Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Crystal Creek Post-acute during CMS and state inspections, most recent first.
A resident with chronic pain and orthopedic and spinal conditions had pain levels repeatedly documented as 0/10, yet an LPN administered PRN acetaminophen ordered for mild pain without completing an updated pain assessment or documenting a clinical rationale. The MAR showed the medication was given despite the last recorded pain score being 0, and there was no follow-up documentation of the resident’s response, contrary to facility policy requiring detailed pain assessment and documentation of intervention results.
A resident with chronic pain, spinal stenosis, and recent orthopedic aftercare had a documented pain score of 4/10, but staff did not administer any ordered PRN pain medication or document non-pharmacological interventions or reassessment. The resident had active PRN orders for hydromorphone and acetaminophen with specified non-drug measures, and the facility maintained an emergency narcotic eKIT. An LN reported the ordered pain medication was not available, did not contact the provider or pharmacy for alternatives, attempted but did not document an offer of acetaminophen that the resident refused, and no interventions or follow-up assessments were recorded, as later confirmed by the DON and pharmacy and medical providers.
A resident with multiple conditions, including spinal stenosis, hyperlipidemia, and chronic pain syndrome, did not receive several scheduled medications (amitriptyline, gabapentin, simvastatin, and dicyclomine) when they were not available at the scheduled administration time. The LN confirmed the drugs were unavailable, took no alternate steps to obtain them, and did not notify the provider or pharmacy. The NP later reported he was not contacted and could have authorized use of the eKIT, and the DON confirmed that medications were not given as ordered and that required notifications were not made, contrary to facility policy requiring timely administration per prescriber orders.
A resident with multiple orthopedic conditions and a documented moderate fall risk, who required substantial/maximal assistance with toileting/hygiene, fell from bed and sustained a distal humerus fracture while a CNA performed in‑bed incontinence care using a single‑person assist. During linen changing, the CNA released manual support so both hands could be used to pull soiled sheets while the resident was on her side, and the resident fell to the floor; there were no bed rails or fall mats in place at that time. Subsequent IDT documentation referenced low bed and landing mat interventions, but the DON later confirmed that a fall mat was not actually in place until days after the fall and that bed rails, ordered and consented to later, were not installed until two days after the order. The DON acknowledged that the resident’s injury was preventable and the physician stated that two CNAs should have been providing the in‑bed care.
A facility failed to keep call lights within reach for four residents with significant medical needs. One resident with hemiplegia, aphasia, and osteoarthritis, another with hemiplegia, COPD, CHF, and failure to thrive, a resident with cerebellar ataxia and hospice care, and a resident with spinal stenosis and COPD were each observed with the call light hanging from the bed rail, bed frame, or bedside drawer instead of being accessible. Each resident stated they could not reach the call light to ask for help, and staff confirmed the call lights should have been within reach.
Care plans were not developed for two residents as required. One resident had PTSD on the active problem list, but the DON confirmed there was no PTSD-specific care plan or trauma assessment for an extended period. Another resident used a speech device after laryngectomy, but staff said no care plan existed for the device until later, and they did not know how it functioned or how to care for it.
Water or fluids were not available at the bedside for three residents. One resident with adult failure to thrive and kidney inflammation had an empty pitcher placed out of reach, another resident with CKD and a fall history had no fluids available and was on thickened liquids that delayed access, and a third resident with Alzheimer’s disease and diverticulosis was also observed without water at the bedside. Staff confirmed the lack of readily available fluids and noted the associated dehydration and fall concerns.
Kitchen sanitation and dishwashing practices were not maintained. A can opener in the cook's prep area was observed with chipped metal, food residue, shavings, and an oily substance; several tray line pans were stacked wet in the ready-to-use area; and a Dietary Aide moved between dirty and clean dish areas without washing hands or changing apron and gloves. The RD confirmed these conditions did not meet facility expectations and were inconsistent with facility policy for cleaning, drying, and hand hygiene.
Failure to Offer and Document Flu Vaccination Consent: The facility did not offer, obtain informed consent for, or document flu vaccine decisions for three sampled residents. One resident said she repeatedly asked for the vaccine and usually received annual flu and pneumonia shots, while the IP stated another resident had signed consent but later chose not to proceed and that this was not documented. The IP also stated a third resident was not asked for consent, and the DON said flu vaccination should be offered to all residents or their RPs with the decision and any refusal documented.
Staff failed to protect a resident's privacy during personal care when the room door and privacy curtain were left open, allowing care to be seen by others. Staff also referred to another resident as a feeder during breakfast, which was acknowledged as a dignity issue by LN, CNA, RD, and DON. The residents had diagnoses including dementia and other conditions affecting cognition and function.
A resident with Alzheimer's Disease, dementia, and PTSD was found to lack decision-making capacity but was still listed as her own RP, with no POA, family, conservator, or other legal representative on record. The DON verified that the POLST lacked clear documentation of who discussed or signed it, and staff stated that Social Services should have initiated conservatorship or CAPRIS involvement when the resident was admitted. Facility policy required documentation of a resident representative and identification of the primary decision-maker when a resident cannot make healthcare decisions.
A resident with anxiety had a PRN Ativan order written for 30 days, even though the facility typically limited PRN psychotropic meds to 14 days unless the prescriber documented a clinical rationale for extending the order. The DON confirmed the order exceeded the usual timeframe and that no prior justification was present in the resident’s record.
Failure to Develop Person-Centered Care Plans for Diabetes and Anxiety: A resident admitted with diabetes and anxiety disorder had physician orders for busPIRone and Insulin Lispro, but the care plan review showed no person-centered care plans were developed or implemented for either diagnosis. The DSD confirmed the missing care plans, and the DON stated they should have been developed on admission. The facility policy required comprehensive care plans with measurable objectives and timetables within 7 to 21 days of admission.
Two residents did not receive timely pain management. One resident with broken and missing teeth had sore gums and mouth pain, but the ordered Magic Mouthwash was not entered on the MAR or administered, and the dental consult was not scheduled or documented. Another resident with osteoarthritis and a stage 4 pressure ulcer reported severe pain, but a CNA told her to wait while the nurse was on break, did not provide comfort measures, and pain medication was not given until later.
Invalid Bed Rail Consent Obtained From Resident Without Capacity: The facility obtained informed consent for bed rail use from a resident who lacked decision-making capacity and had diagnoses including dementia and schizophrenia. The resident had a left side bed rail in place, but staff and leadership stated the resident could not understand the risks and that consent should have been signed by the resident’s representative instead of the resident.
A resident with COPD, oxygen dependence, depression, and anxiety developed sore gums and mouth pain, and the NP ordered Magic Mouthwash and a dental eval for worsening symptoms. Nursing did not get the mouthwash onto the MAR or administer it, and SS was not aware of the dental consult request, so the resident was not seen during the dentist’s facility visit and remained without timely dental follow-up despite ongoing pain and difficulty eating.
An LPN entered a resident’s contact isolation room and checked the resident’s pulse without wearing gloves or a gown. The resident had pneumonia and acute respiratory failure with hypoxia, and the DON later confirmed ESBL in the resident’s urine. The IP stated that staff were expected to follow contact isolation PPE requirements.
A resident with hemiplegia reported to a family member that she was hit on the head by an unknown person during care. The family member informed facility staff, who documented the allegation and initiated an internal investigation, but did not report the suspected abuse to the state licensing agency as required. Multiple staff interviews confirmed the failure to report, and the incident was not reflected in the resident's care plan or progress notes.
A resident with hemiplegia reported to a family member that she was hit on the head by a staff member during care. The allegation was communicated to facility staff, but the facility did not report it to the state agency as required. Additionally, the facility's investigation did not include interviews with other residents who received care from the accused staff member, contrary to facility policy.
The facility did not consistently employ a qualified IP responsible for infection prevention and control, with gaps in both employment and documentation of required training or certification. Staff interviews and record reviews confirmed periods without a designated or properly trained IP, and missing employee files further hindered verification of compliance.
A licensed nurse failed to notify a resident's responsible party after the resident exhibited physical aggression towards another resident. Although documentation indicated the family had been informed, the nurse later admitted the notification did not occur due to being busy. This resulted in the family being unaware of the incident, in violation of facility policy requiring prompt communication of changes in condition.
A resident with a history of falls experienced multiple falls without new interventions added to their care plan. Despite hospice providing a 3-hour sitter, falls continued during evening shifts. Staff interviews indicated the sitter schedule was ineffective, and the facility's IDT did not adjust the care plan after recent falls, waiting for medication effectiveness.
The facility failed to ensure safe food storage and sanitation practices, affecting 127 residents. Observations revealed opened and expired food items in storage, wilted and moldy vegetables in the refrigerator, ice buildup in a freezer, and a dishwasher operating below the required temperature. These issues were confirmed by the Dietary Manager Assistant and Registered Dietitian, indicating potential risks of foodborne illnesses.
The facility failed to accommodate the needs of three residents, leading to deficiencies in their care. A resident with a history of stroke and contracture was unable to use a conventional call light and was not assessed for an adaptive one. Another resident with dementia and hemiplegia also struggled with a conventional call light and had a fall mat improperly positioned. A third resident experienced distress due to a lost wheelchair, which was replaced with an unsuitable one, limiting his mobility. The facility's failure to provide appropriate equipment and timely response resulted in significant deficiencies.
The facility failed to ensure safe smoking practices for eight residents, who were found with unsecured cigarettes and lighters in their rooms, despite being assessed as high risk for accidental injury. Some residents required supervision and protective equipment while smoking, but the facility did not consistently enforce these measures. Staff interviews revealed a lack of training and awareness regarding the facility's smoking policy, leading to potential fire hazards, especially for residents on oxygen.
The facility failed to prepare and serve food consistently and appetizingly, with two residents reporting cold meals and test trays found to be bland. Additionally, recipes for pureed diets were not followed, potentially affecting meal intake.
The facility failed to coordinate hospice care for three residents by not reviewing hospice visit notes, despite receiving them via email. This lack of review spanned several months, affecting the residents' care coordination. The DON emphasized the importance of having these notes in the residents' hospice binders weekly.
The facility failed to implement timely isolation precautions for a resident with C. difficile, delaying contact isolation until days after symptoms began. Additionally, glucometers were not properly sanitized according to manufacturer guidelines, risking cross-contamination. These lapses in infection control could negatively impact resident health.
A resident with obesity was upset after overhearing a CNA make negative comments about her weight and wheelchair size to an LN. The incident affected her self-worth and self-esteem, and despite her complaint, there was no follow-up from social services. The facility failed to update her care plan or adhere to policies on resident rights and care planning.
A resident with morbid obesity requested help with weight loss, and the physician recommended exercise with RNA assistance. However, the resident's inability to participate in the exercise program was not communicated to the physician, leading to a potential delay in interventions. The resident experienced significant weight gain and expressed demoralization, while the facility failed to update the physician on the resident's decline in functional abilities.
A confidentiality breach occurred when a resident's EHR contained another resident's PHI, including personal details and medical information. Interviews with the MRD and ADON confirmed the error, highlighting the importance of correct record filing to protect privacy. Facility policies emphasize the need for confidentiality in handling resident records.
The facility failed to complete accurate MDS assessments for two residents, leading to potential inaccuracies in care planning. One resident's discharge MDS was not completed, leaving their health status untracked, while another resident's MDS inaccurately indicated the use of a feeding tube. Facility staff confirmed these errors, acknowledging non-compliance with the facility's MDS Standard of Practice.
A facility failed to update the PASARR form for a resident after a significant change in her mental illness diagnosis, resulting in the resident not receiving necessary specialized mental health services. The oversight was due to a lack of communication and clarity among staff regarding the process for initiating a new PASARR when a diagnosis changes.
The facility failed to create individualized care plans for two residents, one with vision issues due to diabetic cataract and glaucoma, and another at high risk for falls. The absence of a vision care plan for the first resident and a fall care plan for the second resident was confirmed by staff, indicating non-compliance with facility policies. This oversight risked inadequate care for the residents' specific health needs.
A resident with diabetic cataract and glaucoma experienced a delay in obtaining vision services due to the facility's failure to follow up after being deemed ineligible by an outside provider. Despite the resident's repeated requests and having medical insurance, the facility did not seek alternative providers, leading to the resident's frustration and potential impact on their well-being. The facility's process for handling vision service requests was not adhered to, as confirmed by staff interviews and record reviews.
The facility failed to administer medications according to professional standards for two residents. One resident had medications, including controlled substances, left unattended at the bedside without authorization to self-administer. Another resident received medications via G-Tube instead of orally, contrary to physician orders. Staff interviews and policy reviews confirmed these practices were against facility protocols.
A medication error rate of 17.8% was identified in a facility when a resident received medications via G-Tube instead of the prescribed oral route. The error involved five medications, including Carvedilol and Losartan, and was confirmed by the physician, ADON, and Pharmacist Consultant. The facility's policy requires verification of the correct route, which was not followed.
A facility failed to store medications in a clean and sanitary environment, as a loose, unidentifiable pill was found in a medication cart. A nurse acknowledged the importance of preventing loose pills for cleanliness and accountability, while the ADON noted the infection control risk. The facility's policy requires medications to be stored in their original containers.
Two residents did not receive meals according to their documented food preferences, leading to potential health risks. One resident received a meal with disliked items, while another did not receive a necessary protein portion. The RD confirmed these discrepancies, which were against the facility's policy to honor resident food preferences.
A resident admitted with hemiplegia and hemiparesis did not receive necessary PT and OT services as indicated in their hospital discharge summary. The facility's staff failed to assess the resident for these therapies, and no orders were found in the EHR. Interviews revealed a breakdown in the process of verifying and implementing hospital discharge orders, leading to a potential decline in the resident's physical function.
The facility did not follow the planned menu for 18 residents on pureed diets during a lunch meal service, serving pureed carrots instead of the listed squash. This was due to a staff member being occupied with other tasks. The administrator confirmed the importance of menu adherence for meeting resident needs.
The facility failed to prepare pureed foods according to recipe directions, resulting in an unappetizing texture for 18 residents. Additionally, meals were served late and cold to two residents, with one resident reporting consistently cold meals. The DON confirmed the delay in meal service.
The facility failed to prepare pureed food correctly for 18 residents on a pureed diet. A staff member added unmeasured water and thickener to pureed carrots, resulting in a runny consistency. The RD confirmed water was not in the recipe, and the staff member admitted to not measuring ingredients, leading to an unsuitable texture for residents with swallowing difficulties.
The facility failed to store clean dishes according to food safety standards, affecting 144 residents. Observations revealed that food trays and plastic drinking glasses were stacked while still wet, preventing proper drying. The RD and DON confirmed the presence of moisture, identifying it as a potential environment for pathogen growth, which could lead to foodborne illnesses.
A resident with cancer and heart failure did not receive timely physician visits as required, with the last documented visit occurring months prior. Despite a system to track overdue visits, the facility failed to ensure compliance with federal regulations, resulting in a lapse in care.
A resident with multiple fractures and a contusion did not have follow-up appointments with specialists scheduled as ordered, compromising her care. The Social Services Director and Director of Nurses confirmed the lack of documentation for these appointments, which were necessary for the resident's recovery.
Failure to Accurately Assess and Document Pain Prior to PRN Analgesic Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate clinical assessment and documentation related to pain management for one resident. The resident was admitted with multiple diagnoses including orthopedic aftercare, spinal stenosis, and chronic pain syndrome. Facility records titled Weights and Vitals Summary showed that the resident’s pain level was consistently documented as 0 out of 10 on the numeric pain scale during the evening and early morning time frame in question. Despite these documented pain scores of 0, the Medication Administration Record (MAR) indicated that a nurse administered two 500 mg acetaminophen tablets as needed for mild pain. Interview and record review revealed that the nurse administered the PRN acetaminophen without completing an updated pain assessment to support the clinical indication for the medication. The nurse acknowledged that the resident’s pain level was documented as 0 at the time and stated she had been overwhelmed with multiple tasks and had not performed a new pain assessment. The DON confirmed there was no documentation in the medical record to justify the administration of acetaminophen, nor any follow-up pain assessment to evaluate the effectiveness of the medication. This was inconsistent with the facility’s Pain Assessment and Management policy, which required implementation of the medication regimen as ordered and careful documentation of the resident’s reported level of pain and the results of interventions.
Failure to Implement Ordered PRN Pain Management for Resident With Chronic Pain
Penalty
Summary
The deficiency involves the facility’s failure to implement physician-ordered pain management interventions for a resident with documented chronic pain and orthopedic conditions. The resident was admitted with diagnoses including orthopedic aftercare, spinal stenosis, and chronic pain syndrome. On the facility’s Weights and Vitals Summary for the period 3/23/26 through 3/24/26, the resident’s pain level was documented as 4 out of 10 (moderate pain) at 8:04 p.m. on 3/23/26. Despite this documented pain level, there was no corresponding documentation of any pain intervention or reassessment at or around that time. The resident had multiple active PRN pain medication orders, including hydromorphone oral tablets for moderate to severe pain (pain rating 4–10/10) and acetaminophen for mild pain, with specified non-pharmacological interventions to be attempted prior to or along with medication administration. The facility also maintained an emergency narcotic eKIT containing controlled pain medications such as hydromorphone, morphine sulfate, oxycodone, and hydrocodone/acetaminophen for immediate use when ordered medications were not yet available. However, there was no documentation that any of the ordered PRN pain medications or the listed non-pharmacological interventions were implemented when the resident reported a pain level of 4 on 3/23/26 at 8:04 p.m. During interviews, the licensed nurse acknowledged that the resident’s pain was documented as 4/10 and stated that the ordered pain medication was not available at the time of the pain assessment. The nurse reported not considering calling the physician or pharmacy to obtain medications from the eKIT and stated she attempted to administer acetaminophen, which the resident refused, but she did not document this refusal. The pharmacy operations manager confirmed that staff could use the eKIT when medications were not available and were expected to notify the physician and pharmacy in such situations. The nurse practitioner stated nursing staff should have notified him about the missing pain medications so he could provide additional orders, including authorizing eKIT use. The director of nursing confirmed that no pain medication was administered when the resident reported pain and that there was no documentation of any intervention or reassessment, despite the facility’s pain assessment and management policy defining pain management as alleviating the resident’s pain based on clinical condition and treatment goals.
Failure to Administer Ordered Medications and Notify Provider/Pharmacy
Penalty
Summary
The deficiency involves the facility’s failure to ensure that physician-ordered medications were administered as prescribed for one resident. The resident was admitted with multiple diagnoses, including orthopedic aftercare, spinal stenosis, hyperlipidemia, and chronic pain syndrome. Review of the Medication Administration Record (MAR) for March showed that several medications scheduled for administration at 9 PM on a specific date—amitriptyline 50 mg at bedtime, gabapentin 600 mg (two tablets) at bedtime, simvastatin 20 mg at bedtime, and dicyclomine 10 mg (two capsules) four times daily—were not administered. Progress notes documented that these prescribed medications had not yet been delivered from the pharmacy at the time they were due. During interview and record review, the licensed nurse confirmed that the medications were not available when scheduled and acknowledged that no alternate measures were taken to obtain them. The nurse did not notify the physician or the pharmacy about the unavailable medications and stated she was overwhelmed while managing multiple tasks. The nurse practitioner confirmed he was not notified of the missed or unavailable medications and stated staff should have contacted him and could have used the emergency medication kit with an appropriate order. The DON also confirmed that the scheduled medications were not administered as ordered and that staff failed to notify the physician and pharmacy when medications were not available. Facility policy on administering medications stated that medications are to be administered in a safe and timely manner, as prescribed, and within one hour of their prescribed time unless otherwise specified.
Failure to Ensure Safe In‑Bed Care and Timely Fall‑Prevention Measures
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe care and adequate supervision during in‑bed care for a resident, resulting in a fall and fracture. The resident was admitted in 2025 with multiple orthopedic and musculoskeletal conditions, including intervertebral disc degeneration of the lumbar region, a closed right patella fracture, an infection of an internal fixator in the right ankle, and a history of an unspecified fall. A Fall Risk Assessment dated 10/18/25 scored the resident at 25, categorized as a moderate fall risk. The resident’s MDS Section GG, dated 9/22/25, documented a need for substantial/maximum assistance with toileting and hygiene, meaning staff performed more than half the effort and held or lifted the trunk and limbs. On the morning of 1/23/26, CNA 2 provided incontinence care after finding the resident incontinent of stool in bed. CNA 2 rolled the soiled linens and tucked them under the resident while the resident was on her side. CNA 2 reported that she had one hand on the resident to steady her and one hand on the tucked linen, and then attempted to pull the soiled linen out with one hand but was unable to do so. CNA 2 stated she instructed the resident to hold onto the cabinet or bed frame so that CNA 2 could use both hands to pull the linens. CNA 2 then removed the hand that had been supporting the resident in order to use both hands on the linens. According to CNA 2, the resident indicated it was acceptable for her to let go, and CNA 2 proceeded to pull the linens; at that point, the resident fell from the bed onto the floor on her right side. The resident later reported that she had been holding the privacy curtain when she fell. At the time of the fall, there were no side rails on the bed and no fall mats on either side of the bed. Following the fall, the resident complained of right arm pain, with documentation of pain at level 7 and painful, limited ROM in the upper extremity. An x‑ray obtained that day showed a horizontal distal humerus fracture without displacement of the right elbow. The IDT Falls Progress Note dated 1/25/26 documented that the resident fell when CNA 2 was turning her and that, per the resident’s statement, she was holding onto the side of the mattress and leaning too much, resulting in loss of balance and a fall. Predisposing factors listed included a history of falls, muscle weakness, gait/balance deficit, poor safety awareness, and overestimation of limits. The same IDT note listed preventive measures such as a low, locked bed and a landing mat on the floor to reduce impact and injury of falls, but the DON later confirmed that a fall mat was not actually in place at the time of the fall and was only placed days later. The DON also confirmed that a physician’s order for quarter side rails for mobility and positioning was dated 1/26/26, with a bed rail assessment and resident consent completed that same day, but the rails were not installed until 1/28/26. The DON acknowledged that once the resident fell, a fall mat should have been placed immediately and that the resident’s injury was preventable. The resident’s treating physician stated he was not aware that only one CNA had provided incontinence care at the time of the fall and stated that there should have been two CNAs providing that care.
Call Lights Not Within Reach for Four Residents
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of four sampled residents when their call lights were not within reach. During observations, Resident 45, Resident 52, Resident 93, and Resident 149 each had a call light positioned out of reach or hanging from the bed rail, bed frame, or bedside drawer rather than being accessible to them while seated or in bed. Each resident stated they could not reach the call light or could not use it to call staff for help. Resident 45 had diagnoses including hemiplegia and hemiparesis following cerebral infarction, atrial fibrillation, aphasia, and osteoarthritis of the left wrist. Resident 45 was observed sitting in a wheelchair with the call light hanging from the right-side bed rail down to the bed frame. Resident 45 stated the call light was not within reach and that she could not call staff if she needed help. A CNA stated the call light should have been within reach and that Resident 45 could have fallen when trying to reach it. Resident 52 had diagnoses including hemiplegia and hemiparesis following cerebral infarction, COPD, CHF, adult failure to thrive, and an unspecified mood disorder. Resident 52 was observed with the call light hanging from the right-side bed rail down to the bed frame and stated staff could not come right away if he needed help because he could not reach the call light. Resident 93 had diagnoses including early onset cerebellar ataxia, dysphagia, glaucoma, major depressive disorder, anxiety disorder, and palliative care; her call light was not in bed and not within reach, and she stated she could not find it. A nurse stated the call light was stuck on the bed frame between the headboards and that lack of access could place residents at risk for falls, injury, and unmet needs, and could delay comfort measures for Resident 93. Resident 149 had diagnoses including spinal stenosis, COPD, atrial fibrillation, and pain in the left hip and leg; he was observed in a wheelchair with the call light hanging from the bedside top drawer and stated he could not call staff if he needed help, including if he had trouble breathing. A CNA stated the call light should be within reach and that Resident 149 could have fallen and hurt his arm when reaching for it.
Care Plans Not Developed for PTSD and Speech Device
Penalty
Summary
A comprehensive care plan was not developed within the required timeframe for a resident with PTSD. The DON reviewed the resident’s admission record, external referral information, and care plans and confirmed that PTSD was on the active problem list, with an onset date of 10/26/22. The DON stated the facility did not have a care plan specific to PTSD until 12/17/25, and also stated the facility did not have a Trauma Screening Tool when it was aware of the PTSD diagnosis on 10/28/22. The DON further stated the facility did not have a comprehensive assessment for PTSD for this resident since 10/28/22. The facility policy on Care Plans required the comprehensive person-centered care plan to be developed within 7 days of completion of the required MDS assessment and to be based on a thorough analysis of assessment information. The policy on Trauma Informed Care stated individualized care plans should address past trauma in collaboration with the resident and family, as appropriate. A care plan was also not developed for a resident’s speech device after admission. The resident’s record showed diagnoses including major depressive disorder, muscle weakness, dysphagia, tracheostomy status, and acquired absence of larynx, and documents stated the resident communicated using a speech device following laryngectomy. The inventory of personal effects identified the speech device as an item of specific value, and staff interviews confirmed the resident had used the device since admission, but no care plan for the device was implemented until 12/17/25. Staff stated they did not know how the device functioned, how to care for it, or whether it could be taken into the shower, and the Administrator stated there should have been a care plan for the speech device.
Water Not Available at Bedside for Three Residents
Penalty
Summary
The facility failed to ensure that three sampled residents had water or fluids available at the bedside. Resident 52, who had diagnoses including adult failure to thrive and tubule-interstitial nephritis, was observed lying in bed with a water pitcher placed on the nightstand far from reach; when checked, the pitcher was empty, and the resident stated water was not readily available when needed. A nurse confirmed the empty pitcher and stated the resident was at risk for dehydration when water was not readily available. Resident 87, who had chronic kidney disease and a history of falling, was observed lying in bed without a water pitcher or fluids at the bedside. A CNA stated the resident did not have water readily available and explained that because the resident was on thickened fluids, staff had to obtain thickening mixtures from nurses before providing fluids, which delayed access to water. Resident 87 stated that each time water was needed, it was not readily available because staff could not come right away. Resident 99, who had Alzheimer’s disease and diverticulosis of the large intestine, was also observed in bed without water at the bedside and stated that water was not readily available and had to be requested from staff. A nurse confirmed there was no water at the bedside and stated residents without water available might try to get up on their own, placing them at risk for falls; the resident’s care plan also directed that the resident have access to water whenever possible.
Kitchen sanitation and dishwashing practices not maintained
Penalty
Summary
Food was not stored, prepared, and served in accordance with professional standards in the kitchen. During an initial kitchen tour with the RD, the can opener in the cook's preparation area was observed with a chipped tip, missing metal pieces, a dried layer of food residue, metal shavings, and a black oily substance around it. The RD confirmed the condition of the can opener and stated the chips of metal could get into food prepared for residents. Facility policy stated the can opener should be thoroughly cleaned each work shift, kept in good repair, and replaced as needed, and the Food Code required nonfood-contact surfaces to be kept free of food residue and debris. During the same kitchen tour, seven of 18 large tray line pans were observed stacked on a shelf with water collected on the inside and bottom rim of the pans. The RD confirmed the pans were wet and directed staff to re-wash them. The RD stated the expectation was for dishes to be washed, placed on a rack to air dry, and then stacked in the assigned area. The facility's manual dishwashing procedure stated all items are air-dried and no water droplets are to be present before storage. In the dishwashing area, a Dietary Aide washed dishes and handled both clean and dirty dishes without removing and replacing his apron and gloves or washing his hands. The aide acknowledged going back and forth from the dirty area to the clean area and stated he was supposed to wash his hands before moving from dirty dishes to clean dishes. The RD stated that if a kitchen staff member went from the dirty to the clean side, the apron should be removed and hands washed, and that safe dishwashing practices were not maintained. Facility policies required handwashing, proper glove use, and a strict handwashing routine when moving between soiled and clean areas.
Failure to Offer and Document Flu Vaccination Consent
Penalty
Summary
The facility failed to offer influenza vaccination, obtain informed consent, and provide education to a resident or the resident’s representative about the flu vaccine for three of five sampled residents. Resident 159 stated she had asked for the flu vaccine several times, said she did not refuse vaccines, and reported that she usually received flu and pneumonia shots every year. She also stated she had not received the flu, COVID-19, or pneumonia vaccine and was told she needed to sign a document, but the vaccine was still not given to her. During record review and interviews, the Infection Preventionist stated the flu clinic began the prior September. Resident 110’s record showed consent for the flu vaccine was signed on admission, but the resident later decided not to proceed on the day of vaccination; the IP stated this was not documented and that if it was not documented, it was not done. Resident 8’s record showed a prior flu vaccine, but the IP stated she had not given the flu vaccine to Resident 8 and had not asked for consent. The IP also stated Resident 159 had refused all vaccines with no history documented, and that she had not yet been given the flu vaccine for the current flu season. The DON stated the flu vaccine should be offered to all residents or their RPs, and that the resident’s or RP’s decision, including refusal and reason for refusal, should be documented.
Failure to Protect Resident Privacy and Use Respectful Language
Penalty
Summary
The facility failed to ensure that two residents were treated with dignity, privacy, and respect. Resident 2, who was admitted with diagnoses including unspecified dementia, depression, schizoaffective disorders, and a left knee contracture, was observed during personal care with the room door and privacy curtain left open while CNA 10 and CNA 11 were providing care. During the observation, LN 8 stated that the care activities could be seen by others passing by the room and that the door and curtain should have been closed to protect privacy. CNA 10 later stated that she repositioned Resident 2, adjusted the resident's clothing, and asked CNA 11 to assist pulling the resident up in bed, and acknowledged that the privacy curtain should have been closed during care. The facility also failed to ensure that Resident 27, who was admitted with dementia, was treated with dignity during mealtime. During observation of the resident's breakfast tray, LN 1 and CNA 1 referred to Resident 27 as a feeder. Both staff members stated they should not have used that term and acknowledged it was a dignity issue. The RD and DON also stated that staff should not call residents feeders, and the facility policy on dignity states that residents are to be treated with dignity and respect at all times and provided with a dignified dining experience.
Failure to secure legal representative for resident lacking decision-making capacity
Penalty
Summary
The facility failed to ensure that a resident who lacked the capacity to make medical decisions had an appropriate legal representative involved in healthcare decisions. Resident 9 was admitted with diagnoses of Alzheimer's Disease, dementia, and PTSD, and facility records indicated she did not have the mental capacity to make healthcare decisions. Despite this, she was listed as her own Responsible Party on the admission record, and the DON verified that she had no family, no Power of Attorney, and no conservatorship or alternate legal authorization on record. During observation on 12/17/25, Resident 9 was seen sitting up in bed and eating breakfast independently, but during the attempted interview she was unable to answer simple questions. A friend listed as Emergency Contact #1 could not be reached. Review of the POLST signed by the physician on 11/1/22 showed that Section D did not indicate with whom the document was discussed, did not clearly identify who signed the form, and did not indicate the date the document was signed. The DON stated that because Resident 9 lacked decision-making capacity and was listed as her own RP, the facility should have initiated a referral under the Epple Act at admission, and later stated that CAPRIS had replaced that process for obtaining a representative for residents without capacity, family, POA, guardian, or conservator. The DON and SSD both stated that Social Services was responsible for initiating conservatorship when a resident lacked capacity and had no legal representative, and the SSD expected an interdisciplinary team meeting to discuss the resident's case and next steps. Facility policies stated that resident representatives are to be documented, advance directives are honored under state law, and the interdisciplinary team identifies the primary decision-maker when a resident lacks decision-making capacity.
PRN Ativan Order Extended Without Documented Rationale
Penalty
Summary
The facility failed to ensure that one resident with a diagnosis of anxiety had a PRN Ativan order that complied with the facility’s psychotropic medication timeframe requirements. Resident 3’s admission record identified anxiety, and the order listing showed Ativan 0.5 mg by mouth every 6 hours as needed for anxiety with severe restlessness, written for a 30-day duration. During interview and record review, the DON confirmed the facility typically applied a 14-day stop date for PRN psychotropic medications and stated that continued use beyond 14 days required a physician-documented clinical justification. A follow-up review of the resident’s record showed the PRN Ativan order had been extended past 14 days, and the DON stated that the physician had been asked to document the rationale after the issue was identified. No prior clinical justification was found in the resident’s medical record.
Failure to Develop Person-Centered Care Plans for Diabetes and Anxiety
Penalty
Summary
The facility failed to ensure Resident 71 had person-centered care plans developed and implemented for diagnoses of diabetes and anxiety. Resident 71 was admitted with diagnoses that included diabetes and anxiety disorder, and the clinical record showed physician orders for busPIRone every 12 hours for anxiety manifested by inability to relax, as well as Insulin Lispro three times a day and Insulin Lispro per sliding scale for diabetes. Review of the resident’s care plans showed that no care plans had been developed for either diagnosis. During interviews, the DSD confirmed that care plans had not been developed and implemented for Resident 71’s anxiety or diabetes. The DSD stated that licensed nurses need care plans to know how to care for a person with diabetes and that care plans are the roadmap for diabetes care. The DON stated the diabetic and anxiety care plans should have been developed and implemented on admission. The facility policy titled Care Plans, Comprehensive Person-Centered, required a comprehensive person-centered care plan with measurable objectives and timetables to be developed and implemented for each resident within seven days and no more than 21 days after admission.
Delayed Pain Relief and Missed Dental Follow-Up
Penalty
Summary
The facility failed to provide timely and proper pain relief for two residents who were experiencing pain. One resident had sore gums and mouth discomfort related to broken and missing teeth, but the ordered Magic Mouthwash and dental evaluation were not carried out as documented. The resident had diagnoses including depression and anxiety disorder, and nursing notes described ongoing monitoring of a broken tooth and mouth pain managed with PRN pain medication. A physician progress note later documented mouth pain and ordered a dental referral and Magic Mouthwash, but the medication did not appear on the MAR and was not administered, and the dental consult was not scheduled or documented by Social Services. The resident stated that the mouthwash had helped numb the gums during a hospital stay and that she had asked multiple staff members about it at the facility because it helped her eat. She also stated that she had seen a dentist in the facility and was told authorization was needed to extract her teeth, but she had not received an update. Nursing staff acknowledged they had not located the mouthwash order at first, had not called the doctor about it, and later recognized that the order existed but had not been entered so it would populate on the MAR. Social Services staff stated they were not aware of the dental consult order and could not locate documentation showing the appointment had been scheduled. A second resident with bilateral knee osteoarthritis and a stage 4 sacral pressure ulcer reported pain all over, especially in the arms, and had care plan interventions for prompt response to pain and non-medication comfort measures. During observation, the resident used the call light for pain, but a CNA told the resident the nurse was on break and that she would need to wait. The CNA did not ask additional pain questions or offer comfort measures at that time. The resident continued to report severe pain before a nurse assessed and medicated her later, and the MAR showed pain medication was given after a delay. Staff interviews confirmed that pain should have been communicated to the nurse right away and that non-medication measures such as repositioning could have been offered immediately.
Invalid Bed Rail Consent Obtained From Resident Without Capacity
Penalty
Summary
The facility failed to ensure that informed consent for the use of bed rails was obtained from the appropriate resident representative for one of 35 sampled residents, Resident 107. The record showed Resident 107 was admitted with diagnoses including dementia, schizophrenia, and major depressive disorder. A doctor’s order dated 11/1/25 included a left side grab bar, and during observation on 12/16/25, Resident 107 had a bed rail on the left side of the bed. When interviewed, Resident 107 stated he could not remember whether staff explained the pros and cons of a bed rail. Record review and staff interviews showed that Resident 107 signed the bed rail informed consent form even though the medical record indicated the resident did not have the mental capacity to make healthcare decisions. Licensed Nurse 6 stated the consent was invalid because Resident 107 lacked decision-making capacity and was not fully alert to understand the safety issues related to bed rails. The ADON and DON both stated that Resident 107 could not understand the risks of bed rail use, that consent should have been signed by the resident’s representative, and that the signed consent was not valid. The care plan addressed bed rail use and included educating the resident and/or representative on the risks and benefits, and the facility policy required informing the resident or representative and obtaining informed consent before using bed rails.
Delayed dental treatment and consult follow-through
Penalty
Summary
The facility failed to provide routine and 24-hour emergency dental care for one resident when ordered mouthwash and a dental consult were not carried out in a timely manner. The resident had been admitted earlier in 2025 with diagnoses including acute and chronic respiratory failure, COPD, dependence on supplemental oxygen, depression, and anxiety disorder. Nursing documentation showed the resident developed sore gums and discomfort, with pain rated 4/10, and the medical provider was notified. A care plan was initiated for impaired oral/dental condition, with goals to maintain oral mucosal integrity and decrease gum soreness. On 11/25/25, the nurse practitioner evaluated the resident for sore mouth, documented that the resident needed to see a dentist, and wrote orders for Magic Mouthwash every 6 hours as needed for sore gums prior to meals and for a dental evaluation for worsening sore gums. The resident’s medication administration record for November and December did not show the mouthwash was ordered or administered. During interview, the resident stated she had received Magic Mouthwash while hospitalized, that it helped numb her gums so she could eat, and that she repeatedly asked staff for it at the facility but still had not received it. She also stated she continued to have significant mouth pain and could only eat certain foods because of missing teeth and sore gums. Staff interviews and record review showed the dental consult was not followed through in a timely manner. Nursing staff acknowledged they did not locate or act on the mouthwash order, did not call the doctor about it, and did not see the progress note documenting the order. Social services staff stated they were not aware of the dental consult request and could not find documentation that it had been scheduled. The resident was not placed on the dentist’s list for the facility visit on 12/11/25, and the consult was not scheduled until the resident was later told about an outside dental appointment for 1/5/26. The DON acknowledged the dental consult should have been carried out timely and that the resident should have been on the dentist consult list for the facility visit.
Failure to Use PPE in Contact Isolation Room
Penalty
Summary
The facility failed to ensure that staff used appropriate PPE when entering a contact isolation room for a resident who was admitted with acute respiratory failure with hypoxia and pneumonia. A contact isolation sign was posted outside the resident’s room, and the resident stated that she had pneumonia. During observation, LN 3 was inside the room checking the resident’s pulse without wearing gloves or a gown, and LN 3 acknowledged that he entered the room without PPE. The DON later reviewed the resident’s laboratory records and confirmed that ESBL was detected in the resident’s urine. The DON stated that LN 3’s provision of care without wearing contact isolation PPE did not meet her expectations. The IP also stated that LN 3 entering the isolation room without PPE did not meet her expectations because the room was designated for contact isolation and staff were expected to follow PPE requirements.
Failure to Report Alleged Abuse to State Authorities
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident who had hemiplegia of her right dominant side. The resident communicated to a family member that she had been hit on the head by an unknown person while receiving care. The family member reported this allegation to facility staff, who acknowledged the report and stated they would investigate. However, the facility did not report the allegation to the state licensing and certification agency as required by policy and regulation. Interviews with facility staff, including the Social Services Director, Director of Nursing, and Director of Staff Development, confirmed that the allegation was not reported to the Department. Staff acknowledged that all allegations of abuse, regardless of whether they are believed to be factual, should be reported to the appropriate authorities, including the Department, ombudsman, and law enforcement. The facility's own policy required immediate reporting of suspected abuse, but this was not followed in this case. A review of the resident's clinical records and grievance documentation showed that the allegation was documented internally, but there were no progress notes, care plans, or social services notes addressing the abuse allegation. The facility's failure to report the incident as required by law and policy was confirmed by multiple staff members and documented in the facility's records.
Failure to Report and Investigate Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of abuse to the state licensing and certification agency after a resident reported to a family member that she had been hit on the head by a staff member during care. The family member relayed this allegation to facility staff, but the facility did not notify the Department as required. The resident involved had a diagnosis of hemiplegia affecting her right dominant side and was admitted with significant physical limitations. A review of the facility's grievance and complaint resolution documentation showed that the investigation into the alleged abuse did not include interviews with other residents who may have had contact with the accused staff member. Interviews with the DON and Social Services Director confirmed that other residents were not interviewed, despite facility policy requiring such actions as part of a thorough investigation. The policy specifically states that all allegations are to be thoroughly investigated, including interviews with other residents to whom the accused employee provides care.
Failure to Consistently Employ Qualified Infection Preventionist
Penalty
Summary
The facility failed to consistently employ a qualified Infection Preventionist (IP) responsible for the infection prevention and control program from January 1, 2021 through December 31, 2022. During this period, there were gaps in documentation and employment records for individuals designated as IPs. Payroll and Human Resources were unable to provide information on IPs for the specified timeframe due to missing employee files, which had been sent to a previous corporation. The Administrator was only able to provide names of two individuals who served as IPs but could not initially provide their employee files or evidence of their qualifications. Upon receiving the files, it was found that one IP had no documented IP certification, and the other had a certificate but was not employed as IP for the entire period in question. Further review of employee records indicated that there was no IP employed from December 3, 2021 through May 4, 2022. Additionally, when one individual was serving as IP, there was no documented evidence of specialized training or certification required for the role. Interviews with facility staff, including the DON, confirmed the necessity of a full-time, qualified IP to ensure infection prevention protocols were followed. The lack of a qualified IP during the specified period was directly observed through record reviews and staff interviews.
Failure to Notify Responsible Party of Resident's Change in Condition
Penalty
Summary
A deficiency occurred when a licensed nurse failed to notify the responsible party (RP) of a resident's change in condition, specifically a behavioral incident involving physical aggression towards another resident. Although the nurse documented in the clinical record that the resident's son had been made aware of the incident, the nurse later admitted during an interview that she had become busy and forgot to actually notify the RP. This omission resulted in the resident's family being uninformed about the altercation. The facility's policy and procedure on change in condition, reviewed with both the Administrator and Assistant Director of Nursing, clearly required licensed nurses to assess, document, and communicate changes in a resident's condition, including notifying the responsible party. Both the Administrator and ADON confirmed the importance of promptly updating the RP regarding any changes in the resident's status or plan of care. The failure to follow this policy led to the deficiency cited in the report.
Inadequate Fall Prevention and Supervision for Resident
Penalty
Summary
The facility failed to ensure a safe environment and adequate supervision for a resident with a history of falls. The resident experienced multiple falls on specific dates, and no new interventions were added to their fall care plan after the incidents on two of those dates. The resident was admitted with several diagnoses, including anxiety disorder, brain stem stroke syndrome, bipolar disorder, and was receiving palliative care. Despite the implementation of a 3-hour one-to-one supervision by hospice on certain days, the resident continued to fall, particularly during evening shifts and shift changes. Interviews with staff revealed that the hospice-provided sitter was not effective as it was scheduled during the day, while falls occurred in the evening. The facility's IDT met after each fall to review and adjust care plans, but no new interventions were added after the falls on two specific dates, as they were waiting for a mood stabilizing medication to reach full effectiveness. The facility's administrator acknowledged the ineffectiveness of the current sitter schedule and mentioned that one-to-one sitters are provided for residents with frequent falls or aggressive behaviors, but no adjustments were made for this resident's care plan after the recent falls.
Deficiencies in Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to maintain safe and sanitary food storage practices, affecting 127 residents who received food from the kitchen. During an inspection, it was observed that food items in the dry storage area were found in opened and unsealed containers, and some were past their use-by or best-by dates. In the walk-in refrigerator, vegetables were wilted, decomposing, and moldy, and containers of sour cream were past their best-by dates. Additionally, Freezer #2 had ice buildup on all four walls, indicating potential temperature issues. The dishwasher's water temperature was also found to be below the required range, which could compromise the sanitation of dishes. The Dietary Manager Assistant confirmed that the items past their use-by dates should not have been available for use. The Registered Dietitian stated that opened, unsealed foods should not be used, and all food items should be dated when opened and disposed of by their use-by dates. The RD also noted that the ice buildup in the freezer suggested it may have been above the temperature range at some point. The dishwasher, a low-temperature model, should maintain a temperature of 120°F to ensure proper sanitation, but it was observed to be operating below this temperature, posing a risk of foodborne illnesses to residents.
Failure to Accommodate Resident Needs and Preferences
Penalty
Summary
The facility failed to accommodate the needs of three residents, leading to deficiencies in their care. Resident 21, who had a history of stroke and contracture of the left hand, was unable to use a conventional push button call light due to her physical limitations. Despite being at high risk for falls, she was not assessed for an adaptive call light that would have been more suitable for her condition. Observations revealed that Resident 21 struggled to use the call light, causing her distress and increasing her risk of falls and injury. Similarly, Resident 94, who suffered from dementia and hemiplegia following a stroke, was also unable to use a conventional call light due to weakness in her hands. Her call light was found out of reach, and her fall mat was not properly positioned, further increasing her risk of falls. Despite being identified as a high fall risk, Resident 94 was not provided with an adaptive call light, and the facility's policies on fall prevention and accommodation of needs were not followed. Resident 50 experienced emotional distress and isolation due to the loss of his wheelchair, which was replaced with one that was too large and uncomfortable. This unsuitable wheelchair did not fit through his door, limiting his mobility and independence. Despite being informed of the issue, the facility delayed in providing a properly sized wheelchair, which affected Resident 50's ability to move safely and independently. The facility's failure to provide appropriate equipment and timely response to the residents' needs resulted in significant deficiencies in their care.
Unsafe Smoking Practices in Facility
Penalty
Summary
The facility failed to ensure safe smoking practices for eight residents who were identified as smokers. These residents were found to have cigarettes and lighters unsecured in their rooms, despite being assessed as high risk for accidental injury and requiring supervision while smoking. Specifically, Resident 38, who was not an independent smoker, had cigarettes and a lighter on his bedside table and in an unlocked drawer. Resident 49, who was on continuous oxygen, also kept her cigarettes and lighter unsecured in her room. Both residents were not following the facility's smoking policy, which required supervision and the use of protective equipment. Additionally, several other residents, including Residents 53, 120, 118, 112, 22, and 61, were found to have their smoking materials unsecured in their rooms. Some of these residents were assessed as safe smokers, while others required supervision and the use of a smoking apron. Despite these assessments, the facility did not ensure that smoking materials were secured, and residents were observed smoking without supervision or protective equipment. The facility's policy required staff to control the distribution of smoking materials and provide appropriate supervision, which was not consistently followed. Interviews with staff revealed a lack of training and awareness regarding the facility's smoking policy. Licensed Nurse 1 and CNA 2 confirmed that residents had access to unsecured smoking materials and were not always supervised while smoking. The Activity Director acknowledged that only a few residents had their smoking supplies locked, and none of the lockboxes had keys. The Assistant Director of Nursing highlighted the risks associated with unsecured smoking materials, especially for residents on oxygen, but confirmed that the facility's smoking policy was not being adhered to.
Inconsistent Food Preparation and Service
Penalty
Summary
The facility failed to prepare and serve food in a consistent and appetizing manner, as evidenced by observations and interviews with residents and staff. Two residents reported that their meals were consistently served cold. During a test tray sampling, the Registered Dietitian (RD) confirmed that the pureed beef, rice, and potatoes were bland and not served at an appetizing temperature. The RD acknowledged that food temperatures and palatability are important for meal consumption, and there is a risk of residents not consuming their meals if they are not palatable. Additionally, the facility did not follow recipes for residents receiving pureed diets. Observations revealed that dietary staff did not add liquids or thickeners to pureed foods as required by facility recipes. The RD stated that residents on pureed diets should receive the same foods as other residents, and recipes should be followed to ensure proper consistency and taste. The facility's policy emphasized the use of standardized recipes to ensure consistent food quality, but this was not adhered to, potentially affecting the meal intake of residents.
Failure to Coordinate Hospice Care
Penalty
Summary
The facility failed to ensure proper coordination of care with hospice services for three residents receiving hospice care. For Resident 139, there were no hospice visit notes available in the facility's binder for extended periods, despite the hospice provider's assurance that notes were left or sent to the facility. The Medical Records Director confirmed that no emails containing these notes were received, and the Assistant Director of Nursing (ADON) emphasized the importance of these notes for coordinating care and following up on hospice visits. Similarly, for Resident 121, the facility did not review hospice care provider nursing notes for several months, even though the hospice provider sent weekly emails containing these notes. The ADON confirmed that these emails were not opened or reviewed. For Resident 25, there were no hospice care provider nursing notes in the facility's binder for several months, and the ADON acknowledged that the notes were in emails that had not been opened or reviewed. The Director of Nursing stated that hospice notes should be placed in the resident's hospice binder weekly to ensure facility staff have access to the necessary clinical information.
Infection Control Lapses in Isolation Precautions and Glucometer Sanitization
Penalty
Summary
The facility failed to implement timely isolation precautions for a resident diagnosed with Clostridium difficile (C. difficile), a highly contagious infection. The resident, who had a history of diabetes mellitus and end-stage renal disease, exhibited symptoms of loose stools starting on November 4, 2024. Despite these symptoms, the resident was not placed on contact isolation precautions until November 8, 2024, after the lab results confirmed the presence of C. difficile. The Infection Preventionist (IP) acknowledged that the resident should have been placed on isolation precautions when the symptoms first appeared to prevent the potential spread of infection. Additionally, the facility did not ensure proper cleaning and sanitization of glucometers, which are used to measure blood sugar levels. During observations, it was noted that licensed nurses did not adhere to the manufacturer's guidelines for disinfecting the glucometers. The contact time between the disinfectant wipe and the glucometer was insufficient, and in some cases, the glucometer was not sanitized at all. The IP confirmed that the glucometers need to be visibly wet for two minutes to effectively kill organisms and prevent cross-contamination. These deficiencies highlight lapses in the facility's Infection Prevention and Control Program, which could lead to cross-contamination and negatively impact the health and well-being of residents. The facility's policies and procedures were not followed, and there was a lack of communication with external facilities, such as the dialysis clinic, regarding the resident's infectious status.
Resident Dignity Compromised by CNA's Negative Comments
Penalty
Summary
The facility failed to ensure that Resident 118 was treated with dignity and respect, as evidenced by an incident involving a certified nursing assistant (CNA 2) who made negative comments about the resident's weight and wheelchair size. Resident 118, who was admitted to the facility with a diagnosis of obesity, overheard CNA 2 speaking to a licensed nurse (LN 2) about the physical difficulty of pushing her wheelchair due to her size. This incident left Resident 118 feeling upset, hurt, and crying, impacting her self-worth and self-esteem. Despite Resident 118's complaint to LN 2 and the Social Services Director (SSD), there was no follow-up from the social services department to address her emotional and psychosocial needs. The facility's documentation, including the Grievance/Complaint Resolution Report, indicated that CNA 2 was aware of the resident's discomfort but did not realize she overheard the conversation. The Director of Staff Development (DSD) acknowledged that CNA 2 received a verbal in-service on professionalism and communication, but the resident's care plan was not updated to reflect the incident. The Assistant Director of Nursing (ADON) emphasized the importance of maintaining residents' dignity by preventing them from overhearing negative comments. The facility's policy on resident rights and care planning was not adhered to, as there was no episodic care plan developed for the temporary change in Resident 118's condition following the incident.
Failure to Communicate Resident's Inability to Exercise to Physician
Penalty
Summary
The facility failed to consult the physician for a resident when the resident's physician recommended exercise in response to the resident's request for help with weight loss. The resident, who was admitted in 2022 with diagnoses including morbid obesity and abnormalities of gait and mobility, had requested to try semaglutide injections for weight loss. The physician, through a Nurse Practitioner, recommended weight loss through exercise with the assistance of a Restorative Nursing Assistant (RNA). However, the order for RNA assistance with walking and exercise was discontinued and not completed, and the resident's inability to participate in the exercise program was not communicated to the physician. The resident experienced a significant weight gain and expressed feelings of demoralization due to previous failures in weight loss efforts. The Assistant Director of Nursing (ADON) acknowledged that the resident's inability to exercise should have been communicated to the physician to discuss alternative options for weight loss. The facility's failure to update the physician on the resident's decline in functional abilities and inability to follow the exercise program potentially delayed interventions to assist the resident with his weight loss goals.
Confidentiality Breach in Resident Medical Records
Penalty
Summary
The facility failed to maintain the confidentiality of personal and medical records for two residents. Resident 89's electronic health record (EHR) contained a clinical document titled 'Consultation Report' that belonged to Resident 95. This document included Resident 95's personal health information (PHI), such as birthdate, gender, medication details, and a recommendation for lab work. This error resulted in Resident 95's PHI being accessible to Resident 89, violating Resident 95's right to confidentiality. Interviews with the Medical Records Director (MRD) and the Assistant Director of Nursing (ADON) confirmed the presence of Resident 95's PHI in Resident 89's EHR. The MRD acknowledged the importance of correctly filing resident clinical records to protect confidentiality and privacy. The facility's policy on HIPAA Privacy Policies, reviewed in 2019, emphasized the need to remove any portion of the record relating to someone other than the resident. Additionally, the facility's Resident Rights document assured residents of confidential treatment of their health records.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure accurate completion of the Minimum Data Set (MDS) assessments for two residents, leading to potential inaccuracies in care planning and tracking. Resident 51's discharge MDS was not completed for a discharge that occurred in July 2024, leaving the resident's health status untracked in the MDS system. The MDS coordinator confirmed the oversight, acknowledging the importance of the discharge assessment in reflecting the facility's true census and informing the Centers for Medicare Services (CMS) of the resident's discharge status. The facility's policy required MDS assessments to be completed and transmitted within specific timeframes, which was not adhered to in this case. For Resident 102, the MDS assessment inaccurately indicated the use of a feeding tube, despite the resident being on a pureed diet and never having received nutrition via a feeding tube. This error was confirmed during a review of the resident's electronic health record and through interviews with facility staff, including a Certified Nursing Assistant and the MDS nurse. The Director of Nursing and the Administrator acknowledged that the facility's MDS Standard of Practice, which emphasizes accurate coding and data integrity, was not followed, resulting in the incorrect documentation of the resident's nutritional status.
Failure to Update PASARR After Change in Mental Health Diagnosis
Penalty
Summary
The facility failed to update the Preadmission Screening and Resident Review (PASARR) form for one resident after a significant change in her mental illness diagnosis. Resident 43, who had a diagnosis of a serious mental illness, was initially screened with a Level I PASARR, which was positive and required a Level II screening. However, after her diagnosis was updated to include schizoaffective disorder, a new Level I screening was not completed, and consequently, a Level II evaluation was not scheduled. This oversight meant that Resident 43 did not receive an updated assessment that could have identified necessary specialized mental health services to improve her condition and quality of life. Interviews with facility staff, including the Admissions Department and the Minimum Data Set (MDS) Nurse, revealed a lack of clarity and communication regarding the process for initiating a new PASARR when a resident's mental health diagnosis changes. The Admissions Department acknowledged that they were responsible for initiating PASARRs upon receiving new diagnosis information from the MDS Nurse, but this process was not followed. The Director of Nursing and Administrator also confirmed that the facility's policy, which requires the Level I screening to reflect the resident's current condition, was not adhered to, resulting in the deficiency.
Failure to Develop Individualized Care Plans for Vision and Fall Risk
Penalty
Summary
The facility failed to develop and implement individualized care plans for two residents, leading to potential unmet care needs. Resident 54, who was admitted with diagnoses of diabetic cataract and glaucoma, did not have a vision care plan addressing these conditions. Despite being legally blind and experiencing worsening vision, Resident 54's care plan lacked focus and interventions for his vision problems. Interviews with staff confirmed that the care plan was not updated to include these critical diagnoses, and the facility's policy for comprehensive care planning was not followed. Resident 94, diagnosed with dementia, hemiplegia, and hallucinations, was identified as a high fall risk. However, the facility did not develop a fall care plan despite a fall risk assessment indicating a high risk score. Observations revealed that Resident 94's call light was out of reach, and the fall mat was improperly positioned, increasing the risk of falls. The lack of a fall care plan was confirmed during interviews with staff, who acknowledged that the facility's policy for fall prevention and response was not adhered to. The facility's policies required comprehensive care plans to be developed and updated based on residents' needs and risk assessments. However, in both cases, the facility did not follow its own procedures, resulting in the absence of necessary care plans for vision and fall risk management. This oversight placed both residents at risk of not receiving adequate care to meet their specific health needs.
Failure to Assist Resident in Obtaining Vision Services
Penalty
Summary
The facility failed to assist a resident, identified as Resident 54, in obtaining necessary vision services in a timely manner. Resident 54, who was admitted with diagnoses including diabetic cataract and glaucoma, expressed concerns about worsening vision and had requested an evaluation two months prior. Despite having medical insurance, the resident was deemed ineligible by an outside vision provider, and the facility did not follow up or attempt to find another provider. This lack of action led to Resident 54 feeling frustrated and potentially impacted their psychosocial well-being. Interviews and record reviews revealed that the Social Services Assistant (SSA) and Social Services Director (SSD) were aware of the ineligibility status but did not take further steps to secure vision services for Resident 54. The SSA was unsure of the meaning of 'ineligible' and did not document any follow-up actions. The SSD also confirmed the lack of documentation regarding attempts to arrange a vision referral. The Assistant Director of Nursing (ADON) acknowledged that the facility's process for addressing vision service requests was not followed, as there was no notification or accommodation of appointments for the resident.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to ensure medications were administered in accordance with professional standards of practice for two residents. For Resident 111, medications, including controlled substances, were left unattended at the bedside. This occurred despite there being no physician order or care plan assessment allowing the resident to self-administer medications. During an observation, a plastic cup with medications was found on Resident 111's bedside table, and the resident confirmed they were his medications. Licensed Nurse 6 admitted to leaving the medications at the bedside upon the resident's request, acknowledging the risk that another resident could have taken them. The facility's policy clearly stated that medications should not be left unattended, and staff should observe the resident's consumption of the medication. For Resident 105, the facility did not ensure the correct route of medication administration. Although the resident's physician had clarified that medications should be administered orally (PO), they were given via a gastrostomy tube (G-Tube). During a medication pass observation, Licensed Nurse 1 administered several medications through the G-Tube, despite verbalizing that the route ordered was PO. The resident's order summary and medication administration report confirmed that the medications were ordered to be given PO. Interviews with staff, including Licensed Nurse 4 and the Assistant Director of Nursing, revealed that the medications should have been administered PO as per the physician's orders, and any issues should have been communicated to the physician. The facility's policy on medication administration required verification of the correct medication, time, and route before administration. The Pharmacist Consultant was unaware that medications were being administered via G-Tube and emphasized the importance of following physician orders. The physician confirmed that the medications should have been administered PO, especially since the resident was no longer receiving G-Tube feeding and had normal oral intake. The failure to follow the correct route of administration could affect the efficacy of the medications, particularly if they were not suitable for G-Tube administration.
Medication Administration Error Due to Incorrect Route
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 17.8% due to five errors out of 28 opportunities. These errors were identified during medication administration observations conducted over multiple days and locations within the facility. The errors involved a single resident, Resident 105, who received medications via a gastrostomy tube (G-Tube) instead of the prescribed oral (PO) route. The medications involved included Carvedilol, Losartan, Jardiance, a multivitamin with minerals, and Senna, all of which were ordered to be administered orally. During interviews, the licensed nurse (LN) responsible for the administration acknowledged the error, and both the physician and the Assistant Director of Nursing (ADON) confirmed that the medications should have been given orally as per the physician's orders. The ADON highlighted that certain medications, especially extended-release forms, should not be crushed and administered via G-Tube as it could affect their efficacy. The Pharmacist Consultant was unaware of the route change and emphasized the importance of following physician orders. The facility's policy on medication administration requires verification of the correct medication, time, and route before administration, which was not adhered to in this case.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure medications were stored in a clean and sanitary environment, as observed during a survey. A loose pill was found at the bottom of the Station 2 Medication Cart, which was not in its bubble pack, making it unidentifiable. This observation was made during an interview with a licensed nurse (LN) who acknowledged the importance of maintaining cleanliness and accountability by ensuring no loose pills were present in the medication cart drawer. The Assistant Director of Nursing (ADON) further explained that having loose pills in the medication cart posed a danger to the nurse and was an infection control issue. A review of the facility's pharmacy policy indicated that medications and biologicals should be stored in their original containers, highlighting a deviation from the established protocol.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to honor the food preferences of two residents during lunch on November 7, 2024. Resident 28, who had documented dislikes for carrots and hamburger, received a meal tray containing both items. Similarly, Resident 101, who had significant weight loss and dietary restrictions against beef and pork, was served a meal without a protein portion, despite her need for protein to prevent muscle loss. These discrepancies were observed during a tray line observation and confirmed by the Registered Dietitian (RD), who acknowledged that the residents' dietary preferences should have been followed. On November 8, 2024, further observations revealed that Resident 101's meal tray potentially lacked a protein portion or contained a disliked item. The RD, upon reviewing a picture of the meal, could not identify the tan food item on Resident 101's plate, which could have been pork or wheat bread. The facility's policy on resident food preferences, dated November 2016, mandates that all food and dining services staff be aware of and adhere to residents' food preferences and allergies, ensuring that residents receive meals that satisfy their tastes and nutritional needs.
Failure to Initiate Rehabilitation Services for Resident
Penalty
Summary
The facility failed to provide necessary rehabilitation services to a resident, identified as Resident 94, upon their admission. Resident 94 was admitted with diagnoses of hemiplegia and hemiparesis affecting the left dominant side, as noted in the hospital discharge summary, which recommended skilled physical therapy (PT) and occupational therapy (OT). However, these services were not initiated, and the resident was not assessed for PT and OT. The Director of Rehab confirmed the absence of an order for these therapies and acknowledged that the resident depended on staff for needs due to the inability to use the left dominant side. Interviews with facility staff revealed a breakdown in the process of verifying and implementing hospital discharge orders. Licensed Nurse 8 stated that the usual procedure involved verifying orders with the Medical Director, but no PT or OT orders were found in the Electronic Health Record. The Assistant Director of Nursing (ADON) was responsible for reviewing hospital orders for new admissions, but this was not effectively carried out. The Medical Director and Director of Nursing confirmed that the expectation was for the resident to receive PT, OT, or Restorative Nurse Aide services, and if not, a note should have been entered into the resident's record. The failure to initiate these services had the potential to result in a decline in the resident's physical function.
Failure to Follow Menu for Pureed Diets
Penalty
Summary
The facility failed to adhere to the planned menu for 18 residents on pureed diets during a lunch meal service. Instead of serving the squash listed on the menu, the staff member prepared and served pureed carrots. This deviation from the menu was observed during a kitchen inspection, where the staff member was seen blending cooked carrots with thickener and hot water, then serving the pureed mixture. The staff member admitted to not following the menu due to being occupied with other preparation tasks, acknowledging that the residents should have received the squash as planned. The facility's administrator confirmed the importance of following menus to meet resident preferences and needs. The administrator acknowledged that failing to serve the menu items as planned could result in unmet needs for the residents. A review of the facility's spring menu and policy indicated that the menu for the day included 'Aunties Baked Squash' for lunch, and the policy emphasized the importance of menu adherence for nutritional variety and effective dining service planning.
Deficiency in Meal Preparation and Temperature
Penalty
Summary
The facility failed to ensure that pureed foods were prepared according to recipe directions, resulting in an unappetizing texture for 18 residents on a pureed diet. During an observation, a staff member prepared pureed carrots by adding an unmeasured amount of hot water and thickening product, leading to a runny consistency that spread over the plate and mixed with other food items. The staff member admitted to not using a measuring cup for the water or thickener, confirming the carrots were not the right consistency for pureed food. The facility's policy indicated that recipes should be available and utilized, which was not followed in this instance. Additionally, the facility failed to serve meals at an appetizing temperature, as observed when the lunch meal was served late to two residents. The meal cart arrived 45 minutes after the scheduled mealtime, and residents reported that their food was cold. One resident noted that the food had been cold all week, while another resident found their meal too hard and cold to eat. The Director of Nursing confirmed that lunch was not served as scheduled on that day.
Improper Preparation of Pureed Food
Penalty
Summary
The facility failed to prepare and serve pureed food at the correct texture for 18 residents who required a pureed diet. During an observation, a staff member prepared pureed carrots by placing cooked carrots into a blender, adding an unmeasured amount of hot water and a thickening product, and blending the items together. The Registered Dietitian confirmed that water was not listed in the recipe for pureed carrots, which specified using a specific amount of food thickener to achieve the correct consistency. The prepared carrots were observed to be too runny, spreading over one-third of the plate and mixing with other food items. The staff member admitted to not using a measuring cup for the water or thickener, resulting in a consistency that was not suitable for pureed food, which should resemble mashed potatoes. This improper preparation increased the risk of swallowing difficulty for residents who required a modified food texture, potentially affecting their meal intake. The staff member acknowledged that sending out food that is too runny or too thick could make it difficult for residents to eat properly.
Improper Dish Drying Practices in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food safety by improperly storing clean dishes, affecting 144 residents who received meals from the kitchen. During an observation, it was noted that food trays and plastic drinking glasses were stacked while still wet, preventing proper air circulation and drying. This was confirmed during interviews with the Registered Dietician (RD) and the Director of Nursing (DON), who both acknowledged the presence of moisture on the drying trays and inside the plastic cups. They identified this moisture as a potential environment for pathogen growth, which could lead to foodborne illnesses among residents.
Failure to Ensure Timely Physician Visits for a Resident
Penalty
Summary
The facility failed to ensure that a resident was examined by a physician at least every 30 to 60 days, as required. The resident, who was admitted in mid-2023 with diagnoses including rectal and intestinal cancer and heart failure, reported not having seen a doctor since a change in her physician two months prior. A review of the resident's clinical record confirmed that the last documented physician visit was in September 2023, with no subsequent visits recorded in the Electronic Health Record (EHR). Interviews with facility staff, including Health Information Management (HIM) personnel and the Director of Nurses (DON), confirmed the lack of physician visits for the resident. The HIM department had a system in place to track overdue physician visits and notify physicians, but this process did not prevent the oversight. The Medical Director acknowledged the lapse, attributing it to the sudden departure of the resident's previous physician. The facility's policy and federal regulations require physician visits every 30 days for the first 90 days after admission and at least every 60 days thereafter, which was not adhered to in this case.
Failure to Schedule Follow-Up Appointments for Resident
Penalty
Summary
The facility failed to provide medically related social services for a resident when follow-up appointments with medical specialists were not scheduled as ordered. The resident was admitted to the facility with multiple fractures and a contusion, requiring follow-up care with an orthopedist and a neurosurgeon. Despite orders for these follow-up appointments, there was no documentation in the electronic health record (EHR) or facility transport book to indicate that the appointments were scheduled or attended. Interviews with the Social Services Director (SSD) and the Director of Nurses (DON) confirmed the lack of documentation and the expectation that physician orders for follow-up appointments should be carried out. The SSD acknowledged the risk of delayed treatment if the resident did not attend the appointments, which were necessary for the resident's recovery from her injuries. The facility's policy emphasized the role of social services in addressing the well-being of residents, but the failure to schedule the appointments compromised the resident's care.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 486 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Stockton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Meadowood A Health And Rehabilitation Center | 0.6 mi | ★★★★★ | 1 | 0 |
| Creekside Center | 1.1 mi | ★★★★★ | 15 | 0 |
| Delta Oaks Post Acute | 2.2 mi | ★★★★★ | 36 | 0 |
| Clearwater Healthcare Center | 3.3 mi | ★★★★★ | 9 | 0 |
| Crestwood Manor - 104 | 3.6 mi | ★★★★★ | 5 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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 June 2026) and official state health department websites.