Average — CMS composite of the measures below.
The next survey window likely opens around May 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 Cedarwood Post Acute during CMS and state inspections, most recent first.
Food storage and kitchen sanitation practices were not followed when frozen foods were left open and undated, kitchen staff failed to wash hands after entering the kitchen, after glove removal, and after returning from cart delivery, and cold coleslaw rose from 41F to 47F during service while plated without cooling support. Wet stainless steel pans were also stacked before drying, and staff acknowledged the pans should have been completely dry.
Incomplete restorative nursing and splint orders led to missed and unmonitored ROM-related services for two residents. One resident with Parkinson's disease and weakness had an OT-to-RNA transition order that was not clarified or communicated, and the resident did not receive RNA services for months. Another resident with hemiplegia and a left hand contracture had a splint order that did not specify wear time, and staff did not document when it was applied, removed, or how long it was worn.
Medication Administration Errors Exceeded Allowed Rate: During a medication pass, an LPN committed 4 errors in 26 opportunities, including giving omeprazole after breakfast instead of 30 minutes before meals for two residents, administering metoprolol without a current BP check despite hold parameters, and giving clopidogrel late because it was not in the med cart. The DON acknowledged the medications were not given as ordered.
A nurse did not wear a gown while administering tube feeding to a resident on EBP for MDRO risk and a feeding tube, even though PPE was available at the door. In a separate case, a resident with an MRSA-positive wound culture remained on EBP instead of timely contact precautions after the result was known, and the DON confirmed the contact order was delayed. Staff interviews and record review showed the required precautions were not followed as documented.
A resident with a Foley catheter for wound management was ambulated in the hallway with the catheter tubing and drainage bag exposed on a wheelchair instead of being placed in a privacy bag. The uncovered bag was half-filled with urine and visible to residents, staff, and a visitor in the hallway. An LPN confirmed the bag was visible and said it should have been in a privacy bag because it was a dignity issue; the DON also stated that an exposed catheter is a dignity issue and that staff should cover the urinary bag for privacy and dignity.
A resident’s MDS skin section was coded as having no ulcers or open wounds even though the chart documented chronic venous insufficiency, a lower-extremity venous stasis wound, and a neck wound requiring ongoing wound care. TARs showed the resident received ordered treatments, and the RMDSC confirmed the MDS was coded incorrectly because the wounds should have been captured during the look-back period.
A resident with encephalopathy, cognitive impairment, and a fall risk had care plans and IDT notes that did not include adequate supervision or monitoring interventions after an initial fall from an unlocked W/C, and she later fell again, sustaining a head contusion, cephalohematoma, skin tears, and a hand fracture. Another resident with severe neurologic impairment and dependence for care was observed with her call light string clipped to her pillow and lying around the back of her neck; an TN stated the string was a hazard and removed it.
A resident with a G-tube, dysphagia, GERD, pneumonia, respiratory failure, Parkinson's disease, and dementia was observed in bed with the HOB elevated to less than 30 degrees despite orders and care plan directions to keep it at 30 to 45 degrees, or 45 degrees, during and after bolus tube feedings. Staff acknowledged the position and stated the HOB should be elevated to 45 degrees at all times, especially with bolus feedings, to prevent aspiration.
Unlabeled oxygen tubing was observed for a resident receiving O2 via nasal cannula. The RT stated the tubing should have a date label so staff know how long it has been in use, and the DON stated tubing should be replaced every 7 days and labeled with the date, but there was no charting showing the tubing had been changed.
Failure to Reassess PRN Pain Medication and Follow Ordered Pain Scale Monitoring: Staff did not timely reassess one resident after PRN oxycodone was given, and they did not follow a physician’s order to assess another resident’s pain every shift using a 0-10 pain scale. The DON confirmed that staff documented checkmarks instead of pain scores for the second resident, and the care plan did not include the ordered pain-monitoring intervention.
A resident on a NAS soft & bite sized diet was served lunch with a salt packet despite the tray ticket showing NAS. The CDM confirmed the resident should not have received salt, and the resident’s family noted the resident likely should not have had salt because of HTN. The resident also had CKD, and the facility policy stated therapeutic diets are prescribed by the attending physician.
Failure to Track Staff COVID-19 Vaccination Status and Education: The facility did not maintain a system to monitor staff COVID-19 vaccination status or document staff education on vaccine benefits and potential side effects. An LPN stated the vaccine information was provided and offered yearly, while the IP said the only recordkeeping was in personnel files, relied on staff self-reporting for outside vaccinations, and there was no electronic or handwritten tracker or record of staff vaccine education or screening.
Frayed Bed Control Cord Left with Exposed Wires: A resident with dementia, metabolic encephalopathy, COPD, and dysphagia had a bed control power cord observed wrapped around the bed rail with frayed insulation and exposed wires on repeated observations. An LPN confirmed the cord was frayed and exposed, the DON said staff were expected to report such damage to maintenance, and the MD stated the issue was not in the maintenance log and the cord needed replacement.
A resident admitted with a femur fracture did not have an MDS Significant Change in Status Assessment completed after developing a facility-acquired stage 3 sacral pressure injury. The admission assessment showed no pressure ulcer, but the wound record later documented the stage 3 injury as acquired in the facility. The MDS LN confirmed no SCSA was performed, and the DON stated that a significant change in condition requires a comprehensive assessment.
MDS assessments did not accurately reflect the clinical status of two residents. One resident’s admission MDS failed to code surgical chest incisions that were documented on the skin assessment and observed during interview, and the care plan did not include incision care interventions. Another resident’s quarterly MDS failed to code dialysis even though the dialysis communication form showed multiple treatments during the look-back period. The MDS LN and DON acknowledged that MDS assessments should accurately reflect resident status.
Surveyors identified multiple deficiencies in food storage, preparation, and service, including wet-stacked utensils, visibly unclean cups, missing freezer thermometers, unlabeled open food items, and uncovered meal trays during distribution. These failures were confirmed by dietary staff and increased the risk of foodborne illness.
Two outside garbage dumpsters were found with lids that had openings, allowing odors and flies to escape, and bags of garbage were visible inside. The DM confirmed the lids were not securely closed, and the MD stated that the lids did not meet facility policy for tight-fitting covers to prevent pest and rodent activity.
A wheelchair and standing fan were found partially blocking an emergency exit, and two Hoyer lifts were stored with unlocked wheels, creating safety concerns. Additionally, a resident's urinary catheter bag was left uncovered, two residents were fed by staff who remained standing, and two residents were not asked about their preference for clothing protectors, all of which failed to uphold resident dignity.
Several residents with physical or cognitive limitations were found unable to access or use their call lights, with some call lights placed out of reach and others lacking appropriate accommodations such as touch pads. Care plans for two residents did not address their inability to use the call light system, and staff confirmed these deficiencies during interviews and observations.
Surveyors observed that multiple residents received medications in ways that did not follow prescriber orders or manufacturer instructions, such as not providing the required amount of water, not ensuring medications were taken with food, and administering pain medication outside of its ordered parameters. These actions resulted in a medication error rate significantly above the regulatory threshold.
Staff failed to properly disinfect a shared BP cuff between residents, with one nurse not cleaning the cuff at all between uses and another using only a small alcohol prep wipe. The infection preventionist confirmed that this did not meet facility policy, and staff interviews revealed a lack of awareness of proper cleaning procedures.
Surveyors found that a resident's urinary catheter bag was left uncovered, two residents were assisted with eating by staff who stood over them rather than sitting at eye level, and two residents were made to wear clothing protectors during meals without being asked for their preference. These actions did not honor resident dignity or individual choice, as required by facility policy.
Two residents did not have their care plans updated to reflect current needs: one self-administered eye drops without a documented assessment or care plan, and another used hand bandages for amputations without care plan interventions, despite requiring assistance with daily care. The DON confirmed these omissions did not align with facility policy.
The facility failed to develop comprehensive care plans for two residents with wound care needs, leading to potential inadequate care. One resident with a diabetic foot ulcer and another with a surgical wound requiring NPWT lacked documented care plans in their electronic health records. Interviews with staff confirmed the absence of these essential care plans.
A resident with end-stage renal disease missed four hemodialysis appointments due to transportation issues, leading to a hospital visit for potential fluid retention. The facility failed to notify the physician of the missed appointments, contrary to policy. Despite attempts to reschedule, transportation was not available or did not enter the facility to pick up the resident.
A resident in an LTC facility did not receive appropriate indwelling catheter care due to missing physician orders, leading to a deficiency. The resident, dependent on staff for toileting hygiene, had no documented catheter care or change for several months, resulting in two UTIs. Facility staff confirmed the oversight, which was contrary to the facility's policy requiring catheter care every shift.
The facility failed to follow professional standards of care, including not changing oxygen equipment weekly, not implementing physician orders for feeding assistance and adaptive devices, and not transcribing medication orders into the MAR. Additionally, there were issues with medication administration and documentation, such as a nurse not observing a resident take medication and undocumented doses of IV antibiotics. These deficiencies increased the risk of unmet therapeutic needs for residents.
The facility failed to secure and properly dispose of resident medical records, as observed when a box containing confidential health information was found unsecured in the Physical Therapy Department. Interviews confirmed that records were not disposed of daily as required, violating the facility's confidentiality policy.
The facility failed to ensure accurate accountability and effective storage of controlled medications for three residents, with discrepancies found between the Medication Administration Record (MAR) and Controlled Drug Record (CDR). Additionally, emergency medication kits were not properly secured, with one kit found in an unlocked drawer and opened kits not exchanged with the pharmacy as required by facility policy.
A medication error rate of 12.82% was observed in an LTC facility, involving three residents. Errors included incorrect timing and administration of medications such as Losartan, Brovana, and insulin aspart. Medications were not given according to prescriber's orders, potentially affecting residents' clinical conditions.
A resident missed 25 doses of Brovana, a medication for breathing issues, because nursing staff did not check the medication storage room refrigerator. The resident, who had a physician's order for Brovana due to congestive heart failure, reported feeling short of breath. The Director of Nursing confirmed the medication was overlooked.
The facility's kitchen staff failed to demonstrate proper sanitation procedures, risking foodborne illness for 49 residents. Dietary aides were unable to correctly test sanitation solutions, and dishwashing processes did not meet required concentration levels. The facility used incorrect test strips, highlighting a lack of training and adherence to sanitation policies.
The facility failed to meet food safety standards, with issues including unsealed food packages, a dirty fan blowing on clean items, incorrect dishwasher test strips, and improperly labeled resident food. These deficiencies could lead to contamination and safety risks, as acknowledged by the Certified Dietary Manager and Director of Nursing.
A resident was administered psychotropic medications without documented informed consent. Despite facility policies requiring informed consent before administering such drugs, the necessary documentation was missing. Interviews with staff confirmed the oversight, with the DON acknowledging the physician's responsibility in obtaining consent.
A facility failed to ensure accurate assessments for a resident admitted with metabolic encephalopathy and generalized weakness. The resident was observed without a urinary catheter, contradicting the MDS assessments. The DON confirmed the inaccuracy, highlighting a potential for incorrect baseline data and treatment.
A facility failed to create a comprehensive care plan for a resident's BiPAP machine use, despite physician orders indicating its necessity at bedtime. The resident, with Type 2 Diabetes and Neurocognitive Disorder, was observed with the BiPAP machine in their room, but no care plan was documented in their EHR. The Clinical Reimbursement Director confirmed the absence of the required care plan, which is against the facility's policy for comprehensive care planning.
A facility failed to ensure proper medication storage when a medication cart and a treatment cart were found unlocked and unattended. Staff interviews confirmed that carts should be locked when not attended, aligning with facility policy requiring all drugs to be stored in locked compartments.
A resident on a renal diet was incorrectly served mashed potatoes, a high-potassium food, despite dietary restrictions noted on their meal tray ticket. The CDM and RD confirmed the error, emphasizing the importance of adhering to renal diet guidelines to prevent potential heart issues.
The facility failed to adhere to infection control practices when a CNA was observed carrying trash bags between resident rooms, allowing them to touch her clothing. Additionally, a resident's BiPAP equipment was improperly stored, left exposed to dust and contamination, against facility policy. The resident has Type 2 Diabetes and a neurocognitive disorder with Lewy Bodies.
A resident with a history of lung tumor and respiratory failure consented to receive a pneumococcal vaccine upon admission. However, due to an error, the resident's record was updated to indicate a declination, and the vaccine was not administered. The Infection Preventionist confirmed the resident's eligibility for the vaccine, which was not provided as per facility policy.
The facility failed to maintain a reach-in freezer in safe operating condition, with ice build-up observed on the freezer ceiling. The freezer door gasket was misshapen, potentially causing the issue. The CDM confirmed the ice build-up could lead to freezer burn and affect food safety. The MS noted the problem might be due to the freezer door not closing tightly. The freezer manual advises defrosting when frost accumulates, and the FDA Food Code stresses proper equipment maintenance for consumer safety.
A resident with dementia and anxiety was unable to use the provided call light due to physical limitations, and the facility failed to document the need for an alternative device in the care plan. Staff confirmed the resident's inability to use the call light, which was not addressed until later, potentially leading to unmet needs and delayed response.
The facility failed to follow infection control practices for two residents. A Social Services Assistant entered a resident's room without PPE, despite MRSA precautions. Similarly, a CNA entered another resident's room without full PPE, despite COVID-19 isolation requirements. Both staff members acknowledged the oversight, and the Infection Preventionist confirmed the necessity of PPE use.
A facility failed to coordinate a Level II PASRR evaluation for a resident with mental illness, despite positive Level I screening results. The resident, with a history of mental illness and frequent hospitalizations, was involved in a physical altercation, highlighting unmet care needs. The DON confirmed the oversight, acknowledging potential links between the resident's behavior and unidentified needs.
The facility failed to notify the Department, LTCOP, and Local Law Enforcement within 2 hours of an alleged abuse incident involving two residents. The incident resulted in one resident sustaining a faint discoloration and a laceration below the eye. Despite staff awareness of the reporting requirement, the state agency was not informed until several hours later, delaying the investigation process.
Food Storage, Hand Hygiene, Temperature Control, and Pan Drying Deficiencies
Penalty
Summary
Food was not stored, handled, and prepared in accordance with professional standards in the kitchen. During observation, frozen dessert puffs were found in an open plastic bag in the freezer with no open date or use-by date, and an opened bag of frozen peas was also found with no dates. A Dietary Aide stated the items should have been dated when opened, and the Certified Dietary Manager stated staff label and date foods when they are received and when opened. The facility policy required foods stored in the refrigerator and freezer to be covered, labeled, and dated with a use-by date. Kitchen staff did not follow proper hand hygiene and glove-use practices during food service. A Dietary Aide entered the kitchen and began working without washing hands, another staff member removed gloves after portioning coleslaw and returned to food handling without washing hands after touching the trash can, and the Dietary Aide returned to the kitchen after delivering a food cart and put on gloves without washing hands. In addition, cold food was not maintained at safe temperatures during service when corn coleslaw measured 41 degrees Fahrenheit at the start of lunch service and later measured 47 degrees Fahrenheit while plated in single-serving containers on a sheet tray with no ice bath or other cooling method noted. Wet stainless steel pans were also stacked on a shelf before drying, and a staff member stated the pans should have been completely dry before stacking.
Incomplete restorative nursing and splint orders
Penalty
Summary
The facility failed to ensure that two residents received treatment and services to maintain or improve range of motion and mobility. One resident had diagnoses including Parkinson's disease and muscle weakness. The resident had an OT evaluation that transitioned him to RNA services, but the order did not clarify the specific interventions, extremities, or frequency of services. The resident's care plan included restorative nursing as ordered, yet the clinical record contained no documented evidence that RNA services were provided after the order was completed. During interview, the resident stated he had become too weak to get out of bed and had not received therapy services for several months. Staff interviews and record review showed that the RNA referral process was not carried through for this resident. The DOR stated the resident should have been receiving RNA services after the OT evaluation and that the referral had been placed. The RNA stated she was not aware of any RNA order in the record and reported the resident had not been receiving RNA services for several months. The DSD stated the order did not populate, was not clear, and did not contain specific needs, what to do, or how often the services were to be offered. The DSD also stated the order should have been clarified with the physician, but it was not done, and the resident did not receive needed services since the order date. A second resident with diagnoses including hemiplegia, hemiparesis following cerebral infarction, left hand contracture, osteoarthritis, and diabetes had an order for a left wrist/hand splint every day as tolerated, but the order did not specify how many hours per day it was to be applied. The task record documented minutes spent assisting with splint application and whether it was applied on certain days, but it did not document how long the splint was worn each day. Observations showed the resident was not wearing the splint at the times observed. Staff interviews confirmed the order did not state when the splint should be applied, removed, or how long it should be worn, and staff stated they did not document the time of application, removal, or duration worn. The DSD stated that without documentation of how long it was worn, it could not be determined whether the splint was effective.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure the medication error rate remained below 5 percent during a medication pass observation, with 4 errors identified in 26 opportunities for a rate of 15.38 percent. The errors involved four residents and included omeprazole not being administered in accordance with ordered timing for two residents, metoprolol being given without a current blood pressure check for one resident, and clopidogrel being administered late for another resident. For one resident, omeprazole 20 mg was ordered to be given at least 30 minutes before a meal on an empty stomach, but the nurse administered it after breakfast had already been eaten and acknowledged it was not given per the order. For another resident, omeprazole 20 mg was ordered twice daily 30 minutes before morning and evening meals on an empty stomach, but it was given after the resident had already eaten breakfast. In both instances, the DON acknowledged the medications were not given according to the prescriber’s orders. For a third resident, metoprolol succinate ER 25 mg, ordered with hold parameters for systolic blood pressure less than 100 and heart rate less than 60, was administered without checking blood pressure at the time of administration. For the fourth resident, clopidogrel 75 mg, ordered daily for thromboembolus prophylaxis, was not available in the medication cart at the scheduled time and was administered later than ordered. The DON acknowledged the metoprolol should have been given with a current blood pressure reading and that the clopidogrel was administered late.
Infection Control Precautions Not Followed for Two Residents
Penalty
Summary
Infection prevention and control precautions were not followed for two sampled residents. Resident 30 was admitted with diagnoses including Parkinsons, neurocognitive disorder with Lewy bodies, carbapenem-resistant enterobacterales carrier status, and a gastrostomy tube. His MDS indicated severe cognitive impairment, and his physician order and care plan identified Enhanced Barrier Precautions (EBP) due to MDRO risk and the presence of a feeding tube. During observation, EBP signage and PPE were present at the room entrance, but when a nurse administered tube feeding through the resident’s G tube, the nurse wore gloves only and did not wear a gown. The nurse acknowledged that a gown should have been worn for the tube feeding. Resident 46 had a wound culture positive for MRSA, and the provider signed the result indicating awareness of the infection. During observation, the room displayed an EBP sign. The DON stated the facility was aware of the MRSA wound result and that a resident with MRSA needs contact precautions rather than EBP, but contact precautions were not ordered until several days after the positive result was received. The order summary showed contact precautions were not started until the later date noted in the record. Staff interviews confirmed the expected precautions for both residents. The LN stated that EBP requires gown and glove use for direct care and that failure to follow EBP could lead to contamination to other residents and staff. The IP stated that if a resident is on EBP, a sign should be at the door and PPE should be put on before providing direct care. The deficiency was based on the failure to use the required gown during tube feeding for Resident 30 and the delay in implementing contact precautions for Resident 46 after the MRSA wound result was known.
Exposed urinary catheter bag during hallway ambulation
Penalty
Summary
The facility failed to promote a dignified environment that maintained a resident’s dignity and privacy when a urinary catheter tubing and drainage bag were not placed in a privacy bag and were exposed while the resident was being ambulated in the hallway. Resident 79 was admitted in the summer of 2026 after hospitalization for a left knee joint infection, and the physician ordered a Foley catheter on 6/12/26 for wound management. During a concurrent observation and interview on 6/14/26, the resident stated she had significant knee pain and difficulty turning in bed, which was why the catheter had been ordered. During an observation on 6/15/26, two therapy staff were ambulating the resident in the hallway while another staff member followed behind pushing a wheelchair with the catheter bag attached to the right side. The bag was uncovered, half-filled with urine, not placed in a privacy bag, and visible to others in the hallway, including a visitor who had an unobstructed view for several minutes. A nurse confirmed the catheter bag was uncovered and visible to residents, staff, and the visitor, and stated it should be in a privacy bag because it was a dignity issue. The DON also stated that an exposed catheter is a dignity issue and that staff should cover the urinary bag for privacy and dignity. The facility policy stated residents are to be treated with dignity and respect at all times and that staff are expected to protect resident privacy during care and treatment procedures.
MDS Skin Condition Not Accurately Coded for Resident With Chronic Wounds
Penalty
Summary
The facility failed to accurately code the skin condition section of the MDS for one resident, whose annual assessment indicated he was cognitively intact but showed no venous or arterial ulcers and no other skin issues, including open wounds. The resident’s record, however, documented chronic peripheral venous insufficiency and physician orders for daily treatment to a right lower extremity venous stasis wound and treatment to a right neck wound of unknown etiology, with both wounds requiring cleansing, dressings, and monitoring for worsening or infection. Treatment Administration Records showed the resident received wound care to the neck every other day and to the leg every day as ordered. During observation, the resident was lying in bed with both lower legs elevated, his left leg below the knee was wrapped in kerlix, and he stated he had a chronic wound to his left leg and another wound on the posterior neck that were not healing well. The Regional MDS Consultant reviewed the MDS and clinical records, including treatment orders and progress notes, and stated the MDS was coded incorrectly because the resident’s skin issues should have been captured during the look-back period.
Failure to Provide Adequate Supervision and Remove a Call Light Hazard
Penalty
Summary
The facility failed to ensure adequate supervision and fall prevention interventions for a resident with encephalopathy, muscle weakness, moderate cognitive impairment, and a documented fall risk. The resident’s care plan identified her as at risk for falls and injuries, but it did not include interventions for oversight, supervision, or monitoring to reduce her fall risk. After an initial fall in which she slipped from an unlocked wheelchair and hit the floor, the post-fall documentation added only that the wheelchair wheels should be locked, and the interdisciplinary team record did not identify additional recommendations to prevent future falls or document evaluation of medications associated with fall risk. The resident later experienced another fall when she was found lying prone wedged between the bed and dresser with significant bleeding from the right hand, a bump to the forehead, and a skin tear to the right elbow. Hospital records showed she sustained an open right hand metacarpal neck fracture with associated skin defect and cephalohematoma to the right side of the head. The record did not contain documented evidence that a post-fall risk assessment was completed after this fall, and the interdisciplinary team documentation again did not identify a root cause or new interventions to ensure the resident’s safety. Staff interviews described the resident as unstable when ambulating, forgetful, and needing frequent checks and assistance with transfers and walking to the bathroom. The facility also failed to keep another resident’s environment free from accident hazards. This resident had diagnoses including nontraumatic intracerebral hemorrhage, hypertension, hemiplegia, quadriplegia, and altered mental status, and was observed lying in bed unable to speak or move her body except for repeated head movements. Her call light string was observed attached to the wall and clipped to her pillow, with the string laying around the back of her neck. During the observation, the treatment nurse stated the call light string location was a hazard and removed it, and also stated she did not know whether the resident could even use the call light or whether another device would be more appropriate.
Head of Bed Not Maintained at Ordered Elevation During Tube Feeding
Penalty
Summary
The facility failed to provide appropriate care for one of 17 sampled residents receiving enteral feeding when the resident's head of bed was not elevated to 45 degrees at all times. Resident 30 was admitted with multiple diagnoses including Parkinson's disease, dementia, gastrostomy tube, pneumonia, respiratory failure, dysphagia, and GERD. The resident's MDS indicated severe cognitive impairment, and physician orders directed aspiration precautions with the head of bed elevated 30 to 45 degrees at all times during feeding and for 30 to 40 minutes after feeding was stopped. The resident also had tube feeding orders for Glucerna 1.2 bolus feedings four times daily with water flushes before and after each bolus. Resident 30's care plan identified the need for tube feeding related to dysphagia and directed that the head of bed be elevated 45 degrees during and thirty minutes after tube feedings. Another care plan entry addressed GERD and stated to avoid lying down at least 1 hour after eating and keep the head of bed elevated. During observation, the resident was found asleep in bed with the head of bed elevated to less than 30 degrees, and a sign above the bed stated to keep the head of bed elevated to 45 degrees. A nurse acknowledged the position and stated the head of bed should be elevated to 45 degrees at all times, especially with bolus feedings, to prevent aspiration. Another nurse later stated the head of bed should be elevated at all times, not just during feeding, due to the resident's high risk of aspiration.
Unlabeled Oxygen Tubing
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not met for Resident 77 when the resident was observed receiving oxygen through a nasal cannula with no label or date on the tubing. During the observation, the tubing in use in the resident’s room had no visible label or date. The Respiratory Therapist stated she did not see a date or label on the tubing and said there should be one so staff know how old the tubing is. The Director of Nursing stated oxygen tubing should be replaced every 7 days and labeled with the date, and also stated there was no charting showing the tubing had been changed for Resident 77. The resident’s Order Summary Report showed no order to change oxygen tubing, and the facility’s Oxygen Administration Policy stated oxygen is administered consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident’s goals and preferences.
Failure to Reassess PRN Pain Medication and Follow Ordered Pain Scale Monitoring
Penalty
Summary
The facility failed to provide safe, appropriate pain management for two residents. For one resident with prostate cancer, major depressive disorder, osteoarthritis, anxiety, a fractured humerus with implant, an artificial right hip, and an older spinal fracture, nursing staff administered PRN oxycodone for pain but did not reassess the resident in a timely manner to determine whether the medication was effective. The resident stated later that the nurse had not returned after giving the medication and that he was still in pain. The nurse stated PRN pain medications were supposed to be checked after 30 minutes to an hour and acknowledged that the reassessment was not charted on the MAR and that she was not sure of the resident’s pain level. For another resident admitted with dorsalgia, spinal stenosis, and recurrent falls, the physician ordered pain monitoring every shift and as needed using a 0-10 pain scale. During observation, the resident was alert, oriented, able to converse meaningfully, and grimaced when turning in bed; the resident described chronic lower back pain as about 4-5 on the pain scale. However, the MAR showed that staff used checkmarks instead of documenting the resident’s pain level every shift as ordered. The care plan addressed pain medication administration and monitoring for effectiveness and side effects, but it did not include interventions for staff to monitor pain every shift as ordered by the physician. The DON acknowledged that nurses were expected to assess pain throughout the shift and document the highest pain level reported using the numeric scale, and also confirmed that staff did not follow the physician’s order for the second resident by documenting checkmarks instead of pain scores. The facility’s pain management policy stated that pain monitoring and follow-up may be documented through the MAR or routine clinical documentation and that pain recognition, monitoring, and interventions are incorporated into the comprehensive person-centered care plan.
Therapeutic Diet Not Followed for Resident on NAS Diet
Penalty
Summary
The facility failed to ensure a resident received the prescribed therapeutic diet when a salt packet was served with lunch to a resident ordered a no added salt (NAS) diet. During observation, the resident was eating lunch in bed with a family member present, and the meal tray ticket identified the diet as NAS. The family member stated the resident was probably not supposed to have salt because of high blood pressure. The Certified Dietary Manager later confirmed the resident did receive the salt packet and stated the resident was on NAS and should not have gotten one. The resident’s diet order indicated NAS soft & bite sized, and the facility policy stated therapeutic diets are prescribed by the attending physician to support the resident’s treatment and plan of care.
Failure to Track Staff COVID-19 Vaccination Status and Education
Penalty
Summary
The facility failed to maintain a system to monitor staff COVID-19 vaccination status and to document staff education related to the benefits and potential side effects of the COVID-19 vaccine. During an interview, a Licensed Nurse stated she had received information about the COVID-19 vaccine and that it was offered yearly. The Infection Preventionist stated he began in January 2026 and confirmed that COVID-19 vaccines are offered to staff, but the facility did not have an electronic or handwritten tracker to monitor staff vaccination status. When asked for a tracking or monitoring log, the Infection Preventionist stated the only tracking of staff vaccinations was in personnel files, including vaccination consents and declinations. He stated that if an employee reported receiving a vaccination, he would place that information in the personnel file, and that he relied on staff to report vaccinations received outside the facility. He also stated there was no record of education or screening of staff for the COVID-19 vaccine. The facility policy required employees to be assessed for vaccination status, offered or provided vaccinations per policy or regulation, and given educational materials to make informed decisions, and the Infection Preventionist job description included tracking employee immunizations and providing personnel with information about vaccination policies.
Frayed Bed Control Cord Left with Exposed Wires
Penalty
Summary
The facility failed to maintain safe equipment for one of 17 sampled residents when Resident 40’s bed control power cord was observed frayed with exposed wires. Resident 40 was admitted in August 2025 with multiple diagnoses including metabolic encephalopathy, dementia, chronic obstructive pulmonary disease, and dysphagia. The MDS dated 4/14/26 indicated the resident had long-term and short-term memory problems and severely impaired cognitive skills for daily decision making. During an observation on 6/14/26, Resident 40 was asleep with the head of the bed elevated, and the bed control power cord was wrapped around the bed rail with exposed wires. During another observation on 6/15/26, the cord was again seen wrapped around the bed rail with exposed wires while the resident was awake and listening to music. LN 5 confirmed the cord was frayed with exposed wires and stated the bed control was working but that the condition was a safety hazard. The DON stated that if a bed control power cord is frayed and wires are exposed, staff were expected to contact maintenance to replace it. The MD stated the issue was not in the maintenance log and that the cord needed to be replaced.
Failure to Complete Significant Change MDS Assessment After New Stage 3 Pressure Ulcer
Penalty
Summary
The facility failed to ensure a Minimum Data Set Significant Change in Status Assessment was completed for Resident 3 after the resident developed a stage 3 pressure ulcer. Resident 3 was admitted in March 2026 with diagnoses that included a femur fracture, and the admission nursing assessment dated 3/14/26 indicated the resident did not have a pressure ulcer at that time. A wound assessment report dated 5/14/26 documented a midline sacral pressure injury staged as stage 3 and identified it as acquired in the facility with a wound acquisition date of 04/30/2026. During record review, no MDS SCSA was found in the medical record. The MDS LN confirmed during interview that Resident 3 developed a stage 3 pressure ulcer in the facility and did not have an MDS SCSA performed. The DON stated that when a resident experiences a significant change in health status, an MDS SCSA should be completed, and the facility policy stated that a comprehensive assessment is conducted when a significant change in physical or mental condition occurs.
MDS Assessments Did Not Accurately Reflect Wounds and Dialysis
Penalty
Summary
The facility failed to ensure that MDS assessments accurately reflected residents’ current clinical status for two sampled residents. For Resident 1, who was admitted in May 2025 with diagnoses including atherosclerotic heart disease, the admission MDS section M dated 6/5/26 indicated that he did not have a surgical wound on admission. However, the SKIN & BODY ASSESSMENT dated 5/23/26 documented three surgical wounds on his chest area at admission. The resident’s care plan also did not include interventions for incision care and monitoring. During a concurrent observation and interview on 6/8/26, Resident 1 had a large incision in the middle of his chest and two smaller incisions, one on the right chest and one on the upper abdomen area, and he stated staff had not closely monitored his incisions and that he had only seen a nurse specifically for his incisions on 6/5/26. For Resident 2, who was admitted in February 2026 with end stage renal disease, the quarterly MDS section O dated 5/27/26 indicated that she had not received dialysis during her stay from 5/1/26 to 5/14/26. However, the Dialysis Communication Form documented that Resident 2 received dialysis on 5/2/26, 5/8/26, 5/9/26, and 5/12/26. During interview and record review, the MDS LN confirmed that Resident 1’s incisions were not captured on the MDS and stated that accurate MDS assessments were important to give staff an accurate representation of the resident. The DON also stated that MDS assessments should be accurate and expected staff to complete them to reflect the resident’s health status. The facility policy titled Certifying Accuracy of the Resident Assessment stated that the information captured on the assessment reflects the resident’s status during the look-back period.
Deficiencies in Food Storage, Preparation, and Service
Penalty
Summary
Surveyors observed multiple failures in food storage, preparation, and service within the facility's dietary department. During an initial tour, nine plate cover lids and two metal bowls were found stored upright with water collected at the bottom, indicating they were stacked while still wet. Both the Dietary Manager and Registered Dietician confirmed that these items should have been air dried before storage to prevent bacterial growth, as required by FDA Food Code standards. Additionally, two plastic cups with visible white film buildup were found on a shelf, and both the Dietary Manager and Registered Dietician acknowledged that these cups were not clean to sight and touch, which is a violation of food safety standards. Further inspection revealed that both freezers in the kitchen were missing thermometers, which are necessary to monitor and ensure safe food storage temperatures. The Dietary Manager confirmed the absence of thermometers and acknowledged that staff would not be able to verify if food was being stored at safe temperatures. Open food items, including frozen waffles, corn, spices, and a box of cream of wheat, were also found without use-by dates, contrary to facility policy and food safety guidelines. The Registered Dietician confirmed that the lack of labeling could result in food being stored for excessive periods without proper tracking. During meal distribution, it was observed that meal trays with desserts were not covered while being transported to residents' rooms. The delivery cart used had plastic bags covering only three sides, and staff had rolled up the coverings, leaving the desserts exposed. The Registered Dietician confirmed that food items should be covered during transport to prevent contamination. These combined failures in food handling, storage, and distribution practices increased the potential for foodborne illness among the facility's residents.
Plan Of Correction
Plan of Correction completion date: 6.30.25 F 812
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to maintain a clean environment for residents and visitors by not ensuring that two outside garbage dumpsters were properly secured with closed lids. During observations, it was noted that the dumpster lids had openings, and bags of garbage were visible inside the bins. There was a noticeable bad odor, and flies were observed coming out from the openings in the lids. The Dietary Manager confirmed that the lids were not securely closed at the time of inspection. Further, the Maintenance Director acknowledged that the lids should have been closed with tight-fitting covers according to facility policy, and that the current lids with openings could not prevent pest and rodent activity. A review of the facility's policy and procedure on food-related garbage and refuse disposal indicated that all garbage and refuse containers must have tight-fitting lids or covers and be kept covered when stored, with food waste stored in a manner inaccessible to pests. The facility census at the time was 49 residents.
Plan Of Correction
Plan of Correction completion date: 6.30.25
Environmental Safety and Resident Dignity Deficiencies
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for its residents, staff, and the public. During an observation, a wheelchair and a standing fan were found partially blocking an emergency exit in one of the facility's wings, which could impede access in the event of an emergency. Additionally, two Hoyer lifts were stored in the same area with their wheels unlocked, presenting a risk of equipment movement and potential injury. The facility's policy requires that all equipment and clinical devices be stored in a safe manner, but this was not followed in these instances. Further deficiencies were identified in the treatment of residents with dignity and respect. One resident's urinary catheter bag was not covered by a dignity bag, compromising privacy. Two residents were assisted with feeding by staff who were standing rather than sitting, which does not align with best practices for respectful care. Additionally, two other residents were not asked about their preference regarding the use of clothing protectors during meals. These actions failed to ensure that residents were treated with dignity and respect as required.
Plan Of Correction
How the corrective action(s) will be monitored to ensure the practice will not recur: Maintenance director and Administrator will conduct daily rounds for 2 weeks, then weekly rounds to verify adherence to the policy of Equipment and device storage. Any issues identified during these audits will be immediately corrected. This plan of correction has been integrated into the facility's Quality Assurance program, and the results of these audits will be reviewed quarterly until substantial compliance is achieved. Plan of Correction completion date: 6.30.25 F 921
Failure to Provide Accessible and Usable Call Lights for Multiple Residents
Penalty
Summary
The facility failed to ensure reasonable accommodation of resident needs and preferences regarding the accessibility and usability of call lights for seven residents. Multiple residents were observed with call lights out of reach or unable to operate their call lights due to physical or cognitive limitations. For example, one resident with muscle weakness and impaired cognition was found lying in bed unable to reach the call light, and another resident with Parkinson's disease and severe cognitive impairment was seated in a wheelchair with the call light hanging from the wall, out of reach. In both cases, staff confirmed the call lights were not accessible as required by facility policy and the residents' care plans. Additional deficiencies were identified for two residents who had severe memory problems and were unable to use the call light system, yet their care plans did not include interventions addressing this inability. One resident was observed calling out for assistance with pain, unable to locate or use the call light, while another could not retrieve food on her tray and did not know where her call light was. Staff interviews confirmed that the lack of specific care plan interventions for these residents' inability to use the call light could result in unmet needs and neglect of care. Another resident with hands wrapped in elastic bandages due to a history of stroke was observed struggling to activate the standard call light, requiring multiple attempts and significant effort to do so. Staff acknowledged that the resident's needs were not accommodated with an appropriate call light device, despite facility policy requiring evaluation and provision of special accommodations such as touch pads or larger buttons. These failures were confirmed through observations, interviews, and record reviews, and were inconsistent with both facility policy and the individualized care plans for the affected residents.
Plan Of Correction
Plan of Correction completion date: 6.30.25 F 558 F 558
Medication Error Rate Exceeds 5% Due to Improper Administration Practices
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with surveyors observing an error rate of 25.81% during medication administration for four out of six residents. Multiple instances were documented where medications were not administered according to prescriber orders or manufacturer specifications. For example, a nurse administered chewable aspirin to a resident without instructing them to chew it, and provided only 5 oz of water instead of the required 8 oz, despite the order specifying the medication should be chewed and taken with food or a full glass of water or milk. Additionally, omeprazole was not given before eating as directed by the manufacturer. Another resident received medications including chewable aspirin, metoprolol, and potassium chloride with only 5 oz of water and no food, even though the orders and manufacturer instructions required administration with food and a full glass of water. The nurse confirmed that the resident had eaten breakfast earlier, but did not provide food or the correct amount of water at the time of administration. The pharmacy consultant emphasized the importance of following these instructions to ensure proper absorption and minimize gastrointestinal irritation. Further observations included a nurse administering tramadol for severe pain when the order specified it was for moderate pain only, and giving carvedilol without food, contrary to the order and manufacturer instructions. Another resident was given allopurinol without food or the required amount of water, despite orders to administer with both. The facility's policy required medications to be administered as prescribed and in accordance with manufacturer specifications, but these procedures were not followed during the observed medication passes.
Plan Of Correction
How the corrective action(s) will be monitored to ensure the practice will not recur: DON/Designee will conduct weekly medication administration audits. Any issues identified will be reported to the Director of Nursing and immediately corrected. This plan of correction has been integrated into the QA program, and the results of these audits will be reviewed quarterly as needed until substantial compliance is achieved. Plan of Correction completion date: 6.30.25 F 759 F 759 F 759 F 759 F 759
Failure to Properly Disinfect Shared Blood Pressure Cuffs Between Residents
Penalty
Summary
Surveyors observed that staff failed to properly clean and disinfect a shared blood pressure (BP) cuff between uses on multiple residents. On one occasion, a licensed nurse took the BP of a resident using a cuff from the medication cart, did not sanitize it after use, and then used the same cuff on another resident without cleaning it in between. The BP cuff was repeatedly placed back into the medication cart without being sanitized after each use. Another incident involved a different licensed nurse who, after taking a resident's BP, cleaned the cuff only with a small alcohol prep wipe before returning it to the cart. The infection preventionist later confirmed that the facility's expectation was to use a specific type of disinfectant wipe for cleaning BP cuffs between residents, and that using a small alcohol prep pad was not effective or acceptable for this purpose. Interviews with staff revealed a lack of awareness regarding the facility's policy on cleaning BP cuffs between resident uses. Review of the facility's policy indicated that reusable items are to be cleaned and disinfected or sterilized between residents, but this procedure was not followed as observed during the survey.
Failure to Maintain Resident Dignity During Care and Mealtimes
Penalty
Summary
Multiple deficiencies related to resident dignity and rights were identified during the survey. One resident with metabolic encephalopathy and a Foley catheter was observed in bed with the urinary catheter bag uncovered, despite a dignity bag being available on the resident's wheelchair. Both a registered nurse and the Director of Nursing confirmed that the catheter bag should have been covered, as per facility policy, to maintain the resident's dignity. In the dining area, two residents with neurological impairments were observed being assisted with eating by restorative nurse assistants who remained standing over them, rather than sitting at eye level. The staff could not explain the importance of sitting while assisting with feeding, and the DON acknowledged that standing over residents during feeding is a dignity issue. Training records indicated that the staff involved had previously received training on dignity and feeding practices. Additionally, two residents with intact cognition were observed wearing clothing protectors during meals without being asked for their preference. One resident expressed that staff did not ask if he wanted to wear a bib, while another stated that wearing the clothing protector made him feel like a baby and contributed to feelings of depression. There was no documentation in their care plans regarding their choice or preference for wearing clothing protectors, contrary to facility policy that emphasizes honoring resident choices and preferences.
Failure to Update Care Plans for Self-Administration and Wound Dressing
Penalty
Summary
The facility failed to review and revise the comprehensive care plans for two residents to reflect their current health status and needs. One resident, who had been admitted with Sjögren's syndrome and required supervision with activities of daily living, was observed to have Carboxymethylcellulose Sodium Ophthalmic Solution (eye drops) at her bedside and reported self-administering the medication daily since admission. However, there was no documented assessment, physician order, or care plan indicating that she was permitted or able to self-administer her medication, as required by facility policy and federal regulations. Another resident, admitted with a history of stroke and requiring supervision with self-care, was observed with both hands wrapped in self-adhering elastic bandages. The treatment nurse confirmed that the resident chose to keep his hand amputations covered, but there was no care plan with goals or interventions addressing the use of the bandages. A certified nursing assistant also noted that the resident needed assistance with care, including eating meals, due to the bandages. In both cases, the Director of Nursing acknowledged that the care plans should have been updated to reflect the residents' current needs and interventions. The facility's policies require that care plans be comprehensive, person-centered, and revised as residents' conditions change, but these requirements were not met for the two residents identified.
Plan Of Correction
Plan of Correction completion date: 6.30.25 F 657
Lack of Comprehensive Wound Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for wound care interventions for two residents, leading to potential inadequate care. Resident 2, who had a diabetic foot ulcer, did not have a care plan documented in their electronic health record despite having a treatment order for the ulcer. During an interview, Resident 2 confirmed the presence of a wound on the right foot with dressings changed every other day, yet no care plan was in place to guide this treatment. Similarly, Resident 4, who had a surgical wound requiring Negative Pressure Wound Therapy (NPWT), also lacked a documented care plan in their electronic health record. The treatment order specified NPWT dressing changes three times a week, but no care plan was available to ensure these interventions were consistently applied. Interviews with a Licensed Nurse and the Director of Nursing confirmed the absence of care plans for both residents, acknowledging that care plans should have been initiated to address their specific wound care needs.
Failure to Provide Hemodialysis Services Due to Transportation Issues
Penalty
Summary
The facility failed to provide hemodialysis services per policy for a resident who missed four outpatient hemodialysis appointments due to transportation issues. The resident, who was admitted with multiple diagnoses including end-stage renal disease, was dependent on hemodialysis. The facility's records indicated that the resident missed appointments on four occasions due to transportation not being available or the driver not entering the facility to pick up the resident. Despite attempts to reschedule appointments, the resident was not transported to the dialysis clinic, leading to a hospital visit for potential fluid retention. The facility's staff, including the Director of Nursing and Social Services Director, acknowledged the missed appointments and transportation issues. Interviews with staff revealed that the physician was not consistently notified of the missed appointments, and there was no documentation of such notifications in the resident's progress notes. The facility's policy required that the physician be informed of any changes in treatment, including missed dialysis sessions, but this was not adhered to in this case. The resident expressed experiencing shortness of breath and was sent to the emergency department after several missed dialysis sessions. The facility's policy emphasized the importance of ensuring safe transportation and communication with the physician regarding any changes in treatment. However, the lack of proper notification and transportation arrangements resulted in the resident missing critical dialysis treatments, which are essential for managing their end-stage renal disease.
Failure in Indwelling Catheter Care Leads to Deficiency
Penalty
Summary
The facility failed to provide appropriate indwelling catheter care and services for a resident who did not have a physician order for catheter care nor a catheter change for several months after admission. The resident, who was admitted with diagnoses including benign prostatic hyperplasia and a stage 4 sacral pressure ulcer, was dependent on staff for toileting hygiene and had an indwelling catheter. Despite the presence of the catheter, there was no documented evidence of catheter care or change from March to June, and the first documented catheter change occurred in July. The lack of catheter care and change orders was confirmed by interviews with facility staff, including a Licensed Nurse, Treatment Nurse, Director of Nursing, and Infection Preventionist. They acknowledged that the absence of orders led to missed care, increasing the risk of urinary tract infections (UTIs), which the resident developed twice during the period in question. The facility's policy required catheter care every shift, but this was not followed due to the missing orders, highlighting a significant oversight in the resident's care management.
Deficiencies in Care and Documentation in LTC Facility
Penalty
Summary
The facility failed to adhere to professional standards of care in several instances, leading to deficiencies in the care provided to residents. For instance, the oxygen tubing and humidifiers for three residents were not labeled, dated, or changed as per the facility's policy, which requires weekly changes to prevent infection. This oversight was confirmed by both a licensed nurse and the Director of Nursing (DON), who acknowledged that the equipment should have been changed and labeled correctly. Additionally, the facility did not implement physician orders for specific residents, which compromised their care. One resident, who required one-on-one feeding assistance due to dysphagia, was left to feed himself, resulting in inadequate food intake. Another resident, who needed a plate guard with meals due to muscle weakness, did not receive this adaptive device, as the dietary staff was not informed of the order. Furthermore, a resident's medication order for a Budesonide inhaler was not transcribed into the Medication Administration Record (MAR), leading to the medication not being administered as prescribed. The facility also failed to ensure proper medication administration and documentation. A nurse did not observe a resident ingest his medication, and there were six undocumented doses of intravenous antibiotics for another resident, which the DON admitted to administering without recording. Additionally, a resident's BiPAP equipment was not stored properly, exposing it to potential contamination. These failures increased the risk of unmet therapeutic needs and potential worsening of medical conditions for the residents involved.
Failure to Secure and Dispose of Resident Medical Records
Penalty
Summary
The facility failed to properly store and maintain the confidentiality of multiple residents' medical records, as observed during a survey. On a specific date, a large open cardboard box containing confidential health information of residents receiving Physical Therapy and Occupational Therapy was found underneath a desk in the Physical Therapy Department. This box was located near a doorway frequently accessed by other residents and visitors, posing a risk of unauthorized access to sensitive information. The facility lacked confidential records bins within the department, with the nearest bins located outside the main entrance, approximately 10 to 12 feet away from where the box was found. Interviews with the Physical Therapist and Administrator confirmed that the box contained treatment records and reports, which were supposed to be disposed of daily into confidential records bins for shredding. However, a review of the box's contents revealed records of both discharged and current residents dating back several months, indicating that the records were not disposed of daily as required. The facility's policy on confidentiality, which mandates that paper notes or reminders with residents' personal or medical information should not be left unattended or viewable by unauthorized persons, was not adhered to, leading to this deficiency.
Controlled Medication Accountability and Storage Deficiencies
Penalty
Summary
The facility failed to ensure accurate accountability and effective storage of controlled medications for three residents. Random audits of the Medication Administration Record (MAR) and Controlled Drug Record (CDR) revealed discrepancies where medications signed out on the CDR were not documented as administered on the MAR. Specifically, for Resident 9, oxycodone was signed out but not recorded on the MAR on two occasions. Similarly, for Resident 28, hydrocodone/APAP was signed out but not documented on the MAR. Resident 296 also had multiple instances where oxycodone was signed out without corresponding entries on the MAR. Interviews with Licensed Nurse 3 and the Director of Nursing confirmed the expectation for documentation on both the CDR and MAR to ensure accurate drug accountability. Additionally, the facility did not implement a system to accurately document and secure emergency medications (E-Kit). During an inspection, it was found that one of the two E-kits containing controlled medications was stored in an unlocked drawer, and opened E-kits were not properly secured. The Director of Nursing acknowledged that E-kits should be securely stored and exchanged with the pharmacy once opened. The facility's policies indicated that controlled substances should be stored under double-lock key and that emergency medications must be replaced upon the next routine drug order, which was not adhered to in this case.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility was found to have a medication error rate of 12.82% during a medication pass observation, exceeding the acceptable threshold of 5%. This was observed when five medication errors occurred out of 39 opportunities. The errors involved three residents, where medications were not administered according to the prescriber's orders, potentially affecting the residents' clinical conditions. One of the errors involved a resident who was supposed to receive Losartan in the evening with a meal, as per the discharge orders. However, the medication was administered in the morning, contrary to the physician's instructions. Additionally, the same resident was given a B-Complex with Vitamin C supplement that did not match the prescribed order. The Licensed Nurse confirmed the discrepancies during a review of the resident's discharge orders. Another error was observed when a resident did not receive their scheduled dose of Brovana, a medication for treating breathing issues, because the nurse could not locate it in the medication cart. It was later found in the medication storage room refrigerator. Furthermore, a third resident received an incorrect administration of insulin aspart and ondansetron ODT. The insulin pen was not primed, and the injection was not held under the skin long enough, potentially leading to an incorrect dose. The ondansetron ODT was swallowed with other medications instead of being allowed to dissolve on the tongue as prescribed.
Failure to Administer Brovana Medication
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when the resident missed 25 doses of Brovana, a medication used to treat breathing problems. This occurred because the nursing staff did not know to check for the medication in the medication storage room refrigerator. During a medication pass observation, a licensed nurse was unable to locate the Brovana in the medication cart and therefore could not administer it as scheduled. The resident had a physician's order for Brovana to be administered twice daily for congestive heart failure. However, the medication administration record indicated that the resident did not receive the medication on multiple days in July and August. The resident reported feeling short of breath due to not receiving the medication as ordered. An inspection of the medication storage room refrigerator revealed multiple orders of the resident's Brovana, which the Director of Nursing confirmed had been overlooked by the nursing staff.
Inadequate Kitchen Sanitation Procedures
Penalty
Summary
The kitchen staff at the facility failed to demonstrate appropriate competencies in kitchen sanitation, which could potentially lead to foodborne illness for the 49 residents consuming facility-prepared food. During an initial kitchen tour, a dietary aide was unable to correctly demonstrate the procedure for testing the concentration of sanitation solution in red buckets, as they held the test strip in the solution for longer than the manufacturer's instructions. Another dietary aide, who had been working at the facility for two months, admitted to not being trained in the procedure. Additionally, a staff member responsible for the dinner meal was unaware of the testing procedure, indicating a lack of proper training and adherence to the facility's policy on routine cleaning and disinfection. Further observations revealed issues with the dishwashing process. A dietary aide was unable to demonstrate effective testing of the sanitizing solution at the plate level, and repeated tests showed that the concentration did not meet the desired level. The Certified Dietary Manager intervened by changing the sanitizing solution and test strips, but the concentration still failed to meet the required level. It was later discovered that the facility had been using incorrect test strips for their contracted sanitation supply company's product. This oversight, combined with the lack of proper training and adherence to policies, contributed to the deficiency in ensuring sanitary conditions for dishwashing.
Food Safety and Sanitation Deficiencies in Facility
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by several deficiencies observed during a survey. Firstly, a bag of previously opened shredded cheddar cheese was found unsealed in the kitchen, which the Certified Dietary Manager (CDM) acknowledged could lead to contamination and bacterial growth. This was in violation of the facility's policy on food safety, which mandates that food be stored in a manner that prevents contamination. Additionally, the United States Food and Drug Administration (FDA) 2022 Food Code requires that food packages maintain their integrity to prevent adulteration. Another deficiency was observed with a dirty fan blowing onto clean plate guards in the kitchen. The CDM confirmed the presence of dirt on the fan and acknowledged that this could lead to contamination of the clean plate covers. This was contrary to the facility's policy on routine cleaning and disinfection, which aims to maintain a sanitary environment and prevent infection transmission. The FDA Food Code also stipulates that non-food-contact surfaces of equipment should be free from dust, dirt, and other debris. Furthermore, the facility was using incorrect test strips to check the sanitation concentration level of the dishwasher, which could lead to ineffective sanitation and cross-contamination. The CDM admitted that the wrong test strips were being used, and the correct ones were only provided after the sanitation company was contacted. Lastly, an ice cream container in the resident refrigerator was labeled only with a room number, lacking the resident's name and date, which the Director of Nursing (DON) acknowledged could lead to potential issues such as allergic reactions or choking hazards. This was against the facility's policy on the use and storage of food brought in by family or visitors, which requires proper labeling to ensure resident safety.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent for the use of psychotropic medications for one resident, identified as Resident 447. This resident was admitted with diagnoses including dementia, bipolar disorder, and schizophrenia. The medical records indicated that the resident was prescribed risperidone and trazodone, both psychotropic medications, without documented informed consent. The Medication Administration Record showed that these medications were administered on multiple occasions without the necessary consent documentation. Interviews with facility staff, including a Licensed Nurse (LN 3) and the Director of Nursing (DON), confirmed that the informed consent forms for these medications were not signed by the physician, as required. The facility's policy and procedure, as well as an All Facilities Letter, mandate that informed consent must be obtained and documented before administering psychotropic drugs. The DON acknowledged that the physician was responsible for obtaining this consent, which was not done in this case, leading to the deficiency.
Inaccurate Resident Assessment
Penalty
Summary
The facility failed to ensure accurate resident assessments for one resident out of nineteen sampled, specifically Resident 15. Resident 15 was admitted in April 2024 with diagnoses including metabolic encephalopathy and generalized weakness. During an observation and interview, it was noted that Resident 15 did not have a urinary catheter, contrary to what was documented in the Minimum Data Set (MDS) assessments dated May and August 2024. The Director of Nursing confirmed that the MDS reports were inaccurate, as there was no urinary catheter ordered or in use for Resident 15. This inaccuracy in the resident's assessment had the potential to establish incorrect baseline data and treatment.
Failure to Develop BiPAP Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive care plan for the use of a BiPAP machine for one resident, identified as Resident 10. This deficiency was identified during a survey that included observation, interview, and record review. Resident 10 was admitted with diagnoses of Type 2 Diabetes and Neurocognitive Disorder with Lewy Bodies, which affects cognitive abilities. During an initial observation, Resident 10 was found lying in bed, appearing comfortable but confused about time and place. A BiPAP machine, which was ordered to be used at bedtime and turned off upon waking, was observed in the room, but there was no corresponding care plan in the resident's Electronic Health Record (EHR). The Clinical Reimbursement Director Nurse Consultant (CRD/NC) confirmed the absence of a care plan for the BiPAP machine after reviewing Resident 10's physician's orders and care plans. The facility's policy, dated March 1, 2023, mandates the development and implementation of a comprehensive person-centered care plan for each resident, which should include measurable objectives and time frames to meet the resident's needs. The lack of a care plan for the BiPAP machine meant that Resident 10 was at risk of receiving inaccurate and inadequate care, as the necessary services to maintain their well-being were not documented or planned for.
Medication Storage Deficiency Due to Unlocked Carts
Penalty
Summary
The facility failed to ensure that medications were stored correctly, as observed during a survey. A medication cart and a treatment cart, both of which are lockable cabinets on wheels used to store drugs and supplies, were found unlocked and unattended. This was confirmed during an observation and interview with the Activities Director, who noted that the treatment cart was unlocked with keys hanging from the lock cylinder while no staff were present. Similarly, Licensed Nurse 1 confirmed that medication cart A was unlocked while unattended, acknowledging that it should have been locked to prevent unauthorized access. Interviews with staff, including Licensed Nurse 4, the Clinical Reimbursement Director/Nurse Consultant, and the Director of Nursing, revealed a consensus that medication and treatment carts should be locked when not attended by staff. The Clinical Reimbursement Director/Nurse Consultant emphasized the importance of locking the carts even when a nurse is nearby but not directly in front of them. The facility's policy, dated March 1, 2023, supports this practice by stating that all drugs and biologicals must be stored in locked compartments, with access limited to authorized personnel.
Failure to Adhere to Renal Diet Restrictions
Penalty
Summary
The facility failed to provide a resident with the appropriate nutritive profile matching the physician-prescribed renal diet. During an observation of a lunch meal, the resident was served turkey, mashed potatoes, and broccoli, despite being on a renal diet that restricts high potassium foods like potatoes. The resident pointed out that potatoes were not allowed on their renal diet, and the tray ticket confirmed that a renal diet had been ordered, with potatoes listed as a dislike. Interviews with the Certified Dietary Manager (CDM) and the Registered Dietitian (RD) revealed that the renal diet restrictions were noted on the meal tray tickets to guide food servers. The CDM confirmed that the resident should not have received mashed potatoes, and the RD explained that the renal diet limits phosphorus and potassium intake to prevent heart issues. The facility's Nutrition Manual indicated that the renal diet is used for residents with renal insufficiency or failure not on dialysis, regulating sodium, potassium, and protein intake to reduce kidney workload.
Infection Control Breach and Improper Equipment Storage
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices, as observed with Certified Nursing Assistant 5 (CNA 5), who was seen carrying trash bags from one resident room to another and allowing them to rest against her clothing. This action was contrary to the infection control guidelines, which prohibit taking trash from one resident room into another and require staff to hold trash away from their body to prevent the spread of germs. CNA 5 acknowledged the breach in protocol, and the Infection Preventionist, Licensed Nurse 4, and the Director of Nursing confirmed the importance of adhering to these guidelines to prevent infection transmission. Additionally, the facility did not properly store respiratory equipment for Resident 10, who was on BiPAP therapy. The BiPAP mask and tubing were left exposed and unprotected from dust and contamination, contrary to the facility's policy, which requires such equipment to be stored in a clean bag when not in use. Resident 10, who has Type 2 Diabetes and a neurocognitive disorder with Lewy Bodies, was observed in a confused state, and the Director of Nursing confirmed the improper storage of the BiPAP equipment.
Failure to Administer Pneumococcal Vaccine
Penalty
Summary
The facility failed to administer a pneumococcal vaccine to one of the sampled residents, identified as Resident 15. Resident 15 was admitted to the facility in April 2024 with a history of having a tumor in the lungs and respiratory failure. Upon admission, Resident 15 consented to receive the pneumococcal vaccine, as indicated in the informed consent dated 4/27/24. However, a review of the Minimum Data Set (MDS) dated 8/3/24 incorrectly indicated that Resident 15 had declined the vaccine. An interview with the Infection Preventionist on 8/22/24 revealed that Resident 15's health record was mistakenly updated to show a vaccine declination, despite the resident's consent. The Infection Preventionist confirmed through the California Immunization Registry that Resident 15 had not been previously vaccinated and was eligible for the pneumococcal vaccine. The facility's policy requires offering the vaccine to residents unless contraindicated or previously immunized, but this was not followed in Resident 15's case.
Ice Build-Up in Freezer Compromises Food Safety
Penalty
Summary
The facility failed to maintain the reach-in freezer in a safe operating condition, as observed during a kitchen inspection. Ice build-up was found on the ceiling of the freezer, with ice crystals approximately 1/2 inch in diameter. The freezer door gasket appeared misshapen in the upper, outer corners, which may have contributed to the issue. The Certified Dietary Manager (CDM) confirmed the ice build-up and acknowledged that it could lead to freezer burn and potentially affect food safety by allowing bacteria to grow when the air is warmed. The Maintenance Supervisor (MS) noted the ice build-up and suggested it might be due to the freezer door not being closed tightly. The Artic Air commercial freezer manual advises defrosting and cleaning the freezer when 1/4 to 1/2 inch of frost accumulates, as frost tends to build up faster on the upper part of the freezer due to warm, moist air entering when opened. The FDA 2022 Food Code emphasizes the importance of maintaining equipment to manufacturer specifications to ensure proper operation and consumer safety.
Inaccessible Call Light for Resident with Dementia
Penalty
Summary
The facility failed to ensure that a call light was accessible for a resident who was not physically able to use the type of call light provided. The resident, who was admitted with dementia and anxiety, was always incontinent and dependent on staff for toileting hygiene. The care plan indicated that the call light should be within reach and the resident should be encouraged to use it for assistance. However, during an observation, the resident was unable to pull the string of the call light to signal for help. Interviews with staff confirmed that the resident could not use the provided call light and had not been offered an alternative until later. The facility's policy required special accommodations for call lights to be documented in the resident's care plan, but there was no documentation indicating the resident's inability to use the call light or the need for special accommodations. This oversight had the potential to result in unmet resident needs and delayed staff response.
Infection Control Lapses in PPE Usage
Penalty
Summary
The facility failed to adhere to infection control practices for two residents, leading to potential infection spread. For Resident 4, who was admitted with sepsis and MRSA, the Social Services Assistant (SSA) entered the room without wearing the required Personal Protective Equipment (PPE), despite Enhanced Barrier Precaution signage and PPE supplies being available. The SSA acknowledged the oversight and confirmed the need to wear PPE to prevent infection spread. Similarly, for Resident 5, who was admitted with sepsis, gangrene, and a post-procedure infection, the Certified Nursing Assistant (CNA 1) entered the room without full PPE, despite the presence of Droplet Precaution signage and PPE supplies. Resident 5 was on contact isolation for COVID-19, and the CNA confirmed the failure to wear gloves, face shield, and gown as required. The Infection Preventionist confirmed the necessity of PPE use to prevent infection transmission.
Failure to Coordinate PASRR Evaluation for Resident
Penalty
Summary
The facility failed to coordinate with the PASRR evaluation program for a resident with a mental disorder, who had positive results on Level I screening, indicating the need for a Level II screening. This oversight placed the resident at risk of not receiving necessary rehabilitative services. The resident's clinical record showed diagnoses including mental illness, mood disorder, unspecified dementia with behavioral disturbance, noncompliance with treatment, and a history of frequent hospitalizations. Despite these indicators, there was no documented evidence that the facility referred the resident for a Level II PASRR evaluation as required. The deficiency was further highlighted by an incident where the resident was involved in a physical altercation, resulting in injuries and subsequent hospitalization. The Director of Nursing confirmed that the Level II screening had not been completed, acknowledging that the resident's altercation, noncompliance, and frequent hospitalizations could have been linked to unmet needs related to their mental illness. The facility's policy required coordination with the PASRR program to ensure appropriate care, but this was not adhered to, leaving the resident's specialized care needs unaddressed.
Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to notify the Department, Long-Term Care Ombudsman Program (LTCOP), and Local Law Enforcement Agency within 2 hours of an alleged abuse incident involving two residents. The incident occurred when a CNA heard a commotion in a room and found one resident standing over another. The resident who was standing had accidentally touched the other resident's face, resulting in faint discoloration and a laceration below the eye. The injured resident was subsequently picked up by an ambulance, and vital signs remained stable with no reported pain. Interviews with staff, including the Director of Nursing (DON), Licensed Nurse (LN), Social Services Director (SSD), and Director of Staff Development (DSD), revealed that they were aware of the requirement to report abuse within two hours. However, the DON did not notify the Administrator until 7:30 a.m., and the state agency was not contacted until 9:16 a.m., well beyond the required two-hour window. The facility's policy clearly stated that all alleged violations must be reported immediately, no later than two hours after observing or obtaining knowledge of the incident. The delay in reporting was confirmed through a review of various documents, including the facility's Abuse Investigation Report and Fax Transmission Result. The report indicated that the incident occurred at 1:45 a.m., but the state agency was not informed until 9:16 a.m. The facility's failure to adhere to its own policy and regulatory requirements resulted in a delay in the investigation process and decreased the potential to protect residents from harm.
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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 Sacramento
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Greenhaven Healthcare Center | 2.1 mi | ★★★★★ | 28 | 0 |
| Capital Post Acute | 3 mi | ★★★★★ | 29 | 0 |
| Pioneer House | 3.2 mi | ★★★★★ | 22 | 0 |
| River Bend Nursing Center | 3.2 mi | ★★★★★ | 16 | 0 |
| Acc Care Center | 3.4 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.