Above average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Coventry Court Health Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a history of wandering and exit-seeking was not adequately monitored or provided with a timely, person-centered care plan to address high risks for elopement and falls. The resident was left unsupervised in a patio area, resulting in a fall with injuries that required hospital transfer. Staff interviews confirmed that the resident's whereabouts were not properly tracked, and care plan interventions were only developed after the incident.
A resident with Type 2 Diabetes repeatedly refused prescribed insulin, as documented in the MAR, but the care plan was not updated to reflect these refusals or to include education about the associated risks. The care plan continued to list only standard interventions, and staff confirmed it should have been revised to address the resident's ongoing medication refusal and monitoring needs.
A resident with Type 2 diabetes repeatedly refused ordered insulin, as documented in the MAR, but staff did not notify the physician of these consistent refusals. Facility policy required physician notification for medication refusals, and both the MDS Nurse and DON confirmed that this documentation was missing.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
A resident was found with Cepacol lozenges at bedside without an IDT assessment, physician's order, or care plan for self-administration, despite facility policy requiring these steps. Staff confirmed the absence of required documentation and assessment for the resident's self-administration of medication.
Three residents were affected by failures in psychotropic medication management, including missing diagnoses and behavioral manifestations in medication orders and consents, lack of required evaluations and care plans, inaccurate blood pressure and behavior monitoring, and duplicate antidepressant prescriptions for the same indication. Nursing staff and the DON confirmed these documentation and monitoring lapses during interviews.
The facility failed to ensure that two residents who had positive PASRR Level I screenings for serious mental illness received the required Level II Mental Health Evaluations. In both cases, there was no documentation of follow-up with the state agency or submission of a new Level I screening, as required by facility policy and state guidelines. Staff interviews confirmed the lack of follow-up and missing documentation.
Two residents did not have individualized care plans addressing their specific needs: one resident refused the COVID-19 vaccine and another was noncompliant with continuous oxygen therapy for COPD. Staff interviews and record reviews confirmed that care plans should have been initiated for both situations, but none were documented.
A resident who sustained a fall with a head injury did not receive complete neurological checks for the required 72-hour period, as some assessments were missed during dialysis and after hospital transfer. Additionally, the facility failed to communicate the fall to the dialysis center, omitting this information from the pre-dialysis assessment form and not notifying the center, which prevented continued monitoring for fall-related injuries.
Two residents did not receive proper respiratory care as required by physician orders and facility policy. One resident with COPD was left without continuous oxygen, resulting in low oxygen saturation and eventual hospital transfer, after staff failed to reapply the nasal cannula or notify others. Another resident's breathing treatment equipment, including oxygen tubing and nebulizer, was not changed weekly as required, with supplies found to be several months old despite ongoing orders for nebulizer treatments.
Two residents did not receive appropriate pain management as required by facility policy, with staff failing to consistently document nonpharmacological interventions and complete pain assessments—including pain location and characteristics—prior to administering PRN pain medications. Nursing staff and the DON confirmed that these documentation steps were not followed as expected.
Two LVNs and the DSD were unable to accurately state facility protocols for glucometer quality control checks, including when to perform QC tests and the correct lifespan of test strips and control solutions, despite having attended in-service training and passed competency assessments. QC test results were not documented as required, and the DON confirmed these findings.
A resident with orders for dialysis and daily furosemide for edema did not receive the prescribed furosemide on two occasions, as staff incorrectly held the medication on dialysis days, believing it was a blood pressure medication. The DON confirmed the medication should have been administered as ordered.
The facility did not ensure that a pharmacist consultant completed monthly MRRs for all residents, as one resident did not have a review for an entire month, and for another, the pharmacist failed to address the use of two antidepressants prescribed for the same behavior. The DON confirmed these omissions during interviews and record reviews.
A licensed nurse failed to administer medications as ordered for a resident, resulting in a medication error rate of 7.14%. The nurse gave sevelamer after the resident's meal instead of with it and did not administer furosemide as prescribed for edema, without clarifying with the physician. The DON confirmed these errors during record review.
Surveyors found expired medications and supplies in medication rooms and carts, improper storage of medications for different routes together, and unlabeled or improperly labeled medications. Additionally, a resident's prescribed skin protectant was left unsecured at the bedside instead of being stored in the treatment cart, contrary to facility policy. Nursing staff and the DON confirmed these deficiencies during the survey.
The facility did not procure food from approved or satisfactory sources and failed to store, prepare, distribute, and serve food according to professional standards.
A new glucometer was used for blood glucose testing without a required Quality Control check, and documentation for control solution expiration dates did not match the actual product labels. An LVN confirmed lack of awareness of proper protocols, and the Infection Preventionist verified that blood sugar checks were performed before the Quality Control check was completed.
A resident was not provided with the estimated daily cost on the SNF ABN Form CMS-10055, leaving them uninformed about potential financial liability if Medicare did not cover certain services. The SSD confirmed the omission and that no other documentation existed to show the resident was informed of possible out-of-pocket costs. The DON acknowledged these findings.
Two residents did not have their discharge MDS assessments completed within the required 14-day period after discharge. The assessments were delayed by several days to several months, as confirmed by record review and staff interview, resulting in late submission of required data to CMS.
A resident with a suprapubic urinary catheter did not receive a timely urology consult as ordered by the physician due to the facility's failure to follow up on scheduling the appointment. Staff interviews and record reviews confirmed that the required follow-up communication with the outside provider was not completed, resulting in the resident not receiving the necessary consultation.
The facility did not complete required annual skills evaluations for three CNAs, as their competency forms lacked documentation indicating whether key trainings and skills checks were met, and did not include scheduled reevaluation dates. The Director of Staff Development confirmed these omissions, which were not in line with facility policy.
A resident with Type 2 Diabetes Mellitus did not have quarterly A1c laboratory testing scheduled as ordered by the physician, despite ongoing high blood sugar readings and recommendations from the consultant pharmacist. Nursing staff failed to enter and communicate the routine lab order to the laboratory, resulting in no pending or future A1c tests being set up.
A resident was found with a container of crackers brought in by family that was not labeled or dated, contrary to facility policy. An LVN confirmed the lack of labeling, and the resident stated the food had been brought in the previous week. Facility policy requires all non-perishable foods from outside sources to be labeled with the resident's name, location, and date.
A resident with lower extremity paralysis was discharged from a facility without proper coordination of palliative care services, despite being dependent on staff for ADL care. The Social Service Manager failed to document the coordination of care, and the discharge summary lacked necessary contact information for the palliative care agency. The resident had to arrange home care services herself after discharge.
The facility failed to ensure food safety and sanitation in the kitchen, with issues such as unclean utensils, improperly stored equipment, and unlabeled food items. Observations included a metal spoon with stains, a frayed spatula, and a can opener with exposed blades. Personnel did not adhere to dress code requirements, and the fan unit in the walk-in refrigerator was unclean. These deficiencies were verified by the CDM and acknowledged by the Administrator.
The facility failed to implement a comprehensive infection control surveillance program, excluding residents not on antimicrobials. Inaccuracies in tracking infections for April and May 2024 were noted, with missing data on infection types. Staff did not follow hand hygiene protocols during meal service, and personal items were found in the laundry room, compromising infection control practices.
The facility failed to implement its antibiotic stewardship program by not completing assessments using McGeer's criteria for residents admitted with antibiotics. Several residents were prescribed antibiotics without proper documentation or physician notification, as confirmed by the ADON/IP. The Administrator and DON acknowledged these deficiencies.
A facility failed to obtain informed consent for a resident prescribed alprazolam, a psychotropic medication, as required by the Nursing Facility Resident Informed Consent Protection Act of 2023. The resident lacked decision-making capacity, and there was no documentation of consent from the responsible party. Interviews with staff confirmed the oversight, highlighting a failure to ensure the resident and their responsible party were informed about the medication's purpose, risks, and side effects.
The facility failed to ensure accurate documentation of advance directives and POLST for three residents, leading to discrepancies in their medical records. One resident's POLST indicated DNR status, conflicting with a full code status in the social services assessment. Another resident's representative was not informed of their right to formulate an advance directive. A third resident's POLST and advance directive did not align, with differences in preferences for CPR and artificial nutrition. These issues were confirmed through interviews with facility staff.
A facility failed to obtain informed consent and conduct a restraint assessment before applying a compression glove to a resident's hand. The glove was used to manage thumb-sucking behaviors, but staff did not consider it a restraint. Observations showed the glove was worn for extended periods, contrary to the physician's order.
A facility failed to implement a care plan for a resident with hemiplegia, as the left 1/2 side rail was not elevated as required. Instead, the right side rail was elevated, contrary to the care plan and physician's order. Staff interviews confirmed the resident's left-sided weakness and the need for the left side rail during care. The Administrator and DON were informed of these findings.
A resident was improperly administered midodrine, an antihypotensive medication, despite having a systolic blood pressure above the physician-prescribed limit. This occurred multiple times in July, as confirmed by medical record reviews and staff interviews, indicating a failure in adhering to medication administration protocols.
The facility failed to monitor the functionality of Wander Guard devices for three residents, posing a risk for serious injuries. A resident attempted to exit the facility unassisted, and documentation for device monitoring was inadequate. Staff interviews revealed confusion about monitoring responsibilities, with the Maintenance Supervisor and LVN acknowledging lapses in daily checks.
A facility failed to document and confirm baseline measurements of a PICC line for a resident, potentially delaying the identification of catheter-related complications. The resident's PICC line, inserted at an acute care hospital, lacked initial measurement documentation in the medical record. Despite weekly measurements, there was no evidence of baseline verification before IV antibiotic administration. Interviews with the RN and DON confirmed the expected protocol was not followed.
The facility failed to provide safe respiratory care for several residents, including improper cleaning of a CPAP machine, oxygen tubing touching the floor, and unlabeled nebulizer equipment. These deficiencies were confirmed through observations and staff interviews, highlighting a lack of adherence to the facility's policies and procedures for respiratory care and equipment maintenance.
A resident did not receive appropriate pain management as the facility administered Norco 5-325 mg for severe pain levels, contrary to physician's orders. The resident's MAR showed multiple instances where the pain level was documented as 7, requiring Norco 10-325 mg, but the lower dosage was given instead. This was confirmed by an RN during a review.
The facility failed to ensure the safety of two residents regarding bed rail use. One resident had a right half side rail elevated without a physician's order or informed consent, despite having hemiplegia. Another resident, who was nonverbal and dependent on staff, had bilateral side rails elevated without proper assessment of their necessity. The facility did not adhere to its policies requiring risk assessment and informed consent, potentially putting residents at risk.
The facility failed to document the physician's rationale for extending the use of alprazolam beyond the recommended period for a resident, and did not monitor another resident for orthostatic hypotension while on antipsychotic medication. Interviews with the RN and DON confirmed these deficiencies, highlighting a lack of proper documentation and monitoring for residents on psychotropic medications.
The facility failed to ensure proper medication storage and disposal, with oral and external medications improperly stored together, unsecured bubble packs, and an unlocked medication cart. Medications were also found at the bedside of two residents without proper authorization. These deficiencies were confirmed through staff interviews and observations.
The facility failed to educate staff and visitors on safe food handling for food brought in from outside, as required by their policy. The document used for guidance lacked instructions on safe food handling, and interviews with the CDM and DSD revealed that critical aspects like hand hygiene and cross-contamination prevention were not addressed. The DON confirmed the deficiency, and the Administrator and CDM acknowledged the findings.
The facility failed to maintain accurate and complete medical records for several residents, including inaccurate smoking evaluations, missing documentation for PRAFO application, and errors in treatment administration records. These deficiencies were confirmed by staff and acknowledged by the DON and Administrator.
The facility failed to provide education and obtain consent for influenza and pneumococcal vaccines for two residents, as required by policy. There was no evidence that the residents or their representatives were informed about the benefits and side effects of the vaccines. Additionally, one resident's immunization record was inaccurate regarding the pneumococcal vaccine. These issues were confirmed by the ADON/IP.
The facility failed to report an allegation of sexual abuse between two residents to the appropriate authorities as required by their policy. A family member reported the incident to staff, but the charge nurse and PTA did not immediately report it. The Administrator was informed a day later, and the DON found the initial report too vague to investigate. This delay in reporting left residents potentially vulnerable to further abuse.
The facility failed to ensure accurate and complete entrapment assessments for residents using side rails, affecting six residents. Assessments inaccurately marked Zone 5 as 'Pass' instead of 'Not Applicable' due to the absence of lower side rails. Additionally, one resident's assessment was incomplete, missing critical information. Another resident used a side rail without a physician's order, informed consent, or entrapment assessment. The Maintenance Supervisor and DON acknowledged these deficiencies, indicating non-compliance with facility policy.
The facility failed to accurately complete the MDS for two residents, leading to potential risks in their care. One resident's fall was not documented, and another's use of a chair and bed alarm was omitted. These inaccuracies were confirmed by the MDS Coordinator and the DON.
The facility failed to properly store garbage in two dumpsters, which were observed overflowing and unable to close due to trash bags and cardboard boxes. This violated the US Food Code and the facility's policy requiring tight-fitting lids. The Maintenance Supervisor confirmed the issue, and the Administrator and CDM acknowledged the findings.
The facility failed to maintain safe operating conditions in Medication Room A, where ice buildup was observed in the freezer compartments of Medication Refrigerators A and B. The freezer of Refrigerator B was also missing a cover. RN 1 was unsure about the responsibility for cleaning and maintaining these refrigerators. The DON confirmed the findings and indicated that the issue should be reported to Maintenance.
Failure to Provide Adequate Supervision and Person-Centered Care Planning for High-Risk Resident
Penalty
Summary
The facility failed to ensure that the care plan accurately reflected the individual care needs of a resident with a history of dementia, high risk for elopement, and high risk for falls. Despite documented assessments indicating the resident's severe cognitive impairment, exit-seeking behavior, and frequent wandering, the care plan did not include timely or adequate interventions to address these risks. The care plan interventions for elopement and falls were only developed after the resident experienced a fall, rather than proactively based on the resident's known behaviors and risks. On the day of the incident, the resident was observed to be unsupervised in the facility's patio, where they sustained a fall resulting in injuries that required transfer to an acute care hospital. Interviews with nursing staff and facility leadership confirmed that the resident's whereabouts were not adequately monitored, and staff were unable to account for the resident's location prior to the fall. The facility's policies required an environment free from accident hazards and person-centered care planning, but these were not followed for this resident, leading to the incident.
Failure to Update Care Plan for Insulin Refusal in Diabetic Resident
Penalty
Summary
The facility failed to revise a resident's comprehensive care plan to reflect ongoing refusals of prescribed insulin for diabetes management. Despite repeated documentation in the Medication Administration Record (MAR) indicating the resident's refusal of insulin over an extended period, the care plan only included interventions for checking blood sugar and administering insulin as ordered. There was no update to address the resident's consistent refusal of medication or to include education about the risks associated with this refusal. Interviews with the MDS Nurse and the DON confirmed that the care plan should have been updated to reflect the resident's refusal, ongoing monitoring, and the risks of not receiving the prescribed treatment. The resident had a diagnosis of Type 2 Diabetes and was determined to have the capacity to make medical decisions. The facility's policy required the care plan to be person-centered and updated as needed, but this was not followed in this case.
Failure to Notify Physician of Repeated Insulin Refusals
Penalty
Summary
The facility failed to provide necessary care and services to ensure a resident with Type 2 diabetes attained and maintained their highest practicable physical well-being. The resident had a physician's order for insulin Glargine to be administered at bedtime, with instructions to hold the medication if blood sugar was less than 90 mg/dl. Review of the Medication Administration Record (MAR) from April to June showed multiple instances where the resident refused the ordered insulin, as documented by nursing staff using the appropriate chart code for refusal. Despite these repeated refusals, there was no documented evidence that the physician was notified about the resident's consistent refusal of insulin. Facility policies required that medications be administered as ordered and that any refusal or withholding of medication be documented, with follow-up documentation as appropriate. During interviews, both the MDS Nurse and the Director of Nursing confirmed that there should have been documentation indicating the physician was informed of the resident's refusal to take insulin. The lack of physician notification was verified through closed medical record review and staff interviews.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence of a comprehensive infection prevention and control program but does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved.
Failure to Assess and Care Plan for Resident Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a resident was properly assessed for the safe self-administration of medication, specifically Cepacol Extra-Strength Sore Throat Benzocaine lozenges, which were found at the resident's bedside. Observation and interview revealed that the resident kept the medication in a duffle bag on her bed and used it during trips to the dialysis center for throat dryness. Despite the resident's capacity to understand and make decisions, as documented in her history and physical examination, there was no evidence in the medical record that the interdisciplinary team (IDT) had conducted an assessment of her ability to self-administer medications. Additionally, there was no physician's order authorizing the resident to self-administer the lozenges, nor was there a care plan developed to address this practice. The facility's policy requires an IDT assessment, a physician's order, and a care plan before a resident is permitted to self-administer medication or keep medication at the bedside. Staff confirmed that these steps had not been completed for this resident, and therefore, the medication should not have been accessible at the bedside.
Deficiencies in Psychotropic Medication Management and Documentation
Penalty
Summary
The facility failed to prevent the use of unnecessary psychotropic medications and did not ensure proper documentation and monitoring for three residents reviewed. For one resident with anxiety disorder and vascular dementia, the physician's orders and informed consents for antipsychotic medications did not include the required diagnoses or specific behavioral manifestations. Additionally, there was no psychoactive medication evaluation or care plan initiated for the use of these medications, and a PRN antianxiety medication order lacked a required stop date. The medical record also did not specify the type of hallucinations being monitored, and the DON confirmed these omissions during interviews. Another resident, with a history of fluctuating capacity for decision-making, had physician's orders for orthostatic blood pressure monitoring that were not accurately followed, as identical readings were recorded for different positions, which staff acknowledged was incorrect. Furthermore, the same resident's behavior monitoring and documentation of nonpharmacological interventions related to antipsychotic use were inconsistent and inaccurate. Staff documented interventions even when no behaviors were observed and failed to document interventions when behaviors were present, as confirmed by interviews with nursing staff and the DON. A third resident was prescribed two antidepressant medications for the same behavioral manifestation of sadness, with both orders indicating the same indication. Nursing staff acknowledged that this duplication made it difficult to assess the effectiveness of each medication and that the orders should have been clarified with the physician. The DON later clarified that one medication should have been indicated for poor oral intake, but this was not reflected in the original documentation.
Failure to Complete Required PASRR Level II Evaluations After Positive Screenings
Penalty
Summary
The facility failed to ensure that two of four sampled residents were accurately screened for mental disorders or intellectual disabilities as required by the PASRR process. For one resident, the PASRR Level I Screening indicated that a Level II Mental Health Evaluation was required due to a suspected serious mental illness, but there was no documented evidence in the medical record of a follow-up call, inquiry to the Department of Health Care Services (DHCS), or submission of a new Level I PASRR screening. The MDS Assistant confirmed that while the Level I PASRR screening was completed, there was no documentation of any follow-up to address the need for a Level II evaluation. For another resident, the PASRR Level I Screening also resulted in a positive finding for serious mental illness, requiring a Level II Mental Health Evaluation. However, the medical record did not show that a new Level I Screening was submitted after the initial positive result. The MDS Nurse verified that a follow-up was required if the facility had not heard from the State agency within 72 hours, and acknowledged that a new Level I PASRR Screening should have been completed but was not. The Director of Nursing was informed and acknowledged these findings.
Failure to Develop Individualized Care Plans for Vaccine Refusal and Oxygen Noncompliance
Penalty
Summary
The facility failed to develop and implement individualized care plans for two residents as required by its own policies and procedures. For one resident who had the capacity to make decisions, the medical record showed a refusal to receive the COVID-19 vaccine, but there was no care plan initiated to address this refusal. Both the Infection Preventionist and a Registered Nurse confirmed during interviews and record reviews that a care plan should have been created for the resident's vaccine refusal, but none was found in the medical record. For another resident, also with decision-making capacity, there was a physician's order for continuous oxygen therapy via nasal cannula to maintain oxygen saturation above 90% due to COPD. Observations and interviews revealed that the resident was not consistently using the oxygen as ordered and sometimes removed the nasal cannula. Staff members, including a CNA and an LVN, acknowledged the resident's noncompliance and stated that a care plan should have been initiated to address this issue, but no such care plan was documented. The Director of Nursing confirmed the absence of a care plan for the resident's noncompliance with oxygen therapy.
Failure to Complete Post-Fall Monitoring and Communicate Fall to Dialysis Center
Penalty
Summary
The facility failed to ensure proper post-fall monitoring and communication for a resident who experienced a fall resulting in a head injury. After the fall, neurological checks were initiated, but the facility did not accurately complete these checks for the full 72-hour period as required by protocol. Specifically, neurological assessments were missed while the resident was out of the facility for dialysis and after transfer to an acute care hospital. Additionally, the log for neurological checks did not cover the full 72-hour period and was not scheduled accurately. The Director of Nursing confirmed that the post-fall neurological checks were not completed as per facility protocol when the resident returned from dialysis. Furthermore, the facility did not communicate the resident's fall to the dialysis center, despite having a process in place to send pre-dialysis assessment forms with the resident. The form sent on the day of the fall did not indicate that the resident had experienced a fall, and there was no documentation showing that the dialysis center was informed. This lack of communication meant the dialysis center was not aware of the need for continued monitoring for fall-related injuries during the resident's treatment. The resident was later transferred to an acute care hospital and diagnosed with a thoracic vertebrae fracture.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents as required by physician orders and facility policy. For one resident with a physician's order for continuous oxygen at 2 LPM via nasal cannula to maintain oxygen saturation above 90% due to COPD, the resident was observed without the nasal cannula in place. The nasal cannula was found inside a set-up bag, and the resident stated he had removed it earlier in the presence of staff. Staff did not ensure the oxygen was reapplied, and the resident's oxygen saturation was later found to be 75%. Despite subsequent interventions, the resident's oxygen saturation could not be stabilized, leading to a transfer to an acute care hospital. Interviews with staff revealed that the CNA who assisted the resident with personal care asked the resident to place the nasal cannula in the set-up bag and instructed him to use the call light for assistance in putting it back on. However, the CNA did not inform other staff or a licensed nurse about the removal of the oxygen, as he was called away to respond to another resident. The licensed nurse also did not notice whether the resident was receiving oxygen during morning rounds. For another resident, the facility failed to change the oxygen tubing, nebulizer, and mask according to facility protocols, which require weekly changes and clear dating of supplies. The resident's breathing treatment equipment was observed to be bagged and dated several months prior, despite an active physician's order for as-needed nebulizer treatments. The nurse confirmed that the equipment should have been changed weekly and verified the outdated supplies.
Failure to Document Pain Assessments and Nonpharmacological Interventions Prior to Pain Medication Administration
Penalty
Summary
The facility failed to provide necessary care and services for pain management for two residents who required such services. For one resident, physician orders required the implementation and documentation of nonpharmacological interventions for pain, as well as a complete pain assessment prior to administering acetaminophen. However, medical record reviews showed that nonpharmacological interventions and their effectiveness were not consistently documented before administering the pain medication. Additionally, the required pain assessments, including details such as pain location, quality, characteristics, and alleviating or aggravating factors, were not documented in the progress notes prior to medication administration. For the second resident, physician orders specified the administration of hydrocodone-acetaminophen for moderate to severe pain, with the care plan requiring documentation of pain characteristics such as quality, severity, anatomical location, onset, duration, aggravating, and relieving factors. Review of the medication administration records revealed that, although pain levels were recorded, there was a lack of documentation regarding the location and characteristics of the pain at the time pain medication was given. Interviews with nursing staff and the DON confirmed that the expected practice was to assess and document pain characteristics and to implement and document nonpharmacological interventions prior to administering pain medication. The staff acknowledged that these steps were not consistently followed or documented for the two residents, as required by facility policy and care plans.
Failure to Ensure Staff Competency in Glucometer Quality Control Protocols
Penalty
Summary
The facility failed to ensure that two licensed nurses and the Director of Staff Development (DSD) demonstrated competency in the operation and quality control protocols for glucometers. During interviews and document reviews, it was found that these staff members were unable to accurately state the facility's protocol for when to conduct quality control (QC) checks, the process for completing the Quality Control Record, or the correct lifespan of test strips and control solutions once opened. The staff incorrectly believed that test strips and control solutions were good for 30 days after opening, whereas the manufacturer's instructions specified a 90-day period for control solutions. Additionally, the QC test results were not available in the glucometer history or documented on the facility's Quality Control Record for the relevant period. Despite having attended in-service trainings and having passed prior competency assessments, the staff interviewed could not accurately verbalize the facility's procedures regarding glucometer QC checks. The DSD confirmed that the training did not cover the correct lifespan of test strips and control solutions. The Director of Nursing (DON) acknowledged and verified these findings, confirming that the staff lacked the necessary knowledge to ensure safe and competent care related to blood glucose monitoring.
Failure to Administer Furosemide as Ordered for Dialysis Patient
Penalty
Summary
The facility failed to administer a resident's furosemide medication as ordered by the physician. The resident, who was admitted with orders for dialysis three times weekly and a daily dose of furosemide for edema, had a physician's order to hold all blood pressure medications prior to dialysis, but there was no order to hold furosemide. On two occasions, the furosemide was not given and was documented as held due to dialysis, with nursing notes indicating it was withheld because all blood pressure medications were to be held on dialysis days. The Director of Nursing confirmed that furosemide was not indicated to be held and should have been administered according to the physician's order.
Failure to Ensure Complete and Thorough Monthly Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that a licensed pharmacist consultant performed a monthly Medication Regimen Review (MRR) for all residents as required by facility policy. For one resident, there was no evidence that a MRR was completed for the entire month of May, despite the resident being present in the facility during that time. The resident's name was not included in the MRR listing for that month, and the Director of Nursing (DON) confirmed the omission during an interview and record review. Additionally, for another resident, the pharmacist consultant conducted MRRs for two consecutive months but did not address the concurrent use of two antidepressant medications, mirtazapine and bupropion, both prescribed for the same behavioral manifestation of verbalizing sadness. The DON verified that there was no documentation or pharmacy recommendations regarding the use of these two medications for the same indication in the MRRs for those months.
Medication Error Rate Exceeds 5% Due to Improper Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as required by policy, with an observed error rate of 7.14%. During a medication administration observation, one of two licensed nurses, LVN 7, did not administer medications according to physician orders for a resident. Specifically, LVN 7 administered sevelamer, a phosphate binder, after the resident had already eaten breakfast, rather than with the meal as ordered. Additionally, LVN 7 did not administer furosemide, a diuretic prescribed for edema, during the medication pass and did not clarify the omission with the physician, despite the medication's indication being for edema and not hypertension. Medical record review confirmed the active orders for both sevelamer and furosemide, and interviews with LVN 7 and the DON verified that the medications were not administered as prescribed. LVN 7 acknowledged the errors, stating she withheld furosemide due to concerns about blood pressure before dialysis, even though the order was for edema. The facility's policy requires medications to be administered as prescribed and in accordance with physician orders, which was not followed in these instances.
Medication Storage, Labeling, and Disposal Deficiencies
Penalty
Summary
Surveyors identified multiple failures in the facility's management of medications and biologicals, including improper storage, labeling, and disposal. During an inspection of the Medication Room, expired acetaminophen suppositories and culture swabs were found, as well as eye drop medications stored together with injectable medications in the same bin. Additionally, boxes of Trulicity injectable medication were found without labels or discard/expiration dates. These findings were acknowledged and verified by the registered nurse present during the inspection. Further inspections of Medication Carts B and C revealed additional expired supplies, such as Tegaderm film, surgical masks, and wound dressings. On Medication Cart C, a bottle of normal saline was found with only the date opened documented, lacking the required time of opening. These deficiencies were confirmed by the nursing staff and infection preventionist during the survey. In a resident's room, three sachets of Calazinc body shield cream were found on the bedside cabinet, rather than being stored in the treatment cart as required by facility policy. The resident, who had orders for Calazinc application to treat skin conditions, confirmed that staff applied the cream as ordered. Both the certified nursing assistant and licensed vocational nurse acknowledged that the cream should not have been left at the bedside and should have been secured in the treatment cart.
Failure to Follow Food Procurement and Handling Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events are provided in the report.
Failure to Perform Quality Control Checks on New Glucometer and Inaccurate Documentation of Control Solution Expiration Dates
Penalty
Summary
The facility failed to ensure that a glucometer on one of two medication carts was maintained in safe operating condition. During an inspection and review of documentation, it was found that a new glucometer was put into use without performing the required Quality Control check prior to its use, as outlined in the manufacturer's instructions. The Quality Control Record for the new glucometer did not show any documentation of a control check before it was used for blood glucose testing. The Infection Preventionist (IP) confirmed that blood sugar checks were performed using the new glucometer before the Quality Control check was completed. Additionally, discrepancies were identified in the documentation of expiration dates for control solutions used with the glucometer. The Quality Control Record listed expiration dates for the Normal and High Control solutions that did not match the actual expiration dates on the solution bottles. A Licensed Vocational Nurse (LVN) verified these findings and stated she was not aware of the facility's protocols for glucometer checks, but agreed that a Quality Control check should be performed when new strips or glucometers are used.
Incomplete SNF ABN Form Fails to Inform Resident of Potential Financial Liability
Penalty
Summary
The facility failed to ensure that the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) Form CMS-10055 was fully completed for a resident who was reviewed for beneficiary notices. Specifically, the SNF ABN form for this resident did not include the estimated daily cost of services, which is required to inform the resident of potential financial liability if Medicare does not cover the services. The resident had selected the option to receive the listed services and have Medicare billed, with the understanding that if Medicare did not pay, the resident would be responsible for payment. However, the absence of the estimated cost on the form meant the resident was not fully informed of the amount they might owe. Interviews with the Social Services Director (SSD) confirmed that it was their responsibility to provide residents with the SNF ABN forms prior to the last day of Medicare-covered services, and that the form should include the estimated cost. The SSD acknowledged that the required information was missing from the resident's form and verified that there was no other documentation in the medical record indicating the resident had been informed of the potential financial responsibility. The Director of Nursing (DON) was also made aware of these findings and acknowledged them.
Failure to Complete Timely Discharge MDS Assessments
Penalty
Summary
The facility failed to complete and submit timely discharge Minimum Data Set (MDS) assessments for two nonsampled residents. For one resident, the discharge MDS assessment was completed more than four months after the required 14-day deadline following discharge, and for another resident, the assessment was completed 18 days after the required deadline. These delays were confirmed through closed medical record reviews and interviews with the MDS Assistant, who acknowledged that the assessments were not completed within the mandated timeframe. The failure to complete these assessments on time resulted in a delay in submitting required data to CMS regarding the residents' health and functional status at discharge. The deficiency was identified through both interview and medical record review, with specific attention to the completion dates of the discharge MDS assessments compared to the required deadlines as outlined in the Resident Assessment Instrument User's Manual.
Failure to Follow Up on Physician-Ordered Urology Consultation
Penalty
Summary
The facility failed to provide necessary care and services for one resident by not following up on a physician-ordered urology consultation. The resident, who had a suprapubic urinary catheter, had a physician's order for a urology consult to address the catheter change. Documentation showed that the Case Manager initially contacted an outside facility to confirm eligibility for the consultation and was instructed to call back if no response was received by a specified time. However, there was no evidence that the Case Manager followed up as directed. Interviews with facility staff, including the LVN, Social Services Designee (SSD), and Case Manager, confirmed that the process for arranging outside consultations involves communication between licensed nurses, the SSD, and the Case Manager. All parties verified that the follow-up call to schedule the urology consult was not made, as required by the physician's order and facility policy. This lapse resulted in the resident not receiving the ordered consultation in a timely manner.
Incomplete Annual Skills Evaluations for CNAs
Penalty
Summary
The facility failed to ensure that annual skill performance evaluations for three certified nurse aides (CNAs) were complete, as required by facility policy. Review of the personnel files for these CNAs showed that their Comprehensive Clinical Competency forms were missing critical documentation. Specifically, the forms did not indicate whether required competency trainings and skills checks were 'Met' or 'Not Met,' and the next reevaluation dates were left blank. The areas lacking documentation included essential topics such as emergency procedures, safety protocols, and customer service. Interviews and policy review confirmed that all sections of the competency forms should have been completed, with clear indications of whether competencies were met and when the next evaluation was due. The Director of Staff Development (DSD) acknowledged that the annual skill check performance forms for the CNAs were incomplete, which was not in accordance with the facility's established procedures.
Failure to Schedule Ordered Laboratory Testing for Diabetic Resident
Penalty
Summary
The facility failed to provide laboratory services as ordered for one resident who was being monitored for unnecessary medication use. Specifically, a physician had ordered quarterly A1c testing for a resident with Type 2 Diabetes Mellitus and unspecified complications. The resident's medical record showed a history of very high blood sugar readings, and the consultant pharmacist had recommended continued quarterly A1c monitoring. Despite this, review of the resident's records revealed that no pending or future laboratory tests for the A1c level were scheduled, as required by the physician's order. Interviews with nursing staff and the Director of Nursing confirmed that the process for scheduling routine laboratory tests was not followed. The licensed nurse who received the order was responsible for both entering the order into the system and notifying the laboratory, but this was not completed. As a result, there was a potential for the resident's laboratory test to be missed, which could have impacted the resident's physical health and well-being.
Unlabeled Food Brought in by Family Not in Compliance with Facility Policy
Penalty
Summary
The facility failed to implement its policy regarding the labeling and storage of food items brought in by families or visitors for residents. During an observation in a resident's room, a plastic container of crackers was found on the bedside table without any labeling or dating, as required by the facility's policy. The resident confirmed that the crackers had been brought by family the previous week, and an LVN verified that the container was not labeled or dated. The facility's policy specifies that non-perishable foods brought in by families or visitors must be labeled with the resident's name, location, and date, and stored or discarded according to specific guidelines. This lapse was identified through observation, interview, and review of facility policy and medical records.
Failure to Coordinate Discharge Care for Resident
Penalty
Summary
The facility failed to ensure the necessary care and services were coordinated for a resident upon discharge, resulting in the resident not having appropriate care at home. The resident, who had lower extremity paralysis related to breast cancer with spinal metastasis, was discharged home with palliative care per her request. However, the facility did not provide the necessary contact information for the palliative care agency, nor did they confirm the coordination of care prior to discharge. The resident was dependent on staff for ADL care and required extensive assistance, which was not arranged by the facility. The Social Service Manager (SSD) was responsible for overseeing the discharge process but failed to document the coordination of palliative care services. The SSD stated that the resident had found the palliative care agency herself and set up the services, but there was no documented evidence of this coordination. The SSD did not provide the resident with information on other home service agency options and did not have the contact information for the chosen palliative care agency. Additionally, the discharge summary and post-discharge plan of care lacked documentation of the palliative care agency's contact details and did not indicate any medical equipment or devices ordered for the resident. Interviews with facility staff, including the Assistant Director of Nursing (ADON) and the Administrator, revealed that the SSD was responsible for ensuring home services and DME were confirmed prior to discharge. However, the SSD did not have documented evidence of coordination with the palliative care agency. The resident had to arrange home care services herself after discharge, indicating a failure in the facility's discharge planning process.
Food Safety and Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to meet food safety and sanitation requirements in the kitchen, as observed during a survey. Several issues were identified, including unclean and improperly stored kitchen utensils and equipment. Specifically, a metal spoon with brown stains, a metal lemon squeezer with dried black food particles, and clean utensils stored on a dirty baking sheet pan were noted. Additionally, the drawer containing these utensils was discolored and left a brownish stain when wiped. These findings were verified by the Certified Dietary Manager (CDM). Further observations revealed that some kitchen utensils were not in good condition. A frayed plastic spatula and a stationary table can opener with chipped stainless-steel coating were found, exposing the blade. These conditions were confirmed by the CDM. Additionally, personnel entering the kitchen were not adhering to proper dress code requirements, as a Maintenance Assistant was observed crossing a marked line without wearing a hair net, which was acknowledged by the Maintenance Supervisor and the CDM. The facility also failed to properly label and date food items once opened. Unlabeled opened bags of hamburger and hot dog buns were found, and the CDM admitted to not knowing when these items were opened. Furthermore, the fan unit inside the walk-in refrigerator was observed with grey fuzz, indicating a lack of cleanliness. These deficiencies were acknowledged by the Administrator and the CDM, highlighting a potential risk of foodborne illnesses for the 88 residents consuming food prepared in the kitchen.
Infection Control Deficiencies in Surveillance and Hygiene Practices
Penalty
Summary
The facility failed to implement a comprehensive infection control surveillance program from August 2023 through June 2024. The surveillance was limited to residents prescribed antimicrobials, excluding those with signs and symptoms of infection who met McGeer's criteria but were not on antimicrobial medications. This oversight was confirmed by the Assistant Director of Nursing/Infection Preventionist (ADON/IP) during interviews, who acknowledged that the monthly Prevention and Control Surveillance Log did not include all necessary data, leading to incomplete tracking of infections. Additionally, the facility did not accurately track and monitor infections for April and May 2024. The surveillance logs for these months had missing entries regarding whether residents had community-acquired infections (CAI), healthcare-associated infections (HAI), or did not meet McGeer's criteria. Specific cases, such as those involving residents prescribed antibiotics like amoxicillin, doxycycline, and cefdinir, were not properly categorized, leading to inaccuracies in the infection data. The facility also failed to ensure proper hand hygiene practices among staff during meal tray distribution. Observations revealed that CNAs did not perform hand hygiene between serving meal trays to different residents, despite the facility's policy requiring it. Furthermore, the laundry room was not maintained according to infection control practices, with personal items like a water bottle and cell phone found on the laundry folding table, which was supposed to be a clean area. These lapses were acknowledged by the staff and administration during interviews.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement its antibiotic stewardship program effectively, as evidenced by the lack of assessments using McGeer's criteria to determine true infections. The facility's policy on antibiotic stewardship, which is part of the Infection Prevention and Control Program, aims to promote appropriate antibiotic use and reduce adverse events. However, the facility did not complete the necessary Surveillance Data Collection Forms for residents admitted from acute care hospitals with antibiotics, as confirmed by the Assistant Director of Nursing/Infection Preventionist (ADON/IP). Several specific cases highlight this deficiency. For instance, Resident 29's form indicated they met McGeer's criteria and were prescribed Augmentin, but the form lacked documentation on whether the infection was healthcare-associated (HAI), community-associated (CAI), or did not meet the criteria. Similarly, Resident 75 was prescribed Levaquin despite not meeting McGeer's criteria, and there was no evidence that the physician was notified of this discrepancy. Resident 537 was prescribed multiple antibiotics without meeting McGeer's criteria, and again, there was no documentation of physician notification. Additionally, Resident 538's case showed a lack of completed documentation for the prescribed antibiotic treatment. The ADON/IP acknowledged these findings, stating that the Surveillance Data Collection Form should be fully completed, including the bottom portion indicating if the infection met McGeer's criteria. The ADON/IP also mentioned that if the criteria were not met, they would discuss with the physician whether to continue the antibiotic, documenting the decision on the form. However, this process was not consistently followed, leading to the identified deficiencies. The Administrator and Director of Nursing (DON) were informed and acknowledged these findings.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain informed consent for the use of psychotropic medication for a resident, identified as Resident 37, who was prescribed alprazolam, an antianxiety medication. This oversight was identified during a medical record review and interviews with facility staff. Resident 37, who lacked the capacity to understand and make decisions, was prescribed alprazolam to be administered every six hours as needed for anxiety. However, there was no documentation of informed consent from the resident's responsible party, which is required by the Nursing Facility Resident Informed Consent Protection Act of 2023. During interviews with RN 2 and the Director of Nursing (DON), it was confirmed that the informed consent was not obtained. The DON acknowledged that the physician should have educated the resident or their responsible party about the medication's purpose, risks, and side effects, and obtained a signed informed consent form. The absence of this documentation indicates a failure to comply with the informed consent requirements for psychotropic medications, posing a risk that the resident and their responsible party were not fully informed about the treatment plan.
Discrepancies in Advance Directives and POLST Documentation
Penalty
Summary
The facility failed to ensure that residents' rights to formulate advance directives were honored and accurately documented in their medical records. Specifically, there were discrepancies in the Physician Orders for Life-Sustaining Treatment (POLST) and advance directives for three residents. Resident 2's POLST indicated a Do Not Resuscitate (DNR) status, while the social services assessment showed a full code status, indicating a lack of consistency in the resident's medical records. Resident 74's medical records did not contain evidence that the resident's representative was informed of their right to formulate an advance directive. This oversight was confirmed during an interview with the Social Services Assistant (SSA), who acknowledged that the representative had not been provided with the necessary information regarding advance directives. For Resident 54, there was a mismatch between the POLST and the advance directive. The POLST indicated a preference for CPR and full treatment, while the advance directive showed a choice to prolong life without artificial nutrition. Interviews with the Social Services Assistant and the Director of Nursing (DON) confirmed these discrepancies, highlighting a failure to align the resident's documented wishes with their actual preferences.
Failure to Obtain Informed Consent and Conduct Restraint Assessment
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints, specifically a compression glove applied to the resident's right hand. The glove was intended to provide support and manage thumb-sucking behaviors, but the facility did not obtain informed consent or conduct a restraint assessment before its application. This oversight posed a risk to the resident's independence and psychosocial well-being. Observations and interviews revealed that the compression glove was applied without proper documentation or assessment. The resident's medical record lacked evidence of informed consent and a restraint assessment. Staff members, including an LVN and an OT, confirmed the glove's use but did not consider it a restraint. The OT stated that the rehabilitation department was responsible for applying and removing the glove, which was used to control thumb-sucking behaviors. Despite the physician's order for limited use, the glove was observed on the resident's hand for extended periods.
Failure to Implement Care Plan for Resident with Hemiplegia
Penalty
Summary
The facility failed to implement a comprehensive care plan for a resident with hemiplegia and hemiparesis following a nontraumatic intracerebral hemorrhage affecting the left non-dominant side. The care plan required the elevation of the left 1/2 side rail as an enabler for bed mobility, as per a physician's order. However, during an observation, it was noted that the right 1/2 side rail was elevated instead of the left, contrary to the care plan and physician's order. Interviews with facility staff, including a CNA and an LVN, confirmed the resident's left-sided weakness and the necessity of the left side rail for care and repositioning. Despite this, the right side rail was elevated, and the left side rail was absent, indicating a failure to provide appropriate, consistent, and individualized care as outlined in the resident's care plan. The facility's Administrator and DON were informed of these findings.
Improper Administration of Antihypotensive Medication
Penalty
Summary
The facility failed to provide appropriate care for a resident by administering midodrine, an antihypotensive medication, when the resident's systolic blood pressure was above the physician-prescribed parameter of 120 mmHg. This oversight was identified during a review of the resident's medical records, which showed multiple instances in July 2024 where the medication was given despite the resident's blood pressure exceeding the specified limit. The administration of midodrine under these conditions had the potential to negatively impact the resident's health and well-being. Interviews with the nursing staff, including RN 2 and the Director of Nursing (DON), confirmed that the medication was administered contrary to the physician's orders. RN 2 acknowledged that a checkmark on the Medication Administration Record (MAR) indicated the medication was given, and the DON verified the findings, stating that the nurses should have withheld the medication when the resident's systolic blood pressure was above 120 mmHg. This failure to adhere to the prescribed medication parameters represents a deficiency in the facility's care practices.
Failure to Monitor Wander Guard Devices
Penalty
Summary
The facility failed to ensure the proper monitoring and functionality of Wander Guard devices for three residents, which posed a risk for serious injuries. Resident 28, identified as a high risk for elopement, had an episode where they attempted to exit the facility unassisted. Although the resident was redirected by staff, the monitoring of the Wander Guard device was not adequately documented or verified for functionality. Similarly, Resident 21 had a physician's order to monitor the Wander Guard every shift, but the documentation on the Medication Administration Record (MAR) lacked the required information to confirm the device's functionality. Resident 47, also at high risk for elopement, had a Wander Guard applied, but there was no physician's order to monitor its placement and functionality. Interviews with staff revealed a lack of clarity and responsibility regarding the monitoring of the Wander Guard devices. LVN 7 was unsure about the process for checking the functionality of the devices and acknowledged that the monitoring was not performed as required. The Maintenance Supervisor confirmed that while he checked the Wander Guard function on exit doors weekly, the responsibility for checking the devices on residents lay with the licensed nurses. The Director of Nursing (DON) verified these findings, indicating a systemic issue in the facility's adherence to its Wander System Monitoring Program and the manufacturer's instructions for daily testing of the devices.
Failure to Document and Confirm PICC Line Measurements
Penalty
Summary
The facility failed to provide necessary care and services to maintain the IV access for a resident with a PICC line. Specifically, the facility did not document the initial PICC line external catheter measurement in the medical record and did not confirm baseline measurements of the PICC line external catheter and arm circumference before administering IV antibiotics. This oversight had the potential to delay the identification of catheter-related complications for the resident. The resident, who was admitted with a PICC line inserted at an acute care hospital, had their arm circumference and external length of the PICC line measured weekly. However, there was no documented evidence of the baseline measurements from the hospital, nor confirmation of these measurements before using the PICC line. Interviews with the RN and DON revealed that the expected protocol was to verify these measurements with the hospital and document them, which was not done in this case.
Deficiencies in Respiratory Care and Equipment Maintenance
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for several residents, as observed during a survey. Resident 8's CPAP machine was not cleaned according to the manufacturer's guidelines, which require daily cleaning of the mask and tubing. Interviews with the resident and staff revealed that the CPAP machine was only cleaned weekly, and there was no record of when the components were last changed. The Director of Nursing (DON) confirmed that the facility did not have a copy of the CPAP machine manual and acknowledged the failure to follow the manufacturer's cleaning instructions. Resident 61 was observed with oxygen tubing touching the floor, which was verified by a Licensed Vocational Nurse (LVN) who stated that the tubing should have been placed in a clear plastic bag to prevent infection. Additionally, Resident 50's nebulizer mask was not stored in a bag when not in use, and the nebulizer tubing was not dated. The Assistant Director of Nursing/Infection Preventionist (ADON/IP) confirmed these observations and acknowledged the failure to follow proper storage and labeling procedures. Resident 687 was receiving oxygen at a higher flow rate than ordered, and the oxygen and nebulizer tubing were not labeled or dated. The ADON/IP verified these discrepancies during an observation and interview. The facility's policies and procedures for oxygen administration and equipment maintenance were not followed, leading to potential risks for equipment contamination and respiratory complications for the residents involved.
Inadequate Pain Management for a Resident
Penalty
Summary
The facility failed to provide adequate and appropriate pain management for a resident, identified as Resident 69, by not administering pain medication according to the physician's orders. The medical record review revealed that Resident 69 had specific orders for pain management, including acetaminophen for mild pain, Norco 5-325 mg for moderate pain, and Norco 10-325 mg for severe pain. However, the facility administered Norco 5-325 mg to Resident 69 on multiple occasions when the resident's documented pain level was 7, which is categorized as severe pain and should have been treated with Norco 10-325 mg as per the physician's orders. The review of the Medication Administration Record (MAR) for July 2024 showed that the Norco 5-325 mg was administered to Resident 69 on several dates and times when the resident's pain level was documented as 7. This discrepancy was confirmed during an interview and concurrent medical record review with RN 2, who verified the findings. The failure to administer the correct dosage of pain medication as per the physician's orders had the potential to result in ineffective pain management for Resident 69.
Deficiencies in Bed Rail Use and Safety Assessment
Penalty
Summary
The facility failed to ensure the safety of two residents, Residents 50 and 54, regarding the use of bed rails, which are associated with accident hazards. For Resident 54, the facility did not obtain a physician's order or informed consent, nor did it conduct a bed rail safety evaluation before using the right half side rail. The resident, who had hemiplegia and hemiparesis following a nontraumatic intracerebral hemorrhage, was observed with the right half side rail elevated, despite having an order and consent only for the left half side rail. Interviews with staff confirmed the lack of proper documentation and assessment for the right side rail. Resident 50 was observed with bilateral half side rails elevated, despite being confused, nonverbal, and unable to use the rails for mobility or repositioning. The facility had a physician's order for the use of these rails as enablers, but interviews with staff revealed that the resident was dependent on staff for activities of daily living and could not effectively use the side rails. The medical record review showed that the resident was dependent for upper dressing, rolling, and sitting to lying, indicating a lack of proper assessment for the necessity and safety of the side rails. The facility's policy requires an assessment of risks and benefits, informed consent, and proper installation and maintenance of bed rails, which were not followed in these cases. The Director of Nursing and Administrator acknowledged the findings, confirming the deficiencies in the facility's adherence to its policies and procedures regarding bed rail use, potentially putting the residents at risk for serious injuries.
Failure to Document Rationale and Monitor Side Effects for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary psychotropic medications. For one resident, the facility did not have documented evidence of the physician's rationale for extending the use of alprazolam, an antianxiety medication, beyond the recommended fourteen-day period. This resident was administered multiple doses of alprazolam over several weeks without proper documentation justifying the extended use. Interviews with the RN and DON confirmed the absence of necessary documentation in the resident's medical records. For another resident, the facility did not monitor for signs of orthostatic hypotension, a potential side effect of antipsychotic medication. The resident was on quetiapine for schizophrenia and clonazepam for anxiety, but the care plan did not include interventions to monitor for orthostatic hypotension. The MAR for this resident showed no documentation of monitoring for this condition. The DON verified that blood pressure monitoring should have been conducted for residents receiving psychotropic medications to check for orthostatic hypotension.
Medication Storage and Disposal Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and disposal of medications, as observed in the medication storage room and on medication carts. Oral medications were not stored separately from externally used medications, and medications in bubble packs were not secured, with some packs showing tears or damage. Additionally, a medication cart was left unlocked and unattended, and expired medications were not removed from the cart. An unopened insulin vial was not stored in the medication refrigerator as required. The facility also failed to prevent medications from being stored at the bedside for two residents. One resident had foot pain relief rubbing oil and an essential oil formula on their bedside dresser without a physician's order or care plan addressing their use. Another resident had a box of joint pain supplement on their bedside dresser, which was brought by family members and not checked by the staff. These deficiencies were verified through observations and interviews with facility staff, including registered nurses and licensed vocational nurses. The facility's policies and procedures for medication storage were not followed, leading to potential negative impacts on residents' well-being.
Failure to Educate on Safe Food Handling for Outside Food
Penalty
Summary
The facility failed to ensure that education on safe food handling was provided to staff and family/visitors as per the facility's policy and procedure (P&P). This deficiency was identified through interviews, facility document reviews, and P&P reviews. The facility's P&P titled 'Food Brought by Family and Visitor' required that residents and their representatives be informed of the policy and provided with safe food handling guidance both verbally and in writing. However, the facility document titled 'Bringing in Food for a Resident' did not include instructions for safe food handling, which was a critical omission. Interviews with the Certified Dietary Manager (CDM) and the Director of Staff Development (DSD) revealed gaps in the implementation of the policy. The CDM was responsible for ensuring that therapeutic diets and textures were met but did not discuss hand hygiene or prevention of cross-contamination with visitors. The DSD, who was responsible for staff education, acknowledged that the document used for in-services did not address safe food handling practices. The Director of Nursing (DON) confirmed that the facility documents lacked education on safe food handling. The Administrator and CDM were informed of these findings and acknowledged the deficiency.
Inaccurate and Incomplete Medical Records
Penalty
Summary
The facility failed to maintain accurate and complete medical records for several residents, leading to potential unmet care needs. For Resident 17, the smoking evaluation was inaccurately completed, despite observations and interviews indicating that the resident had no impairments in her upper extremities and was able to smoke safely. The discrepancy between the evaluation and the resident's actual abilities was confirmed by the Director of Nursing (DON) and other staff members. Resident 50's medical records were incomplete, specifically regarding the documentation of the application of a PRAFO (Pressure Relief Ankle Foot Orthosis) to the right lower extremity. The RNA documentation was missing for several days, which was verified by the Licensed Vocational Nurse (LVN) and acknowledged by the DON and Administrator. This lack of documentation could affect the monitoring and treatment of the resident's condition. Additionally, Resident 14's medical records contained inaccuracies, including missing nurses' initials on the Treatment Administration Record (TAR) for securing a Foley catheter and monitoring edema. Furthermore, another resident's health information was mistakenly included in Resident 14's records. These errors were confirmed by the DON and Administrator, highlighting significant lapses in maintaining accurate and secure medical records.
Failure to Provide Immunization Education and Obtain Consent
Penalty
Summary
The facility failed to offer and provide education on influenza and pneumococcal immunizations to two residents, identified as Residents 20 and 35, as per the facility's policy. The policy mandates that each resident or their legal representative should receive education regarding the benefits and potential side effects of the immunizations before administration. However, there was no documented evidence that Residents 20 and 35, or their representatives, were provided with this information or that consent was obtained prior to receiving the influenza vaccine. Additionally, the facility did not ensure the accuracy of Resident 35's immunization record concerning the pneumococcal vaccine. The record did not reflect that Resident 35 had previously received the pneumococcal vaccine, indicating a lapse in maintaining accurate immunization records. These deficiencies were confirmed during an interview with the Assistant Director of Nursing/Infection Preventionist (ADON/IP), who verified the findings.
Failure to Timely Report Allegation of Sexual Abuse
Penalty
Summary
The facility failed to report an allegation of sexual abuse between two residents to the California Department of Public Health Licensing and Certification (CDPH L&C) and the Long-Term Care Ombudsman Programs as required by their policy and procedure (P&P). The incident involved a family member of Resident 19 reporting that Resident 21 exposed himself and performed a sexual act in the bathroom. Despite being informed by the family member, the charge nurse and the physical therapist assistant (PTA) did not immediately report the incident to the appropriate authorities. The PTA acknowledged forgetting to report the allegation right away and only informed the Administrator the following morning. The Administrator, who is the abuse coordinator, confirmed that he was made aware of the incident by the Ombudsman and the Director of Nursing (DON) a day after the family member's report. Interviews with the Licensed Vocational Nurses (LVNs) revealed that they were informed by the family member and reported the incident to their supervisor and the DON. However, the DON stated that the information received was vague and not clear enough to warrant an investigation. This delay in reporting the allegation of sexual abuse was acknowledged by the Administrator as being late, which had the potential to leave the residents vulnerable to further abuse.
Inaccurate and Incomplete Entrapment Assessments for Residents Using Side Rails
Penalty
Summary
The facility failed to ensure accurate and complete entrapment assessments for six of nine sampled residents using side rails. Specifically, the assessments for Residents 14, 20, 37, 50, 54, and 69 were found to be inaccurate or incomplete. For Residents 14, 20, 37, 50, and 69, the assessments inaccurately marked Zone 5 as 'Pass' when it should have been marked as 'Not Applicable' due to the absence of lower side rails. Additionally, Resident 14's assessment was incomplete, missing information on Zones 1 to 7, type of mattress, mattress condition, and mattress dimensions. Resident 54's case highlighted further deficiencies, as there was no physician's order, informed consent, or entrapment assessment for the right half side rail, which was in use. The Maintenance Supervisor, responsible for conducting the entrapment assessments, acknowledged these inaccuracies and omissions during interviews. The facility's policy requires a physician's order, an IDT assessment, informed consent, and a maintenance-conducted entrapment assessment before side rail use, which was not followed in these instances. The observations and interviews revealed that the facility's staff, including the Maintenance Supervisor, DON, and Administrator, were aware of the deficiencies. The Maintenance Supervisor admitted to marking Zone 5 inaccurately and acknowledged the incomplete assessment for Resident 14. The DON confirmed that the side rails should match the physician's order and that the facility's policy was not adhered to, leading to potential risks for the residents involved.
Inaccurate MDS Documentation for Two Residents
Penalty
Summary
The facility failed to ensure accurate completion of the Minimum Data Set (MDS) for two residents, which posed a risk to their care. For Resident 487, the MDS inaccurately indicated that the resident had no falls since admission, despite a physician's order to send the resident for evaluation after a fall. This discrepancy was confirmed during an interview with the MDS Coordinator, who acknowledged the inaccuracy in the MDS documentation. Similarly, for Resident 61, the MDS failed to reflect the use of a chair and bed alarm, which was ordered by a physician and included in the resident's care plan due to poor safety awareness. The MDS Coordinator verified the presence of the physician's order and care plan but stated that the alarm was not coded in the MDS because it was not considered a restraint. The Director of Nursing also confirmed these findings during a subsequent review.
Improper Garbage Storage in Facility Dumpsters
Penalty
Summary
The facility failed to ensure proper storage of garbage and refuse in two out of three garbage dumpsters, as observed during a survey. The dumpsters were overflowing with garbage, preventing the lids from fully closing, which is a violation of the US Food Code 2022 5-501.113 that requires receptacles to be covered with tight-fitting lids. The facility's policy and procedure on garbage and rubbish disposal, revised in February 2023, also mandates that all garbage containing food waste be kept in containers with tight-fitting lids and covered when not in continuous use. During an observation on July 29, 2024, with the Maintenance Supervisor, it was noted that the lids of two dumpsters were propped open by trash bags and cardboard boxes, preventing them from closing completely. The Maintenance Supervisor confirmed these findings and acknowledged that the dumpster lids should be completely closed and that trash should not exceed the maximum loading level indicated on the dumpsters. The Administrator and CDM were informed of these findings on August 1, 2024, and acknowledged the deficiency.
Ice Buildup in Medication Refrigerators
Penalty
Summary
The facility failed to maintain the equipment in a safe operating condition, specifically in Medication Room A. During an inspection, it was observed that the freezer compartments inside Medication Refrigerators A and B had a buildup of ice. Additionally, Medication Refrigerator B was missing a cover on its freezer compartment. These findings were verified by RN 1, who was unsure if the nursing department was responsible for cleaning and maintaining the medication refrigerators. The Director of Nursing (DON) confirmed the findings and stated that the ice buildup should be reported to the Maintenance Department.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Anaheim
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Buena Vista Care Center | 0.4 mi | ★★★★★ | 30 | 0 |
| Sun Mar Nursing Center | 1.4 mi | ★★★★★ | 1 | 0 |
| Chapman Care Center | 1.6 mi | ★★★★★ | 23 | 0 |
| Harbor Villa Care Center | 1.7 mi | ★★★★★ | 24 | 0 |
| The Grove Post Acute | 2.4 mi | ★★★★★ | 3 | 0 |
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