Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Community Care Center during CMS and state inspections, most recent first.
Controlled meds were signed out on the CDR without matching MAR documentation for several residents, and one resident had a MAR entry without a CDR sign-out. A resident also received morphine outside the ordered parameters and when the order was not active, another resident received metoprolol despite BP being below the hold limit, Ozempic was unavailable on two occasions, and several insulin pens were found in a med cart without date-open labels.
Resident lacked personal clothing and footwear. A resident admitted with cachexia was observed sitting in bed wearing a hospital gown and stated she did not have enough clothing and wanted to buy clothing of her choice, but her request for access to personal funds had not been provided. Her closet contained only a few clothing items, one slipper without a matching pair, and no shoes. An LN said she had given donated clothing but was unaware the resident wanted to use personal funds, and the DON stated the issue involved the resident's dignity and basic needs.
Failure to provide access to a resident’s personal funds. A resident with cachexia was observed wearing a hospital gown and stated she wanted to buy clothing of her choosing but could not access her money. Staff were unaware of the resident’s available funds, social services did not document follow-up with the prior BCF about the resident’s SS income, and the BOM did not update financial records or document the resident’s alleged refusal to sign the bank form needed to open a trust account.
Failure to follow up on a resident’s change in condition occurred when restorative nursing documentation noted increased resistance and joint tightening, but no record showed the LPN follow-up expected after the report. The resident had acute and chronic respiratory failure and bilateral knee contractures, and the restorative notes were described as non-specific and repetitive, with no joint motion limits documented. A physician order was also entered incorrectly.
Failure to Document IV Fluid Intake: A resident with dysphagia was observed receiving IV Dextrose-Sodium Chloride via a PIV while ordered for I&O monitoring every shift and IV hydration. Record review showed nursing staff did not record or document the IV fluid intake every shift, and the ADON stated nursing does not document IV fluid intake. The DON stated IV fluids are part of fluid intake and expected them to be documented, consistent with facility policy requiring IV fluids to be recorded in the medical record and I&O record.
A resident with anoxic brain damage, respiratory failure, a tracheostomy, and g-tube dependence did not receive ordered routine acetaminophen after admission, and the chart showed only PRN oxycodone given for pain scores of 7 or 8. During wound care, the resident frowned and grimaced, and two LNs noted the expression appeared to indicate pain. The DON could not explain why the routine acetaminophen order from the hospital discharge paperwork was not carried over, and no acetaminophen order was found in the facility record.
Medication administration errors resulted in an 11.54% error rate, exceeding the 5% threshold. An LPN gave a calcium carbonate form that did not match the order for a chewable tablet, another LPN crushed levetiracetam tablets despite the drug handbook stating they should not be crushed, and a third LPN administered duloxetine in a form that did not match the ordered sprinkle capsule. The DON stated staff were expected to clarify mismatched dosage forms before giving the medication.
Pain meds were administered outside prescriber parameters for three residents. One resident received oxycodone-acetaminophen multiple times when pain was below the ordered severe-pain threshold, while two other residents received hydrocodone-acetaminophen or oxycodone-acetaminophen when their documented pain level was 0. The DON and ADON acknowledged the MAR entries, and the facility policy stated meds are to be administered in accordance with prescriber orders.
A resident’s ipratropium-albuterol neb vials were found in a med cart with a partially missing Rx label and an incomplete handwritten date opened on the foil pouch. The LPN acknowledged the missing label information, and the DON stated staff were not to alter Rx labels and were to contact the pharmacy for any removed labels; facility policy required complete labeling and that only the dispensing pharmacy could label or alter medication containers.
Sanitary food storage and temperature monitoring failures occurred when milk cartons were stored in cardboard boxes sitting in standing water inside the dairy refrigerator, with water soaking through the boxes and contacting the cartons. During lunch service, the FC plated and sent out resident meals without checking or recording food temperatures, and the RD confirmed no temperatures were documented before service.
A deficiency was cited for not ensuring a resident's right to dignity, self-determination, communication, and the exercise of their rights. The report does not specify the exact circumstances or individuals involved.
A facility failed to provide adequate pressure ulcer care for three residents at risk. One resident was not repositioned every two hours as required, and a low air loss mattress was not used. Additionally, there were missing entries in the wound treatment logs for all three residents, raising concerns about whether treatments were performed as ordered. Interviews with staff highlighted the importance of documentation to ensure treatments were completed, but the facility did not adhere to its policies, resulting in deficiencies.
The facility failed to maintain food safety and sanitation standards in the kitchen, as observed with cutting boards that had deep cuts and stains stored in the clean area. A dietary worker acknowledged the need for replacement, and the Food Services Director emphasized the importance of avoiding contamination. The facility's policy requires utensils and equipment to be clean and in good repair, but this was not followed, exposing residents to potential foodborne illness.
A resident with chronic respiratory failure and a tracheotomy was administered oxygen at a rate of 5 L/min instead of the prescribed 2 L/min. This error was observed over several days and confirmed by a licensed nurse, who acknowledged the risk of excessive carbon dioxide accumulation. The facility's policy on verifying and documenting physician orders was not followed, leading to this deficiency.
The facility failed to ensure kitchen staff properly calibrated food thermometers, as observed when a staff member incorrectly demonstrated the calibration process. The Dietary Supervisor confirmed the expectation for staff to know proper calibration methods to prevent foodborne illnesses. The facility's policy requires using ice water for accurate calibration, which was not followed.
A facility failed to accurately document antibiotic administration for a resident with osteomyelitis and MRSA. The MAR showed discrepancies for Daptomycin and Teflaro administration, which were not recorded as given on a specific date, although the IV Administration Record indicated they were administered. Interviews with LNs and the DON highlighted the importance of consistent documentation to ensure accurate clinical records.
A resident was administered psychotropic medications without appropriate diagnoses or reassessment. Quetiapine was prescribed for schizophrenia without supporting documentation, and alprazolam was given beyond the 14-day PRN limit without physician reassessment. The facility's policy on medication use was not followed.
The facility failed to implement proper infection control measures in two instances involving Enhanced Barrier Precaution (EBP) rooms. A housekeeper removed PPE in the hallway instead of inside the room, and a visitor provided care without wearing the required PPE. Both actions were contrary to the facility's infection prevention policy, which mandates PPE removal before exiting the room and proper education for visitors.
A facility failed to follow a physician's plan of care for a resident, neglecting to perform weekly weights and notify the physician of vital sign deviations. The resident, with Down syndrome and severe constipation, had only two weights recorded and experienced multiple instances of abnormal vital signs without physician notification. Staff interviews revealed lapses in monitoring and communication responsibilities.
A resident admitted with a foley catheter did not have a care plan implemented until several months later, despite the presence of a physician's order. This delay in care planning placed the resident at risk for urinary tract infections. The infection preventionist nurse and DON acknowledged the oversight, which was contrary to the facility's catheter care policy.
Medication Documentation and Administration Errors
Penalty
Summary
Safe and effective pharmaceutical services were not maintained when controlled medications were documented as signed out of the controlled drug record (CDR) but were not documented on the Medication Administration Record (MAR) as administered. For Resident 73, hydrocodone-acetaminophen was signed out on the CDR without a corresponding MAR entry on one occasion. For Resident 4, oxycodone-acetaminophen was signed out on the CDR without MAR documentation on one occasion. For Resident 50, multiple morphine sulfate doses were signed out on the CDR without MAR documentation on several dates and times, and one morphine sulfate administration was documented on the MAR without a corresponding CDR sign-out. The DON stated the CDR and MAR documentation should match and be accurately charted. Resident 50 also had medication administration issues related to prescribed use parameters. The record showed morphine sulfate oral solution was administered on a date when the order was not active, and another dose was documented on the MAR even though the resident’s pain level was below the ordered threshold of 7. The DON acknowledged the documentation and stated the morphine sulfate oral solution was ordered for pain levels greater than or equal to 7. Resident 8 had medication administration not consistent with prescriber orders. The MAR showed metoprolol tartrate was given despite systolic blood pressure readings below the hold parameter of 110 on two occasions. Resident 8 also had Ozempic documented as not given because it was unavailable on two occasions, with the MAR coded as drug not available. In addition, four insulin pens for Residents 4, 31, and 8 were observed in a medication cart with blank date-open stickers, and the DON stated the pens had been opened and were being used.
Resident lacked personal clothing and footwear
Penalty
Summary
The facility failed to ensure that Resident 17 had sufficient personal clothing of choice and available footwear to support dignity. Resident 17 was admitted with cachexia and, during an observation and interview, was found sitting in bed wearing a hospital gown. The resident stated she was wearing the gown because she did not have enough personal clothing and wanted to purchase clothing of her choice. She also stated she had requested access to her personal funds to buy clothing, but the facility had not provided the money after she made the request. Resident 17's closet contained one jacket, one dress, and some folded pants, but no shoes were present. One slipper was in the closet, but the matching slipper could not be located. An LN stated she knew the resident had requested additional clothing and had provided clothing from the facility's donated clothing supply, but she was unaware the resident had personal funds and wanted to buy clothing. The LN acknowledged that the resident not having sufficient footwear or being able to purchase and choose personal clothing was a dignity concern. The DON stated the facility was expected to provide residents' basic needs, such as clothing and food, and that if the resident's request to buy clothing and have access to basic footwear was not met, it could impact emotional well-being and dignity.
Failure to Provide Access to Resident Personal Funds
Penalty
Summary
The facility failed to ensure one resident had access to personal funds when the resident requested money to purchase clothing of choice. Resident 17, who was admitted with cachexia and was observed sitting in bed wearing a hospital gown, stated she wore the gown because she did not have enough personal clothing. She also stated she wanted to buy clothing of her choosing and had requested access to her money, but the facility had not provided access to it. During interviews and record review, the licensed nurse stated she was not aware the resident had personal funds available and said social services handled resident funds. The social service director confirmed the resident had previously lived at a board and care facility and reviewed social services notes showing the resident could not return there, but the notes did not document discussion of the resident’s social security income, personal funds, or access to funds with the board and care facility. The social service director also stated she did not know the resident received social security income until 4/24/26 and that the facility had no documentation of attempts to contact the board and care facility about the resident’s income after the resident became a long-term care resident. The business office manager stated the facility used the MC 171 form to identify resident income and benefits, but Resident 17’s signed MC 171 indicated current income as none. The business office manager stated the business office was not notified after the resident was determined not to return to the board and care facility and did not submit an updated MC 171 or reassess the resident’s social security benefit status. Although the resident signed the Resident Trust Fund Authorization allowing the facility to manage money and deposit Social Security checks into the resident trust account, the business office manager stated the resident declined to sign the separate bank form needed to open the trust account and did not provide documentation of that refusal. The social service director stated that because the resident did not have access to her personal funds, she could not purchase items of her choosing.
Failure to Follow Up on Change in Condition in Restorative Nursing
Penalty
Summary
Professional standards of quality were not followed when a resident’s change in condition was not followed up on. Resident 10 was admitted with diagnoses including acute and chronic respiratory failure, muscle spasm, and contractures of both knees. A restorative nurse’s aide weekly summary dated 4/11/26 documented increased resistance and stated that the licensed nurse was notified, but prior weekly summaries reviewed back to November 2024 used the same non-specific language and did not identify joint motion limits. The Director of Therapy stated the restorative notes were non-specific and may have been copied, and that the notes did not list joint motion limits. During interviews and record review, the DON and ADON stated there were twice-monthly restorative nursing meetings and that residents on restorative programs were discussed, but they could not locate a record showing that the licensed nurse was notified or followed up on the report of joint tightening. The weekly restorative summary was signed by a licensed nurse, and the DON stated it was expected that the licensed nurse would complete further follow-up depending on the issue reported. The physician order dated 4/22/26 was also reviewed and was entered incorrectly as one time only for three months instead of three times weekly for three months.
Failure to Document IV Fluid Intake
Penalty
Summary
The facility failed to record and document fluid intake for a resident receiving IV therapy. Resident 118 was admitted with diagnoses that included dysphagia and, during observation, was found in his room with a peripheral IV line in the back of his right hand and receiving Dextrose-Sodium Chloride Intravenous Solution 5-0.9% for hydration. The physician had ordered intake and output monitoring every shift for 30 days, and the IV fluid order directed 100 ml/hr intravenously every shift for 3 days. Record review showed that the IV fluids started on 4/21/26 were not being recorded and documented by nursing staff every shift. During interview, the ADON stated that nursing does not record or document IV fluid intake. The DON later stated that fluid intake includes IV fluids and that it was her expectation that nurses record and document the IV fluids every shift. Facility policies titled Intravenous Administration of Fluids and Electrolytes and Intake, Measuring and Recording both indicated that IV fluids are to be documented in the resident's medical record and on the intake/output record.
Failure to Monitor and Treat Pain Signs
Penalty
Summary
Provide safe, appropriate pain management for a resident who required such services was not met for Resident 23. The resident was admitted with anoxic brain damage and acute and chronic respiratory failure, had a tracheostomy, was totally fed via g-tube, was unable to speak, and was dependent on staff for all ADLs. The hospital discharge medication orders dated 3/30/26 included routine acetaminophen 325 mg, two tablets via g-tube three times a day, along with acetaminophen 650 mg every 6 hours as needed for pain or fever, but the facility’s current medication list did not include the routine acetaminophen order. The DON could not state why the routine acetaminophen was not carried over to the admission orders, and no physician’s order for acetaminophen was located in the record. The pain medication record showed oxycodone 2.5 mg was given four times in April 2026, with the nurse documenting pain levels of 7 or 8 each time, and acetaminophen was not given during that month. During observed wound care, Resident 23 frowned and grimaced near the end of care and did not respond to verbal reassurance; two LNs observed the facial expression and one stated it appeared to be a sign of pain. The nursing care plan identified acute and chronic pain related to wounds and immobility and included watching for signs of pain such as restlessness, facial grimace, crying, and breathing changes, along with pain relief measures such as repositioning, music, dim lights, reassurance, and giving pain medication as ordered.
Medication Error Rate Exceeded 5 Percent
Penalty
Summary
The facility failed to ensure the medication error rate remained below five percent. Surveyors found three medication errors during 26 observed medication administration opportunities, resulting in an 11.54% error rate for three of five randomly observed residents. The cited errors involved Resident 53, Resident 85, and Resident 106 during medication administration observations and record reviews. For Resident 53, LN 30 administered calcium carbonate 500 mg even though the order in the medical record was for calcium carbonate oral tablet 500 mg four times daily, and the nurse stated she did not see the word "chewable" on the order. For Resident 85, LN 31 crushed all of the resident’s tablets together and mixed them with applesauce, including levetiracetam 500 mg twice daily, even though the facility drug handbook stated levetiracetam tablets should be swallowed whole and not chewed, broken, or crushed. For Resident 106, LN 32 administered duloxetine delayed-release 30 mg capsule even though the order was for duloxetine oral capsule delayed release sprinkle 30 mg, and the nurse stated she did not see that the medication administered matched the sprinkle form in the record. The DON stated nursing staff were expected to clarify orders with the prescriber or pharmacy before administration when the dosage form on hand did not match the order.
Pain Medications Given Outside Ordered Parameters
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors when pain medications were administered outside of the prescribers’ ordered parameters. Resident 93 had an order for oxycodone-acetaminophen 7.5/325 mg, one tablet every 4 hours as needed for severe pain rated 7-10, yet the April 2026 MAR showed 13 administrations when the documented pain level was below 7, including several doses given when pain was 0, 1, 3, 4, 5, or 6. During the concurrent review, the DON acknowledged these entries and stated she expected nursing staff to notify the prescriber if a resident requested a pain medication when the pain level was outside the parameter. Resident 73 had an order for hydrocodone-acetaminophen 7.5/325 mg, one tablet every 6 hours as needed for moderate to severe pain rated 4-10, but the April 2026 MAR showed two administrations when the pain level was documented as 0. Resident 4 had orders for oxycodone-acetaminophen 5/325 mg as needed for moderate to severe pain, including one order that was active from 11/19/25 to 4/15/26 and another from 4/15/26 to 4/24/26; the April 2026 MAR showed three administrations when the pain level was documented as 0. The DON and ADON acknowledged the documented administrations when pain was zero, and the facility policy stated that medications are administered in accordance with prescriber orders.
Missing Medication Label Information and Incomplete Open-Date Documentation
Penalty
Summary
The facility failed to ensure safe and effective prescription labeling when a portion of both a prescription label and the handwritten date opened were missing from ipratropium-albuterol nebulizer vials stored for Resident 38 in Station 1 Medication Cart 2. During observation and interview, two plastic bags containing foil pouches of the medication were found in the cart. One bag had a prescription label with part of the directions missing, and the other bag contained an opened foil pouch with a handwritten date opened on the back that was partially missing; the intact portion read 11/26. The product labeling on the front of the foil pouch stated that once removed from the foil pouch, the individual vials should be used within one week. The nurse acknowledged the missing portion of the label, and after the remaining date was read, stated the opened pouch needed to be discarded. Resident 38 had an active order for ipratropium-albuterol 0.5-2.5 mg per 3 mL inhaled orally every 4 hours as needed for shortness of breath or wheezing, started 1/24/26. The DON stated nursing staff were not to write, touch, or rip any prescription label and were to contact the pharmacy for any removed labels; the facility policy stated that labels for individual resident medications must include necessary information and that only the dispensing pharmacy can label or alter the label.
Sanitary Food Storage and Temperature Monitoring Failures
Penalty
Summary
The facility failed to maintain sanitary food storage and food service practices when individual 4-ounce milk cartons were stored in cardboard boxes sitting in standing water inside the dairy refrigerator. During observation, the refrigerator had about one inch of water across the bottom shelf, and six large cardboard boxes of milk cartons were placed on metal pans faced down in the water. Two of the boxes were saturated, and water had seeped through the cardboard and contacted the exterior surfaces of the milk cartons. The DS acknowledged the standing water and wet milk cartons and stated the condition was a sanitation and infection control concern. The RD also acknowledged the standing water, wet boxes, and milk cartons and stated the refrigerator had previously had pooling water problems. The facility also failed to verify cooking and holding temperatures before serving lunch. During tray line service, the FC placed prepped food in warming trays, removed the plastic wrap, and began plating resident meals without taking the temperature of any meal item. The FC loaded two meal delivery carts without checking the holding temperature of the food and did not record any temperatures in the log. The FC stated temperatures were supposed to be taken and recorded before serving, and the RD confirmed there were no temperatures recorded for the lunch meal items and stated temperatures should be taken before serving to ensure food is safe to serve to residents.
Failure to Honor Resident Rights
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report notes that the facility did not ensure these resident rights were upheld, but does not provide specific details about the actions or inactions that led to this deficiency, nor does it mention any particular events or residents involved.
Deficiencies in Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for three residents identified as being at risk for pressure injuries. Resident 99, who was admitted with a Stage 4 pressure ulcer on the left heel, was not turned and repositioned every two hours as required by his care plan. Observations showed that Resident 99 remained in the same position for extended periods, and a low air loss mattress, which could have helped prevent further skin breakdown, was not utilized. Additionally, there were missing entries in Resident 99's daily wound treatment log, indicating that wound care may not have been consistently provided. Resident 11, admitted for physical therapy, developed a right heel ruptured blister. Despite having a physician's order for daily wound treatment, the Treatment Administration Record (TAR) showed that treatments were missed on two occasions. The lack of documentation raised concerns about whether the treatments were performed as ordered. Similarly, Resident 12, who had Stage 4 pressure ulcers on the left buttock and right hip, also had missing entries in her wound treatment log, with treatments not documented for three days. Interviews with staff, including the Treatment Nurse and Director of Nursing, revealed that the facility's policy required documentation of all treatments to ensure they were completed. The absence of documentation meant there was no assurance that the necessary wound care was provided, potentially leading to additional or worsening skin injuries. The facility's failure to adhere to its own policies and care plans resulted in deficiencies in pressure ulcer care and prevention for these residents.
Deficient Food Safety and Sanitation Practices in Kitchen
Penalty
Summary
The facility failed to ensure food safety and sanitation practices were adhered to in the kitchen, as observed during a survey. Two green cutting boards with deep cuts and food stains were found stored in the clean area, along with one red and one brown cutting board that also had deep cuts. These cutting boards were observed by a dietary worker and were noted to have been recently washed, yet still exhibited visible stains and knife cuts. The dietary worker acknowledged that the green cutting board needed to be changed. An interview with the Food Services Director confirmed the importance of not using stained cutting boards due to the risk of contamination from residue in the cuts. The facility's policy on sanitation, dated 2023, requires all utensils and equipment to be kept clean and in good repair, free from breaks, corrosions, and other defects. The policy also mandates the disposal of plastic ware that becomes unsanitary or hazardous. The failure to adhere to these standards exposed residents to the risk of foodborne illness due to contaminated food surfaces.
Oxygen Administration Error for Resident
Penalty
Summary
The facility failed to administer the correct amount of oxygen to a resident, as per the physician's order. Resident 99, who was admitted with chronic respiratory failure with hypoxia and had undergone a tracheotomy, was observed on multiple occasions receiving oxygen at a flow rate of 5 liters per minute, contrary to the physician's order of 2 liters per minute via trach mask continuously. This discrepancy was noted during observations on February 10 and 11, 2025, and confirmed by a licensed nurse on February 12, 2025. The licensed nurse acknowledged the error and recognized the risk of excessive carbon dioxide accumulation in the resident's bloodstream due to the higher oxygen flow rate. The respiratory therapist and the Director of Nursing both emphasized the importance of adhering to the physician's orders to prevent potential harm. The facility's policy on oxygen administration, which requires verification and documentation of the physician's order, was not followed, leading to this deficiency.
Improper Calibration of Food Thermometers by Kitchen Staff
Penalty
Summary
The facility failed to ensure that the kitchen staff competently performed and carried out the functions of the Food and Nutrition Service department. During an observation and interview, a staff member, referred to as [NAME] 1, was unable to properly demonstrate how to calibrate an analog food thermometer. [NAME] 1 incorrectly attempted to adjust the thermometer by twisting the probe and stated that it was unnecessary to place the thermometer in water if it was already set to 32 degrees Fahrenheit. This incorrect method of calibration was contrary to the facility's policy, which requires the thermometer to be submerged in ice water to ensure accurate calibration. The Dietary Supervisor confirmed that it was expected for all kitchen staff to know how to properly calibrate both digital and analog thermometers. The supervisor emphasized the importance of using a calibrated food thermometer to ensure accurate food temperature readings and prevent undercooked food, which could lead to foodborne illnesses. A review of the facility's policy on thermometer use and calibration outlined the correct procedure, which involves using a mixture of crushed ice and water to calibrate the thermometer. The failure to adhere to this policy had the potential to result in food contamination and posed a risk of foodborne illnesses for all residents consuming food from the kitchen.
Inaccurate Documentation of Antibiotic Administration
Penalty
Summary
The facility failed to accurately document the administration of antibiotics for Resident 88, who was admitted with osteomyelitis and MRSA. The resident's clinical record showed discrepancies in the Medication Administration Record (MAR) for the administration of Daptomycin and Teflaro on January 28, 2025. These medications were not recorded as administered in the MAR, although the facility's IV Administration Record indicated they were given. This inconsistency in documentation could lead to an incomplete and inaccurate clinical record for Resident 88. Interviews with Licensed Nurses (LN) 1 and 2 revealed that the MAR did not reflect the actual administration of the antibiotics, and there were no notes explaining the absence of documentation. LN 2 acknowledged the importance of consistent medication administration to maintain the medication threshold for fighting the infection. The Director of Nursing (DON) expected the MAR to match the IV Administration book to ensure accurate and complete documentation. The facility's policy on Charting and Documentation requires that medications administered be documented in the resident's medical record.
Failure to Ensure Resident is Free from Unnecessary Drugs
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary drugs, as evidenced by the administration of psychotropic medications without appropriate diagnoses or reassessment. Resident 1, who was admitted with diagnoses including respiratory failure and cerebral palsy, was prescribed quetiapine for schizophrenia, despite lacking documentation or symptoms to support this diagnosis. Interviews with a licensed nurse and the resident's family member confirmed that the resident did not exhibit behaviors indicative of schizophrenia, and the psychiatrist acknowledged that the diagnosis was used to justify the medication's continued use, despite the resident being nonverbal and unable to be properly diagnosed. Additionally, the facility did not adhere to the 14-day limit for PRN orders of the anti-anxiety medication alprazolam, as it was administered to the resident multiple times beyond this period without reassessment by a physician. The licensed nurse admitted that the medication should have been reassessed and a new order issued if continued use was necessary. The facility's policy on antipsychotic medication use was not followed, as it requires PRN orders to be reassessed and documented for continued use beyond 14 days.
Infection Control Lapses in EBP Rooms
Penalty
Summary
The facility failed to implement proper infection control measures in two instances involving Enhanced Barrier Precaution (EBP) rooms. In the first instance, a housekeeper was observed exiting an EBP room while wearing personal protective equipment (PPE) and subsequently removing the PPE in the hallway, rather than inside the room. This action was contrary to the facility's infection prevention policy, which requires PPE to be doffed and discarded before exiting the room to prevent the spread of infection. The Infection Preventionist confirmed that the housekeeper's actions were inappropriate and highlighted the risk of contamination from handling items with dirty gloves. In the second instance, a visitor was observed providing care to a resident in an EBP room without wearing the required PPE, except for a surgical mask. The visitor was unaware of the need to wear a gown and gloves, despite the presence of an EBP sign outside the room. The visitor expressed concern about potentially bringing infections home, especially with a pregnant family member. The Infection Preventionist emphasized the importance of educating visitors about PPE requirements to prevent infection spread. The facility's policy mandates infection control measures for both employees and visitors, but these were not adhered to in this case.
Failure to Follow Physician's Plan of Care for Resident
Penalty
Summary
The facility failed to adhere to the physician's plan of care for a resident, specifically regarding the monitoring of weekly weights and the notification of the physician when vital signs were outside the set parameters. The resident, who was admitted with diagnoses including Down syndrome and severe constipation, required weekly weights and specific vital sign monitoring as per the physician's orders. However, the facility did not perform weekly weights consistently, with only two weights recorded between admission and discharge. Additionally, the facility did not notify the physician when the resident's vital signs were outside the prescribed parameters. The resident's heart rate exceeded 90 beats per minute eight times, and the systolic blood pressure was below 100 seven times, yet there was no documentation indicating that the physician was informed of these deviations. Interviews with staff, including CNAs and LNs, revealed that the responsibility for monitoring and reporting these metrics was not adequately fulfilled, leading to a lack of communication with the physician. The Director of Nursing acknowledged the oversight, stating that the weights should have been documented weekly and that the physician should have been notified of any vital sign deviations. The facility's policies on acute condition changes and comprehensive care plans emphasize the importance of following physician orders and documenting any changes, which were not adhered to in this case.
Failure to Implement Foley Catheter Care Plan
Penalty
Summary
The facility failed to implement a care plan for a resident who was admitted with an indwelling foley catheter. The resident, who had a surgical amputation of the right leg and stage 4 pressure ulcers, was admitted on April 13, 2024. However, a physician's order for the foley catheter was not entered until April 23, 2024, and a care plan was not implemented until July 24, 2024. This oversight placed the resident at risk for complications, including urinary tract infections, due to the presence of the foley catheter. During a joint interview and record review, the infection preventionist nurse acknowledged the delay in entering the physician's order and implementing the care plan. The Director of Nursing also confirmed that the care plan should have been in place upon the resident's admission, as it serves as a guide for the resident's care. The facility's policy on catheter care emphasizes the importance of having a care plan to prevent catheter-associated urinary tract infections and to address any special needs of the resident.
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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 La Mesa
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Grossmont Hospital D/p Snf | 0.6 mi | ★★★★★ | 0 | 0 |
| Grossmont Post Acute Care | 0.8 mi | ★★★★★ | 3 | 0 |
| Grossmont Gardens Healthcare Center | 0.8 mi | — | 22 | 0 |
| Parkway Hills Nursing & Rehabilitation | 1.2 mi | ★★★★★ | 34 | 0 |
| Arbor Hills Nursing Center | 1.2 mi | ★★★★★ | 8 | 0 |
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