Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Corona Post Acute Center during CMS and state inspections, most recent first.
The facility failed to follow physician orders and timely respond to changes in condition for several residents. One resident with a coccyx wound debridement had multiple IV antibiotic doses undocumented as given on the MAR. Another resident with a UTI had an ordered IV Ceftriaxone dose not documented as administered, contrary to facility expectations for medication administration and physician notification. A resident reporting right ear pain had a physician-ordered ENT referral with no documented appointment scheduled for several days, despite ongoing pain. A cognitively intact resident with morbid obesity, CKD, and anemia had persistently poor PO intake documented over weeks after a short-term nutrition intervention, without a documented change of condition, RD reassessment, or care plan updates. Another resident with hemiplegia and dysphagia had a physician order for ST evaluation and treatment, but the evaluation occurred four days later, outside the facility’s stated 24–72 hour best-practice timeframe for therapy evaluations.
Advance directive information and recordkeeping were incomplete for multiple residents. Several residents with diagnoses including dementia, anxiety, cirrhosis, aphasia, hemiplegia, and major depressive disorder said they did not recall staff explaining how to complete an AD or wanted more information, while others said they believed an AD existed but could not confirm it. Record review showed AD acknowledgment forms, but quarterly social service and IDT documentation often left the AD section blank, and for some residents the facility could not locate a copy of the AD in the chart. The SSD stated documentation of follow-up assistance, including Ombudsman notification, could not be identified for several residents.
Psychotropic medications were administered to several residents without adequate documentation supporting the diagnosis, target behaviors, non-pharmacological interventions, or adverse-effect monitoring. One resident received quetiapine for schizophrenia even though hospital psychiatry records and the PNP stated the schizophrenia diagnosis was inaccurate and not supported by DSM-5-TR criteria, and required quetiapine monitoring such as lipids, thyroid testing, and an eye exam was not documented. Other residents receiving quetiapine, Xanax, trazodone, and buspirone had incomplete behavior monitoring records, missing target behavior counts and specific interventions, and one resident had no documented provider order for behavioral monitoring with buspirone.
Failure to Monitor and Implement Nutritional Interventions: The facility did not consistently monitor or document the effectiveness of ordered nutrition support for one resident with severe weight loss, pressure injuries, and dysphagia, and staff did not reliably provide the ordered fortified diet items or honor meal preferences. The RD could not verify intake of ONS, pudding, or ice cream, and the resident’s legal guardian was not involved in goal-weight discussions. For another resident with ongoing poor PO intake, the health shake order ended and the facility did not document continued monitoring or adjustment of nutrition interventions despite persistent low meal and fluid intake.
Dietary staff and the RD lacked competency in several food service tasks, including checking dish machine sanitizer concentration, using sanitizer test strips for the correct amount of time, identifying the proper sanitizer range, calibrating thermometers, monitoring cooling for tuna salad and egg salad, submerging kitchenware in sanitizer for the correct time, preparing Mince and Moist meat to the correct IDDSI texture, and knowing the proper manual dishwashing wash temperature. Staff gave inconsistent answers and demonstrated incorrect techniques during observation, and the facility’s policies and manufacturer instructions were not followed.
Therapeutic diet service was not followed as ordered. A cook failed to serve melted margarine to fortified diet residents, staff prepared alternate meals without recipes, and dietary staff used incorrect scoops for pureed dessert and mince and moist meat. The RD stated the missed margarine meant residents did not receive extra calories, the smaller scoop reduced calories for pureed residents, and the larger scoop overfed residents on the mince and moist diet.
A facility failed to serve food at appropriate temperatures and to prepare pureed diets in a way that preserved nutritional value. Several residents reported cold breakfasts and dinners, and a test meal confirmed hot items were below the facility's temperature guide. Staff also prepared pureed foods too early and held them in an oven at 200 to 250 degrees F until service, which the RD and DFN acknowledged was too long.
Incorrect therapeutic diet textures were served during lunch. Pureed beef and bread were grainy instead of smooth for residents on a pureed diet, and beef and green beans were served in pieces larger than allowed for residents on a soft and bite sized diet. The DFN verified the texture problems during a meal test and stated the foods did not meet the required diet definitions.
Food preferences were not honored for two residents. One resident with cirrhosis and intact cognition had a tray ticket for double protein and no carrots, but received only one protein portion and carrots on the tray; the resident reported this happened often. Another resident with dysphagia had a tray ticket instructing soup, but the meal tray arrived without soup, and the LG stated items were often missing from meal trays.
Beverages were not served in accordance with meal tickets for several residents during lunch service. A resident was observed receiving a 4 oz drink when the ticket called for 8 oz, and other residents were observed not receiving the ordered 8 oz beverage. The DFN stated nursing staff were responsible for serving beverages per meal tickets, and the RD stated staff should follow the ticket instructions to support adequate hydration.
Unsafe Food Preparation and Storage Practices: The kitchen had multiple sanitation and food safety failures, including a prep sink without an air gap, dirty ice machine components, grime and splash buildup on walls, ceilings, and equipment, trash on the floor, wet pans stacked before air drying, broken storage containers, exposed facial hair on dietary staff, an expired condiment, and opened frozen foods left exposed. Staff also could not demonstrate proper cooling procedures for egg salad and tuna salad, and two items were found in the temperature danger zone.
Improper Disposal of Garbage and Refuse Around Dumpster: Trash was observed on the floor surrounding the compactor dumpster at the outside back building, along with a strong unpleasant odor and unknown liquid near the dumpster. The DFN stated the area should be kept clean and without smell to avoid attracting pests. Facility policy required outside dumpsters to be kept free of surrounding litter, and FDA Food Code guidance addressed removing refuse often enough to minimize objectionable odors and conditions that attract insects and rodents.
The facility failed to maintain essential kitchen equipment in proper working condition. In the walk-in refrigerator, condensation was observed on copper pipes and dripping onto food stored below. In the walk-in freezer, ice buildup was seen on shelves, the floor, and an opened box of country fried steak. The dish machine was also observed operating below the manufacturer’s required wash temperature, and staff reported monitoring the water booster output instead of the machine’s data plate.
The facility failed to maintain an effective pest control program to keep the kitchen free of pests. Staff and surveyors observed flies in the dishwashing area on multiple occasions, including drain flies identified by the pest vendor, and a house fly in the kitchen prep area. The DFN stated flies were not supposed to be present in the kitchen and could cause cross-contamination, and the RD stated pests could spread bacteria and viruses and result in food borne illness. The facility policy required an ongoing pest control program to keep the building free of insects.
Failure to Assess Self-Administration of Inhaler: A resident with asthma and dementia had a Ciclesonide inhaler kept at the bedside for self-administration, but there was no documented IDT evaluation showing it was clinically appropriate and safe. The resident was alert and oriented during observation, but the record noted fluctuating decision-making capacity, and both an LVN and the DON stated the inhaler should not have been at the bedside without the required assessment.
PASRR screening was not accurately updated for a resident whose record showed anxiety, psychosis, and mood affective disorder. The hospital PASRR Level 1 was marked negative for SMI and did not reflect the resident’s mental health diagnoses or psychotropic use, and the chart contained no evidence of a corrected PASRR Level I or Level II evaluation. The MDS nurse stated the PASRR should have been reviewed and updated on admission to reflect the resident’s psychosis and anxiety treatment.
Incomplete care plan for psychotropic medication: A resident with anxiety and major depressive disorder was prescribed Xanax for self-reported anxiety, and the medication was administered as ordered. However, the care plan only listed the medication order and did not include documented interventions for side effect monitoring, target behaviors, or non-pharmacologic approaches, which the LVN, ADON, and DON all confirmed were missing.
Failure to revise care plan for poor oral intake: A resident with morbid obesity, CKD, and anemia had a care plan that included nutritional support, but ongoing low PO intake was documented along with an MD/RD-ordered health shake intervention. The resident continued to average low meal intake with refusals, yet the care plan was not updated to reflect the change in condition or the ordered nutrition support, as confirmed by the LVN and DON.
Failure to provide oral care was identified for a resident who was dependent for oral hygiene and had hemiplegia after a stroke. The resident was observed with yellowish, dry residue on the tongue, roof of the mouth, and between the teeth, and both CNA and nursing leadership stated oral care should have been provided when the unclean mouth was observed. The care plan required oral inspection and removal of debris, and the facility policy assigned oral care to nursing staff and CNAs.
A resident admitted for mobility rehab with morbid obesity and gait/mobility impairment was observed in bed without the ordered left side rail needed for repositioning. The chart showed a physician order and care plan for the side rail, and PT had recommended it, but nursing and other staff did not complete the steps needed for evaluation, coordination, and installation. The resident reported repeated requests for the rail, and the DON stated facility protocol was not followed.
A resident receiving IV ceftriaxone for a UTI had an unlabeled right forearm IV dressing, and the RN stated it should have included the catheter size, date, time, and nurse initials. The MAR also lacked documentation that the IV site was monitored for signs of complications during therapy, despite the DON stating IV sites were to be labeled and assessed each shift.
An IV Medication E-kit was found open and unsealed in the med storage room, with no logbook documentation showing when it was opened or which medication was removed. The DON identified missing sodium polystyrene and sterile water from the kit, and record review showed a resident had an order for sodium polystyrene and received a dose for abnormal labs. Facility and pharmacy policies required removed emergency meds to be documented, the kit to be resealed, and usage to be logged.
The CP failed to identify and report irregularities during monthly MRRs for two residents receiving psychotropic medications. One resident on quetiapine had no documented lipid, TSH, or eye exam monitoring despite manufacturer guidance, and another resident on Xanax had no documented target behavior monitoring, side effect monitoring, or non-pharmacologic interventions. The DON and CP acknowledged the missing monitoring should have been identified in the MRR.
Medication administration errors resulted in a 12% error rate for one resident. An LVN gave acetaminophen without an active order and administered cholestyramine and doxycycline at the same time as other meds, including calcium- and iron-containing products, despite manufacturer instructions requiring separation; the DON and CP confirmed the timing could affect absorption and effectiveness.
An expired Insulin Lispro vial for a resident with diabetes was found in a medication cart, and the vial had been opened beyond the manufacturer’s discard timeframe. In the medication room refrigerator, an opened Tuberculin PPD multi-dose vial was found without an open date label. The LVN and DON stated the vials should have been dated and discarded according to manufacturer instructions and facility policy.
Surveyors found that the facility did not maintain linens, shower curtains, and privacy curtains in a clean, stain-free condition as required by its infection prevention and control program. During observations with the Director of Housekeeping and Laundry, shower curtains in two shower rooms were noted with black and brown discoloration, and a stained linen item was found folded on a shelf in the clean linen closet, ready for resident use. In a resident’s room, the IP identified a brown streak on the privacy curtain and confirmed it was an infection control issue. The DON stated that linens and curtains designated as clean are expected to be free of stains to support a clean environment and prevent infection, in line with the facility’s infection control policy.
A resident with BPH, urinary incontinence, and urinary retention had an indwelling Foley catheter ordered and documented in the medical record, but the care plan incorrectly listed neurogenic bladder as a related diagnosis. Review of physician documentation and diagnoses showed no evidence of neurogenic bladder, and both the MDS Supervisor and DON confirmed that this diagnosis was inaccurate and should not have been included in the care plan, resulting in an inaccurate medical record.
A resident with chronic kidney disease was discharged, and a written request for their medical records was submitted by the legal representative. The facility failed to provide access to the records within the required 48-hour timeframe, instead delaying the release for 27 days after forwarding the request to the legal department, which did not comply with regulatory requirements.
A resident with a history of spinal fusion and depression was discharged without the required physician documentation providing clinical rationale for the discharge. Although the resident was noted to benefit from continued care, a discharge notice was issued and the medical record did not include evidence that the resident no longer required facility services or that discharge was appropriate, as required by facility policy.
Two LVNs did not wear required gowns while administering medications via G-tube to two residents on Enhanced Barrier Precautions for MDROs, despite care plans and orders specifying the use of PPE for high-contact activities involving feeding tubes and indwelling devices. Both nurses acknowledged the requirement during interviews, and the facility's infection prevention policy confirmed the need for gowns and gloves in these situations.
A resident with a history of metabolic encephalopathy and right-sided hemiplegia, who required supervision with eating, was served a hot beverage by a CNA who failed to check the temperature as required by facility policy. The resident spilled the hot liquid, resulting in second and third degree burns to her right breast and shoulder, necessitating medical intervention. Staff interviews and documentation confirmed that the CNA was unaware of the temperature-checking requirement, and facility policy mandated hot beverages be served at or below 155°F.
Three residents experienced failures in timely assessment, monitoring, and follow-up of skin injuries and changes. One resident with burns did not receive prompt treatment or a specialist follow-up as recommended. Another resident with dementia and on anticoagulant therapy developed significant bruising that was not properly assessed or reported to a physician. A third resident with diabetic ulcers had worsening wounds that were not identified as a change in condition or communicated to the physician. These lapses were confirmed by staff interviews and documentation review.
A resident with ALS was unable to reach staff after her call light fell, and her family member's repeated phone calls to the facility went unanswered and unreturned. Interviews revealed that after-hours calls were not consistently answered or forwarded to residents, and two other residents also reported not receiving intended calls. The administrator acknowledged that calls should be answered and properly forwarded at all times.
A resident with spinal stenosis did not receive prescribed Hydrocodone because the medication was not reordered in advance, as required by facility policy. Nursing staff confirmed that the medication ran out and there was no documentation of a timely reorder, resulting in the pain medication being unavailable when needed.
A facility failed to provide a resident's medical records within the required 48-hour timeframe, resulting in a 14-business-day delay. The resident's legal representative requested the records with valid authorization, but the Medical Record Director did not follow up promptly with the legal team, causing the delay. This failure potentially denied the resident representative timely access to review records and make critical decisions.
The facility failed to provide pressure ulcer treatment as ordered for three residents. A resident with a Stage 4 ulcer was found without a dressing, and staff failed to ensure it was reapplied. Another resident with a similar condition also lacked a dressing, with poor communication among staff. A third resident at risk for ulcers did not receive consistent treatment, as an LVN signed off on care that was not provided. The DON and Administrator acknowledged the need for adherence to treatment orders.
A resident with hemiplegia was provided a wheelchair in poor condition, with burn holes and a torn armrest, by the facility. Staff interviews revealed that the wheelchair was mistakenly taken from a storage area meant for repairs, and the facility failed to ensure it was in good condition before use. The Director of Maintenance and Administrator acknowledged the error, and the Director of Nursing emphasized the expectation for well-maintained equipment.
A facility failed to refer a resident with bipolar disorder for a Level II PASRR screening. The resident was admitted with a negative Level I screening, which inaccurately indicated no serious mental illness. Despite the resident's medical history showing a bipolar disorder diagnosis, the facility did not identify this as an SMI. Interviews revealed that the MDS Coordinator was unaware of the inaccuracy, and the Director of Nursing was not involved in the PASRR process, leading to the oversight.
A resident with hemiplegia and hemiparesis was observed with long, dirty fingernails due to the facility's failure to provide adequate nail care. Despite the resident's request and the availability of nail trimmers, staff did not trim the resident's nails, citing an inability to locate the trimmers. Interviews revealed a lack of communication and awareness among staff regarding the resident's need for nail care.
A resident with COPD did not receive prescribed DuoNeb treatments due to a transcription error in the electronic health record, leading to infrequent administration. The nebulizer was not easily accessible, and staff failed to verify and double-check the order, resulting in inadequate respiratory care.
The facility failed to ensure proper hand hygiene and glove changes during wound and peri-care for two residents with Stage 4 pressure ulcers. Staff did not follow the facility's policy or CDC guidelines, leading to the application of wound treatment with potentially contaminated gloves. Interviews revealed a lack of adherence to hand hygiene protocols, highlighting a significant lapse in infection prevention and control practices.
A resident with sepsis and enterocolitis experienced low blood pressure, recorded at 65/49, but was not reassessed or monitored while awaiting hospital transfer. Interviews revealed that the nursing staff failed to recheck the blood pressure, contrary to facility policy requiring documentation of condition changes.
A resident with Clostridium Difficile (C. diff) was placed on contact precautions, but the facility failed to provide disposable equipment, such as a stethoscope and sphygmomanometer, for the resident in isolation. This deficiency was confirmed by staff, including a CNA, RN, IP, and DON, who acknowledged the need for such equipment to prevent infection spread. The facility's policies emphasize the importance of dedicated equipment for residents on transmission-based precautions, but these were not followed, increasing the risk of infection transmission.
A legally blind resident with multiple medical conditions did not receive necessary assistance with meals, as observed during an unannounced visit. Despite care plan instructions for feeding assistance, staff left the resident's lunch tray without providing help. Interviews with staff confirmed a lack of adherence to the facility's policy on meal assistance.
The facility failed to provide requested medical records for four residents within the 48-hour timeframe as per their policy. The process involved sending requests to the corporate office for approval, which took one to two weeks due to short staffing. This delay was identified during an unannounced visit, with requests pending approval and not fulfilled within the required timeframe.
A resident with Alzheimer's Disease was found with their call light out of reach during an unannounced visit. An LVN admitted the oversight occurred after repositioning the resident. The DON confirmed that staff are expected to ensure call lights are always accessible, as per facility policy.
A resident was exposed to pesticide vapor when the Maintenance Supervisor sprayed pesticide in the room while the resident was present, without notifying nursing staff or moving the resident. The facility's protocol requires residents to be relocated before such treatments, which was not followed, compromising the resident's safety and comfort.
A resident with a stage 4 pressure ulcer was not repositioned every two hours as required by their care plan. Observations showed the resident remained in the same position for over three hours. A CNA admitted to not repositioning the resident due to being busy, which was against the facility's policy and care plan directives.
The facility failed to maintain a clean and sanitary environment in two resident rooms. Observations revealed a brown splatter, dirty gloves, and dried blood in one room, and trash, food crumbs, and dust behind headboards in another. A resident confirmed the blood was from their toe, and the housekeeper admitted to not cleaning behind the headboards. A Registered Nurse verified the unclean conditions, which contradicted the facility's policy for a homelike environment.
A resident with depression and schizoaffective disorder was discharged to a hospital without receiving a written notice of transfer. The DON confirmed that the required Notice of Proposed Transfer/Discharge form was incomplete and not acknowledged by the resident, contrary to facility policy.
Failure to Follow Physician Orders and Timely Respond to Changes in Condition
Penalty
Summary
The deficiency involves multiple failures to provide treatment and care according to physician orders and to recognize and respond to changes in residents’ conditions. For one resident with a coccyx wound debridement, physician orders dated in late February directed administration of IV Meropenem every 12 hours until early March and IV Linezolid every 12 hours until a similar date. Review of the MAR showed no documentation that Linezolid was administered on several specified dates and times, and no documentation that a scheduled Meropenem dose was given on one evening. The Infection Preventionist confirmed that if a medication was not documented as administered in the MAR, it was considered not given. Another resident admitted with a UTI had a physician order for IV Ceftriaxone once daily for five days. Review of the eMAR showed that the 6 a.m. dose on one of the ordered days was not documented as administered. A RN confirmed the eMAR reflected that the dose was not given and stated the medication should have been administered as ordered and the physician notified of the missed dose. The DON stated that licensed nurses were expected to administer medications as ordered, document administration in the eMAR, and notify the physician when medications were not administered, and acknowledged that the facility’s process for following physician orders for medication administration was not followed. A separate deficiency involved a resident who reported right ear pain during a care conference and for whom a physician order and IDT note documented a referral to ENT for right ear issues. From the days following the order through a specified review period, there was no documentation that an ENT appointment was scheduled. The resident reported that several days had passed without any update on the appointment and that she continued to experience increased right ear pain. The Social Service Director, who was responsible for scheduling the ENT consultation, stated that the resident had been placed on the next six‑month ENT visit and acknowledged she should have asked the resident about seeing an outside physician and that not scheduling the resident for acute ear pain as soon as applicable had the potential to result in a delay in medical care and worsening pain. The Administrator confirmed there was no documentation that the ENT consultation was scheduled during the review period and stated the consultation should have been arranged in a timely manner. Another resident with morbid obesity, chronic kidney disease, and anemia had an MDS showing intact cognition and a nutritional assessment indicating the resident consumed mostly 25% of meals. An intervention was initiated for health shakes three times daily for 14 days, with instructions to monitor intake, skin, weight trends, and labs. Nutrition reports and meal intake documentation over several weeks showed ongoing poor intake, including multiple instances of 25–50% intake, 0–25% intake, and refusals. Despite this continued poor intake after the intervention was started and completed, there was no evidence of a documented change of condition, no reassessment by the RD, no ongoing nutritional monitoring, no progress notes reflecting deteriorating intake, and no care plan updates. Staff interviews confirmed that such intake patterns should have triggered a change of condition process and physician notification, and the DON stated the facility did not recognize and address the resident’s ongoing poor intake. For another resident admitted with hemiplegia and dysphagia, a physician order was placed for speech therapy evaluation and treatment on the date of admission. The resident’s history and physical indicated the resident did not have capacity to make medical decisions. The record showed that the speech therapy evaluation did not occur until four days after the order. The Speech Therapist stated residents are usually evaluated the day after an order, or on Monday if the order is placed on a weekend, and that this resident should have been evaluated earlier. The Director of Rehab stated that speech therapy evaluations are expected within one to two days of the order and acknowledged the evaluation was not timely. The ADON also stated that if a speech therapy order is placed on a Saturday, the resident should be evaluated by Monday and that this resident should have been evaluated sooner to ensure correct diet texture and prevent aspiration. Facility policy on therapy evaluations indicated evaluations should be completed as soon as possible, with a best practice of 24–72 hours, which was not met in this case.
Advance directive information and records were not maintained for multiple residents
Penalty
Summary
The facility failed to ensure that advance directive (AD) information was followed up on and that ADs were available in the medical record for 13 of 15 residents reviewed: Residents 17, 20, 25, 10, 55, 6, 97, 110, 117, 119, 126, 155, and 159. The report states that these residents either did not have documented evidence that they or their resident representatives were provided follow-up information about the right to formulate an AD, or the facility could not locate a copy of the AD in the record when one had been indicated as completed. The deficiency involved residents with a range of diagnoses, including dementia, anxiety disorder, cirrhosis of the liver, hemiplegia, hemiparesis, aphasia, cerebrovascular disease, and major depressive disorder. Several residents interviewed stated they were unsure whether the facility had discussed ADs with them or said they wanted more information. Resident 6, Resident 17, Resident 119, Resident 110, Resident 20, Resident 155, Resident 25, and Resident 159 each indicated they could not recall staff explaining how to formulate an AD, or they wanted to know more about it. Resident 10 stated he did not wish to execute an AD and was aware of his right not to have one, but only vaguely remembered staff discussing it. Resident 126 stated he believed he had an AD but could not recall whether the facility had one or whether it had ever been reviewed with him. Resident 117, whose acknowledgment form was completed verbally by a family member, also had no documented follow-up information in the record. Record review showed AD acknowledgment forms for the residents, but the Social Services quarterly evaluations and interdisciplinary team notes often had the AD section left unchecked or noted as reviewed with no changes. For Residents 126 and 155, the Social Services Director stated the acknowledgment forms indicated an AD had been completed, but copies could not be located in the medical record. The Social Services Director also stated she could not identify documentation that assistance was provided, including notification to the Ombudsman, for Residents 17, 20, 25, 55, 6, 97, 110, 117, 119, and 159. The facility policy titled Advance Directives stated that residents would be informed of their rights to formulate ADs, that copies would be placed in the medical record, and that ADs would be reviewed and updated upon admission, quarterly, and with changes in condition.
Psychotropic Medications Given Without Required Diagnosis and Monitoring Documentation
Penalty
Summary
The facility failed to ensure five sampled residents were free from unnecessary psychotropic medication use when psychotropic drugs were administered without adequate documentation of diagnosis, behavioral monitoring, non-pharmacological interventions, and adverse-effect monitoring. Resident 16 was receiving quetiapine for schizophrenia, but the record did not contain documentation supporting a schizophrenia diagnosis under DSM-5-TR criteria. Hospital psychiatry records stated the diagnosis of schizophrenia appeared inaccurate, and the PNP later stated the resident did not meet DSM-5-TR criteria for schizophrenia. The resident’s psychiatric follow-up notes listed depression, anxiety, impulse control disorder, and psychosis, but not schizophrenia. Resident 16 also received quetiapine without documented manufacturer-specified monitoring. The DON acknowledged there was no documented evidence of lipid testing, TSH/free T4 monitoring, or an eye exam in the resident’s record, despite the manufacturer warnings for dyslipidemia, cataracts, and hypothyroidism. The facility’s psychopharmacological policy stated that appropriate diagnosis and monitoring were required for psychopharmacological drugs, and the DON confirmed the resident’s schizophrenia diagnosis had not been appropriately evaluated when quetiapine was started. For Resident 2, quetiapine was ordered for psychosis manifested by unprovoked physical aggression, but the behavior monitoring order did not specify the target behavior, and the MAR documentation did not record the number of behavior episodes or the specific non-pharmacological interventions attempted. For Resident 45, Xanax and trazodone were administered, but there was no documented evidence of non-pharmacological interventions, target behavior monitoring, or adverse-effect monitoring for Xanax, and trazodone behavior monitoring entries did not include the number of target behaviors or the specific interventions attempted. For Resident 159, buspirone and trazodone were administered, but there was no provider order for behavioral monitoring or non-pharmacological interventions for buspirone, and trazodone monitoring lacked the number of behaviors and specific interventions. For Resident 119, buspirone was administered for anxiety, but the behavior monitoring documentation did not include the number of episodes of target behavior or the specific non-pharmacological intervention attempted. The DON and ADON acknowledged these documentation gaps during record review and interviews.
Failure to Monitor and Implement Nutritional Interventions
Penalty
Summary
The facility failed to provide and monitor nutritional care for Resident 117, who had a history of stage 4 sacral pressure ulcer, unstageable heel pressure injury, colon cancer, dysphagia, dementia, chronic kidney disease, and severe unplanned weight loss. The record showed repeated weight decline from 165 lbs. on admission to 109 lbs. on readmission, with the RD documenting estimated nutritional needs and multiple nutrition interventions over time, including ONS, pudding, ice cream, double protein portions, large portions, and a fortified diet. The RD also documented that the resident had increased nutrition needs related to wound healing and that the weight loss was unplanned and undesired. Surveyors observed and reviewed records showing that the facility did not consistently monitor the effectiveness of the nutrition interventions ordered for Resident 117. Staff interviews showed that the amount of ONS, ice cream, and pudding consumed was not individually documented, and the RD stated the intake amounts could not be located in the EMR and could not determine how many extra calories the resident received. The RD acknowledged that without monitoring and documenting the interventions, the effectiveness of the nutrition plan could not be determined. The RD also stated the estimated calorie and protein needs were too low and that revised calorie and protein needs were not documented. The facility also did not follow the ordered fortified diet for Resident 117 during lunch on April 7 and April 9, 2026. Surveyors observed that the trayline did not provide the ordered melted margarine for the fortified diet, and on April 9 the resident’s meal tray was missing the melted margarine and soup listed on the meal ticket. The resident’s legal guardian stated that no one had discussed the resident’s goal weight, and the RD stated he had not completed a care plan for the resident and could not locate documentation of discussion with the legal guardian. For Resident 101, the record showed ongoing poor oral intake, an average meal intake of 41%, multiple meal refusals, and average fluid intake of 871 mL per day, but the health shake order ended after 14 days and there was no documented evidence that the facility consistently monitored, evaluated, or adjusted nutritional interventions despite continued poor intake.
Dietary Staff Lacked Competency in Sanitizer Testing, Thermometer Calibration, Cooling, and Texture Preparation
Penalty
Summary
The facility failed to ensure dietary staff were trained and competent to carry out food and nutrition service functions safely and effectively. During observation, interview, and record review, Food and Nutrition Specialist 1 did not know the correct concentration of the dish machine sanitizer and checked it by dipping the test strip into the dish machine water tank. The Registered Dietitian stated the sanitizer should be checked on the dish surface, not by dipping the strip into the water tank, and the facility’s Ware Washing policy required chlorine at 50 to 100 ppm on the dish surface. Several dietary staff did not follow the manufacturer’s instructions for testing sanitizer concentration in the three-compartment sink and other sanitizer solutions. The manufacturer’s guideline posted above the sink indicated the test strip should be dipped for 10 seconds, but staff demonstrated different times, including 3 seconds, 30 seconds, and 2 seconds. The Registered Dietitian and Director of Food and Nutrition gave different answers about the correct dipping time, and the test strip container itself indicated 10 seconds. Staff also did not know the correct sanitizer concentration range, with responses varying from 150 to 200 ppm, 150 to 400 ppm, and uncertainty about what to do if the solution reached 500 ppm. The report also found that a cook and the Registered Dietitian did not know how to calibrate a thermometer correctly. The cook stated the thermometer should be calibrated to 35 F, while the facility documentation instructed staff to place the stem in ice water and rotate the head until it reads 32 F. In addition, two dietary staff were unable to demonstrate the cooling process for egg salad and tuna salad, and one staff member stated she had never performed that process or seen a cooling log. Another dietary staff member stated kitchenware should be submerged in sanitizer for 30 minutes, while the manufacturer’s guideline and the facility’s discussion indicated one minute. A cook also prepared Mince and Moist meat with a texture that the Registered Dietitian and Director of Food and Nutrition identified as incorrect during lunch service, and one dietary staff member did not know the required wash temperature for manual dishwashing, which the facility policy listed as approximately 110 F.
Therapeutic diet portions and alternate meal recipes were not followed
Penalty
Summary
The facility failed to follow the Therapeutic Spreadsheets during lunch service on 4/7/2026 when fortified diet residents were not served the ordered 1 oz of melted margarine. During a concurrent observation at the trayline, no melted margarine was available at the steamtable or trayline, and CK 2 plated fortified diet trays without serving the margarine. In interview, CK 2 stated she forgot to serve melted margarine to all fortified diet residents. The RD later stated fortified diet residents were prescribed this diet to help with weight gain and wound healing, and that not receiving the melted margarine meant they did not receive the extra calories ordered. The Food and Nutrition Department also did not have recipes available for alternate meals. During observation, an assistant cook prepared grilled cheese without referring to a recipe, and CK 2 prepared cheese quesadillas without a recipe. FNS 6 was observed preparing chef salad and stated she was unsure whether to use 2 or 3 slices of turkey because there was no chef salad recipe to follow. FNS 7 stated she had worked at the facility for 5 years and had never seen a chef salad recipe, and had been trained to make it without one. The RD stated the alternate meals should have recipes to ensure correct portions and adequate nutrition. The facility also did not follow portion directions on the Therapeutic Spreadsheets for pureed and mince and moist diets. For the pureed diet, the spreadsheet directed pureed yellow cake to be served with a number 12 scoop, but FNS 5 used a blue number 16 scoop to portion the cake into individual containers. For the mince and moist diet, the spreadsheet directed 3 oz of meat, but CK 2 used a grey 4 oz scoop at the trayline. The RD stated the smaller scoop for pureed cake resulted in residents receiving less calories, and the larger scoop for mince and moist meat overfed the residents on that diet.
Cold meal service and improper holding of pureed diets
Penalty
Summary
The facility failed to follow its Point of Service Food Temperature Guide to provide appetizing food at appropriate temperatures for five sampled residents. Resident 84 stated breakfast was consistently cold. Resident 8 stated she received cold breakfasts and dinners. Resident 10 stated eggs were cold, the butter would not melt in the oatmeal because the oatmeal was cold, and pancakes were cold. During a Resident Council meeting, multiple residents reported that food was served cold, including sausage that appeared refrigerated and breakfast items that were not served at appropriate temperatures. A test meal observed at the nursing station showed the fortified regular diet items were below the guideline range, including egg at 89.7 degrees F, turkey sausage patties at 84 degrees F, and toast at 80.6 degrees F; the DFN verified the temperatures and stated the food items were cold. The facility also failed to ensure that 11 residents receiving a pureed diet were provided foods prepared in a manner that preserved nutritional value. Staff interviews showed cooks prepared pureed diets between 9:00 a.m. and 9:30 a.m. and stored the finished foods in an oven at 200 to 250 degrees F until service. The DFN and RD acknowledged the pureed foods were prepared too early, and the DFN stated prolonged holding of pureed foods in the oven could lead to loss of nutrients and compromise the integrity, taste, and quality of the food. The facility's Food Production Policy stated food shall be prepared in a manner that preserves nutritional value and palatability.
Incorrect Therapeutic Diet Textures Served at Lunch
Penalty
Summary
The facility failed to provide food in the correct texture for residents on therapeutic diets during lunch service. During a test meal with the Director of Food and Nutrition, the pureed beef and pureed bread served to residents on a pureed diet were observed and tasted grainy rather than smooth. The DFN stated that pureed food should be a smooth, pudding-like consistency and that the beef and bread should have remained in the blender longer with broth added to achieve the proper texture. The report identified 11 residents on a pureed diet who were affected by this meal service. The facility also served incorrect textures to residents on a soft and bite sized diet. During observation, a cook removed a pan of beef and stated it would be served for regular and soft and bite sized diets, and the beef appeared to be a larger size than appropriate for the soft and bite sized texture. During the meal test, the DFN verified that the beef was not chopped to the correct size and that some green bean pieces were larger than 1.5 cm by 1.5 cm. The DFN stated the beef was more consistent with an easy to chew diet and that the green beans were not the right texture for soft and bite sized residents. The report identified 13 residents on the soft and bite sized diet.
Food Preferences Not Honored on Meal Trays
Penalty
Summary
The facility failed to ensure that resident food preferences were honored for two sampled residents. Resident 10, who had diagnoses including cirrhosis of the liver and a BIMS score of 15, had a meal ticket dated April 6, 2026 that instructed double protein and listed carrots as a dislike. During a concurrent observation and interview in the resident’s room, the lunch tray contained only one portion of protein, and the resident stated a second tray was later delivered. The second tray included carrots, and the resident stated he frequently received single portions of protein and foods he disliked, including carrots. Resident 117, who had diagnoses including dysphagia, had a lunch meal tray ticket dated April 9, 2026 that instructed to give soup and noted a preference for grilled cheese with tomato soup. During a concurrent observation and interview at the bedside with the resident’s legal guardian and CNA 6, the resident’s meal tray was observed without soup, and CNA 6 confirmed the tray was missing soup. The legal guardian stated food items were often missing from the resident’s meal trays. The facility policy stated resident food preferences are to be identified, honored, and incorporated into care, and that meals will be provided in accordance with preferences.
Beverages Not Served per Meal Tickets
Penalty
Summary
The facility failed to ensure beverages were served in accordance with residents’ meal tickets during lunch service for four of seven sampled residents. On April 6, 2026, Resident 90 was observed in the RNA dining room being served a 4 oz beverage when the meal ticket indicated an 8 oz beverage. During the same meal service, Resident 102 was observed not being served the 8 oz beverage indicated on the meal ticket, Resident 146 was observed not being served the 8 oz beverage indicated on the meal ticket, and Resident 139 was observed being served a 4 oz beverage when the meal ticket indicated an 8 oz beverage. On April 7, 2026, the Director of Food and Nutrition stated that the Food and Nutrition Service Department would supply pitchers of beverages such as coffee, juices, and water in the dining room and nursing staff would serve the beverages in accordance with each resident’s meal ticket. During additional observations, CNA 5 confirmed that Resident 146 and Resident 102 were not served the required 8 oz beverage. On April 8, 2026, the Registered Dietitian stated nursing staff should serve beverages in accordance with residents’ meal tickets and that dehydration risk could happen without following the meal ticket serving fluid. The facility policy titled Hydration stated residents will be offered adequate hydration based on assessed needs and that the Food and Nutrition Service Department will supply fluids on trays or with meals as appropriate for assessed needs.
Unsafe Food Preparation and Storage Practices
Penalty
Summary
The facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen. During observation of the prep area, the Registered Dietitian confirmed that a food preparation sink did not have an air gap, even though the facility’s policy stated that air gaps shall be maintained on food prep sinks. The report also noted brown grime buildup inside the ice maker, brown splash spots on the wall and ceiling in the dishwashing and prep areas, grease buildup above the griddle, dust and grime on multiple pieces of kitchen equipment, trash on the kitchen floor in several areas, and four broken plastic containers and covers being used to store utensils. The dietary staff also did not demonstrate knowledge of the cooling process for egg salad and tuna salad. One half steam pan of tuna salad labeled with a preparation date of 4/6/26 was found at 44 F, and one half steam pan of egg salad labeled with a preparation date of 4/7/26 was found at 51.6 F in the walk-in refrigerator. The Director of Food Service discarded both items because they were in the dangerous temperature zone. When asked to demonstrate how to monitor cooling for egg salad and tuna salad, two dietary staff were unable to do so, and one stated she had worked at the facility for 5 years, had never done the cooling process for tuna and egg salad, and had never seen a cooling log. Additional observations showed several dietary staff working with exposed facial hair without beard guards, an expired soy sauce in the cook area, and opened food items in the walk-in freezer exposed to the air. Cooking pans were observed stacked wet and stored on a rack instead of being air dried before storage. The facility’s policies and the FDA Food Code cited in the report addressed air gaps, cooling, sanitation, clean equipment, hair restraints, expired food, and sealed frozen food storage, but the observed practices did not match those standards.
Improper Disposal of Garbage and Refuse Around Dumpster
Penalty
Summary
The facility failed to dispose of garbage and refuse properly when trash was observed outside and surrounding the compactor dumpster at the outside back building. During a concurrent observation and interview with the Registered Dietitian and Director of Food and Nutrition, trash was seen on the floor around the dumpster, along with a strong unpleasant odor and unknown liquid on the ground near the compactor dumpster. The DFN stated that the area surrounding the compactor dumpster should be kept clean and without any smell, otherwise it was going to attract pests. A review of the facility policy titled Food - Related Garbage and Rubbish Disposal, dated January 23, 2026, indicated that outside dumpsters provided by garbage pickup services will be kept free of surrounding litter. A review of FDA Food Code 2022, Section 5-502.11, indicated that refuse shall be removed from the premises at a frequency that will minimize objectionable odors and other conditions that attract or harbor insects and rodents.
Kitchen Equipment Not Maintained per Manufacturer Requirements
Penalty
Summary
The facility failed to ensure proper maintenance of essential equipment in the kitchen area. During observation of walk-in refrigerator #3, water condensation was seen on the copper pipes, and on a later observation water was dripping from the condensation onto foods stored below the pipe. The DFN stated that the condensation water could contaminate the foods. The walk-in freezer was also observed with ice condensation buildup on storage shelves under the ventilator and ice on the floor, and an opened box of country fried steak stored under the ventilator was covered with a layer of ice. In addition, the dish machine was not maintained at the manufacturer-specified wash temperature. The data plate on the machine indicated a wash water temperature of 120 F, but the machine was observed operating at 90 F and later at 100 F and 106.9 F. Staff stated they were monitoring the water booster output temperature instead of the data plate, and the RD stated he did not check the dish machine water temperature.
Pest Control Program Failed to Keep Kitchen Free of Flies
Penalty
Summary
The facility failed to maintain an effective pest control program to keep the kitchen free of pests. During a concurrent observation and interview in the dishwashing area, five flies were seen on the wall of the dishwasher room, and the Director of Food and Nutrition stated flies were not supposed to be present in the kitchen. The Director also stated that flies could move throughout the kitchen, causing cross-contamination and creating a food safety concern. On the following day, five flies were again observed on the dishwashing room wall, and the Director confirmed they were not the same flies seen the day before and that dietary staff had eliminated the earlier flies. A Registered Dietitian later observed a house fly in the kitchen preparation area and stated the kitchen should not have pests because pests could spread bacteria and viruses and may result in food borne illness. The pest management vendor identified the flies on the dishwashing room wall as drain flies, and another observation later found three more drain flies on the wall. The facility policy titled Pest Control stated the facility shall maintain an effective pest control program and keep the building free of insects.
Failure to Assess Resident for Self-Administration of Inhaler
Penalty
Summary
The facility failed to ensure the Interdisciplinary Team (IDT) determined that self-administration of medication was clinically appropriate and safe before allowing a resident to keep a prescribed Ciclesonide inhaler at the bedside for self-administration. On April 7, 2026, the resident was observed alert, oriented, and sitting on the edge of the bed, with one Ciclesonide 160 mcg inhaler on the bedside table available for use. During the observation, the resident stated the inhaler was for emergency use and that he kept it at his bedside. The resident’s record showed diagnoses including asthma and dementia, and the history and physical dated March 29, 2026, indicated fluctuating capacity to make and understand medical decisions. The BIMS dated March 28, 2026, showed a score of 13. The physician order dated March 27, 2026, directed Ciclesonide inhalation aerosol 80 mcg, 2 puffs twice daily for shortness of breath. There was no documented evidence that the resident was evaluated by the IDT for self-administration of the inhaler. An LVN stated the inhaler should not have been at the bedside without an assessment for self-administration, and the DON stated the resident should not have had the inhaler at the bedside without an evaluation. Facility policies stated residents may self-administer medications only if the IDT or attending physician and care planning team determined it was clinically appropriate and safe.
PASRR Not Updated for Documented Mental Health Diagnoses
Penalty
Summary
PASRR screening for mental disorders or intellectual disabilities was not accurately updated for one resident. The resident’s hospital PASRR Level 1 screening dated January 3, 2025, was marked negative for serious mental illness and indicated that the individual did not have a serious diagnosed mental disorder such as anxiety, psychosis, or mood disorder, and did not receive psychotropic medications. However, the resident’s admission record listed diagnoses that included anxiety, psychosis, and mood affective disorder. The resident’s history and physical dated January 9, 2025, stated the resident did not have the capacity to understand and make decisions. A physician order dated December 8, 2025, also showed buspirone 5 mg by mouth three times daily for anxiety manifested by unprovoked physical and verbal aggression. The record contained no documented evidence that the facility corrected the PASRR Level I or completed a Level II evaluation to address the documented psychosis, anxiety, or ongoing use of medication for anxiety. During interview and record review on April 8, 2026, the MDS nurse stated the PASRR should have been reviewed and updated on admission to reflect the diagnosis of psychosis and the use of medication for anxiety.
Incomplete Care Plan for Psychotropic Medication
Penalty
Summary
The facility failed to ensure a comprehensive, person-centered care plan for Resident 45 after the resident was prescribed Xanax 0.5 mg, 2 tablets by mouth twice a day for anxiety manifested by self-report of anxiety. Resident 45’s record showed diagnoses including major depressive disorder and anxiety, and the medication was administered as ordered from February 2, 2026 through April 8, 2026. The care plan for alteration in mood state/anxiety listed the Xanax order as an intervention, with a goal to minimize side effects from medication, but it did not include additional interventions tied to the psychotropic medication. During interviews and record review, the LVN, ADON, and DON all confirmed that the care plan initiated for Xanax was incomplete. They stated it should have included monitoring for side effects, target behaviors, and non-pharmacologic interventions, but the documented care plan only listed the medication order and did not include those additional interventions. The facility policy required a comprehensive, person-centered care plan with measurable objectives and timetables, and the psychopharmacological policy required documentation of target behaviors, potential interventions, behavior monitoring, and alternatives to psychopharmacological drug use.
Failure to Revise Care Plan for Poor Oral Intake
Penalty
Summary
The facility failed to revise Resident 101’s comprehensive care plan to reflect ongoing poor oral intake and the ordered nutritional intervention. Resident 101 was admitted with diagnoses including morbid obesity, chronic kidney disease, and anemia, and the MDS dated March 15, 2026 indicated a BIMS score of 15. The care plan dated March 16, 2026 included interventions for nutrition, including nutritional supplements as ordered and a health shake with meals for inadequate PO intake for 14 days. A food and nutritional assessment dated March 18, 2026 documented that the resident consumed mostly 25% of all meals, and the nutrition intervention/recommendation was 4 oz Health Shake TID with meals for 14 days for inadequate PO intake. The nutrition report from March 18 to April 8, 2026 showed an average meal intake of 41% with multiple instances of intake less than 50% and documented meal refusals. A progress note dated March 19, 2026 documented the MD and RD order for the health shake intervention, but the care plan contained no documented revision after March 18, 2026 to reflect the resident’s ongoing poor intake or the ordered intervention. During interviews, LVN 1 stated decreased intake should prompt a change of condition, physician notification, and care plan revision, and the DON stated the care plan had not been revised to address the resident’s poor oral intake.
Failure to Provide Oral Care
Penalty
Summary
Provide care and assistance to perform activities of daily living for any resident who is unable was not met when Resident 180 was observed with poor oral hygiene. During a concurrent observation and interview, the resident had several areas of yellowish, dry, clumpy, old residue on the tongue, the roof of the mouth, and lodged between the teeth. Resident 180 stated oral care had not been performed, and CNA 2 stated the resident did not look like oral care had been provided and that it should have been. CNA 2 also stated oral care should be performed by the assigned CNA in the morning and after dinner. Resident 180 was admitted with diagnoses including hemiplegia and was documented as lacking capacity to make medical decisions. The MDS indicated the resident was dependent for oral hygiene. The care plan directed oral inspection and oral care to remove debris because the resident was at risk for aspiration related to difficulty swallowing after an acute stroke. The DSD and ADON both stated CNAs were responsible for oral care in the morning, after meals, and as needed, and both stated the resident should have received oral care when residue was observed in the mouth. The facility policy stated all residents would receive routine oral care and that nursing staff and CNAs were responsible for providing and documenting it.
Failure to Install Ordered Side Rail for Mobility Assistance
Penalty
Summary
The facility failed to ensure that an ordered left side rail for Resident 175 was evaluated, care planned, and installed. Resident 175 was admitted with diagnoses including morbid obesity and abnormalities of gait and mobility, had a BIMS score of 15, and was observed lying on her left side in bed without any side rails present. During interview, the resident stated she had been admitted for mobility rehab, that the lack of side rails made it difficult to reposition herself in bed, and that she had requested rails but had not received follow-up. The resident’s record showed a physician order dated April 2, 2026 stating she may have a left side grab bar (side rails) for mobility, and the care plan dated April 1, 2026 identified a need for a side rail bar to assist with self-repositioning in bed. The DOR stated PT recommended a left-side side rail and that nursing was responsible for obtaining the physician’s order, coordinating an IDT meeting, working with maintenance for installation, and implementing the order after PT approval. The DON stated an IDT meeting should be held before installing side rails, along with obtaining the physician order, resident and/or family consent, and maintenance installation, and stated staff did not follow facility protocol. On follow-up observation, the side rail still had not been installed, and the resident stated she had told nursing staff several times that it had not been installed.
Unlabeled IV Site and Missing Monitoring Documentation
Penalty
Summary
The facility failed to ensure intravenous (IV) sites were maintained in accordance with professional standards of practice for one resident who received IV ceftriaxone sodium for a urinary tract infection. On April 6, 2026, the resident was observed alert, oriented, and lying in bed with her right arm exposed. Her right forearm IV site had an unlabeled dressing. During the same observation, the resident stated the IV had been placed in the hospital and removed when she returned to the facility, and that a facility nurse removed the hospital IV and inserted a new IV. RN 1 observed the site and stated the dressing was not labeled and should have included the catheter size, date, time, and initials of the nurse who inserted the IV. Record review showed a physician’s order for ceftriaxone sodium 1 gram IV daily for five days and a nursing progress note documenting two attempts and a right forearm 22-gauge IV line. The resident’s April 2026 MAR did not show documented monitoring of the IV site for signs and symptoms of complications, including infection, during the course of IV therapy. The DON stated the facility’s process was to label all IV sites, document IV insertion, and monitor IV sites every shift for signs and symptoms of infection, and that licensed nurses should have labeled the IV site and documented ongoing monitoring.
Unsealed IV Medication E-kit With Missing Documentation and Inventory
Penalty
Summary
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist was not met when an IV Medication E-kit was found stored open and unsealed in the medication storage room at the North Station. During observation and interview, the DON stated nursing staff should have resealed the E-kit after it was opened, documented the medication use in the E-kit logbook, and called the pharmacy for replacement. The DON also stated he could not locate documentation in the logbook and could not identify when the E-kit was opened, which medication(s) were used, or which resident(s) received them. The pharmacy label on the outside of the IV Medication E-kit showed it had been filled on March 30, 2026. After comparing the remaining contents to the inventory list, the DON identified that one bottle of sodium polystyrene 15 g powder for suspension and one 60 ml bottle of sterile water were missing. On further record review, the DON identified Resident 44 had a physician order for sodium polystyrene suspension 15 g/60 ml and that one dose was administered shortly after the order was written. A nursing progress note documented that medication was given for abnormal labs and was tolerated well. The facility policy required any medication removed from the emergency kit to be documented on the emergency medication administration log, and the pharmacy policy required the kit to be identified, resealed, and logged when opened.
Pharmacist Failed to Report Missing Monitoring for Psychotropic Medications
Penalty
Summary
The facility failed to ensure the Consultant Pharmacist identified and reported irregularities during the monthly medication regimen review for two sampled residents. For one resident, who had diagnoses including schizophrenia, vascular dementia, TIA/stroke, major depressive disorder, generalized anxiety disorder, hyperlipidemia, and cataract, the record showed an order for quetiapine 12.5 mg by mouth every 8 hours for schizophrenia manifested by physical aggression. The DON reviewed the manufacturer specifications and confirmed there was no documented evidence of monitoring for lipids, TSH, or an eye exam during quetiapine use. The DON also stated that monitoring for adverse reactions according to the manufacturer specifications should have been completed, and the CP later stated he should have identified and reported the missing monitoring. The monthly MRRs for that resident, spanning June 2025 through March 2026, contained no recommendations from the CP related to the missing lipid monitoring, TSH monitoring, or eye exam. The facility policy for psychopharmacological medications stated the primary care physician was responsible for ordering appropriate lab tests to assure adequate monitoring of psychopharmacological drugs. The manufacturer instructions for quetiapine indicated fasting blood lipid testing at the beginning of and periodically during treatment, and noted that lens changes had been observed during long-term treatment and that both TSH and free T4 should be measured at baseline and follow-up. For the second resident, who had diagnoses including major depressive disorder and anxiety, the record showed an order for Xanax 0.5 mg, 2 tablets by mouth twice a day for anxiety manifested by self-report of anxiety. The medical record contained no documented evidence of physician orders for non-pharmacologic behavior interventions, monitoring of target behavior, or monitoring for adverse side effects related to Xanax. Nursing staff and facility leaders confirmed there was no documented evidence of side effect monitoring, target behavior monitoring, or non-pharmacologic interventions during Xanax use, and the DON and CP later acknowledged the CP should have identified and reported the missing target behavior monitoring and side effect monitoring during the monthly MRRs.
Medication Administration Errors
Penalty
Summary
A medication error rate of 12% was identified when three medication errors occurred during 25 medication administration opportunities for one resident. During a medication pass observation, an LVN prepared and administered famotidine 10 mg, a multivitamin with minerals, ferrous sulfate 325 mg, doxycycline 100 mg, cholestyramine 4 g powder mixed in water, and two acetaminophen 325 mg tablets for a resident who requested pain medication for a pain level of 4 out of 10. Review of the resident’s record showed there was no active physician’s order for acetaminophen 650 mg by mouth for pain level 4 out of 10, and the LVN acknowledged the medication was given without an order. The same medication pass showed cholestyramine and doxycycline were administered at the same time as other medications. The DON’s drug reference indicated cholestyramine should be separated from other medications by at least 1 hour before or 4 to 6 hours after administration, and doxycycline should be separated from calcium- and iron-containing products. The LVN stated she was not aware cholestyramine should be given separately from all medications and was not aware doxycycline should not be given at the same time as multivitamins with minerals and ferrous sulfate. The DON stated staff were expected to follow manufacturer instructions, and the facility policy stated medications are administered in accordance with prescriber orders.
Expired insulin vial and undated PPD vial found in medication storage
Penalty
Summary
Medication storage and labeling were not maintained for one medication cart and one medication room in South Station. In Medication cart D, an inspection with LVN 3 identified one expired Insulin Lispro vial for Resident 25 that had been opened on a prior date and was labeled by the pharmacy to be discarded 28 days after opening. LVN 3 stated the vial was good until a later date and should have been discarded, and there was no other Insulin Lispro vial or prefilled pen available in the cart. Resident 25 had a physician order for Insulin Lispro injection solution 100 units/ml to be given by sliding scale before meals and at bedtime for diabetes, and the MAR showed multiple doses were administered over several days after the vial had been opened. In the South Station medication room refrigerator, an opened and used multi-dose vial of Tuberculin PPD 5 TU per 0.1 ml was found without an open date label during a concurrent observation and interview with LVN 3. LVN 3 stated the vial should have been dated so staff would know when it expired and that the opened, undated vial should have been discarded. The DON stated nursing staff were expected to date the vial and that opened vials should be discarded 30 days after opening. The manufacturer instructions stated vials in use more than 30 days should be discarded due to possible oxidation and degradation affecting potency, and the facility policy stated the date opened is recorded on the container.
Soiled Linens and Curtains Not Maintained Clean Under Infection Control Program
Penalty
Summary
The facility failed to implement its infection prevention and control program to ensure linens and environmental surfaces, including shower and privacy curtains, were maintained clean and free of visible soil. During an observation in the North shower room at 10:24 a.m., a shower curtain was noted with black stains and discoloration on the bottom; the Director of Housekeeping and Laundry (DHL) acknowledged it needed to be removed and washed. At 10:28 a.m., in the Medically Complex Unit shower room, another shower curtain was observed with brown stain discoloration, and the DHL again stated the curtain needed to be removed and washed. At 10:20 a.m., in the North clean linen closet, a linen item folded on the shelf and ready for resident use was observed with a visible stain mark, which the DHL stated should not be present and that the item needed to be discarded. At 10:52 a.m., in a resident’s room, the Infection Preventionist Nurse (IP) observed and acknowledged a brown streak stain on the resident’s privacy curtain, stating it should not have a stain, needed to be replaced, and that it was an infection control issue. Later, the Director of Nursing (DON) stated that clean linens in the clean linen closet, resident privacy curtains, and shower curtains should be clean and free from stain marks, and that the expectation is to maintain a clean and homelike environment and prevent the spread of infection, consistent with the facility’s Infection Prevention and Control Policy requiring a safe, sanitary environment with cleaning, disinfection, and linen handling procedures.
Inaccurate Diagnosis Documented in Catheter Care Plan
Penalty
Summary
The facility failed to ensure the accuracy of the medical record and care plan for one sampled resident when an incorrect diagnosis was documented. The resident was admitted with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, unspecified urinary incontinence, and urinary retention, and had an indwelling Foley catheter in place per physician orders and history and physical documentation. Review of the physician documentation and diagnoses showed no evidence that the resident had a diagnosis of neurogenic bladder. Despite the absence of this diagnosis in the medical record, the resident’s care plan documented that the resident had an indwelling catheter related to neurogenic bladder, BPH, and urinary retention. During interview and concurrent record review, the MDS Supervisor stated that an MDS nurse had completed the care plan, confirmed that the resident did not have neurogenic bladder, and acknowledged that this diagnosis should not have been included. In a separate interview, the DON also confirmed that the resident did not have a diagnosis of neurogenic bladder and that its inclusion in the care plan was incorrect, stating the facility was responsible for ensuring the accuracy of residents’ medical records.
Delayed Release of Medical Records to Resident's Legal Representative
Penalty
Summary
The facility failed to provide timely access to medical records for a resident who had been discharged with chronic kidney disease. The resident's legal representative submitted a written request for the resident's medical records, which was received by the Medical Records Director (MRD) on August 12, 2025. According to facility policy, records should have been released within 48 hours (two working days) of the request. However, the MRD forwarded the request to the facility's legal department, and the facility did not respond until September 8, 2025, resulting in a 27-day delay. The MRD confirmed that this delay did not comply with the regulatory requirement or facility policy for timely release of records.
Lack of Physician Documentation for Resident Discharge
Penalty
Summary
The facility failed to ensure that the physician documented the clinical rationale for the discharge of a resident who had been admitted with diagnoses including spinal fusion and depression. Record review showed that, as of June 1, the resident was recommended for follow-up imaging and was noted to benefit from continued care. Despite this, a Notice of Proposed Transfer/Discharge was issued, and subsequent documentation did not provide clinical justification that the resident no longer required facility services or that discharge was in the best interest of the resident's health and safety. Progress notes later stated the resident was independent and cleared for discharge, but lacked supporting clinical rationale from the physician. Interviews with facility staff, including the Social Service Director, Nurse Practitioner, and Director of Nursing, confirmed that discharge planning began with a physician order, but the medical record did not reflect the necessary assessment or documentation supporting discharge readiness. The facility's policy required that the basis for transfer or discharge be documented in the resident's clinical record by the attending physician, which was not done in this case.
Failure to Use PPE During G-Tube Medication Administration for Residents on Enhanced Barrier Precautions
Penalty
Summary
Licensed Vocational Nurses (LVNs) failed to implement required infection control practices for two residents who were on Enhanced Barrier Precautions (EBP) due to the presence of indwelling catheters, feeding tubes, and wounds. Both residents had care plans and physician orders specifying that staff must use gowns and gloves during high-contact care activities, including medication administration via G-tube. During observations, LVNs were seen entering the residents' rooms and administering medications through G-tubes without wearing the required isolation gowns, despite the established protocols and documented requirements in the residents' records. Interviews with the involved LVNs confirmed that they were aware of the need to wear isolation gowns but failed to do so, with one stating she forgot and the other acknowledging the requirement to protect residents and prevent infection spread. The Infection Preventionist also confirmed that staff are expected to follow the designated precaution protocols and use appropriate PPE as indicated. Facility policy reviewed further supported the necessity of gowns and gloves for high-contact activities involving device care, such as feeding tubes.
Failure to Ensure Safe Serving Temperature of Hot Beverages Resulting in Resident Burns
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) served a hot beverage to a resident without checking the temperature to ensure it was within a safe serving range. The resident, who had a history of metabolic encephalopathy and multiple strokes resulting in right-sided hemiplegia, required supervision and set-up assistance with eating. Despite these needs, the CNA heated water in a microwave, prepared tea, and served it to the resident without verifying the temperature, contrary to facility policy. The incident resulted in the resident spilling the hot beverage on herself, causing significant burn injuries to her right breast and shoulder. Documentation and interviews confirmed that the resident experienced severe pain and required medical intervention, including an emergency room visit and follow-up wound care for second and third degree burns. The resident's care plan indicated a need for assistance with eating, and staff interviews revealed that the CNA was unaware of the requirement to check beverage temperatures before serving, while another CNA confirmed that such checks were part of their training and policy. Facility policies reviewed specified that hot beverages must be served at or below 155°F and that temperatures should be measured with a calibrated thermometer prior to service. The Director of Nursing confirmed that the CNA did not follow this policy, leading to the resident's injury. The resident recalled not being warned about the hot beverage and did not remember if the spill was caused by staff or occurred after she awoke from a brief sleep.
Failure to Assess, Monitor, and Follow Up on Skin Injuries and Changes
Penalty
Summary
Three residents experienced failures in assessment, monitoring, and follow-up of skin conditions and injuries. One resident, with a history of metabolic encephalopathy and diabetes, sustained burn injuries from a hot beverage spill. Upon return from the hospital, there was no evidence that treatment for the burns was initiated or monitored for several days, and a follow-up appointment with a burn specialist, as recommended by the hospital, was not arranged in a timely manner. Documentation gaps were noted, and staff interviews confirmed that the treatment nurse was not informed of the incident until four days later, delaying necessary wound care and evaluation. Another resident, with dementia, diabetes, and on long-term aspirin therapy, developed significant bruising on both hands. The skin changes were identified by a CNA and reported to nursing staff, but there was no documented assessment, monitoring, or referral to a physician for further evaluation and treatment. The care plan and physician orders required monitoring for signs of bleeding and prompt reporting, but these steps were not followed. Staff interviews confirmed that the bruising was not properly assessed or documented, and the DON acknowledged that the required protocols were not adhered to. A third resident, with diabetes and peripheral vascular disease, had known diabetic ulcers on both feet. Over a two-week period, the size of the wounds increased, but this change in condition was not identified or communicated to the physician. Weekly wound documentation failed to note the progression, and staff interviews revealed that the increase in wound size should have been recognized as a change in condition and reported. The DON confirmed that the lack of timely communication and documentation could have led to a delay in appropriate care.
Failure to Ensure Timely Response to Resident Telephone Calls
Penalty
Summary
The facility failed to ensure that telephone calls for a resident were answered by staff, resulting in a lack of immediate access to the resident. During an unannounced visit, it was found that a resident with ALS, a progressive neurodegenerative disease, was unable to use her call light after it fell to the floor. She called out for assistance but received no response from staff. The resident then contacted a family member for help. The family member reported making multiple unsuccessful attempts to reach facility staff by phone over an 11-minute period, eventually being transferred to the nurses' station without the call being answered or receiving a callback. Interviews with facility staff revealed that after the receptionist left at 9 p.m., incoming calls were transferred to the Registered Nurse Supervisor, who stated that calls might not be answered immediately if she was attending to resident care. Additional interviews with two other residents indicated that calls intended for them were also not forwarded. The administrator confirmed that the expectation was for calls to be answered and forwarded appropriately during and after office hours.
Failure to Timely Reorder Pain Medication Resulting in Unavailability
Penalty
Summary
The facility failed to ensure that Hydrocodone, a strong pain medication, was reordered in a timely manner for a resident with spinal stenosis of the lumbosacral region. The resident was admitted with diagnoses that included this condition, which can cause significant pain, numbness, and weakness. On review of the resident's progress notes, it was found that Hydrocodone 5-325 was not administered as prescribed because the medication was not available on a documented date. Interviews with a Licensed Vocational Nurse (LVN) and the Registered Nurse Supervisor (RNS) confirmed that the medication was not reordered when only seven pills remained, as required by facility policy. Both staff members acknowledged that there was no documentation of a timely reorder, and the facility's policy indicated that medications should be ordered in advance. This lapse resulted in the resident not receiving the physician-ordered pain management regimen due to the unavailability of the medication.
Delayed Provision of Medical Records
Penalty
Summary
The facility failed to provide a resident's medical records within the required 48-hour time frame, as mandated by their policy. The legal representative of a resident, who had been admitted with diagnoses including a pressure ulcer and diabetes mellitus, requested the resident's medical records on January 16, 2025, with a valid authorization dated January 8, 2025. Despite the facility's policy requiring records to be provided within 48 hours, the records were not delivered until February 5, 2025, which was 14 business days after the request was made. The Medical Record Director (MRD) acknowledged receiving the request on January 16, 2025, and instructed the Medical Record Assistant to forward it to the facility's corporate legal team. However, the MRD did not follow up with the legal team until January 22, 2025, resulting in a delay. The Administrator confirmed that the facility's protocol required records to be provided within approximately 48 hours, but the legal representative did not receive the records until February 5, 2025. This delay had the potential to deny the resident representative access to review records and delay critical legal or medical decision-making for the resident.
Failure to Provide Ordered Pressure Ulcer Care
Penalty
Summary
The facility failed to provide pressure ulcer treatment as ordered by the physician for three residents, leading to deficiencies in care. Resident #57, who was admitted with a Stage 4 pressure ulcer, did not have a dressing in place during an observation, despite orders to replace it as needed. The treatment nurse and CNAs were aware of the issue but failed to ensure the dressing was reapplied, and documentation was inconsistent with the actual care provided. Resident #63, also with a Stage 4 pressure ulcer, was found without a dressing during an observation. The CNA who provided care did not report the missing dressing to a nurse, and the treatment nurse expressed frustration over the lack of communication and follow-through. The facility's policy required that any nurse could replace the dressing if notified, but this protocol was not followed. Resident #160, at risk for pressure ulcers, had treatment orders for redness on the heels that were not consistently followed. The LVN responsible for the treatment admitted to signing the treatment administration record without actually providing the care, leading to missed treatments. The DON and Administrator acknowledged the expectation for staff to follow treatment orders and document care accurately, but these standards were not met in practice.
Facility Fails to Provide Safe Wheelchair for Resident
Penalty
Summary
The facility failed to provide a wheelchair in good condition for a resident, leading to a deficiency in maintaining a safe and homelike environment. The resident, who was admitted with conditions including hemiplegia and muscle wasting, was dependent on staff for transfers and used a wheelchair provided by the facility. Observations revealed that the wheelchair had multiple burn holes in the seat and a torn armrest with exposed foam, which posed a potential safety hazard. The resident's family confirmed that the wheelchair was provided by the facility, and the resident denied being a smoker, suggesting the damage was not self-inflicted. Interviews with facility staff, including a physical therapist, the Director of Maintenance, and the Administrator, revealed a breakdown in the process of ensuring wheelchairs were in good condition before being assigned to residents. The physical therapist acknowledged the wheelchair's poor condition but stated that cosmetic repairs were not their responsibility. The Director of Maintenance admitted that the wheelchair was not part of the facility's standard equipment and should not have been used. The Administrator confirmed that the wheelchair was mistakenly taken from a storage area meant for repairs and was not suitable for resident use. The Director of Nursing emphasized the expectation for equipment to be clean, well-maintained, and functional, highlighting the facility's failure to adhere to its own policies regarding wheelchair maintenance and safety.
Failure to Refer Resident for Level II PASRR Screening
Penalty
Summary
The facility failed to ensure that a resident with a diagnosis of bipolar disorder was referred for a Level II Preadmission Screening and Resident Review (PASRR). The resident was admitted with a negative Level I screening, which incorrectly indicated that the resident did not have a serious mental illness (SMI). Despite the resident's medical history and hospital records indicating a diagnosis of bipolar disorder, the facility did not identify this as an SMI and did not refer the resident for the necessary Level II PASRR screening. Interviews with facility staff revealed a lack of awareness and oversight in the PASRR screening process. The MDS Coordinator, responsible for checking the accuracy of PASRR screenings, was unaware that the resident's Level I PASRR was inaccurate. The Director of Nursing stated he was not involved in the PASRR process, and the Administrator indicated that the Admission Director and MDS Coordinator were responsible for ensuring the accuracy of PASRR screenings. This oversight led to the failure to identify and refer the resident for appropriate mental health services.
Failure to Provide Adequate Fingernail Care
Penalty
Summary
The facility failed to provide adequate fingernail care for a resident who required assistance with activities of daily living. The resident, who had a medical history of hemiplegia and hemiparesis following a stroke, was observed with long and dirty fingernails. Despite the resident's request for nail trimming, the staff did not fulfill this need, citing a lack of available nail trimmers. The resident had previously purchased nail trimmers, but they were taken by the staff and not used to trim the resident's nails. Interviews with facility staff revealed a lack of communication and awareness regarding the availability of nail trimmers. Certified Nurse Aides and a Licensed Vocational Nurse were unaware of the resident's need for nail care, and the Director of Nursing and Administrator stated that nail trimmers were available in the utility room. However, the staff failed to locate and use them, resulting in the resident's unmet need for personal hygiene care.
Failure to Administer Respiratory Treatments as Ordered
Penalty
Summary
The facility failed to provide respiratory breathing treatments as ordered by the physician for Resident #15, who was diagnosed with chronic obstructive pulmonary disease (COPD). The resident was supposed to receive DuoNeb treatments every six hours for seven days, but the order was incorrectly transcribed into the electronic health record as every six hours every seven days. This transcription error led to the resident receiving the treatment only once since the order was initiated in December 2024. Observations and interviews revealed that the nebulizer machine was not readily accessible, being covered by personal items, and the medication cannister and tubing were dated 12/30/2024, indicating infrequent use. Despite the resident's complaints of shortness of breath, cough, and congestion, the treatments were not administered as frequently as ordered. The respiratory therapist renewed the order on 01/02/2025 but did not correct the scheduling error, resulting in continued inadequate treatment. Interviews with staff, including LVNs and the Director of Nursing, highlighted a lack of verification and double-checking of the orders entered into the electronic health record. The Director of Nursing and the Administrator acknowledged that the orders should have been verified and checked by another nurse to ensure accuracy. The failure to provide the prescribed respiratory care was due to a combination of transcription errors, oversight in order verification, and inadequate monitoring of the resident's treatment schedule.
Failure in Hand Hygiene and Glove Changes During Wound Care
Penalty
Summary
The facility failed to ensure proper hand hygiene and glove changes during wound and peri-care for two residents with Stage 4 pressure ulcers. The facility's policy on wound care and the CDC's recommendations for hand hygiene were not followed by the staff. Specifically, during the care of Resident #57, the Treatment Nurse and Certified Nurse Aide did not change gloves or perform hand hygiene after providing incontinence care and before proceeding with wound care. This resulted in the application of wound treatment with potentially contaminated gloves. Similarly, for Resident #63, the staff did not adhere to proper hand hygiene protocols. The Certified Nurse Aide did not change gloves or perform hand hygiene after providing incontinence care and before assisting with wound care. The Treatment Nurse also failed to perform hand hygiene between glove changes while treating the resident's sacral wound and an additional open area on the resident's back. These actions were contrary to the facility's policy and CDC guidelines, which emphasize the importance of hand hygiene before and after glove use and between different care tasks. Interviews with the staff, including the Treatment Nurse, Certified Nurse Aides, Licensed Vocational Nurses, the Director of Nursing, and the Administrator, revealed a lack of adherence to hand hygiene protocols. The staff acknowledged the need for hand hygiene before and after care and between glove changes, but their actions during the observed care did not reflect this understanding. The deficiency highlights a significant lapse in infection prevention and control practices within the facility.
Failure to Reassess and Monitor Low Blood Pressure
Penalty
Summary
The facility failed to reassess and monitor the vital signs of a resident who was experiencing low blood pressure, which was initially recorded at 65/49. This deficiency was identified during a review of the resident's records and interviews with facility staff. The resident, who had been admitted with diagnoses including sepsis and enterocolitis, showed a change in condition on November 5, 2024, when abnormal vital signs were noted. Despite receiving an order to transfer the resident to a hospital for further evaluation, there was no documentation of any reassessment or monitoring of the resident's blood pressure while waiting for the transfer. Interviews with the Director of Nursing and nursing staff revealed that the licensed nurse did not recheck the resident's blood pressure after the initial low reading, despite acknowledging that it should have been done. The facility's policy required documentation of changes in a resident's condition, but there was no record of reassessment or interventions provided to the resident. This lack of action and documentation could have delayed prompt response to the resident's condition.
Inadequate Infection Control for Resident with C. diff
Penalty
Summary
The facility failed to implement proper infection control practices for a resident diagnosed with Clostridium Difficile (C. diff), a highly contagious bacteria. The resident was readmitted to the facility with enterocolitis due to C. diff and was placed on contact precautions. However, during an observation and interview, it was noted that disposable equipment, such as a stethoscope and sphygmomanometer, was not readily available for the resident in isolation. This lack of designated disposable equipment was confirmed by a Certified Nursing Assistant (CNA), a Registered Nurse (RN), the Infection Preventionist (IP), and the Director of Nursing (DON), all of whom acknowledged that such equipment should be available to prevent the spread of infection. The facility's policy and procedure documents, including those titled 'Clostridium Difficile' and 'Isolation-Categories of Transmission Based Precautions,' emphasize the importance of using dedicated equipment for residents on transmission-based precautions to prevent the transmission of infections. Despite these guidelines, the facility did not ensure that the necessary disposable equipment was available for the resident, increasing the risk of spreading the infection to other residents and staff. This oversight highlights a deficiency in the facility's infection prevention and control program.
Failure to Assist Legally Blind Resident with Meals
Penalty
Summary
The facility failed to provide necessary assistance with meals to a resident, who was legally blind and had multiple medical conditions including type 2 diabetes mellitus, anxiety disorder, coronary artery dissection, and hypertensive heart disease. The resident's care plan indicated a need for assistance with feeding due to her inability to read the menu and her risk for aspiration related to difficulty swallowing. Despite these documented needs, during an unannounced visit, it was observed that a staff member placed the resident's lunch tray in front of her and left the room without providing the required assistance. Interviews conducted with the resident, a CNA, an RN, and the DON revealed a lack of adherence to the facility's policy on meal assistance. The resident expressed her inability to read the menu and her reliance on others to inform her about the meals. The CNA admitted to not knowing if the resident was aware of what was being served, while the RN acknowledged that assistance should be provided to someone who is blind. The DON confirmed that assistance should have been given to the resident, as per her care plan and the facility's policy, which mandates that residents receive meal assistance tailored to their individual needs.
Delayed Medical Records Requests
Penalty
Summary
The facility failed to provide requested medical records for four residents within the 48-hour timeframe as stipulated by their policy and procedure. The process for obtaining medical records involved the requestor filling out a form, which was then sent to the corporate office for approval. This process was confirmed by both the Medical Records Assistant and the Medical Records Director, who stated that it typically took one to two weeks to fulfill a request. This delay was attributed to the medical records department being short-staffed, which resulted in the department falling behind in processing requests. The deficiency was identified during an unannounced visit to the facility, where it was found that requests for medical records for four residents were pending approval at the corporate office. These requests had been received between August 12 and August 20, 2024, but had not been fulfilled within the required timeframe. The Interim Administrator acknowledged that the medical records department was expected to complete requests within 48 hours, as per the facility's policy. The facility's policy, revised in November 2009, stated that residents could access their records within 48 hours of a request, excluding weekends and holidays.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure the call light was within reach for one of the sampled residents, identified as Resident 3. During an unannounced visit, it was observed that Resident 3, who has Alzheimer's Disease, was in bed with the call light clipped to her pillowcase and hanging off the left side of her bed, making it inaccessible. A Licensed Vocational Nurse (LVN) confirmed the call light was out of reach and admitted it was due to not repositioning the call light after the resident was repositioned. The Director of Nursing stated that the expectation is for nursing staff to ensure call lights are always within reach of residents. The facility's policy, revised in September 2022, also indicates that call lights should be accessible to residents when in bed.
Pesticide Application Conducted with Resident Present in Room
Penalty
Summary
The facility failed to provide a safe and comfortable environment for a resident when pest treatment was conducted while the resident was inside the room. On August 20, 2024, an observation was made of the resident lying in bed, unresponsive to interview questions. The Maintenance Supervisor admitted to spraying pesticide inside the resident's room while the resident was present, stating that the spray was not toxic to humans and only a small amount was used. The Maintenance Supervisor did not move the resident or consult with the visitor present at the time before proceeding with the pesticide application. The facility's Administrator stated that the protocol for spraying pesticides in resident rooms includes moving the resident out and deep cleaning the room afterward. The Administrator expected the Maintenance Supervisor to notify nursing staff before spraying so that residents could be relocated. However, Registered Nurse 1 was unaware of the pesticide application in the resident's room and would have expected to be informed to move the resident out to prevent direct exposure. The facility's policy on maintaining a homelike environment emphasizes providing a safe, clean, and comfortable setting, which was not adhered to in this instance.
Failure to Reposition Resident with Stage 4 Pressure Ulcer
Penalty
Summary
The facility failed to ensure that a resident with an existing stage 4 pressure ulcer was repositioned at least every two hours, as outlined in the resident's care plan. Observations on a specific day revealed that the resident remained in the same position on her back with the head of the bed elevated at 30 degrees for over three hours, from 9:50 a.m. to 12:59 p.m. This was contrary to the care plan's directive to turn and reposition the resident at least every two hours to minimize skin impairment. During an interview, a CNA assigned to the resident admitted to not repositioning the resident during the observed period, citing being busy as the reason. The facility's policy on repositioning, revised in May 2013, emphasizes the importance of repositioning immobile residents every two hours to prevent skin breakdown and promote circulation. The Director of Nursing confirmed that the expectation is for nursing staff to adhere to the care plan's repositioning schedule.
Failure to Maintain Clean and Sanitary Resident Rooms
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in two of four resident rooms, as observed during an unannounced visit. In one room, a brown-colored splatter of an unknown substance was found on the window wall, dirty gloves were on the floor outside of the trash can, and three dried drops of blood were on the floor near Bed B. A resident in this room confirmed that the blood was from their toe but could not specify how long it had been there. The housekeeper admitted that she had not yet cleaned this room on the day of the observation. In another room, trash, food crumbs, and dust were found behind the headboards of Beds A and B, despite the housekeeper stating that she had already cleaned the room. The housekeeper acknowledged that she had not cleaned behind the headboards, which she should have done. A Registered Nurse verified the unclean conditions and expressed that the room should have been cleaned better. The facility's policy, titled 'Homelike Environment,' emphasizes providing a clean, sanitary, and orderly environment, which was not adhered to in these instances.
Failure to Provide Written Notice of Transfer/Discharge
Penalty
Summary
The facility failed to provide a written notice of transfer or discharge to a resident and their representative, as required by regulations. This deficiency was identified during a review of the records for a resident who was admitted with diagnoses including depression and schizoaffective disorder. The resident was discharged to an acute hospital for psychiatric evaluation and medication management, but there was no documentation indicating that a written notice of transfer was provided to the resident or their representative. The Notice of Proposed Transfer/Discharge form was incomplete, with no entries for the name or relationship of the person notified, and no indication that it was mailed to a representative. During interviews, the Director of Nursing (DON) confirmed that the licensed nurses are responsible for providing the Notice of Proposed Transfer/Discharge form to the resident upon transfer. However, the form was neither signed nor dated by the resident, indicating that the notice was not acknowledged. The DON acknowledged that the licensed nurse who facilitated the transfer should have ensured the resident received a written notice. The facility's policy, revised in December 2016, mandates that residents and their representatives be notified in writing of the reasons for transfer or discharge and the facility's bed-hold policy.
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What surveyors actually found near you
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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 Corona
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Corona Regional Medical Center D/p Snf | 0.8 mi | ★★★★★ | 6 | 0 |
| Corona Health Care Center | 1.9 mi | ★★★★★ | 1 | 0 |
| Arlington Gardens Care Center | 6.9 mi | ★★★★★ | 20 | 1 |
| Palm Terrace Care Center | 7.2 mi | ★★★★★ | 4 | 0 |
| Riverwalk Post Acute | 8.4 mi | ★★★★★ | 21 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.