified nurse assistant did not change gloves or perform hand hygiene between different stages of the wound treatment, despite handling both the resident and the wound dressings. This was confirmed by both the CNA and the licensed vocational nurse involved in the treatment. The facility's policy on hand hygiene was reviewed and indicated that hand hygiene should be performed before and after direct contact with residents and before handling clean or soiled dressings.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 682 citations issued within 25 miles in the last 12 months — including the 3 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
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Sunnyvale
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sunnyvale Gardens Post Acute | 0.6 mi | ★★★★★ | 0 | 0 |
| Idylwood Care Center | 2.2 mi | ★★★★★ | 0 | 0 |
| Sunnyvale Post-acute Center | 2.2 mi | ★★★★★ | 3 | 0 |
| Sunny View Manor | 3.4 mi | ★★★★★ | 0 | 0 |
| Courtyard Care Center | 3.4 mi | ★★★★★ | 2 | 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 June 2026) and official state health department websites.