Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
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 Cornerstone Care Center during CMS and state inspections, most recent first.
A resident’s emergency discharge was inadequately documented when only a brief PN noted aggressive behavior toward a CNA, injury to the CNA’s wrist, involvement of the DON and police, and transfer by emergency transport, with no further details recorded. The assigned LVN, who was new, stated she did not realize she needed to complete an SBAR, and the Administrator later confirmed that both the PN and SBAR were incomplete and lacked information about the transfer. Facility policy required nursing staff to document assessment findings and other relevant information for emergency transfers/discharges, but this was not done for this resident.
Two residents with significant pressure injuries were not provided with specialized pressure-redistributing mattresses as ordered by their physicians. Both were observed on regular mattresses, and in one case, the need for a specialized mattress was not included in the care plan. The facility was out of specialized mattresses and did not notify the physician about the unavailability, contrary to facility policy.
Surveyors identified deficiencies in food safety practices, including an improper air gap installation under the food prep sink, failure to follow thawing protocols for ground beef, and improper storage of butter croissants outside the freezer. Staff interviews and policy reviews confirmed that these actions did not meet professional standards for food service safety.
Three outside trash bins were found overfilled with garbage and debris, preventing the lids from closing as required by facility policy. Staff interviews confirmed that trash should not exceed the top of the bins and that lids must remain closed.
The facility exceeded the acceptable medication error rate when multiple residents received medications not in accordance with prescriber orders, including blood glucose checks performed after meals instead of before, medications administered at incorrect times relative to meals, and administration of the wrong medication formulation. Nursing staff and the DON acknowledged these errors, which were observed during medication passes and confirmed through interviews and record reviews.
Staff failed to properly store and dispose of medications and biologics, including placing a partially used insulin pen in the wrong container, allowing a medication destruction bin to overflow and remain unsecured, and leaving partially opened and undated IV saline bags in a medication cart. These actions did not follow facility policy and procedures, as confirmed by staff interviews and policy review.
The facility did not ensure that two residents received the correct portion sizes as ordered by their physicians, with one receiving a full portion instead of a small portion and another receiving a regular portion instead of a double portion of protein. Additionally, all residents on a regular diet were served smaller portions of baked chicken than prescribed. Staff interviews and record reviews confirmed that dietary and nursing staff did not consistently verify that meals matched physician orders and menu requirements.
Staff failed to consistently follow enhanced barrier precautions and proper disinfection procedures, as two residents with invasive devices received personal care from CNAs who wore gloves but not gowns, and a nurse did not fully disinfect a glucometer between uses. These actions were contrary to facility policy and staff training, resulting in lapses in infection control.
A resident with a urinary catheter was found with the catheter bag uncovered and visible to others, contrary to facility policy requiring privacy bags to maintain dignity. The resident, who had multiple medical conditions, was unaware of the reason for the exposure. Staff interviews confirmed the expectation that catheter bags should always be covered to respect resident privacy.
A resident admitted with multiple pelvic fractures and post-surgical aftercare experienced a significant change in condition when a new order for weight bearing as tolerated was received. The MDS nurse did not complete the required Significant Change in Status Assessment (SCSA) within 14 days, as mandated by facility policy and professional guidelines, despite being aware of the new order and the assessment requirement.
The facility did not complete or transmit required discharge MDS assessments for two residents—one discharged to a hospital and another who left against medical advice. The MDS nurse acknowledged not completing these assessments within the required timeframes, despite facility policy and job descriptions mandating timely and accurate MDS processing.
A resident with multiple medical conditions and an ongoing pressure ulcer was not accurately coded for the ulcer in the MDS assessment, despite continued treatment and documentation of the wound. The MDS nurse acknowledged the error, and interviews revealed that the DON did not check MDS assessments for accuracy, relying instead on individual staff responsibility. Facility policy required accurate assessments, but this was not followed, resulting in the deficiency.
A resident with cognitive impairment and medical orders for daily compression stockings was not provided with the prescribed care, as the assigned CNA was unaware of the order and the LVN documented administration in the eTAR without verifying the resident was wearing the stockings. The DON confirmed that staff are expected to check before signing off on care provided.
Several residents received medications such as high-dose Vitamin D, Torsemide, Sevelamer, and amiodarone without appropriate diagnoses, indications, or required laboratory monitoring. Nursing and pharmacy staff acknowledged the lack of baseline and ongoing lab assessments, incorrect medication indications, and failure to follow up on critical lab values and provider orders, resulting in deficiencies in safe medication management.
A resident with diabetes and kidney failure, who was cognitively intact, was repeatedly served milk with meals despite documented preferences for alternative beverages except at breakfast. Staff interviews and records confirmed the resident's preferences were known but not followed, resulting in the resident's distress and potential impact on nutritional intake.
Two residents experienced deficiencies in their living environment, including a bedroom wall with deep scratches and missing paint, and a bathroom wall with a hole, both of which were observed and confirmed by staff. One resident felt unimportant due to the lack of repairs, and staff acknowledged that these issues should have been addressed through the maintenance process. Facility policies require regular inspections and a homelike environment, but these were not upheld in these cases.
The facility did not follow its policy requiring English to be spoken in resident care areas, as reported by three residents who heard staff speaking non-English languages in their presence. This failure potentially impacted the residents' rights and dignity by causing confusion and leaving them uninformed about their health status in a language they could understand.
The facility failed to maintain secure and monitored exits, as multiple doors leading to the exterior were not properly alarmed or monitored. The C-Wing exit door's alarm was non-functional for over three weeks, and a sliding door to an outdoor patio had a broken alarm, with an unlocked gate leading to a public street. Nine additional sliding doors from resident rooms to the patio were neither locked nor alarmed, posing a risk for residents with cognitive impairments who may wander.
The facility failed to maintain electrical safety by overloading outlets with adapters and improperly using an extension cord. Observations revealed a six-outlet adapter plugged into a two-outlet receptacle and an extension cord connected to a power strip adapter. The facility's policy prohibits such practices, highlighting a potential safety risk.
The D-Wing shower room was found unclean, with dark spots on the floor and door, after being used to shower a resident. A CNA confirmed its use, and the DON acknowledged it should have been clean. The facility's policy requires daily cleaning by housekeeping, with nursing staff assisting as needed.
A long-term care facility failed to administer medications and conduct fingerstick blood sugar tests as prescribed for several residents, leading to potential risks of decreased medication absorption and inaccurate blood sugar readings. Additionally, a medication cart was left unlocked and unattended, posing a risk of unauthorized access.
A resident with a history of hearing loss was not provided with a hearing aid upon admission to an LTC facility, despite previous use documented in hospital records. Staff interviews revealed a lack of awareness and assessment regarding the resident's need for a hearing aid, impacting communication and daily interactions.
A resident was administered unnecessary psychotropic medications without prior non-pharmacological interventions, leading to falls, weight gain, and dysphagia. The facility failed to document clinical rationale for the use and dosage increases of alprazolam, aripiprazole, and quetiapine. The resident's medical records did not support the diagnoses used to justify these medications, and the facility did not attempt gradual dose reductions or adequately assess the ongoing need for these medications.
The facility did not post the most recent survey results in an accessible location for residents and their representatives. The survey binder, located between the administrator's office and the nurses' station, lacked the 2022 recertification survey results. The Administrator confirmed that these results were kept in a separate, unlabeled binder in his office, contrary to the facility's policy on resident rights, which mandates that survey results be readily accessible.
The facility failed to maintain food service safety standards by not having an air gap in the food preparation sink, risking backflow of contaminated water. Observations revealed the absence of an air gap, and a cook was seen using the sink to thaw a pork roast, increasing contamination risk. The facility did not meet the FDA Food Code 2022 requirements for backflow prevention.
The facility failed to maintain a homelike environment for several residents, with issues such as a damaged ceiling, broken light pull string, and a burned-out bulb. These deficiencies were not logged or addressed by the maintenance staff, affecting the residents' living conditions.
The facility failed to develop and implement comprehensive care plans for several residents, leading to unaddressed medical needs and potential risks. A resident on anticoagulant medication lacked a care plan to monitor side effects, while another resident ambulated without proper footwear, posing a fall risk. Additionally, a resident's care plan for fall prevention was not followed, and three residents on antibiotics had no care plans to monitor treatment effectiveness and side effects.
The facility failed to provide adequate foot care for three residents, resulting in long and thick toenails that posed a risk for complications. Despite having a policy for routine foot care, there was a breakdown in communication and procedure adherence among staff, leading to missed podiatry appointments. The residents had various medical conditions, and the lack of care was deemed unacceptable by the DON.
The facility failed to provide adequate pharmaceutical services, including missing insulin in the emergency kit and improper administration of diclofenac gel without dosing sticks for two residents. Additionally, the facility lacked a system for reconciling controlled drugs, leading to unaccounted oxycodone-acetaminophen tablets for a resident. These deficiencies were acknowledged by the DON and observed by surveyors.
The facility failed to properly label and store medications, leading to deficiencies in multiple medication carts. In the C wing, Normal Saline bags lacked use-by dates. In the D wing, a discontinued nystatin cream was not separated from active medications. In the A wing, several discontinued medications, including ondansetron and hydrocodone/acetaminophen, were not separated, and a fluticasone diskus lacked a use-by date. Staff were unaware of the proper procedures for handling discontinued medications, as outlined in the facility's policy.
The facility failed to maintain an effective infection prevention and control program, as evidenced by soiled toilets not being promptly cleaned, dirty linens left on the floor, and improper disinfection of a shared glucometer. These actions involved multiple residents and staff, including CNAs and LVNs, who did not adhere to established protocols, potentially leading to cross-contamination and infection spread.
A resident's urinary catheter bag was left uncovered, visible to others, compromising their dignity and privacy. Despite the facility's policy and staff acknowledgment that catheter bags should be covered, the bag was observed uncovered on multiple occasions. The resident, with conditions requiring a catheter, was not aware of the exposure, and staff admitted the oversight, recognizing it as a dignity issue.
A resident's MDS assessment failed to accurately reflect their anxiety diagnosis, despite being on antianxiety medications. The MDSN acknowledged the error, and the DON noted the need for complete and accurate assessments. The facility lacked a specific policy for MDS assessments, relying on RAI guidelines.
A resident was inappropriately administered antipsychotic medications due to an inaccurate mental health diagnosis of schizoaffective disorder, despite no prior history of such a condition. The resident's behaviors, such as slamming doors and confusion, were used to justify the medication, leading to adverse effects like weight gain. The facility failed to complete a required PASRR and lacked proper documentation and communication among healthcare providers.
A resident with a confirmed dementia diagnosis did not receive appropriate treatment and services due to the facility's failure to update their medical records and develop a comprehensive care plan. Despite displaying symptoms like confusion and aggression, the resident's dementia was not documented in their electronic medical record or MDS, leading to inadequate management of their condition.
A resident with a history of seizures was not properly monitored for levetiracetam levels after a dosage increase in an LTC facility. Despite being placed on hospice and having lab orders discontinued, the resident's levetiracetam level rose significantly, posing a risk of unnecessary drug administration. Interviews revealed a lack of documentation for discontinued labs and no observed symptoms of toxicity, highlighting a failure in monitoring the drug regimen.
A resident's bathroom was found to have cockroaches, indicating an ineffective pest control program. The DON and IP acknowledged the issue, noting that pest control services were provided monthly or as needed. The resident and housekeeper confirmed sightings of cockroaches, and maintenance logs showed a previous infestation.
Failure to Document Resident Condition and Events During Emergency Discharge
Penalty
Summary
The deficiency involves the facility’s failure to document the condition and circumstances surrounding the emergency discharge of one resident. The resident was admitted on 1/21/26 and discharged on 6/25/25, and the clinical record contained a single progress note dated 6/25/26 stating that the resident was very aggressive toward a CNA during care and injured the CNA’s wrist. The note further indicated that the DON witnessed the incident, called the police, and that the resident was sent out around 10:30 a.m. on a gurney via emergency transportation. No additional progress notes were documented regarding this event, and the resident’s record did not contain further details of the emergency discharge or the events leading to the transfer. During interview and concurrent record review, the LVN who wrote the progress note stated she was assigned to the resident that day but did not clearly remember the incident because the DON handled the situation while she was passing medications. The LVN reported she was a brand-new nurse and did not know she was supposed to complete an SBAR for the event. The Administrator confirmed that the DON referenced in the note was no longer employed at the facility and that the LVN had started but not completed an SBAR. The Administrator stated there should have been notes about the resident’s transfer and acknowledged that both the progress note and SBAR were incomplete. Review of the facility’s Transfer and Discharge policy showed that for emergency transfers/discharges initiated by the facility, nursing staff are required to document assessment findings and other relevant information regarding the transfer in the medical record, which was not done in this case.
Failure to Provide Specialized Mattresses for Residents with Pressure Injuries
Penalty
Summary
The facility failed to provide specialized mattresses to two residents who had significant pressure injuries to their sacrum, despite physician orders and documented needs for pressure redistribution devices. One resident was admitted with a stage 4 pressure ulcer and had repeated documentation in progress notes indicating the need for a pressure redistributing mattress, but was placed on a regular mattress throughout their stay. The Assistant Director of Nursing (ADON) confirmed that the resident should have been on a specialized air mattress, such as a low air loss mattress (LALM), and acknowledged that this intervention was not included in the resident's care plan. Another resident with a pressure injury to the tailbone was also observed on a regular mattress, despite a physician's order for a LALM. The ADON stated that the facility was out of specialized mattresses and could not find documentation that the physician was notified about the unavailability of the ordered mattress. The facility's policies require the use of appropriate pressure-redistributing support surfaces for residents with pressure injuries and mandate that such interventions be documented in the care plan. These failures were identified through observation, interviews, and record reviews.
Deficient Food Preparation, Thawing, and Storage Practices
Penalty
Summary
The facility failed to prepare and handle food in accordance with professional standards for food service safety in three key areas. First, the food preparation sink was equipped with an air gap that was not appropriate for use in a nursing facility. The Certified Dietary Manager (CDM) and Regional Maintenance Director (RMD) were unable to clearly explain the function and compliance of the installed air gap, which was described as a closed system with a one-way valve, and the RMD did not consult the Department of Health Care Access and Information prior to installation. This setup did not meet the requirements outlined in the FDA Food Code for preventing backflow and potential contamination of the water supply. Second, the facility did not follow proper thawing procedures for six packages of ground beef. The ground beef was removed from the freezer and stored in the refrigerator for a period exceeding the facility's policy and professional guidelines, which specify that frozen meat should be thawed in the refrigerator for no more than three days before use. Staff interviews confirmed that the meat was left in the refrigerator too long, increasing the risk of bacterial growth, and the packages were ultimately discarded as unsafe for consumption. Third, two boxes of butter croissants were found stored in the walk-in pantry instead of the freezer, contrary to the product's storage instructions and facility policy. The croissants were delivered and not immediately placed in the freezer, and staff were unsure if they were being thawed for use or had been left out in error. Facility policy requires that frozen food deliveries be placed in freezers immediately and not allowed to reach room temperature. These failures in food storage and handling practices were observed and confirmed through staff interviews and policy review.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to follow its policy and procedure for garbage and rubbish disposal, as observed when three out of three outside trash bins were filled above the rim, preventing the lids from closing properly. During an observation, the lids were found resting on top of overflowing cardboard boxes, plastic, and other debris. Interviews with the Certified Dietary Manager, Maintenance Supervisor, and Administrator confirmed that trash should not exceed the top of the bins and that lids should remain closed to prevent exposure. A review of the facility's policy indicated that all garbage should be placed in containers with tight-fitting lids and emptied as often as necessary to prevent overfilling.
Medication Error Rate Exceeds Acceptable Threshold Due to Improper Administration Practices
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, with a reported rate of 15.38 percent based on 27 observed opportunities and four medication errors involving three residents. One resident had their blood glucose checked after beginning a meal, contrary to prescriber orders requiring assessment before meals. This resulted in an inaccurate blood glucose reading and subsequent insulin administration based on a non-fasting value. Both the nurse and the Director of Nursing confirmed that the timing of the blood glucose check did not comply with the prescriber's instructions and could affect insulin dosing. Another resident experienced two errors: their blood glucose was also checked after eating, and a phosphate-binding medication (calcium acetate) was administered after the meal instead of with the meal as ordered. The resident confirmed having already eaten prior to the medication administration. The nurse acknowledged both errors, and the Director of Nursing stated that the medication would not be effective if not given as ordered. Manufacturer instructions for the medication also specify administration with meals to ensure efficacy. A third resident was administered a different phosphate binder (sevelamer carbonate) instead of the prescribed sevelamer hydrochloride, and the medication was not given in accordance with the prescriber's order. The nurse recognized the error and noted the importance of administering the correct medication for the resident's specific diagnosis. The facility's policy requires verification of the five rights of medication administration and adherence to prescriber orders, which was not followed in these instances.
Improper Storage and Disposal of Medications and Biologics
Penalty
Summary
Facility staff failed to ensure proper storage and disposal of medications and biologics according to facility policy and procedures. A partially used Lantus insulin pen for a resident was found discarded in a container labeled for medications to be destroyed, rather than being placed in a sharps container as required. Staff interviews confirmed that insulin pens should be disposed of in sharps containers to prevent access to the medication, and facility policy specified that syringes and needles must be placed in puncture-resistant, one-way containers. Additionally, the medication destruction bin was observed to be overflowing with medication blister packs, with several packs protruding above the rim and the lid unable to close securely, leaving medications exposed and unsecured. Staff acknowledged that the bin should not be overflowing and that medications should be destroyed before the bin reaches capacity. Further, two 100 ml 0.9% Normal Saline IV bags were found in a medication cart with partially opened manufacturer overwraps and no dates, contrary to facility expectations that opened items be dated with both the open and expiration dates. Staff interviews confirmed that this practice is necessary to prevent administration of expired medications. Facility policy indicated that certain medications, such as IV solutions, require an expiration date shorter than the manufacturer's date to ensure medication purity and potency.
Failure to Follow Physician-Ordered Diets and Menu Portion Sizes
Penalty
Summary
The facility failed to ensure that planned menus and physician-ordered diets were followed for residents, resulting in discrepancies in portion sizes served. Specifically, one resident with an order for small portions received a full portion of protein, bread, side dish, and dessert, while another resident with an order for a double portion of protein received only a regular portion. These errors were confirmed through observation, interviews with staff, and review of meal tickets and order summaries. The Registered Dietitian verified that the residents did not receive their correct diet orders as prescribed. Additionally, during a lunch meal service, residents on a regular portion diet were served baked chicken portions that were smaller than the prescribed 3 ounces. Weighing of the chicken pieces revealed that the portions ranged from 1.3 to 2.6 ounces, which did not meet the menu requirements. The dietary staff acknowledged that the correct portion sizes were not served, and the Certified Dietary Manager was unable to explain why the ordered four-ounce boneless chicken pieces did not meet the required portion size after preparation. Interviews with dietary and nursing staff revealed a lack of clarity and consistency in the process for checking and verifying that residents received the correct diets. The Certified Dietary Manager and Director of Nursing both indicated that it was the responsibility of dietary and nursing staff to ensure accuracy, but there was uncertainty about whether trays were double-checked before distribution. Facility policies and job descriptions reviewed indicated that staff were expected to follow meal cards and menu spreadsheets to ensure proper diets were served, but these procedures were not consistently followed.
Failure to Follow Enhanced Barrier Precautions and Proper Disinfection Procedures
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by staff not following enhanced barrier precautions (EBP) and improper disinfection of shared medical equipment. For two residents with significant medical conditions, including muscle weakness, spinal fusion, hemiplegia, and the presence of invasive devices such as a PICC line and urinary catheter, staff did not consistently wear the required personal protective equipment (PPE) during high-contact care activities. Observations showed that certified nursing assistants provided personal hygiene and handled urinary catheter bags for these residents while wearing gloves only, omitting gowns, despite clear signage and facility policy requiring both gloves and gowns for EBP cases. Staff interviews confirmed a lack of awareness or adherence to EBP protocols, even though the facility had provided training and had clear expectations for PPE use during such care activities. Additionally, a licensed vocational nurse was observed cleaning a glucometer used for multiple residents without properly disinfecting all surfaces according to manufacturer instructions and facility policy. The nurse acknowledged not using a new wipe for each surface and not ensuring the device remained wet for the required contact time. This improper disinfection practice was confirmed during interviews and was contrary to both the manufacturer's guidelines and the facility's written procedures for glucometer cleaning and disinfection. These lapses in infection control practices, including failure to use appropriate PPE during high-contact care and inadequate disinfection of shared medical equipment, created conditions that could facilitate the transmission of infectious agents among residents and staff. The facility's own policies and staff statements indicated an understanding of the required procedures, but observations and interviews demonstrated inconsistent implementation at the point of care.
Uncovered Urinary Catheter Bag Compromises Resident Dignity
Penalty
Summary
A deficiency was identified when a resident's urinary catheter bag was observed hanging uncovered and visible to others in the resident's room while the resident was eating lunch. The catheter bag, filled with yellow urine, was not concealed by a privacy bag, making it visible to anyone entering the room. The resident, who had a history of hemiplegia, hemiparesis, obstructive and reflux uropathy, and benign prostatic hyperplasia, stated he was unaware of why the catheter bag was left uncovered. Staff interviews confirmed that the standard practice and facility policy require catheter bags to be covered with privacy bags to maintain resident dignity and privacy. The Certified Nurse Assistant responsible for the resident acknowledged the oversight and immediately covered the bag upon noticing the deficiency. Both the Infection Preventionist and the Director of Nursing confirmed that all staff are expected to ensure catheter bags are covered at all times, as outlined in the facility's dignity and resident rights policies.
Failure to Complete Timely MDS Significant Change Assessment After Resident Status Change
Penalty
Summary
The facility failed to complete a Minimum Data Set (MDS) Significant Change in Status Assessment (SCSA) within 14 days for a resident who experienced a significant change in condition. Specifically, the resident was admitted with multiple pelvic fractures and post-surgical aftercare, and later received a new order allowing weight bearing as tolerated following an orthopedic follow-up. Despite this significant change, the MDS nurse confirmed that no SCSA was completed within the required timeframe, and the last MDS assessment on record was a Medicare 5-day assessment related to the change in weight bearing status. Interviews and record reviews revealed that the MDS nurse was aware of the new order and the requirement for a significant change assessment but did not complete it as mandated. The facility's policies and job descriptions require timely and accurate completion of MDS assessments, and professional guidelines specify that a SCSA must be completed within 14 days of determining that criteria are met. The administrator stated an expectation for timely and accurate MDS completion, but this was not met in this instance.
Failure to Complete and Transmit Discharge MDS Assessments Timely
Penalty
Summary
The facility failed to meet required timelines for encoding and transmitting Minimum Data Set (MDS) assessments for two residents. Specifically, the Minimum Data Set Nurse (MDSN) did not complete or transmit the discharge MDS assessment for two residents who were discharged from the facility. One resident was discharged to a general acute hospital and did not return, while the other left the facility against medical advice. In both cases, the MDSN acknowledged that the discharge MDS assessments were not completed or transmitted as required by regulations. For the first resident, the clinical record showed admission with diagnoses including asthma, hypertension, and pain. The resident was sent to a general acute hospital and did not return, but the required discharge MDS assessment was not found in the record. The MDSN confirmed that the assessment was not completed within the 14-day requirement following discharge. For the second resident, who had diagnoses of muscle weakness, COPD, and anemia, the record indicated the resident left against medical advice. The MDSN also did not complete or transmit the required discharge MDS assessment within the 30-day timeframe for this resident. Interviews with the MDSN and the Administrator confirmed that it was the MDSN's responsibility to ensure all assessments were opened, completed, and transmitted in a timely manner. Facility policy and job descriptions reviewed during the survey also indicated the expectation for timely and accurate completion of MDS assessments. The failure to complete and transmit these assessments as required constituted a deficiency in the facility's assessment and discharge process.
Inaccurate MDS Assessment of Pressure Ulcer
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident's health and functional status, specifically regarding the presence and stage of a pressure ulcer. A resident with a history of dysphagia, hemiplegia, hemiparesis, and shortness of breath was observed with a low air loss mattress and had an ongoing pressure ulcer on the right buttock, initially diagnosed as an unstageable pressure injury and later changed to a Kennedy ulcer with stage 3 appearance. Despite ongoing treatment for the open ulcer, the MDS quarterly assessment did not code the presence of any ulcer, which the MDS nurse acknowledged as an error in coding and an inaccurate assessment. Interviews with facility staff revealed that the Director of Nursing did not verify the accuracy of MDS assessments and relied on the staff responsible for completing them to ensure correctness. The MDS nurse admitted to the coding error, and the administrator confirmed the expectation for accurate, complete, and timely assessments. Facility policy required qualified staff to conduct accurate assessments and document medical and functional problems, but this was not followed in this instance, resulting in the resident's pressure ulcer not being properly documented in the MDS.
Failure to Ensure Accurate Administration and Documentation of Compression Stockings
Penalty
Summary
A deficiency occurred when a Licensed Vocational Nurse (LVN) documented in the electronic Treatment Administration Record (eTAR) that a resident was wearing compression stockings, despite the resident not having them on at the time of observation. The resident, who had diagnoses including encephalopathy, hypertension, and muscle weakness, was moderately cognitively impaired and had a physician's order for daily application of compression stockings to address lower leg swelling. During observation, the resident was found wearing only non-skid socks and reported not remembering ever wearing compression stockings since admission. The assigned Certified Nursing Assistant (CNA) confirmed the resident was not wearing compression stockings and stated she was unaware of the order for daily use. Further review revealed that the LVN signed off on the eTAR without verifying whether the resident was actually wearing the compression stockings, acknowledging during interview that it was his responsibility to check before documenting. The Director of Nursing (DON) stated that the expectation was for licensed nurses to assess or check before signing the eTAR or eMAR. Job descriptions for both the LVN and CNA roles indicated responsibilities for providing care as ordered and completing assigned tasks, but these were not followed in this instance, resulting in the resident not receiving the prescribed care.
Failure to Monitor and Appropriately Indicate Medications in Drug Regimens
Penalty
Summary
The facility failed to ensure that residents' drug regimens were free from unnecessary drugs and that appropriate monitoring was conducted for certain medications. For two residents receiving high-dose Vitamin D supplementation, there was no documentation of baseline or ongoing laboratory monitoring to assess Vitamin D levels. Both the LVNs and the DON acknowledged that Vitamin D was being administered without lab orders or monitoring, and the pharmacy consultant confirmed the importance of obtaining baseline labs and periodic monitoring to determine the necessity and safety of continued supplementation. One resident was administered Torsemide for edema and Sevelamer HCl for hypocalcemia, but the resident did not have a diagnosis of edema or hypocalcemia. The order for Sevelamer HCl was written for hypocalcemia, but the medication is indicated for high phosphate levels, and the resident's calcium levels were within normal range while phosphate levels were elevated. The DON and pharmacy consultant both acknowledged that the indications for these medications were incorrect and that clarification with the physician was necessary before administration. Additionally, two residents were administered amiodarone without appropriate monitoring of thyroid-stimulating hormone (TSH) levels, despite the known risk of thyroid dysfunction associated with this medication. In one case, a resident had a critical TSH lab value and a nurse practitioner's order to adjust levothyroxine dosage and recheck TSH in six weeks, but there was no documentation that these orders were implemented. In another case, a resident had a TSH level of 0.00, a critical value, with no follow-up or new lab orders completed. The DON and pharmacy consultant confirmed that these lapses in monitoring and follow-up did not meet expectations for safe medication management.
Failure to Honor Resident Beverage Preferences During Meals
Penalty
Summary
A deficiency occurred when a resident with diabetes mellitus and kidney failure, who was cognitively intact, did not receive food in accordance with his documented preferences. Despite clear documentation in the resident's admission record, meal ticket, and progress notes indicating a preference for no milk except with breakfast and a request for alternative beverages at other meals, the resident was repeatedly served milk with his meals. The resident expressed frustration and upset at receiving milk for all scheduled meals, stating that staff were not listening to his requests. Interviews with facility staff, including a Licensed Vocational Nurse, Certified Dietary Manager, Registered Dietician, and Director of Nursing, confirmed that the resident's preferences were known and should have been honored. The facility's policy required staff to document and follow resident food preferences, but this was not done in this case. The failure to provide the requested beverage alternatives resulted in the resident being upset and had the potential to impact his nutritional intake.
Failure to Maintain Homelike and Well-Kept Resident Environment
Penalty
Summary
The facility failed to maintain a comfortable and homelike environment for two residents, as evidenced by direct observations and interviews. In one instance, a resident's bedroom wall had deep scratches, missing paint, and exposed white chalky building material. The resident expressed feeling unimportant and not listened to, attributing the lack of repairs to her financial situation. The resident's medical history included borderline personality disorder, muscle weakness, paroxysmal atrial fibrillation, and hypertension. Both a Licensed Vocational Nurse and the resident confirmed the poor condition of the wall, with the nurse stating that the environment was not homelike. In another case, a resident's bathroom wall had a one-inch by one-inch hole, which was confirmed during observation and interview. The resident reported that holes and missing paint were present throughout the building and had never been repaired. A Certified Nurse Assistant acknowledged not noticing the hole previously and stated it should have been logged for maintenance, noting the potential for pest entry. The Maintenance Director confirmed that such issues should be recorded and repaired, and that the current state did not provide a homelike environment. Facility policies reviewed indicated requirements for regular maintenance inspections and a homelike, well-kept environment.
Non-English Language Use in Resident Care Areas
Penalty
Summary
The facility failed to adhere to its policy requiring that only English be spoken in resident care areas, as evidenced by interviews with three residents who reported hearing staff converse in non-English languages in their presence. Resident 6, who is cognitively intact, expressed confusion when staff spoke in their native tongue in his room, making it difficult for him to understand what was happening. Similarly, Resident 7, with moderately impaired cognition, and Resident 1, who is also cognitively intact, reported frequent occurrences of staff speaking non-English languages in their rooms and hallways. The facility's policy, dated July 1, 2008, mandates that employees speak the language of the majority of residents, which is English, in all resident care areas to ensure residents' rights to dignity, respect, and being fully informed of their health status. The administrator confirmed that English should be spoken unless communicating with a resident who speaks another language. The failure to comply with this policy potentially compromised the residents' rights and dignity by causing confusion and leaving them uninformed about their health status in a language they could understand.
Failure to Maintain Secure and Monitored Exits
Penalty
Summary
The facility failed to ensure that the environment was free from accident hazards, as evidenced by multiple doors leading to the exterior of the facility that were not properly alarmed or monitored. Specifically, the C-Wing exit door had an electronic keypad that was not functioning, allowing the door to open directly to the outdoors without sounding an alarm. This issue had persisted for over three weeks due to a delay in receiving the correct replacement part. Additionally, the facility had residents with cognitive impairments who were prone to wandering, increasing the risk of unsupervised exits. Furthermore, a sliding door leading to an outdoor patio courtyard was observed to have a broken alarm, and the gate leading from the patio to a public street was unlocked. Nine additional sliding doors from resident rooms also led to the patio, none of which were locked or alarmed, and there was no system in place to monitor these doors. The facility's assessment tool indicated that they accepted residents with conditions such as Alzheimer's and dementia, who require careful supervision to prevent elopement. The facility's policy on elopements and wandering residents emphasized the need for adequate supervision and functioning alarms, which were not in place at the time of the survey.
Electrical Safety Violations Due to Overloaded Outlets
Penalty
Summary
The facility failed to ensure electrical safety by overloading two electrical outlets with adapters and using an extension cord improperly. During an observation and interview with the Director of Maintenance (DM), it was noted that a six-outlet adapter was plugged into a two-outlet receptacle at the reception desk, with three electrical cords connected to it. Additionally, an orange extension cord was plugged into a power strip adapter to power a Christmas tree, which the DM acknowledged should not have been in use. At the facility's front door area, a three-receptacle adapter was plugged into a two-outlet receptacle, with three cords connected, which the DM was unaware of and confirmed should not have been there. The facility's policy on Electrical Safety, dated 12/19/22, clearly states that electrical outlets should never be overloaded, and extension cords are for temporary use only by maintenance personnel. Adapters must be securely attached to the wall receptacle and contain circuit breakers or fuses for overcurrent protection. The policy also prohibits plugging extension cords or power strips into adapters. The Maintenance Director is responsible for inspecting and testing electrical components, including receptacles, power strips, extension cords, and equipment. The facility's failure to adhere to these policies resulted in a potential compromise of safety due to the risk of electrical circuit overload and fire.
Unclean Shower Room in D-Wing
Penalty
Summary
The facility failed to maintain cleanliness in one of its shower rooms, specifically the D-Wing shower room. During an observation and interview, a Certified Nursing Assistant (CNA) confirmed that the room had been used to shower a resident earlier that day. The shower room was found to have a trail of dark spots on the floor, extending into the hallway, and similar spots on the interior side of the door. The Director of Nursing (DON) acknowledged that the shower room should have been clean. The facility's undated Policy and Procedure on Housekeeping and Facility Cleanliness mandates that housekeeping staff are responsible for daily cleaning and sanitization of all facility spaces, with nursing staff assisting as needed. This failure to ensure cleanliness had the potential to affect residents using the shower room.
Medication Administration and Security Lapses
Penalty
Summary
The facility failed to adhere to professional standards of practice by not administering medications and conducting fingerstick blood sugar (FSBS) tests as prescribed for 10 of 16 sampled residents. Licensed Vocational Nurse (LVN) 2 did not administer medications and perform FSBS tests before meals as required by physician orders. This oversight affected residents with conditions such as diabetes mellitus, hypothyroidism, and gastroesophageal reflux disease (GERD), who required timely medication administration for effective treatment. Observations revealed that medications and FSBS tests were conducted after residents had started or finished their meals, which could lead to decreased medication absorption and inaccurate blood sugar readings. The report highlights specific instances where residents received their medications late. For example, Resident 7, diagnosed with diabetes mellitus and other conditions, received levothyroxine after breakfast had been served, despite the medication needing to be taken on an empty stomach. Similarly, Resident 9, with Parkinson's disease and type 2 diabetes, had her blood sugar checked and medication administered after she began eating breakfast. These delays in medication administration and FSBS testing were consistent across multiple residents, indicating a systemic issue with the timing of medication passes. Additionally, the facility failed to secure the medication cart properly. LVN 1 left the medication cart unlocked and out of sight, which posed a risk of unauthorized access to medications by staff or residents. The Director of Nursing (DON) and other staff acknowledged the importance of locking the cart when not in use to prevent potential access to medications, including narcotics. The facility's policy mandates that medication carts be locked when out of the nurse's sight, a protocol that was not followed in this instance.
Failure to Provide Hearing Aid to Resident
Penalty
Summary
The facility failed to provide a hearing aid to a resident who was extremely hard of hearing, despite being assessed for its use. The resident, who was admitted with a diagnosis of unspecified hearing loss, was observed without a hearing aid and had difficulty communicating with staff. The resident's hospital medical records indicated that he wore a hearing aid in his right ear prior to admission. However, upon admission to the facility, there was no documentation or assessment conducted to ensure the resident had access to a hearing aid. Interviews with staff, including a CNA, LVN, and the Social Services Director, revealed that the resident's need for a hearing aid was not addressed. The staff were unaware of the resident's previous use of a hearing aid and did not take steps to verify or provide the necessary assistive device. The Medical Director and Director of Nursing acknowledged the oversight, noting that the lack of a hearing aid could impact the resident's social activities and daily interactions, but no care plan was developed to address this need.
Failure to Implement Non-Pharmacological Interventions and Inappropriate Use of Psychotropic Medications
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medications, leading to several adverse effects. The resident was administered alprazolam without prior implementation of non-pharmacological interventions, and the dosage was increased without documented clinical rationale. This resulted in the resident experiencing falls, weight gain, and dysphagia. The facility's consultant pharmacist noted that the alprazolam dosage was inappropriate for an elderly patient and could cause dizziness and confusion, which are risk factors for falls. Additionally, the resident was prescribed aripiprazole and quetiapine without documented clinical rationale for their administration and dosage increases. The resident's medical records did not support a diagnosis of schizoaffective disorder or bipolar disorder, which were used to justify the use of these medications. The facility's staff, including the physician, acknowledged that the concurrent use of these antipsychotics was inappropriate and could lead to side effects such as weight gain and dysphagia. The resident's care plan and medical records lacked documentation of non-pharmacological interventions for managing anxiety and behaviors. The facility's staff failed to update the resident's diagnosis of dementia in the medical records, which could have influenced the approach to care. The resident's weight gain was significant over several months, and the registered dietician noted that antipsychotic medications could contribute to this issue. The facility did not adequately assess the ongoing need for these medications or attempt gradual dose reductions as recommended.
Failure to Post Survey Results in Accessible Location
Penalty
Summary
The facility failed to post the most recent survey results in a location that was easily accessible to residents and their representatives. During an observation, a binder labeled 'Survey Binder' was found in a holder between the administrator's office and the nurses' station. However, this binder did not contain the recertification survey results for the year 2022, which was the facility's last recertification survey. The absence of these results in the designated binder was confirmed during an interview with the Administrator, who acknowledged that the survey results should have been available in an easily accessible area, such as the nurses' station. Further interviews revealed that the previous survey results were kept in a separate, unlabeled binder in the Administrator's office, which was not readily accessible to residents and their family members. The Director of Nursing also confirmed that the survey results should have been available in a highly visible area to ensure that residents and family members could independently view the survey findings. The facility's Policy and Procedure on Resident Rights, dated August 2009, indicated that residents have the right to examine survey results, highlighting the importance of making these documents accessible.
Lack of Air Gap in Food Prep Sink Risks Contamination
Penalty
Summary
The facility failed to adhere to professional standards for food service safety by not having an air gap in the food preparation sink, which is essential to prevent the backflow of contaminated water. During an observation and interview with the Registered Dietician and the Certified Dietary Manager, it was noted that there was no air gap under the food preparation sink. The Registered Dietician acknowledged the absence of a drain to install an air gap and emphasized the risk of dirty water backflowing into the sink, potentially contaminating food and causing illness among the 93 residents. Additionally, during another observation and interview, a cook was seen using the sink to thaw a frozen pork roast under running water, which further highlighted the risk of contamination due to the lack of an air gap. The facility's job description for the Certified Dietary Manager requires compliance with all food handling, storage, and sanitation requirements, which was not met in this instance. The FDA Food Code 2022 mandates backflow prevention through an air gap, underscoring the facility's failure to comply with these standards.
Facility Fails to Maintain Homelike Environment for Residents
Penalty
Summary
The facility failed to provide a clean and homelike environment for several residents, as observed during a survey. In the rooms of Residents 8, 44, and 56, the ceiling had a hole with water stains and peeling, cracked paint, indicating water damage from a previous leak. This condition was confirmed by a Certified Nursing Assistant and the Maintenance Supervisor, both acknowledging that the ceiling's state did not promote a homelike environment. The Director of Nursing also confirmed that the ceiling should have been in a clean and intact condition, emphasizing the importance of a homelike environment for residents, especially those with severe cognitive impairments. In Resident 85's room, the wall-mounted light had a broken pull string, which the resident had improvised by tying a garbage bag to it. The Maintenance Facility Director was unaware of this issue, as it was not logged in the maintenance records. This oversight resulted in the resident having to use a makeshift solution to control the light, which was not in line with providing a homelike environment. Resident 96 experienced a similar issue with inadequate lighting, as one of the bulbs in the wall-mounted light fixture was burned out and had not been replaced despite the resident's repeated reports since February. The Maintenance Facility Director was also unaware of this issue, and the Director of Nursing acknowledged that the broken light should have been fixed to ensure a homelike environment and prevent potential falls due to insufficient lighting.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for six residents, leading to potential risks and unaddressed medical needs. Resident 18, who was severely impaired in daily decision-making, was prescribed an anticoagulant medication, apixaban, without a corresponding care plan. This oversight was acknowledged by both the Minimum Data Set Coordinator Nurse and a Licensed Vocational Nurse, who confirmed that a care plan should have been initiated within 24 hours of the medication order to monitor for side effects such as bleeding or bruising. Resident 40, also severely impaired in decision-making, was observed ambulating in the facility without proper footwear, wearing only regular socks. Despite being reported as non-compliant with wearing appropriate footwear, no care plan was developed to address this behavior, which posed a risk of falls and injuries. The Director of Nursing confirmed that a care plan should have been in place to manage Resident 40's non-compliance and mitigate the risk of accidents. Additionally, the facility failed to follow the care plan for Resident 44, who was at risk of falls. The care plan required a floor mat to be placed beside the bed, but it was not present, increasing the risk of injury from falls. Furthermore, Residents 22, 55, and 74 were prescribed antibiotics without corresponding care plans, which are essential for monitoring the effectiveness and side effects of the medications. The absence of these care plans was confirmed by nursing staff and the Director of Nursing, highlighting a systemic issue in care plan management.
Failure to Provide Adequate Foot Care
Penalty
Summary
The facility failed to provide adequate foot care and schedule necessary podiatry appointments for three residents, leading to long and thick toenails that posed a risk for painful, ingrown toenails and infections. Resident 6 was observed with long toenails that made it difficult to wear socks, and he could not recall the last visit from a podiatrist. His medical history included rheumatoid bursitis, muscle weakness, and a psychotic disorder, but he was cognitively intact. Resident 64 had thick, long toenails with a lifting toenail and dark drainage, indicating a potential infection. He had Parkinson's disease, dysarthria, anarthria, and muscle weakness, with moderate cognitive impairment. Resident 81 also had long, thick toenails with discoloration and dry skin, and she was embarrassed by their appearance. Her medical history included cerebral infarction, muscle weakness, and nail fungus, but she was cognitively intact. Interviews with staff revealed a breakdown in communication and procedure adherence. Certified Nursing Assistants (CNAs) were responsible for noting issues like long toenails during resident showers and reporting them to licensed nurses, who would then inform the social service designee (SSD) to schedule podiatrist visits. However, CNAs did not recall reporting the toenail issues for these residents, and the SSD did not receive requests to schedule podiatrist visits for them. The SSD confirmed that the podiatrist typically visited every two to three months, but there was no record of recent visits for these residents. The Director of Nursing (DON) acknowledged that the unkempt toenails were unacceptable and should have been addressed. The facility's policy on foot care emphasized providing care in accordance with professional standards, including routine toenail clipping by trained staff. Despite this policy, the lack of communication and follow-through resulted in the residents not receiving the necessary foot care, highlighting a deficiency in the facility's care practices.
Deficiencies in Pharmaceutical Services and Medication Administration
Penalty
Summary
The facility failed to provide adequate pharmaceutical services, resulting in several deficiencies. Firstly, the injectable emergency kit (e-kit) in the medication room was found to be missing insulin medications necessary for emergency use. The Licensed Vocational Nurse (LVN) acknowledged that the e-kit was missing four injectable medications and stated that the process was to call the pharmacy before using the e-kit. The Director of Nursing (DON) confirmed that the e-kit had been opened and used, and that the replacement process was not timely, potentially delaying residents' access to necessary medications. The facility's policy indicated that opened kits should be replaced within 72 hours, but this was not adhered to. Additionally, the facility failed to administer diclofenac gel 1% correctly to two residents. The gel was applied without using the dosing stick provided by the manufacturer, which is necessary to ensure the correct dosage. Observations revealed that the dosing sticks were unused, and the Clinical Leader (CL) and Director of Staff Development (DSD) were unsure how the nursing staff was administering the doses. The Physician Orders for both residents specified the dosage and frequency, but the facility's practice did not align with these orders or the manufacturer's instructions. Furthermore, the facility lacked an adequate system for reconciling controlled drugs, as evidenced by the inability to account for 30 oxycodone-acetaminophen tablets for a resident. The DON could not provide documentation for the administration of these tablets and admitted that the facility did not have a system in place for periodic reconciliation of controlled drugs. This failure to reconcile controlled substances could lead to medication errors and potential drug diversion, as the facility's Control Drug Destruction Log did not indicate the quantity of drugs disposed of.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications, leading to several deficiencies. In the C wing IV medication cart, three 0.9% Normal Saline bags were found in opened manufacturer overwrap packaging without a use-by date. The Licensed Vocational Nurse (LVN) was unaware of how long the packaging had been open, and the Director of Nursing (DON) confirmed that there was no way to determine when the bags were opened. Manufacturer instructions indicated that all units should be used promptly once the pouch is opened. In the D wing medication cart, a discontinued nystatin cream for a resident was not separated from active medications. The Director of Staff Development (DSD) and Clinical Leader (CL) observed this and noted that the order for the cream was for 14 days. The expectation was for nursing staff to remove discontinued medications from the cart and place them in a container for destruction. The DSD emphasized the importance of checking orders to prevent discontinued medications from being mistakenly used for other residents. In the A wing medication cart, several discontinued medications for multiple residents were not separated from active medications. These included ondansetron, hydrocodone/acetaminophen, lorazepam, and oxycodone/acetaminophen. Additionally, a partially used fluticasone diskus was found without a use-by date. The Registered Nurse (RN) confirmed that the orders for these medications had been discontinued and that one resident had been discharged. The DON stated that discontinued narcotic medications should be given to the DON for destruction, while non-narcotic medications should be separated in the medication room. The facility's policy indicated that medications should be removed from the cart immediately upon receipt of a discontinuation order.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during a survey. In one instance, the toilet and toilet seat commode in a shared resident room were found soiled with feces, which was not promptly cleaned by the Certified Nursing Assistants (CNAs) or housekeeping staff. This oversight involved three residents who shared the toilet, potentially exposing them to cross-contamination and infection. Interviews with staff, including the Medical Records Director, Director of Staff Development, and Infection Preventionist, confirmed that the facility's protocol required CNAs to clean the toilet immediately and then call housekeeping for thorough sanitization, which was not followed in this case. Another deficiency was observed when two bags of dirty linens were left on the floor in a resident's room after a bed bath was provided. The CNA responsible acknowledged that placing the linens on the floor was against infection control practices, as the floor is considered dirtier than the bagged linens. The Director of Staff Development and Infection Preventionist reiterated that the facility's policy required dirty linens to be placed on the top corner of the resident's bed and then transported directly to the hamper to prevent cross-contamination. Additionally, two Licensed Vocational Nurses (LVNs) failed to properly disinfect a shared glucometer after use on residents. The LVNs did not follow the manufacturer's instructions for disinfecting the device, which required complete coverage and adherence to the specified contact time to ensure effective disinfection. The Director of Nursing confirmed that the expected practice was to thoroughly disinfect the glucometer to prevent the spread of infections among residents.
Failure to Cover Urinary Catheter Bag Compromises Resident Dignity
Penalty
Summary
The facility failed to ensure that a resident's urinary catheter bag was covered, compromising the resident's dignity and privacy. During observations, it was noted that the catheter bag was visible and uncovered, both when the resident was in a wheelchair and when the bag was attached to the bed frame. This visibility was confirmed by multiple staff members, including a Certified Nursing Assistant (CNA), the Director of Staff Development (DSD), an Infection Preventionist (IP), a Licensed Vocational Nurse (LVN), and the Director of Nursing (DON), all of whom acknowledged that the catheter bag should have been covered to respect the resident's dignity. The resident involved had been admitted with conditions including hemiplegia, hemiparesis, obstructive and reflux uropathy, and benign prostatic hyperplasia, necessitating the use of a urinary catheter. Despite the facility's policy emphasizing the importance of treating residents with dignity and respect, the catheter bag was left uncovered, visible to other residents, staff, and visitors. This oversight was recognized by the staff, who admitted that the catheter bag should have been placed in a privacy bag to maintain the resident's dignity.
Inaccurate MDS Assessment for Resident's Anxiety Diagnosis
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the health and functional status of a resident, specifically regarding the diagnosis of anxiety. Resident 64, who was admitted with diagnoses including unspecified psychosis and dementia, was receiving antianxiety medication. However, the MDS assessment did not accurately code the resident's anxiety diagnosis, despite the resident being on medications such as alprazolam and buspirone for anxiety management. This oversight was identified during a review of the resident's records and an interview with the Minimum Data Set Nurse (MDSN), who acknowledged the error in coding. The Director of Nursing (DON) confirmed that the MDSN and other staff responsible for completing the MDS assessments needed to ensure that resident assessments were complete and accurate. The DON stated that the MDSN should have included and accurately coded the anxiety diagnosis, given the resident's medication regimen. It was also noted that the facility lacked a specific policy and procedure for MDS assessments, relying instead on the Resident Assessment Instrument (RAI) guidelines. The professional guidelines indicate that physician-documented diagnoses related to the resident's current functional status should be accurately reflected in the MDS assessment.
Inaccurate Mental Health Diagnosis Leads to Inappropriate Medication Administration
Penalty
Summary
The facility failed to ensure accurate documentation of a mental health diagnosis for a resident, leading to inappropriate administration of antipsychotic medications. The resident's medical record was incorrectly marked with a diagnosis of schizoaffective disorder, despite no prior history of such a diagnosis. This resulted in the resident being administered aripiprazole and quetiapine, which led to adverse events, including significant weight gain. The resident, who had a history of ataxia following a cerebral vascular accident, was observed to have behaviors such as slamming doors, barricading doors, and jumping on the bed. These behaviors were used to justify the administration of antipsychotic medications. However, the resident's Minimum Data Set (MDS) assessments did not indicate a diagnosis of psychiatric or mood disorders, and there was no documented history of hallucinations or delusions. Interviews with staff and review of progress notes revealed that the resident was often confused, forgetful, and agitated, but did not exhibit symptoms consistent with schizoaffective disorder. The facility's failure to accurately document the resident's mental health diagnosis and the inappropriate use of antipsychotic medications were compounded by a lack of communication and coordination among healthcare providers. The physician admitted to using a diagnosis of schizoaffective disorder to justify medication orders, despite not having diagnosed the resident with the condition. Additionally, the facility did not complete a Preadmission Screening and Resident Review (PASRR) when the resident was given a new psychiatric diagnosis, which is a federal requirement. This oversight contributed to the inappropriate treatment and adverse effects experienced by the resident.
Failure to Address Dementia Care Needs
Penalty
Summary
The facility failed to comprehensively assess and address the dementia care needs of a resident, leading to a deficiency in providing appropriate treatment and services. The resident, diagnosed with dementia, was not given a proper individualized care plan with measurable goals and interventions. Despite displaying symptoms consistent with dementia, such as forgetfulness and confusion, the facility did not update the resident's electronic medical record or Minimum Data Set (MDS) to reflect this diagnosis. This oversight resulted in a lack of coordinated care and appropriate interventions for the resident's condition. The resident's medical history included a cerebral vascular accident, ataxia, and suspected dementia, which was confirmed by the physician in progress notes. However, the facility staff, including the Director of Nursing and the Minimum Data Set Nurse, were unaware of the dementia diagnosis. This lack of awareness led to the absence of a dementia-specific care plan, which is crucial for managing the resident's behavioral symptoms and ensuring their highest level of functioning. The resident exhibited behaviors such as aggression, confusion, and hallucinations, which were not adequately addressed due to the missing care plan. Interviews with facility staff and the resident's responsible party revealed inconsistencies in the resident's diagnosis and treatment. The resident was administered medication for schizophrenia, despite the responsible party believing the resident had dementia. The facility's failure to update the resident's diagnosis and develop a comprehensive care plan resulted in inadequate management of the resident's dementia-related symptoms, impacting their quality of life and care.
Failure to Monitor Levetiracetam Levels in Resident
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs, specifically regarding the monitoring of levetiracetam, a medication used to treat seizure disorders. The resident, a female with a history of seizures, was observed to be unresponsive and bedridden. Her levetiracetam levels were not monitored after an increase in dosage from 500 mg to 750 mg twice daily, as the physician discontinued lab orders when the resident was placed on hospice. This lack of monitoring led to a significant increase in the resident's levetiracetam level, as evidenced by lab results showing a level of 45.8, which is close to the laboratory alert level of 50 mcg/mL. Interviews with facility staff, including an LVN, the Medical Director, and the Director of Nursing, revealed that there was no documentation of physician orders for discontinued labs, and the nursing staff did not observe any symptoms of levetiracetam toxicity. The Consultant Pharmacist indicated that monitoring the drug levels was important to ensure the medication's efficacy and safety, especially after a dosage change. The Medical Director acknowledged that the pharmacy should have recommended monitoring the drug levels. Despite the lack of observed symptoms, the failure to monitor the drug levels after the dosage increase posed a risk of unnecessary drug administration and potential side effects.
Ineffective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of cockroaches in the bathroom of a resident. During an observation and interview with the Director of Nursing (DON), two small brown insects identified as cockroaches were found in the resident's bathroom. The resident confirmed having seen cockroaches in the bathroom before and mentioned having stomped on them. The housekeeper also reported seeing cockroaches in the facility, expressing that there should not be any cockroaches present. Interviews with the Infection Preventionist (IP) and the DON revealed that the facility's pest control program, managed by a pest control vendor, was expected to be effective, but the presence of cockroaches indicated otherwise. The IP stated that pest control services were provided monthly or as needed, but acknowledged that the program needed re-evaluation if pests were still present. A review of the facility's maintenance logs showed a previous roach infestation in a specific hall, and the facility's pest control policy indicated an ongoing program to keep the building free of insects.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 354 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Sanger
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| California Home For The Aged | 6 mi | ★★★★★ | 1 | 0 |
| Fowler Care Center | 6.1 mi | ★★★★★ | 2 | 0 |
| Vineyards At Fowler | 7.6 mi | ★★★★★ | 25 | 0 |
| Grace Healthcare Center | 8.3 mi | ★★★★★ | 33 | 0 |
| Pacific Gardens Nursing And Rehabilitation Center | 8.6 mi | ★★★★★ | 30 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Cornerstone Care Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.