Average — CMS composite of the measures below.
The next survey window likely opens around April 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 Country Oaks Care Center during CMS and state inspections, most recent first.
Beds Not Kept Low for Fall-Risk Residents: Three residents with confusion, cognitive impairment, mobility problems, seizures, and prior falls were found with their beds positioned above waist level instead of in the lowest position directed by their care plans. One resident had recently fallen and sustained a laceration above the eyebrow, and staff including an LVN, CNA, and DON acknowledged the beds should have been kept low for safety.
A cook stored a personal protein shake inside a kitchen freezer instead of in a designated employee area, and a resident kept outside food items at the bedside, including bakery cupcakes with dated labels. The resident had Huntington’s disease and immunodeficiency, and was cognitively intact with capacity to make decisions.
Unlabeled personal care items were found in two shared restrooms between double-occupancy rooms, including a hair comb, shampoo/body wash, and body lotion. CNAs stated the items should have been labeled with resident names to prevent use by another resident and for infection control, and the IP stated these items should be labeled with resident names and room numbers and stored at the bedside or in the closet.
Call lights were found on the floor and out of reach for three residents who were observed in bed in a shared room. The affected residents had significant cognitive impairment, and their records included diagnoses such as cerebral infarction sequelae, dementia, dysphagia, psychosis, gait abnormalities, and contractures. The DSD stated this could prevent residents from requesting assistance, and the DON stated it could create an infection control concern and risk of injury if a resident tried to retrieve the call light.
Failure to develop person-centered care plans for two residents: one resident with bipolar disorder and another resident with impaired hearing and hearing aids. The record review and staff interviews showed the first resident had bipolar disorder, depression, and intact cognition, yet no care plan addressed the mental health condition. The second resident had hearing issues, received hearing aids, and was observed wearing them, but no care plan addressed the hearing impairment or proper hearing aid use.
A resident had Australian Dream Arthritis Pain Relief Cream at the bedside without a physician order or self-administration assessment. The resident said the cream was brought from home and used for arthritis. The RN Supervisor identified it as an OTC medication and stated bedside storage required a physician order and risk discussion, while the DON stated the product should have been ordered after a self-administration assessment per facility policy.
Failure to Reposition Residents With Active Skin Breakdown: Two residents with active skin breakdown and care plans calling for frequent repositioning were repeatedly observed lying on their backs with the HOB elevated at 45 degrees. One resident said she was often left in that position and had to request repositioning, and when she asked the TN to be turned, the TN did not reposition her because she was scheduled to get out of bed soon. The DON stated there was no formal log to track repositioning times, and the DSD stated residents with skin breakdown should be repositioned every 2 hours and as needed.
A resident with bilateral 1/4 side rails in use did not have a required Bed Rail Assessment completed. The resident had diagnoses including metabolic encephalopathy, abnormal posture, muscle weakness, and bilateral hip OA, and the care plan identified side rails as an enabler for transferring, repositioning, and ADL care. Staff stated the assessment should be completed before bedrails are implemented and then annually, but it had not been done for this resident.
A resident admitted with acute cystitis and difficulty walking had incomplete medical record documentation related to their responsible party (RP). The Admission Record did not list the RP or any RP contact information, even though the H&P identified the RP as the surrogate decision maker because the resident could not make medical decisions. The Consent for Treatment form for this resident was also incomplete, lacking the RP’s last name and the date of signature. Staff interviews confirmed that facility policy requires complete RP identification and dating of consent forms, and that such information should be entered promptly into the medical record.
A resident with acute pulmonary edema, ESRD, and severe sepsis experienced altered mental status and respiratory compromise, but the CICE form was left incomplete, containing only earlier vital signs and lacking behavioral, respiratory, cardiovascular, GI, GU, and neuro assessments or physician notification. An LVN documented that the resident was pale with shallow breathing and low O2 sat and that 911 was called, but the recorded time of the 911 call conflicted with an RN’s account. The RN reported placing the resident on a non-rebreather mask, initiating continuous O2 and heart rate monitoring, and remaining at the bedside until paramedics arrived, yet none of these assessments or interventions were documented in the medical record, resulting in incomplete and inaccurate documentation.
Six licensed nurses responsible for Pleurx catheter care did not have documented competency assessments, despite receiving in-service training. The Director of Staff Development confirmed the absence of competency validation, and facility policies require such assessments for specialized care. This failure meant there was no verification that staff could properly manage Pleurx catheters.
A resident admitted with a Pleurx catheter and multiple complex diagnoses did not have a care plan developed upon admission to address the presence and management of the catheter. Staff interviews and record reviews confirmed that no care plan specific to the device was created, despite facility policy and the resident's clinical needs.
A resident did not receive care and treatment in accordance with physician orders and their stated preferences and goals, as identified by surveyors through observation and record review.
A resident with a G-tube and complex medical needs experienced redness and leaking at the G-tube stoma, which was noted in a change in condition evaluation but not documented in the required nursing progress notes over several shifts. Multiple LVNs and the DON confirmed that such findings should have been recorded in the skin assessment section of the medical record, in accordance with facility policy.
A staff member transferred a resident using a mechanical lift without the required assistance of a second staff member, contrary to facility policy. The resident, who required total assistance for transfers due to multiple medical conditions and impaired balance, was observed being lifted by only one staff member. Both the staff member and the DSD confirmed that two staff are required for such transfers to ensure safety.
Staff failed to follow hand hygiene and Enhanced Barrier Precautions when caring for a resident with a gastrostomy tube and tracheostomy. Two sitters provided care without wearing gloves and did not perform hand hygiene before donning gloves, despite facility policy and posted instructions. The sitters were unable to explain the importance of these precautions or the purpose of EBP, and the DON confirmed that these actions were required to prevent the spread of MDROs.
The facility failed to maintain a clean and safe environment, with issues in the kitchen, resident rooms, and a shared bathroom. Observations included cracked plaster, worn and chipped tiles, and unpainted walls. Staff were unaware if these issues had been reported, and maintenance logs did not reflect necessary repairs. The Maintenance Supervisor acknowledged the need for repairs, recognizing the potential health hazards posed by the unsanitary conditions.
The facility failed to provide adequate gastrostomy tube (GT) care for two residents. One resident's GT was disconnected, causing feeding to spill on the floor, while another resident's GT tip touched the floor, violating infection control protocols. Additionally, a CNA improperly handled the GT feeding pump, contrary to facility policy. Both residents had severe cognitive impairments and required staff assistance for daily activities.
Two residents with impaired cognition and respiratory conditions had unlabeled IV sites, contrary to facility policy, risking potential complications and infections. Observations confirmed the absence of date and time labels on the IV dressings, which were required to track changes and prevent infections.
The facility failed to ensure proper medication administration and accountability, leading to two deficiencies. Narcotic medications in a medication cart were not accurately accounted for during shift changes, as the off-going nurse's signature was missing from the Controlled Substances Shift Count Log. Additionally, a resident with severe cognitive impairment did not receive the correct dose of Polyvinyl Alcohol Ophthalmic Solution as prescribed, with only one drop administered per eye instead of the ordered two drops.
Facility staff failed to adhere to infection control protocols in two instances. A Respiratory Therapist did not properly secure an isolation gown during tracheostomy care for a resident under enhanced barrier precautions, risking contamination. Additionally, a Certified Occupational Therapy Assistant did not wear required PPE while assisting a resident on contact isolation for potential C. diff infection. These actions violated facility policies designed to prevent infection spread.
A facility failed to maintain a safe and sanitary bathroom for four residents, with issues such as mold, cracked tiles, and exposed screws. The maintenance logs did not show any repairs or checks for the bathroom, and the Maintenance Supervisor acknowledged the need for repairs. The residents had respiratory conditions, making them vulnerable to the unsanitary conditions.
A resident with impaired cognition and at risk for falls was found without access to a call light, contrary to the facility's policy. The call light was observed hanging out of reach, and both a nurse and the DON confirmed the necessity for it to be accessible for safety and assistance.
A facility failed to provide information about an Advance Directive (AD) to the responsible party of a resident with severe cognitive impairment. The resident's medical record incorrectly indicated an AD was executed, but the social worker admitted the form was filled out incorrectly. The Director of Nursing confirmed the need for discussion of AD forms upon admission, and the responsible party stated they were unaware of what an AD was, as it was not discussed with them.
A resident received Aripiprazole for schizophrenia without a documented diagnosis, leading to an inaccurate MDS assessment. The resident's Admission Record did not list schizophrenia, and the MDS did not reflect it as an active diagnosis, despite hospital notes indicating it. The facility's policy requires accurate assessment coding, which was not followed.
A facility failed to develop a care plan for a resident's IV therapy, despite the resident's severe cognitive impairment and dependency on staff for daily activities. The resident was admitted with chronic respiratory failure and pneumonia, and a physician's order was in place for IV therapy. Interviews with staff confirmed the absence of a care plan, which was required by the facility's policy.
A resident with Alzheimer's and rheumatoid arthritis, identified as high risk for falls, experienced an unwitnessed fall due to inadequate supervision. Despite a history of falls and a policy requiring a sitter, the facility failed to ensure continuous supervision, leading to the incident. Staff interviews confirmed the absence of a sitter at the time of the fall, contrary to the facility's Fall Prevention Program.
A resident with complex medical conditions had their indwelling urinary catheter bag lying on the floor, contrary to infection control guidelines. Staff acknowledged the risk of infection due to this oversight, as the facility's policy emphasized proper catheter positioning to prevent complications.
A resident with chronic respiratory failure and severe cognitive impairment did not have their nasal cannula properly placed, as it was found on their forehead instead of inside the nostrils. This oversight was confirmed by the facility's Infection Prevention Nurse and Director of Nursing, who both stated that proper placement is necessary to maintain the resident's oxygen saturation levels as per the physician's order.
A CNA was observed disconnecting and operating a gastrostomy tube (GT) machine for a resident, actions outside their scope of practice. The resident, with severe cognitive impairment, required GT feeding as per a physician's order. Facility policy indicated that CNAs were not trained or authorized to perform these tasks, as confirmed by interviews with nursing staff.
A facility failed to ensure a specific indication for Ativan use for a resident, as required by their policy on psychotropic medications. The resident, admitted with chronic respiratory failure and hypoxia, was prescribed Ativan for agitation, which was not considered a specific diagnosis. The Director of Nurses confirmed that the indication was insufficient, as the facility's policy requires a specific diagnosed condition for administering psychotropic drugs.
A cook in an LTC facility was observed using the same gloves to handle ready-to-eat food after touching potentially contaminated surfaces, risking cross-contamination. The Dietary Supervisor confirmed the need for glove changes to prevent foodborne illness, aligning with facility policies and FDA guidelines.
The facility failed to provide adequate space in 11 resident rooms, each with three beds and only 190 square feet, falling short of the required 80 square feet per resident. Despite a waiver request and CNA's ability to provide care, the rooms were noted to be tight, potentially impacting care delivery.
A facility failed to create a comprehensive care plan for a resident who refused to be changed after becoming soiled with urine, increasing the risk of UTIs. Despite being incontinent and at risk for recurrent UTIs, the resident's care plan did not address their refusal behavior. Staff interviews confirmed the resident's refusal to be changed, and the ADON acknowledged the lack of a care plan addressing this issue, contrary to facility policy.
A resident with functional quadriplegia was unable to reach the overhead light pull cord, leading to a trash can liner being tied to it as a makeshift solution. The facility's maintenance staff was not informed of the issue, and there was no documentation in the Maintenance and Repair Log. The Assistant Director of Nursing confirmed that the pull cord should have been replaced to ensure a safe and comfortable environment.
A resident with severe cognitive impairment and multiple health issues was verbally and physically abused by a CNA. The incident was witnessed by two sitters who reported that the CNA grabbed the resident's head, used derogatory language, and threatened the resident with a bed remote. The facility's policies on abuse were not effectively implemented, leading to this deficiency.
Two residents experienced delays in receiving abdominal X-ray results, leading to a three-day interruption in G-tube feeding and medication. Despite multiple follow-ups, the facility's new diagnostic company failed to provide timely results, necessitating one resident's transfer to a hospital for confirmation. Staff interviews highlighted previous timely service from a different provider.
The facility failed to provide necessary in-service training to several LVNs before they signed forms indicating they had received training on topics such as Dementia, Care of Visually Impaired Residents, Abuse, and Medication Administration. Interviews revealed that LVNs were instructed to sign the forms without attending training sessions, and the Director of Staff Development admitted there was no system to track completed training.
Two residents with severe cognitive impairments and physical limitations did not receive adequate incontinence care, as required by their care plans. Facility staff failed to check and change the residents every two hours, leading to instances where residents were found soaked with urine. This failure was attributed to staffing shortages and high workloads, as reported by CNAs. The facility's policy on incontinence care was not consistently followed, posing a risk of UTIs and skin breakdown.
The facility failed to provide adequate staffing to ensure timely incontinence care for two residents, leading to potential risks of skin breakdown and UTIs. Both residents were dependent on staff for toileting and were always incontinent. Interviews with CNAs revealed that residents were often found soaked with urine due to staffing shortages, particularly during night shifts. The facility's policies emphasized the need for sufficient staffing, but the staffing levels were inadequate to meet residents' needs.
The facility did not post actual worked nursing hours at the start of each shift as required by their policy. An observation revealed outdated staffing information, and the Director of Staff Development confirmed the oversight, stating that postings were projections and not updated for staff call-offs.
The facility failed to ensure the safe use of a Hoyer lift for transferring residents, leading to a risk of falls and injury for four residents. CNAs did not follow proper procedures, with one CNA holding a resident by the feet during a transfer, and another operating the lift alone without assistance. The facility's policy requires two staff members for such transfers, especially for residents with tracheostomies, to prevent potential harm.
The facility failed to conduct a reference check for a CNA before hiring, as required by their P&P on Abuse, Neglect, and Exploitation. The CNA's file lacked documentation of reference checks, which the DSD confirmed were not performed. This oversight placed 70 residents at risk, as the facility's policy mandates screening for a history of abuse, neglect, or exploitation.
A housekeeping staff member failed to follow the facility's infection control policies by not wearing gloves on both hands and neglecting hand hygiene while handling soiled linen. The staff member transported an uncovered barrel of soiled linen through the hallway, contrary to the facility's procedures, which could lead to cross-contamination and infection spread.
The facility failed to maintain a homelike environment by not ensuring cleanliness in two shower rooms. Observations revealed chipped paint and a black substance in the shower room of SNF 1, confirmed by the Maintenance Supervisor as dirt buildup. The Housekeeping Supervisor also noted the black substance in both SNF 1 and SA shower rooms, acknowledging it was the housekeeping department's responsibility to clean the showers. The facility's policy required maintaining a sanitary environment, which was not followed.
A resident with moderate cognitive impairment reported that a CNA failed to clean them properly, left them soiled, and spoke disrespectfully, violating their dignity. Another resident confirmed hearing the CNA yell at the affected resident. The DON acknowledged that staff should not raise their voices at residents, aligning with the facility's policy on maintaining resident dignity.
A resident with functional quadriplegia and moderate cognitive impairment was unable to reach their call light, which was found on the floor behind their bed. The resident had to yell for help due to the call light's inaccessibility. A CNA confirmed the improper placement, and the DON highlighted the importance of accessible call lights for resident safety.
A resident with severe cognitive impairment was physically abused by another resident with a history of agitation and psychosis. The incident occurred after a verbal altercation, and staff intervention was required to separate the residents. Despite existing policies to prevent abuse, the facility failed to prevent this incident.
A resident with dementia physically grabbed another resident, but the incident was not reported to authorities within the required timeframe. Despite staff recognizing the event as abuse, the Administrator delayed reporting for 15 days, contrary to facility policy requiring immediate notification to protect resident safety.
A resident with mobility issues and occasional incontinence was not provided with appropriate toileting assistance, leading to unnecessary incontinence. Despite being able to verbalize the need for help, staff instructed the resident to urinate in briefs instead of offering alternatives like a bed pan. Interviews revealed that staff found it difficult to use the Hoyer lift, and the resident felt trapped and like a burden. The facility's policy to maintain continence was not followed, resulting in the resident being forced into incontinence.
Beds Not Kept in Lowest Position for Residents at Risk for Falls
Penalty
Summary
The facility failed to ensure that the beds of three residents at risk for falls were maintained in the low position at all times. Resident 1 had diagnoses including metabolic encephalopathy, abnormal posture, muscle weakness, and bilateral hip osteoarthritis. The resident’s fall risk assessment identified intermittent confusion, decreased muscle coordination, and multiple predisposing diseases, and the MDS documented moderate cognitive impairment. Resident 1’s care plan directed that the bed be kept in the lowest position for safety, but during observation the resident was found lying in bed with the head of the bed elevated and the bed positioned above waist level. The LVN stated the bed should have been maintained in a lower position to reduce the risk of injury. Resident 9 had diagnoses including metabolic encephalopathy, contracture of the left knee, right lower extremity amputation, rhabdomyolysis, and seizures. The resident’s care plan directed that the bed be in the lowest position, and the fall risk assessment described the resident as confused and unable to correctly identify key aspects of reality, with a history of falls. The resident’s MDS documented severe cognitive impairment, and nursing progress notes showed three falls. During observation, Resident 9 was lying in bed with the head of the bed elevated and the bed positioned above waist level. The LVN stated the resident was at high risk for falls and the bed should be kept at a lower level. Resident 28 had diagnoses including hemiplegia, seizures, and a history of falling, and the H&P stated the resident did not have the capacity to understand and make decisions. Fall risk assessments identified the resident as at risk for falls, and the MDS documented severely impaired cognitive skills, substantial/maximal assistance needs, and two or more falls without injury. The care plan directed staff to keep the bed at the lowest position at all times when the resident was in bed. After an unwitnessed fall with a laceration above the left eyebrow and transfer to the hospital, Resident 28 was observed lying in bed with the bed about three feet off the floor. CNA staff stated the bed was not in a low position and may have been forgotten after breakfast, and the DON stated the resident was a fall risk who tended to get out of bed and that keeping the bed low was important.
Improper Storage of Staff and Resident Personal Food Items
Penalty
Summary
The facility failed to maintain safe and proper food storage practices in the kitchen by allowing a cook’s personal protein shake to be stored inside Freezer 1. During a concurrent observation and interview in the kitchen, an unlabeled bottle with a green lid containing about half of a light chocolate-colored drink was found on the bottom shelf of Freezer 1. The cook identified the bottle as personal property and stated it was a protein shake that had been placed in the freezer because it had gotten warm. The cook also stated staff had a refrigerator in the employee lounge for personal food items and that personal items should not be stored in the facility kitchen freezers for infection control reasons. The facility’s policy on food safety and food storage stated food would be stored, prepared, distributed, and served in accordance with professional standards and that cross-contamination should be prevented. The facility’s policy on designated employee belongings areas stated personal food and beverages may be stored in designated separate employee areas. The facility also failed to discard personal food items brought from outside for a resident and stored at the resident’s bedside. Resident 17 had diagnoses including Huntington’s disease and immunodeficiency, and the resident’s cognitive skills for daily decision making were intact, with capacity to understand and make decisions. During observation in the resident’s room, the bedside contained a container of Sweet P’s chocolate cupcakes with a bakery sticker dated 4/21/26 and two cupcakes remaining, and a container of Sweet P’s unicorn cupcakes with a bakery sticker dated 4/20/26 and six cupcakes remaining. The resident stated the cupcakes were brought to the facility by the resident’s daughter.
Unlabeled Personal Care Items Found in Shared Restrooms
Penalty
Summary
The facility failed to implement infection prevention and control practices by not labeling and properly storing personal care items in two shared restrooms located between double-occupancy resident rooms. In one restroom between Resident 50 and Resident 20’s room and Resident 65 and Resident 6’s room, an unlabeled hair comb and an unlabeled 8 fl oz bottle of Remedy Essential Cleanse Shampoo & Body Wash were observed on the sink. In the other restroom between Resident 48 and Resident 45’s room and Resident 40 and Resident 67’s room, an unlabeled 10 fl oz bottle of Vaseline Advanced Repair Body Lotion was observed tucked horizontally behind the sink faucet. During interview, CNA 3 stated the comb and shampoo/body wash did not have a resident name and should have been labeled so staff would know not to use them on another resident and to prevent cross contamination. CNA 4 stated the body lotion should have been labeled with Resident 40’s name so other residents would not use it and for infection control. The Infection Preventionist Nurse stated the comb, body wash, and lotion were personal care items and that labeling them with resident names and room numbers and storing them at the resident’s bedside or closet was important for residents and staff to know who the items belonged to and for infection control. The facility policy stated it had an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections, and the resident belongings policy stated belongings would be kept in a neat and orderly fashion and maintained in each resident’s room.
Call Lights Not Within Reach
Penalty
Summary
The facility failed to ensure that call lights were within reach for three of 24 sampled residents, identified in the report as Residents 8, 23, and 84. During a concurrent observation and interview on 5/5/2026 at 10:06 AM in the shared room for these residents, they were positioned in their beds and their call lights were observed on the floor and out of reach. The report states that this failure had the potential to affect the residents' ability to request assistance when needed. Resident 8's Face Sheet listed diagnoses including sequelae of cerebral infarction, abnormalities of gait, lack of coordination, retention of urine, and contracture of the right elbow and right hand, and the resident's MDS dated 3/10/2026 indicated severe cognitive impairment. Resident 23's Face Sheet listed dementia, dysphagia, and psychosis, and the MDS indicated severe cognitive impairment. Resident 84's Face Sheet listed abnormal posture, psychosis, and signs and symptoms involving cognitive awareness, and the MDS also indicated severe cognitive impairment. During interview, the DSD stated that not having the call light within reach could prevent residents from requesting assistance and potentially worsen their existing condition. The DON stated that a call light on the floor could create an infection control concern and could place the resident at risk of injury if they attempted to retrieve it. The facility policy titled Call Lights: Accessibility and Timely Response stated staff will ensure the call light is within reach and accessible while the resident is in bed or other sleeping accommodations.
Failure to Develop Person-Centered Care Plans for Bipolar Disorder and Hearing Impairment
Penalty
Summary
The facility failed to develop or implement individualized, person-centered care plans for two residents. Resident 4 was admitted with diagnoses that included bipolar disorder, depression, and morbid obesity. The history and physical dated 3/10/2926 indicated Resident 4 had the capacity to understand and make decisions, and the MDS dated 3/14/2026 indicated the resident was cognitively intact, had clear speech, and could understand and be understood by others. The MDS also showed dependence with oral and toilet hygiene, upper and lower body dressing, and sit-to-lay and bed-to-chair transfers. During interview and record review on 5/8/2026, the Medical Records Director and the DON stated Resident 4 did not have a care plan for bipolar disorder, and the DON stated a care plan was important to be aware of and address needs and complications that could arise from the disorder. Resident 26 was admitted with diagnoses that included UTI and Type 2 DM with diabetic neuropathy. A progress note dated 4/22/2026 indicated Resident 26 received a pair of hearing aids, and the MDS indicated intact cognition and use of a hearing aid or other hearing appliance. During a concurrent interview and record review on 5/7/2026, LVN 1 stated the resident had hearing issues and used hearing aids, and that a care plan was needed to make nursing staff aware of the hearing aids and their proper use. An observation on 5/7/2026 showed Resident 26 sitting up in bed with hearing aids in both ears. The DON stated care plans needed to be comprehensive and encompass all residents' needs, and that residents with hearing impairments needed a care plan to recognize those needs and provide the best interventions.
OTC Arthritis Cream Kept at Bedside Without Order or Self-Administration Assessment
Penalty
Summary
The facility failed to follow its process for OTC product self-administration for one resident when Australian Dream Arthritis Pain Relief Cream was found at the resident’s bedside without a self-administration assessment or a physician’s order. The resident was admitted with diagnoses including unspecified atrial fibrillation and type 2 diabetes mellitus, and the H&P indicated the resident had the capacity to understand and make decisions. The MDS indicated the resident’s cognitive skills for daily decision making were intact, and the resident required supervision or touching assistance for ADLs. During observation and interview, the resident had a 4 oz container of Australian Dream Arthritis Pain Relief Cream at the bedside and stated the cream was brought from home and used for arthritis. The OSR did not show an order for the cream. The RN Supervisor stated the product was an OTC medication and that residents were allowed to keep OTC medications at the bedside only with a physician’s order and after the risks were explained. The DON stated the cream should have been ordered by the physician after a self-administration assessment, and the facility policy required the interdisciplinary team to determine which medications could be self-administered safely.
Failure to Reposition Residents With Active Skin Breakdown
Penalty
Summary
The facility failed to ensure that two sampled residents with active skin breakdown were repositioned in accordance with their individualized care plans. Resident 1 was admitted with diagnoses including metabolic encephalopathy, abnormal posture, muscle weakness, and bilateral osteoarthritis of the hip. Her care plan, dated 1/14/2026, directed that she be repositioned every 2 hours and as needed. Her MDS dated 2/12/2026 indicated moderate cognitive impairment, and a skin assessment dated 3/4/2026 documented active skin breakdown on the front left leg, perineum, sacrococcygeal area, front right leg, and left heel. Resident 72 was admitted with diagnoses including metabolic encephalopathy, type 2 diabetes, difficulty walking, and lack of coordination. Her care plan, dated 3/16/2026, directed frequent repositioning due to active skin breakdown and immobility, and a skin assessment dated 4/1/2026 documented active skin breakdown on the left outer arm, right outer forearm, coccyx, and perineum. During multiple observations, both residents were repeatedly found lying on their backs in bed with the head of the bed elevated at a 45-degree angle. Resident 72 was observed in this position on 5/5/2026 and 5/7/2026, and Resident 1 was observed in this position on 5/5/2026, 5/7/2026, and 5/8/2026. Resident 72 stated that she was often left lying on her back and had to request repositioning. When Resident 72 asked the TN to be repositioned, the TN stated she was scheduled to get out of bed soon and did not reposition her. Resident 1 also stated she wanted to be repositioned, and CNA 1 then repositioned her. The DON stated there was no formal log used to track repositioning times, and the DSD stated residents with existing skin breakdown should be repositioned every 2 hours and as needed according to the turning schedule displayed on staff badges. The facility policy titled Pressure Injury Prevention and Management stated the facility shall establish and utilize a systemic approach for pressure injury prevention and management.
Missing Bed Rail Assessment for Resident with Side Rails
Penalty
Summary
The facility failed to ensure that a Bed Rail Assessment was completed for one of eight sampled residents who had bed rails in use. Resident 1 was admitted with diagnoses including metabolic encephalopathy, abnormal posture, muscle weakness, and bilateral osteoarthritis of the hip. The resident’s MDS dated 6/29/2025 indicated the resident was cognitively intact. The care plan dated 1/21/2026 stated that bilateral 1/4 side rails were to be used while the resident was in bed as an enabler for transferring, repositioning, and during ADL care. Review of the resident’s Standard Assessments showed the Bed Rail Assessment was past due as of 2/6/2026. During observation on 5/7/2026, the resident was lying in bed with the head of the bed elevated and bilateral 1/4 side rails up. During interview, the RN stated Bed Rail Assessments are to be completed by the MDSC, LVN, or RN prior to implementing bedrails, and the MDSC stated that Bed Rail Assessments are completed upon admission and annually for residents who use bed rails and that one had not been completed for Resident 1. The facility policy titled Proper Use of Bed Rails stated the resident assessment should assess risks of entrapment between the mattress and bed rail or in the bed rail itself and determine whether the bed rail meets the definition of a restraint.
Incomplete Responsible Party Information and Consent Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one sampled resident when key responsible party (RP) information was missing from the admission and consent documents. The resident was admitted with diagnoses including acute cystitis without hematuria and difficulty in walking. The Admission Record did not identify who the resident’s RP was or provide any RP contact information, despite a History and Physical dated the day after admission stating that the resident could make needs known but could not make medical decisions and that the surrogate decision maker was the RP. This omission meant the Admission Record did not reflect who was designated to act on the resident’s behalf. In addition, the resident’s undated Consent for Treatment form was incomplete, as it did not include the RP’s last name or the date the consent was signed. During interviews, an LVN stated that facility policy required the Consent for Treatment to be filled out completely, including the RP’s full name and the date of signature, and that the Admission Record should have included the RP’s contact information shortly after admission, particularly for emergencies. An RN also stated it was important to document the RP’s full name and the date on the consent form to show that the resident was approved to be treated. The facility’s policy on documentation required that each resident’s medical record be accurate, relevant, complete, and timely, with sufficient detail and proper dating, which was not met in this case.
Incomplete and Inaccurate Documentation During Resident Change in Condition
Penalty
Summary
The deficiency involves incomplete and inaccurate medical record documentation for one resident who had serious medical conditions, including acute pulmonary edema, ESRD, and severe sepsis with septic shock. The resident was dependent on staff for ADLs and could make needs known but could not make medical decisions. On the date of the incident, a Change in Condition Evaluation (CICE) form was initiated at 9:35 PM for altered mental status, but it only contained previously recorded vital signs from earlier that afternoon and did not include current vital signs at the time of the change in condition. The CICE form also lacked completed assessments of the resident’s behavioral, respiratory, cardiovascular, abdominal/gastrointestinal, genitourinary, and neurological status, and there was no documentation that the primary physician had been notified of the change in condition. A progress note by an LVN, timed at 11 PM, documented that at 9:30 PM the resident was found pale with shallow breathing and an O2 sat of 88% on 2 L/min via NC, and that the RN supervisor reassessed the resident and called 911 at 7:37 PM, with paramedics arriving within 5 minutes. This documentation conflicted with the RN’s later interview statements about the timing of events. In an interview, the RN stated that around 9 PM the LVN reported the resident was breathing fast with an O2 sat of 86%, that the RN placed the resident on a non-rebreather mask, the O2 sat increased to 90%, 911 was called after 9 PM, and the resident was placed on continuous O2 sat and heart rate monitoring while the RN remained at the bedside until paramedics arrived. None of the RN’s assessment findings, the initiation of the non-rebreather mask, the continuous monitoring, or the physician notification were documented in the resident’s medical record. The DON confirmed on review that the CICE form was incomplete and emphasized the importance of accurate and complete documentation, as required by the facility’s policies on documentation and notification of changes.
Lack of Competency Assessment for Nurses Managing Pleurx Catheters
Penalty
Summary
The facility failed to ensure that six licensed nurses responsible for the care and management of Pleurx catheters had completed competency assessments to demonstrate their ability to safely handle these devices. Interviews revealed that although in-service training on pleural effusion and Pleurx catheters had been provided, there was no documentation or recollection of formal competency assessments for these nurses. The Director of Staff Development confirmed the absence of such documentation and acknowledged that without competency assessments, there was no verification that staff could properly manage Pleurx catheters. A review of the facility's policies and facility assessment tool indicated that the facility is required to validate staff competencies, especially for specialized care such as catheter management, upon hire and routinely thereafter. The policies also state that training and competency validation should be tailored to the needs of the resident population and any new conditions or procedures. Despite these requirements, the facility did not have evidence that the nurses responsible for Pleurx catheter care had demonstrated the necessary competencies, as required by their own policies and regulatory standards.
Failure to Develop Admission Care Plan for Resident with Pleurx Catheter
Penalty
Summary
The facility failed to develop a care plan upon admission for a resident who had a Pleurx catheter in place. The resident was admitted and re-admitted with diagnoses including malignant neoplasm of the prostate, pleural effusion, and neutropenia. Documentation showed that the resident required partial to full assistance with activities of daily living and mobility. Medical records indicated the Pleurx catheter was placed prior to admission due to recurrent pleural effusion. Despite this, no care plan specific to the management of the Pleurx catheter was created at the time of admission. Interviews with facility staff, including a Licensed Vocational Nurse, Registered Nurse Supervisor, and Director of Staff Development, confirmed that a care plan addressing the Pleurx catheter was not developed upon admission. Staff acknowledged the importance of timely care planning for medical devices to ensure proper monitoring, drainage, infection prevention, and clear staff guidance. Facility policies reviewed also required comprehensive, person-centered care plans to be developed upon admission, especially for residents with medical devices, but this was not followed in this case.
Failure to Follow Treatment Orders and Resident Preferences
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident's preferences and goals. This deficiency was identified through surveyor observation and review of records, which indicated that care provided did not align with the documented orders or the expressed wishes and objectives of the resident. Specific details regarding the nature of the treatment or the resident's medical history and condition at the time of the deficiency are not provided in the report.
Failure to Document G-Tube Stoma Condition in Medical Record
Penalty
Summary
The facility failed to maintain accurate and complete medical records for one resident by not documenting redness and leaking from the resident's gastrostomy tube (G-tube) stoma in the Progress Notes under Advanced Skilled Evaluation (PN ASE) over several days. The resident, who had a history of chronic respiratory failure with hypoxia, tracheostomy, and was dependent on staff for all activities of daily living, was readmitted with a G-tube in place. A Change in Condition Evaluation noted the presence of redness and leaking around the G-tube stoma, but subsequent PN ASE entries by licensed nurses did not include any documentation of these findings. Interviews with multiple licensed vocational nurses (LVNs) confirmed that it was standard practice to document head-to-toe assessments, including skin assessments, in the PN ASE. The LVNs acknowledged that redness and leaking from a G-tube stoma should have been documented in the skin assessment section, and failure to do so could result in other staff being unaware of the issue. The Director of Nursing (DON) also stated that it was the responsibility of all licensed nurses to document skin issues every shift in the PN ASE to ensure accurate and timely care. A review of the facility's policy and procedure on documentation indicated that each resident's medical record should provide a comprehensive picture of the resident's progress, with all assessments, observations, and services documented accurately and completely. Despite this policy, the required documentation regarding the resident's G-tube stoma condition was missing from the medical record during the specified period.
Mechanical Lift Transfer Conducted Without Required Two-Person Assistance
Penalty
Summary
A deficiency occurred when a staff member used a mechanical lift to transfer a resident without the required assistance of a second staff member, as mandated by the facility's policy and procedure for safe resident handling and transfers. During an observation, a restorative nursing assistant was seen operating the mechanical lift alone while transferring a resident who was dependent on two-person assistance for all activities of daily living, including transfers. The resident was lifted above the bed using a sling attached to the mechanical lift, with no other staff present in the room. The resident involved had multiple medical conditions, including acute and chronic respiratory failure with hypoxia, type 2 diabetes mellitus with hyperglycemia, and acute pulmonary edema. The resident's care plan and assessment indicated a need for total assistance from two staff members for transfers due to confusion and impaired balance. Both the staff member involved and the Director of Staff Development confirmed that facility policy requires two staff members to be present when using a mechanical lift, with one operating the lift and the other supporting the resident. The facility's policy, revised in December 2022, explicitly states that two staff must be utilized for mechanical lift transfers to ensure safety.
Failure to Follow Hand Hygiene and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to follow its own infection prevention and control policies and procedures regarding hand hygiene and Enhanced Barrier Precautions (EBP) for a resident with significant medical needs, including a gastrostomy tube and tracheostomy. During an observation, two sitters providing care to the resident were seen wearing gowns but not gloves while repositioning the resident and handling the tracheostomy tubing. The sitters were unable to explain the importance of wearing gloves or performing hand hygiene before care, and only donned gloves after being prompted, without performing hand hygiene beforehand. Further, the sitters admitted they did not perform hand hygiene before entering the resident's room, despite signage indicating that hand hygiene and the use of gowns and gloves were required for anyone entering. The sitters also demonstrated a lack of understanding of EBP and its significance in preventing the spread of multidrug-resistant organisms (MDROs), especially for residents with devices such as feeding tubes and tracheostomies. The Director of Nursing confirmed that staff are expected to perform hand hygiene before entering rooms, before and after care, and before donning PPE, and acknowledged the importance of glove use for residents on EBP. Review of facility policies confirmed these requirements, including that hand hygiene must be performed prior to donning gloves and immediately after removing them, and that EBP training is required for staff. The observed failures had the potential to transmit and spread infection within the facility.
Facility Fails to Maintain Safe and Sanitary Environment
Penalty
Summary
The facility failed to maintain a clean, safe, sanitary, and homelike environment, affecting multiple areas including the kitchen, resident rooms, and a shared bathroom. In the kitchen, surveyors observed cracked and bubbled plaster on the ceiling near the food preparation area, and worn, cracked, and chipped floor tiles. The Dietary Supervisor acknowledged these issues and stated that the Maintenance Department had been informed, but repairs had not been completed. The Maintenance Supervisor confirmed the need for repairs, recognizing the potential health hazards posed by the unsanitary conditions. In two resident rooms, unpainted plaster and peeling paint were observed, which had not been addressed by the Maintenance Department. Certified Nursing Assistant 6 and Licensed Vocational Nurse 8 were unaware if these issues had been reported, and the maintenance logs did not reflect any repairs or reports for these rooms. The Maintenance Supervisor admitted to previously repairing a wall but failing to paint it, acknowledging the oversight. The unaddressed repairs posed a health risk to the residents, particularly due to the potential for plaster dust exposure. In a shared bathroom, multiple issues were noted, including a dark black substance near the toilet, warped baseboards, cracked and peeling plaster, and exposed screws on a safety grab bar. The Maintenance Supervisor acknowledged the need for repairs, as the conditions were not only unsanitary but also not homelike for the residents. The maintenance logs did not indicate any repairs or inspections for the bathroom, highlighting a lack of adherence to the facility's policy and procedure for maintaining a safe and comfortable environment.
Inadequate GT Care and Infection Control Lapses
Penalty
Summary
The facility failed to provide adequate gastrostomy tube (GT) treatment and services for two residents receiving enteral feedings. For Resident 40, the GT was observed disconnected from the feeding pump, resulting in enteral feeding spilling onto the floor. This incident occurred after Licensed Vocational Nurse (LVN) 7 had powered off the GT feeding pump and disconnected the resident for a bed bath, but the disconnection was not communicated to the incoming Certified Nursing Assistant (CNA) 4. The Director of Nursing (DON) acknowledged that such disconnections could lead to a loss of track of the amount of enteral feeding received, potentially causing weight loss. For Resident 20, the facility failed to follow infection control precautions, as the tip of the resident's GT touched the floor. Additionally, CNA 1 improperly handled the GT feeding pump by disconnecting the feeding and turning the machine on and off, actions that were against the facility's policy. The DON confirmed that CNAs were not permitted to disconnect or operate the GT feedings and emphasized the importance of preventing GT tubing from touching the floor to avoid contamination. Both residents had severe cognitive impairments and were dependent on staff for various activities of daily living. Resident 40 had a history of chronic respiratory failure and dysphagia, while Resident 20 had a diagnosis related to gastrostomy and swallowing difficulties. The facility's policy on the care and treatment of feeding tubes, revised in December 2022, was not adhered to, leading to these deficiencies.
Failure to Label IV Sites as per Policy
Penalty
Summary
The facility failed to ensure proper labeling of peripheral IV sites for two residents, Resident 52 and Resident 116, as per the facility's policy and procedure on Intravenous Therapy. On March 3, 2025, observations revealed that the IV sites for both residents were not labeled with the date and time of the dressing change. This omission was confirmed during interviews with the Infection Prevention Nurse and the Director of Nursing, who acknowledged that the IV sites should have been labeled to prevent infections and to track when the dressing was last changed. Resident 52, who had severe impaired cognition and was dependent on staff for various activities of daily living, had a physician order to restart the IV every 96 hours and change the dressing with site change. Similarly, Resident 116, with moderately impaired cognition and also dependent on staff, had a physician order to rotate the IV site every 7 days. Both residents were admitted with diagnoses including chronic respiratory failure and pneumonia. The lack of labeling on their IV sites had the potential to result in complications and infections, affecting their well-being.
Medication Administration and Accountability Deficiencies
Penalty
Summary
The facility failed to ensure proper accountability and administration of medications, leading to two deficiencies. Firstly, the facility did not maintain accurate records for narcotic medications stored in one of the medication carts (Med Cart #2) during shift changes on March 1, 2025. The off-going nurse's signature was missing from the Controlled Substances Shift Count Log (SCL) for both the AM and PM shifts, which is necessary to confirm that narcotics were counted and accounted for by both the off-going and on-coming nurses. This lapse in procedure could potentially lead to the diversion of narcotic medications. Secondly, the facility did not administer the correct dose of Polyvinyl Alcohol Ophthalmic Solution to a resident (Resident 50) as ordered by the physician. The resident, who had severe cognitive impairment and was dependent on staff for various activities, was prescribed two drops of the solution in each eye every 12 hours. However, during a medication administration observation, the nurse administered only one drop per eye. This failure to follow the physician's order resulted in the resident not receiving the adequate dose of medication, which could affect the treatment of the resident's eye condition.
Infection Control Lapses in PPE Usage
Penalty
Summary
Facility staff failed to implement proper infection control practices in two separate instances, leading to potential risks of infection spread. In the first instance, a Respiratory Therapist (RT) did not properly wear an isolation gown while performing tracheostomy care on a resident under enhanced barrier precautions. The RT donned the gown but failed to secure the ties at the back, leaving their clothing exposed and in contact with the resident's bed. This oversight was acknowledged by the RT, who admitted that a loose gown could lead to contamination and potential infection spread. In the second instance, a Certified Occupational Therapy Assistant (COTA) did not wear the required personal protective equipment (PPE) while assisting a resident on contact isolation. The resident was being evaluated for Clostridium difficile (C. diff) infection, and the care plan required staff to wear gloves and a gown. However, the COTA was observed assisting the resident without these protective measures. The COTA acknowledged the need for proper PPE to prevent infection spread. Both instances were in violation of the facility's policies and procedures for infection control. The facility's Enhanced Barrier Precautions policy mandates the use of gowns and gloves during high-contact activities to prevent the transmission of multidrug-resistant organisms. Similarly, the Transmission-Based Precautions policy requires donning PPE upon room entry and discarding it before exiting to contain pathogens. These deficiencies highlight lapses in adherence to established infection control protocols, potentially affecting the health of residents and staff.
Failure to Maintain Safe and Sanitary Bathroom Environment
Penalty
Summary
The facility failed to maintain a safe and sanitary bathroom environment for four residents, as observed during a survey. The bathroom shared by these residents exhibited several issues, including a dark black substance on the corners and baseboard near the toilet, warped baseboards, a brown substance and cracked wall around the water shut-off valve, and a cracked tile floor. Additionally, the safety grab bar had cracked and peeling plaster with an exposed screw, and there was a black substance and crack where the sink met the wall. Under the sink, there was a brown substance and cracked plaster, and the baseboard was also cracked and unpainted. The maintenance logs from January 2024 to February 2025 did not indicate any repairs or maintenance checks for the bathroom in question. During an interview, the Maintenance Supervisor acknowledged the need for repairs due to the hazardous conditions. The residents using this bathroom had respiratory diagnoses, such as COPD and chronic respiratory failure with hypoxia, making them particularly vulnerable. The facility's policies required regular maintenance inspections to ensure a safe and sanitary environment, but these were not followed, leading to the observed deficiencies.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a call light was kept within reach for a resident, which was contrary to the facility's policy and procedure titled 'Call Lights: Accessibility and Timely Response.' The resident, who was admitted with diagnoses including difficulty with walking and chronic respiratory failure with hypoxia, was identified as being at risk for falls due to being chair-bound, taking multiple medications, and having several predisposing disease conditions. The resident's care plan indicated a need for the call light to be within reach and for staff to encourage its use for assistance. During an observation, the resident was found lying in bed with the call light hanging on a pole out of reach. The resident expressed an inability to find the call light. A Licensed Vocational Nurse confirmed that the call light was not within reach and acknowledged the necessity for it to be accessible for safety and assistance. The Director of Nursing also stated that call lights should always be within reach for residents. The facility's policy, implemented and revised in December 2022, required staff to ensure call lights were within reach and secured as needed.
Failure to Provide Advance Directive Information to Resident's Representative
Penalty
Summary
The facility failed to provide information regarding an Advance Directive (AD) to the responsible party (RP) of a resident with severe cognitive impairment. The resident, who was admitted with conditions including a gastrostomy and dysphagia, had an AD Acknowledgement Form in their medical record indicating that an AD was executed. However, during an interview, the social worker admitted that the form was filled out incorrectly and that neither the resident nor the RP had executed an AD. The social worker acknowledged that the AD should have been discussed and explained to the RP upon admission. The Director of Nursing confirmed that the social worker needed to discuss AD Acknowledgement forms with residents or their RPs upon admission. The facility's policy and procedure stated that if a resident is unable to formulate an AD due to cognitive impairment, the facility should provide information and education to the resident's representative. The RP of the resident stated they were unaware of what an AD was, as the facility had not discussed it with them. This oversight had the potential to result in a lack of knowledge regarding care and treatment decision-making.
Inaccurate MDS Assessment for Resident
Penalty
Summary
The facility failed to ensure accurate documentation of active diagnoses on the Minimum Data Set (MDS) for a resident, leading to an inaccurate assessment. Resident 168 was administered Aripiprazole for five days to treat schizophrenia, despite not having a documented diagnosis of schizophrenia in their Admission Record. The resident's Admission Record listed other diagnoses, including metabolic encephalopathy, acute and chronic respiratory failure with hypercapnia, depression, and unspecified psychosis, but not schizophrenia. The MDS for Resident 168, dated 3/3/25, indicated that the resident was cognitively intact and had moderate depression, with no indicators of hallucinations or delusions. The active diagnoses selected under Psychiatric/Mood Disorder were depression and psychotic disorder, excluding schizophrenia. However, the Medication Administration Record (MAR) showed that Aripiprazole was administered for schizoaffective disorder, and the care plan noted the use of psychotropic medications for psychosis. Interviews with the MDS Coordinator and the Director of Nursing revealed that the hospital notes upon admission mentioned schizophrenia, but this was not reflected in the MDS. The Director of Nursing acknowledged the error, stating that the MDS should have indicated schizophrenia as an active diagnosis, given the administration of antipsychotic medication. The facility's policy requires accurate coding of assessments, following guidelines from the Resident Assessment Instrument Manual, which was not adhered to in this case.
Failure to Develop Care Plan for IV Therapy
Penalty
Summary
The facility failed to develop a care plan for a resident, identified as Resident 52, which included the management of intravenous (IV) therapy. This deficiency was identified during a review of the resident's medical records and interviews with facility staff. Resident 52 had severe impaired cognition and was dependent on staff for various activities of daily living. The resident was admitted with chronic respiratory failure and pneumonia, and there was a physician's order to restart IV therapy. However, there was no clinical documentation indicating that a care plan was initiated or implemented for the management of the IV therapy. Interviews with Registered Nurse 1 and the Director of Nursing confirmed the absence of a comprehensive care plan for Resident 52's IV therapy. The facility's policy and procedure on comprehensive care plans, revised in December 2022, required the development and implementation of a person-centered care plan with measurable objectives and timeframes to meet the resident's needs. The lack of a care plan for IV therapy had the potential to result in unmet individualized needs and affect the resident's physical well-being.
Failure to Provide Adequate Supervision for High-Risk Resident
Penalty
Summary
The facility failed to provide adequate supervision and implement necessary interventions for a resident, identified as Resident 18, who was at high risk for falls. Resident 18, admitted with Alzheimer's disease and rheumatoid arthritis, had a history of falls and required maximal assistance for mobility. Despite a fall risk score indicating a high risk and a history of unassisted falls, the facility did not ensure continuous supervision as per their Fall Prevention Program policy. On 2/27/2025, Resident 18 experienced an unwitnessed fall, which was not prevented due to the absence of a sitter, a measure that had been previously implemented after a prior fall. Interviews with facility staff, including a Licensed Vocational Nurse, the Director of Staff Development, and the Director of Nursing, revealed that the sitter intervention was not consistently maintained, particularly during the night shift when the fall occurred. The facility's policy required the implementation of interventions based on the resident's risk assessment, which included the use of a sitter. However, there was no documentation to confirm the presence of a sitter at the time of the fall, and staff acknowledged that the fall could have been prevented with proper supervision.
Infection Control Lapse with Indwelling Catheter
Penalty
Summary
The facility failed to adhere to appropriate infection control guidelines for a resident with an indwelling urinary catheter, leading to a potential risk of urinary tract infections. During an observation, the catheter bag of Resident 167 was found lying on the floor, which is against the facility's policy and standard infection control practices. The resident, who was admitted with multiple complex medical conditions including anoxic brain damage, chronic respiratory failure, and neuromuscular dysfunction of the bladder, was at risk due to this oversight. The care plan for Resident 167 specifically included interventions to prevent catheter-related infections, such as ensuring the catheter bag and tubing were positioned below the bladder and away from the floor. Interviews with staff, including the Infection Preventionist Nurse and a Certified Nursing Assistant, confirmed that the catheter bag should not have been on the floor as it posed a contamination risk. The staff acknowledged the issue and recognized the potential for infection if the catheter bag was contaminated. The facility's policy on the use of indwelling catheters emphasized the importance of preventing complications through proper positioning and maintenance, which was not followed in this instance.
Improper Nasal Cannula Placement for Resident
Penalty
Summary
The facility failed to ensure proper placement of a nasal cannula for a resident, identified as Resident 50, who was dependent on supplemental oxygen due to chronic respiratory failure with hypoxia. During an observation, it was noted that the nasal cannula was positioned on the resident's forehead instead of being placed inside the nostrils as required for effective oxygen delivery. This improper placement was confirmed by the facility's Infection Prevention Nurse, who acknowledged that the nasal cannula needed to be inside both nostrils to maintain the resident's oxygen saturation levels as ordered by the physician. Resident 50, who had severe cognitive impairment and was dependent on staff for various activities of daily living, was at risk due to this oversight. The facility's Director of Nursing also confirmed that the nasal cannula must be correctly positioned to ensure the resident receives the necessary oxygen therapy. The facility's policy on oxygen administration, revised in May 2024, mandates that oxygen is administered under a physician's order and consistent with professional standards, which was not adhered to in this instance.
Incompetent GT Care by CNA
Penalty
Summary
The facility failed to ensure that a Certified Nurse Assistant (CNA 1) was competent in providing gastrostomy tube (GT) care for a resident (Resident 20) in accordance with the facility's policy and procedure. Resident 20 was admitted with a gastrostomy and severe impaired cognition, requiring staff assistance for various daily activities. The resident had a physician's order for a specific nutritional formula to be administered via GT at a set rate and duration. During an observation, CNA 1 was seen disconnecting the GT feeding from Resident 20 and turning the machine off and on, actions that were outside the CNA's scope of practice. Interviews with Licensed Vocational Nurse 1 and the Director of Nursing confirmed that CNAs were not trained or authorized to perform these tasks. The facility's policy on feeding tube care, revised in December 2022, indicated that feeding tubes should be utilized in accordance with current clinical standards, which CNA 1 did not adhere to.
Failure to Ensure Specific Indication for Ativan Use
Penalty
Summary
The facility failed to ensure a specific indication for the use of Ativan for one of the residents, as required by their policy and procedure on the use of psychotropic medications. The resident, who was admitted with diagnoses including difficulty with walking and chronic respiratory failure with hypoxia, was prescribed Ativan via gastrostomy tube every six hours as needed for agitation. However, the indication for use, 'agitation,' was not considered a specific diagnosis, which is a requirement for administering such medication according to the facility's policy. During a review of the resident's medical records, the Director of Nurses acknowledged that the indication for Ativan use was not specific enough, as agitation does not qualify as a specific diagnosis. The facility's policy mandates that psychotropic drugs should only be administered when necessary to treat a specific condition that is diagnosed and documented in the clinical record. This oversight had the potential to lead to the use of unnecessary psychotropic drugs and could result in an adverse drug event for the resident.
Improper Food Handling Practices Observed
Penalty
Summary
The facility failed to ensure proper food handling practices during a lunch tray line observation. A cook was observed wearing blue nitrile gloves and using silver oven mittens while assisting a dietary assistant with plating lunch food. The cook used the oven mittens to remove hot plates from the oven and then touched various surfaces, including the table and the top of the oven mittens, without changing gloves. Subsequently, the cook sliced bread with the same gloves, which had been in contact with potentially contaminated surfaces, and then handled ready-to-eat food without changing gloves. This practice was identified as a potential source of cross-contamination, which could lead to foodborne illness for 31 of the 64 residents receiving food from the kitchen. The Dietary Supervisor confirmed during an interview that the cook should have changed gloves before handling the bread to prevent cross-contamination. The facility's policy and procedure on personal hygiene and food safety emphasize the importance of using gloves when handling ready-to-eat foods and changing them after touching surfaces that could cause contamination. The U.S. Food and Drug Administration Food Code also supports these guidelines, stating that single-use gloves should be used for one task only and discarded when soiled. The failure to adhere to these practices was observed and documented, highlighting a deficiency in the facility's food handling procedures.
Deficiency in Resident Room Size
Penalty
Summary
The facility failed to ensure that 11 out of 32 resident rooms met the minimum requirement of 80 square feet per resident in rooms with more than one resident. Specifically, rooms 115, 116, 117, 118, 119, 120, 129, 130, 131, 132, and 133 were identified as having three beds each, with a total room size of 190 square feet, which equates to approximately 63.33 square feet per resident. This deficiency was identified through a review of the facility's Census List and Client Accommodation analysis, which confirmed the inadequate space allocation per resident. During an observation and interview with a Certified Nursing Assistant (CNA), it was noted that the rooms were tight, although care could still be provided, including the use of a hoyer lift for residents with limited mobility. The facility had submitted a room waiver request letter, indicating that the arrangement was in accordance with the special needs of the residents and maintained their best interest. However, the deficiency in room size had the potential to result in inadequate space for nursing care or resident care devices.
Failure to Address Resident's Refusal to Change Leads to Deficiency
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident who exhibited behavior of refusing to be changed after becoming soiled with urine. This deficiency was identified during a review of the resident's care plan, which did not include interventions to address the resident's refusal to be changed. The resident, who was admitted and readmitted to the facility with diagnoses including metabolic encephalopathy, functional quadriplegia, and hypertension, was at risk for recurrent urinary tract infections (UTIs) due to incontinence. The care plan indicated that staff were to ensure the resident was clean and dry every two hours, but it did not address the resident's refusal behavior. Interviews with facility staff, including a Certified Nursing Assistant (CNA) and a Licensed Vocational Nurse (LVN), confirmed that the resident often refused to be changed when wet with urine, sometimes delaying changes until after lunch. The Assistant Director of Nursing (ADON) acknowledged that the resident's medical record lacked a care plan addressing the refusal behavior, despite the facility's policy requiring comprehensive care plans that include measurable objectives and timeframes. The policy also stated that alternate methods for refusal of treatment should be attempted and documented, which was not done in this case.
Improper Modification of Overhead Light Pull Cord
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for a resident when a trash can liner was tied to the end of the pull cord for the resident's overhead light. This makeshift solution was implemented because the resident, who had been admitted with conditions including metabolic encephalopathy, functional quadriplegia, and hypertension, was unable to reach the pull cord. The resident required substantial assistance for personal hygiene and dressing and was dependent on staff for toileting hygiene and bathing. The issue was identified during a review of the resident's admission record and a telephone interview with the resident's responsible party, who observed the trash bag tied to the pull cord. The Assistant Director of Nursing confirmed that maintenance staff should have replaced the pull cord to accommodate the resident's needs, but there was no documentation in the facility's Maintenance and Repair Log indicating that the pull cord needed to be lengthened. The Maintenance Supervisor later replaced the pull cord, acknowledging that it was too short and that they had not been informed of the issue until the surveyor's observation.
Resident Abuse by CNA
Penalty
Summary
The facility failed to protect a resident from verbal and physical abuse by a Certified Nursing Assistant (CNA). The incident involved a resident who was admitted with chronic respiratory failure, profound intellectual disability, and anxiety disorder. The resident was severely impaired in cognitive skills and dependent on staff for personal care. On the day of the incident, the resident was agitated and had two sitters assigned for supervision. The abuse occurred when the CNA was providing care to the resident, who was trying to get out of bed. The incident was reported by two sitters who witnessed the CNA's actions. According to the sitters, the CNA grabbed the resident's head and jaw, yelled at the resident, and used derogatory language. The CNA also threatened the resident with a bed remote, shaking it in the resident's face. The sitters described the CNA's behavior as abusive and inappropriate, making them feel uncomfortable. The CNA denied being rough or using foul language but was suspended pending an investigation. The facility's policy on abuse, neglect, and exploitation emphasizes the protection of residents' health, welfare, and rights. It prohibits any form of abuse, including verbal and physical abuse, and requires the implementation of policies to prevent such incidents. Despite these policies, the facility failed to prevent the abuse of the resident, as evidenced by the actions of the CNA and the observations of the sitters.
Delayed X-ray Results Impact Resident Care
Penalty
Summary
The facility failed to ensure timely receipt of abdominal X-ray results for two residents, leading to a delay in the confirmation of gastrostomy tube (G-tube) placement. Resident 1, who was admitted with chronic respiratory failure and dysphagia, had a dislodged G-tube that was replaced by a wound care consultant. An abdominal X-ray was ordered to confirm the placement, but the results were delayed, preventing the resumption of tube feeding and medication for three days. Despite multiple follow-up calls to the diagnostic company, the results were not received, and the resident had to be sent to a general acute care hospital for confirmation. Similarly, Resident 2, also admitted with chronic respiratory failure and dysphagia, experienced a dislodged G-tube that was replaced, necessitating a stat X-ray for confirmation. The X-ray results were delayed for three days, during which the resident could not receive tube feeding. The facility's licensed nurses repeatedly contacted the diagnostic company, but the results were not available until three days later, delaying the resumption of feeding and medication. Interviews with facility staff, including licensed vocational nurses and the Director of Nursing, revealed that the facility previously received X-ray results within 24 hours from a different diagnostic company. The change in diagnostic service providers resulted in significant delays, impacting the residents' care. The facility's policy requires timely laboratory services to meet residents' needs, which was not adhered to in these cases.
Failure to Provide Required In-Service Training to LVNs
Penalty
Summary
The facility failed to ensure that four of six sampled Licensed Vocational Nurses (LVNs) received the necessary in-service training before signing the facility's In-Service Form, which indicated that they had received such training. The training topics included Dementia, Care of Visually Impaired Residents, Abuse, and Medication Administration. Interviews with LVNs revealed that they were instructed by facility management to sign the forms without actually receiving the training. LVNs reported that the forms were left at the nurse's station, and they were told to sign them, which they did without attending any training sessions. The Director of Staff Development (DSD) acknowledged the importance of in-service training for staff to ensure proper care for residents and stated that staff should not sign the forms without receiving training. However, the DSD admitted there was no system in place to track which training each staff member had completed. The facility's policy and procedure on training requirements emphasized the need for an effective training program and documentation system, but this was not implemented, leading to the deficiency.
Failure to Provide Adequate Incontinence Care
Penalty
Summary
The facility failed to provide appropriate care for two residents, identified as Residents 8 and 9, who were incontinent of bladder, leading to a potential risk of urinary tract infections (UTIs). Both residents were dependent on staff for toileting, dressing, and bathing due to severe cognitive impairments and physical limitations. The care plans for both residents required staff to check for incontinence and provide care every two hours, including cleaning the perineal area and changing clothing as needed. Observations and interviews revealed that the facility staff did not consistently adhere to the two-hour incontinence check and care schedule. Certified Nursing Assistants (CNAs) reported instances where residents were found soaked with urine, particularly during shifts when the facility was short-staffed. CNA 3 admitted to not being able to change residents frequently enough due to a high workload, and CNA 4 confirmed that Resident 8 was not checked for incontinence for over four hours, resulting in the resident being wet with urine. The Assistant Director of Nursing (ADON) acknowledged that both residents were always incontinent and unable to communicate their needs, emphasizing the importance of regular checks to prevent skin breakdown and UTIs. The facility's policy on incontinence care, dated 12/19/2022, required appropriate treatment and services for incontinent residents to prevent infections, which was not consistently followed, leading to the identified deficiency.
Inadequate Staffing Leads to Incontinence Care Deficiency
Penalty
Summary
The facility failed to provide sufficient staffing to ensure timely incontinence care for two residents, leading to potential risks of skin breakdown and urinary tract infections. Resident 8, admitted with chronic respiratory failure, COPD, and encephalopathy, was dependent on staff for toileting and was always incontinent of bowel and bladder. The care plan for Resident 8 required staff to check and clean the perineal area every two hours, but this was not consistently done due to staffing shortages. Similarly, Resident 9, who had multiple sclerosis, chronic respiratory failure, and paraplegia, was also dependent on staff for toileting and was always incontinent. The care plan for Resident 9 included similar interventions as Resident 8, but these were not consistently followed. Interviews with CNAs revealed that residents were often found soaked with urine, particularly during shifts when staffing was inadequate. This was corroborated by the Director of Staff Development, who acknowledged the staffing challenges, especially during weekends. The facility's policies and procedures emphasized the need for sufficient staffing to meet residents' needs and prevent infections. However, the facility's staffing levels were insufficient to meet these requirements, as evidenced by the experiences of the CNAs and the condition of the residents. The Assistant Director of Nursing confirmed that both residents were incontinent and unable to communicate their needs, highlighting the importance of regular checks and care to prevent adverse outcomes.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post actual worked nursing hours at the start of each shift for one of three days, as required by their policy and procedure titled 'Nurse Staffing Posting Information' dated August 2022. During an observation, it was noted that the nurse staffing posting was dated several days prior and did not include the current date's information. This oversight was confirmed during an interview with the Director of Staff Development (DSD), who acknowledged that the nurse staffing information should be updated by the night shift for the upcoming day. The DSD admitted to not knowing why the staffing information was not posted for the observed date and explained that the postings were generally projections rather than actual hours worked. The facility's policy requires that the nurse staffing sheet be updated at the beginning of each shift, including any changes due to staff call-offs, which was not being adhered to. This failure had the potential to result in residents and visitors not being informed of the facility's nurse staffing information.
Improper Use of Hoyer Lift Puts Residents at Risk
Penalty
Summary
The facility failed to ensure the safe use of a Hoyer lift, a mobile patient lift, for transferring residents, which put four residents at risk for falls and injury. Certified Nurse Assistants (CNAs) 5 and 7 did not use the Hoyer lift appropriately when transferring Resident 6 from the bed to a geri-chair. Instead of following the proper procedure, CNA 7 held Resident 6 by the feet during the transfer, which is against the facility's policy and procedure. The Director of Staff Development (DSD) confirmed that the correct procedure involves one staff member operating the lift and another guiding the resident by holding the sling, not the feet, to ensure safety. Additionally, CNA 4 operated the Hoyer lift alone for Residents 2, 4, and 5, despite the facility's policy requiring two staff members for such transfers. CNA 4 admitted to transferring these residents without assistance multiple times, citing a lack of available help from other staff members. This practice was particularly concerning for residents with tracheostomies, as it posed a risk of dislodging the tracheostomy or causing respiratory distress. The Director of Nursing (DON) and a Respiratory Therapist (RT) emphasized the importance of having two staff members present during transfers, especially for residents with tracheostomies. The facility's policy, titled "Safe Resident Handling/Transfers," mandates the use of two staff members for transfers involving a mechanical lift and requires staff to be trained on safe handling practices. However, the facility did not have a specific policy on operating the Hoyer lift, which may have contributed to the improper use observed. The lack of adherence to established procedures and inadequate staffing during transfers led to the identified deficiencies, putting residents at risk of injury.
Failure to Conduct Reference Check for CNA
Penalty
Summary
The facility failed to conduct a reference check before hiring a Certified Nursing Assistant (CNA), which was a requirement according to their Policy and Procedure (P&P) titled, Abuse, Neglect and Exploitation. This policy, dated 5/31/2024, mandates that potential employees be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. The CNA's employee file contained a blank Pre-Employment Check List, which should have documented at least two references for the applicant. The Director of Staff Development (DSD) confirmed that the reference checks were not conducted as instructed by the Pre-Employment Check List. The DSD acknowledged the importance of conducting reference checks to ensure that new staff do not have a history of abusing residents and to determine if it is safe for them to care for residents at the facility. The failure to conduct these checks placed 70 residents at risk for abuse by the CNA. The facility's P&P also stated that background, reference, and credentials checks should be conducted on potential employees, and documentation of proof that the screening occurred should be maintained. However, this was not done in the case of the CNA in question.
Infection Control Breach in Handling Soiled Linen
Penalty
Summary
The facility failed to adhere to its Infection Prevention and Control Program, specifically in the areas of hand hygiene and handling soiled linen. During an observation, a housekeeping staff member was seen transporting an uncovered barrel labeled as soiled linen through the facility's hallway. The staff member only wore a glove on one hand and did not perform hand hygiene before and after handling the soiled linen. This practice was contrary to the facility's policy, which requires staff to wear gloves on both hands and perform hand hygiene before and after handling soiled items. Interviews with the housekeeping staff member, the Infection Preventionist, and the Housekeeping Supervisor confirmed the deviation from the established procedures. The Infection Preventionist emphasized the importance of covering the soiled linen barrel during transport to prevent cross-contamination. The facility's policies, revised in December 2022, clearly state the necessity of hand hygiene and the use of personal protective equipment to prevent the spread of infection. The failure to follow these procedures had the potential to result in cross-contamination and the spread of infection throughout the facility.
Failure to Maintain Cleanliness in Shower Rooms
Penalty
Summary
The facility failed to maintain a homelike environment by not ensuring cleanliness in two shower rooms. During an observation, the shower room in Skilled Nursing Facility 1 (SNF 1) was found to have chipped paint on the tiles inside the shower stall and a black colored substance in the far-right corner of the shower stall. The Maintenance Supervisor (MS) confirmed the presence of peeling paint and black substance, describing it as dirt buildup. The MS acknowledged missing the chipping paint and stated that housekeeping was responsible for cleaning the shower rooms. Further observations with the Housekeeping Supervisor (HS) revealed the presence of a black substance in the corners and between tiles in both the SNF 1 and Subacute (SA) shower rooms. The HS confirmed that it was the housekeeping department's responsibility to clean the showers and stated that the black substance should not be present. The facility's Policy & Procedure, titled 'Safe & Homelike Environment,' indicated that housekeeping and maintenance services should maintain a sanitary, orderly, and comfortable environment, which was not adhered to in this instance.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to maintain the dignity of a resident, identified as Resident 4, which violated their right to be treated with respect. Resident 4, who was readmitted with diagnoses including dysphagia, functional quadriplegia, and noninfective gastroenteritis and colitis, was found to have moderate cognitive impairment and was dependent on staff for personal care. During an interview, Resident 4 reported that a Certified Nurse Assistant (CNA) did not clean them properly, only cleaning the front and leaving them soiled. The CNA allegedly pulled off Resident 4's covers, pointed a finger at them, and instructed them to stop yelling because others were sleeping, which made Resident 4 feel awful and angry. Another resident, identified as Resident 2, corroborated the incident by stating they heard the CNA yell at Resident 4, denying that Resident 4 was wet. The Director of Nursing (DON) confirmed that staff should not raise their voices at residents, as it could cause emotional issues and make residents feel disrespected. The facility's policy on promoting and maintaining resident dignity emphasized treating residents with respect and dignity, speaking respectfully, and avoiding discussions about residents that could be overheard. This incident highlights a breach in the facility's policy and procedure regarding resident dignity.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call light for one of the residents was within reach, which could potentially delay care. The resident, who was readmitted with diagnoses including dysphagia, functional quadriplegia, and moderate cognitive impairment, was unable to locate or reach the call light due to mobility issues. During an interview, the resident expressed that they had to yell for help because the call light was placed on the side they could not move. An observation confirmed that the call light was on the floor behind the resident's bed, making it inaccessible. A CNA acknowledged that the call light should not have been placed there and suggested that it might have been moved by a previous CNA. The Director of Nursing emphasized the importance of keeping call lights within reach to ensure residents can alert staff when assistance is needed. The facility's policy requires staff to ensure call lights are accessible to residents, but this was not adhered to in this instance.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to prevent physical abuse between residents, specifically involving Resident 1 and Resident 2. On June 5, 2024, Resident 2 hit Resident 1 on the right upper arm after an altercation where Resident 1 allegedly called Resident 2 a 'stupid idiot.' Resident 2, who was admitted on March 15, 2024, had no cognitive impairment according to the Minimum Data Set (MDS) but exhibited paranoid delusions and poor impulse control as noted in an Initial Psychiatric Evaluation on the day of the incident. Resident 2 was on medication for psychosis, including Risperidone, and had a history of agitation and disagreements with other residents. Resident 1, admitted on March 20, 2024, had severe cognitive impairment and was dependent on staff for most activities of daily living. The incident was documented in Resident 1's Situation, Background, Assessment, and Recommendation (SBAR) Communication Form, which noted the physical altercation. Interviews with staff, including a Certified Nursing Assistant (CNA), the Assistant Director of Nursing (ADON), and a Respiratory Therapy Supervisor (RTS), revealed that Resident 2 was known to have episodes of forgetfulness and agitation, and the RTS witnessed the altercation and intervened to separate the residents. The facility's policy on Abuse, Neglect, and Exploitation, dated December 19, 2022, mandates the prevention of abuse through written policies and procedures. The policy defines abuse as the willful infliction of injury and requires the facility to implement measures to prevent abuse, including identifying and addressing situations where abuse is more likely to occur. Despite these policies, the facility failed to prevent the altercation between Resident 1 and Resident 2, resulting in physical abuse.
Failure to Timely Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report an allegation of resident-to-resident physical abuse within the required timeframe. On 4/22/2024, Resident 4, who had a history of physical aggression due to dementia, grabbed Resident 2's right upper arm. This incident was reported to the Administrator (ADM) by the staff, but the ADM did not report it to the Department of Public Health until 5/7/2024, 15 days later. The ADM did not consider the incident as abuse, despite the facility's policy requiring such incidents to be reported within two hours. Resident 4 was admitted with diagnoses including dementia and type II diabetes mellitus, and had a care plan indicating a potential for physical aggression. Resident 2, who was grabbed, had Huntington's disease and difficulty walking. The incident was initially reported by a certified nurse assistant to a Licensed Vocational Nurse (LVN), who then informed the Registered Nurse Supervisor and the Director of Nursing (DON). The facility's policy mandates that any allegations of abuse be reported immediately to protect residents' health and well-being. Interviews with the ADM, LVN, and DON revealed that the ADM, who is the facility's abuse coordinator, failed to report the incident as required. The ADM acknowledged that grabbing another resident could be considered abuse and that such allegations should be reported within two hours. The facility's policy on abuse, neglect, and exploitation emphasizes the importance of timely reporting to prevent further incidents and ensure resident safety.
Failure to Provide Appropriate Toileting Assistance
Penalty
Summary
The facility failed to provide appropriate treatment and services to restore continence for a resident who was occasionally incontinent of urine and had mobility issues. The resident, who was admitted with functional quadriplegia and gait abnormalities, was able to verbalize the need for assistance and was continent of bowel and bladder function according to the care plan. However, the staff did not offer alternative methods for toileting, such as a bed pan, and instead instructed the resident to urinate in the incontinence brief, which was then changed afterward. Interviews with the resident and staff revealed that the resident felt trapped and like a burden, as staff found it too difficult to use the Hoyer lift for transfers. The CNAs admitted to not offering a bed pan or other alternatives, despite the resident's ability to control urination. The LVN and MDS Coordinator confirmed that the resident was mostly continent and should have been offered toileting assistance to maintain or improve continence status. The lack of a toileting program or schedule further contributed to the resident's unnecessary incontinence. The Director of Nursing acknowledged that the resident should have been assisted with toileting to promote independence and reduce the risk of infections and falls. The facility's policy indicated that residents should receive appropriate treatment to maintain continence, but this was not followed in the case of the resident. The failure to provide necessary assistance and alternatives for toileting led to the resident being forced into incontinence, which was not reflective of their actual continence status.
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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 Pomona
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pomona Vista Care Center | 0 mi | ★★★★★ | 4 | 0 |
| Park Avenue Healthcare & Wellness Center | 0.7 mi | ★★★★★ | 8 | 0 |
| Inland Valley Care And Rehabilitation Center | 0.9 mi | ★★★★★ | 64 | 0 |
| Laurel Park Behavioral Health Center | 1.1 mi | ★★★★★ | 15 | 1 |
| Landmark Medical Center | 1.4 mi | ★★★★★ | 26 | 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.