Above average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Cypress Ridge Care Center during CMS and state inspections, most recent first.
A resident with hemiplegia, hemiparesis, morbid obesity, difficulty walking, muscle weakness, and a history of falls required partial to moderate assistance with toilet transfers but experienced repeated delays in staff response to call lights, including a documented 15‑minute wait with no response. After reporting that staff did not come when the call light was pressed, the resident transferred independently to a shared restroom and fell. Other residents reported that call light responses either did not occur or typically took 20–45 minutes, depending on staffing. The DON and ADON acknowledged that call lights were not answered timely, despite a facility policy requiring prompt response to residents’ requests and needs.
A resident with neuropathy and COPD developed a widespread erythematous maculopapular rash, but no care plan was created to address this condition. The DON confirmed the lack of a care plan, despite facility policy requiring comprehensive, measurable care plans for identified problems.
A resident with neuropathy and COPD experienced a fall resulting in severe pain and a hip fracture. Staff received X-ray results indicating a fracture but did not document timely notification of a clinician or prompt transfer to the hospital, resulting in a two-day delay before the resident was sent for further care. The DON confirmed the delay was not acceptable and facility policy required prompt notification and action.
A resident admitted with diabetes and chronic ulcers did not have wound care and insulin orders from the hospital discharge instructions properly transcribed into the facility's records. This led to missed wound care treatments and a delay in blood glucose monitoring and insulin administration, as the responsible LVN used the wrong medication list for reconciliation.
Several residents reported that their meals were bland, with one describing the meat as dry and overcooked. Dietary staff and supervisors confirmed through test tray tasting that the food lacked flavor. Additionally, cooked items were held in a heated oven for several hours before serving, contrary to facility policy and federal guidance, which led to decreased palatability and potential loss of nutritive value.
Surveyors found unsanitary conditions in the kitchen, including eight large pans with discoloration and rust, as well as an ice scoop stored on a dusty, unclean tray. Both the dietary supervisor and registered dietitian acknowledged these issues, which were not in accordance with the facility's policies for maintaining clean and safe food service equipment.
Surveyors identified multiple infection control deficiencies, including an LVN not performing hand hygiene between tasks, improper glove use by a nurse during IV medication administration, and respiratory therapy equipment such as nasal cannulas and nebulizer masks being undated and improperly stored. Additionally, medication storage areas were found unclean, with dark brownish substances present. These issues were confirmed by staff and were not in line with facility policies.
A resident with multiple chronic conditions and moderate cognitive impairment was found with several medication bottles at bedside and self-administering them without a physician's order, assessment, or care plan in place, contrary to facility policy requiring interdisciplinary evaluation and authorization for self-administration.
Four residents, all alert and oriented with various neurological diagnoses, reported during a council meeting that they were unaware of the facility's previous survey results or the location of the survey results binder. Interviews with staff confirmed that the DOA was also unaware of the binder's location, and the facility's policy requiring survey results to be accessible and communicated to residents was not followed.
A resident's clinical record did not contain a completed advance directive or POLST form as required by facility policy. The DON confirmed during record review that the form was missing, despite policy stating such documentation should be prominently displayed and retained in the medical record.
A resident's discharge status was incorrectly coded on the MDS as a transfer to an acute hospital, when the individual was actually discharged home with home health services. This discrepancy was confirmed by the MDSC during record review and interview.
A resident with idiopathic peripheral autonomic neuropathy, who was alert and actively participating in group activities, did not have a comprehensive activity care plan in place. Despite orders permitting participation in activities, there were no documented interventions or updates regarding her activities, and both the DOA and DON confirmed the absence of an activity care plan, contrary to facility policy.
Two residents did not receive care in accordance with professional standards: one did not have prescribed wound care dressings and offloading boots applied while in bed, resulting in a noted deep tissue injury, and another had a physician's order for Chlorhexidine Gluconate mouth rinse incorrectly transcribed, leading to the use of an inappropriate concentration for oral care.
Two residents experienced deficiencies in pharmaceutical services when one did not receive a prescribed oral rinse for several days after a dental procedure due to unavailability, and another received the wrong type of insulin after the pharmacy linked incorrect medication orders in the eMAR. Nursing staff administered medications based on these errors, and the pharmacy did not communicate medication availability issues or ensure accurate order processing.
Surveyors observed a medication error rate above 5% when two residents did not receive medications as ordered: one did not receive a prescribed oral rinse due to unavailability, and another was given a different type of rapid-acting insulin than ordered, with the nurse administering insulin aspart instead of insulin lispro without a new physician order.
A resident with severe cognitive impairment was moved to another room against her wishes, causing her distress. Despite her protests and the objections of staff, the ADON insisted on the move. The DON later acknowledged the error, noting the facility's policy to treat residents with dignity and respect.
The facility failed to conduct weekly assessments of pressure ulcers for four residents, leading to undetermined wound status. A resident with severe obesity and cognitive deficits had a stage 2 sacral ulcer unassessed for several weeks. Another resident with dementia had an unstageable sacral ulcer not assessed for the same period. A third resident with peripheral vascular disease had a deep tissue injury on her foot unassessed for weeks. A fourth resident with sepsis had a stage 3 sacral ulcer unassessed over multiple periods. The DON confirmed these lapses, and notes from a PA-C indicated the need for weekly evaluations.
Three CNAs failed to follow proper infection control practices by not sanitizing or washing their hands after glove removal and exiting residents' rooms. CNA A and CNA B were observed not sanitizing their hands after glove removal, while CNA C discarded gloves in the hallway. The backup infection preventionist confirmed the correct procedure was not followed.
A registered nurse left an unlocked medication cart unattended in the hallway while checking on a resident's knee, contrary to the facility's policy requiring medication carts to be locked when not attended. Both the nurse and the DON acknowledged the error.
A CNA worked without a valid certificate from August 2023 to April 2024, providing care to residents despite not being certified. The facility's job description requires CNAs to be licensed, but CNA A was allowed to work after passing the exam portions without obtaining certification. Interviews with the DON and DSD confirmed the oversight, and CNA A was removed from the schedule in May 2024.
The facility failed to conduct weekly wound assessments for four residents, as required by their policy. The DON confirmed that the necessary evaluations were not performed, resulting in undetermined wound status for the affected residents.
A resident with moderately impaired cognition was discharged home without a caregiver, despite the physician's indication that the resident could not manage self-care. The SSD provided pamphlets on caregiving services but did not confirm that these services were set up before discharge.
A resident with a diagnosis of rash did not receive the prescribed Triamcinolone cream as per the physician's order on multiple occasions from February to April 2024. Both the DON and ADON confirmed the lapses, and the facility's policy indicated that treatments should be provided as scheduled.
The facility failed to develop and implement a comprehensive care plan for a resident with dysphagia following a hospital admission. Despite recommendations for a puree diet and nectar thick liquids, no care plan was created to address the resident's condition, leading to increased risk of aspiration or choking. Observations and interviews confirmed the resident often stayed in bed during meals and experienced coughing, with no interventions in place.
Delayed Call Light Response Leading to Unassisted Toilet Transfers and Falls
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate residents’ needs and preferences by not providing timely responses to call lights, resulting in delayed assistance with toilet transfers. Resident 1, who had hemiplegia and hemiparesis affecting the left non-dominant side, morbid obesity, difficulty walking, muscle weakness, and a history of multiple falls, required partial to moderate assistance with toilet transfers per his MDS dated 3/3/26. During an interview in his room on 4/20/26, Resident 1 reported that staff did not respond to his call lights and that he had fallen in the bathroom several times after waiting too long for help. While being interviewed, he pressed his call light and waited 15 minutes without any staff response. Review of his clinical record showed three falls in 2025 and one fall on 2/14/26. On 4/22/26, Resident 1 again stated that no one came after he pressed his call light, and later that day he was assessed by a nurse practitioner after falling while transferring himself to a shared restroom without CNA assistance, following another instance in which no one responded to his call light. Additional resident interviews supported a pattern of delayed call light response: on 4/22/26, another resident stated that staff did not come after pressing the call light, and on 4/24/26, a third resident reported that call light responses usually took 20 to 45 minutes and depended on how many staff were working on the floor. During an interview on 4/24/26, the DON and ADON acknowledged that call lights were not responded to in a timely manner for Resident 1. The facility’s policy titled “Answering the call light,” dated 2001, stated that its purpose was to ensure timely response to residents’ requests and needs, which was not followed in these instances.
Failure to Develop Care Plan for Rash
Penalty
Summary
The facility failed to develop a care plan to address the treatment of a rash for one of five residents. The resident was admitted with diagnoses including neuropathy and chronic obstructive pulmonary disease (COPD). A Change of Condition Note documented that the resident had fragile skin and an erythematous maculopapular rash scattered over the trunk, back, and all extremities. Review of the resident's care plans showed there was no care plan in place to address the rash. During an interview, the DON confirmed the absence of a care plan for the rash. The facility's policy requires comprehensive, person-centered care plans to include measurable objectives and timeframes for identified problem areas, but this was not followed in this case.
Failure to Timely Notify Clinician and Transfer Resident After Hip Fracture
Penalty
Summary
Staff failed to provide care and services in accordance with professional standards of practice for a resident who was admitted with neuropathy and COPD. The resident experienced a fall and was found on the floor complaining of severe pain, rated 10 out of 10. An X-ray performed the following day revealed a deformity of the right femoral neck consistent with a subcapital fracture, and further imaging was recommended. Documentation showed that the X-ray results were sent to the physician and placed in a box for review, but there was no record of a timely response from the physician on the day the results were received. The resident remained in pain, and staff interviews confirmed that the resident was not sent to the hospital until two days after the fall. The DON acknowledged that the delay in sending the resident to the hospital was not acceptable. Facility policy required prompt notification of the attending physician and timely transfer to a hospital or treatment center when there is a significant change in a resident's condition, such as after an accident or incident. The lack of timely clinician notification and delayed transfer to the hospital constituted a failure to meet professional standards of quality care.
Failure to Reconcile and Transcribe Admission Orders for Wound Care and Insulin
Penalty
Summary
The facility failed to properly reconcile and transcribe medication and wound care treatment orders for a resident admitted from the hospital. Upon admission, the wound care treatment order for the resident's right lower extremity, as specified in the hospital discharge instructions, was not transcribed into the facility's Treatment Administration Record (TAR) until several days after admission. As a result, wound care treatments scheduled for specific days were missed, with no documented evidence that treatments were provided on three separate occasions. The lapse was confirmed by a Licensed Vocational Nurse (LVN), who acknowledged that the wound care order should have been transcribed on the day of admission and that the treatments should have been administered as ordered. Additionally, the facility did not transcribe two insulin aspart orders from the hospital discharge instructions onto the facility's medication list, resulting in a delay in initiating blood sugar monitoring and insulin administration according to the prescribed sliding scale. The LVN responsible for medication reconciliation used the hospital inpatient medication list instead of the discharge to SNF medication list, leading to the omission of these critical orders. Consequently, blood sugar checks and insulin administration were not performed for an extended period after admission, despite the resident's diagnoses of type 2 diabetes mellitus and chronic skin ulcers.
Failure to Ensure Palatable and Nutritive Food Service
Penalty
Summary
The facility failed to ensure that food served to residents was palatable and maintained its nutritive value. Multiple residents reported that their meals tasted bland, with one resident describing the meat as dry and overcooked. These observations were confirmed during a test tray tasting by both the dietary supervisor and the director of dietary services, who agreed that the country fried steak in all textures (puree, minced/moist, soft/bite-sized, and regular) lacked flavor. The registered dietitian also acknowledged that all foods should be palatable. The facility's policy requires that each resident is provided with a nourishing, palatable, well-balanced diet that meets their daily nutritional and special dietary needs, considering resident preferences. Additionally, the facility did not maintain proper food preparation and holding practices. Cooked items such as minced/moist country fried steak, soft/bite-sized country fried steak, veggie patties, and mashed potatoes were stored in a heated oven at 200°F for an extended period, from the morning until the tray line preparation began several hours later. Both the dietary supervisor and director of dietary services confirmed that foods should be prepared near or within one hour of tray line preparation to preserve taste and nutritive value. The registered dietitian also verified this standard. The facility's policy and federal guidance specify that food should not be held at hot temperatures for hours prior to meal service, as this can result in a loss of vitamins and diminished food quality. The residents involved had various medical conditions, including hemiplegia, hemiparesis following cerebrovascular disease, unspecified fracture of the femur, and idiopathic peripheral autonomic neuropathy. All were alert, oriented, and able to communicate their dissatisfaction with the food. The deficiencies were identified through direct observation, resident interviews, and review of facility records and policies.
Unsanitary Kitchen Equipment and Improper Ice Scoop Storage
Penalty
Summary
Surveyors observed unsanitary conditions in the facility's kitchen, specifically noting the storage of eight large pans with brownish to blackish discolorations and rusty spots. Both the dietary supervisor and the registered dietitian acknowledged the presence of these pans and confirmed that they should not have been kept in the kitchen. The facility's own policy requires that all utensils and equipment be kept clean, maintained in good repair, and free from corrosion or damage that could affect their use or cleaning. Additionally, the ice scoop for the ice machine was found placed on top of a dusty and unclean tray. The dietary supervisor confirmed the unsanitary condition of the tray and acknowledged that the ice scoop should not have been stored there. The registered dietitian also verified that the ice scoop should not be placed on a dirty tray. The facility's policy on food storage practices specifies that scoops must be stored in a sanitary container that allows for water drainage away from the scoop.
Infection Control and Prevention Failures in Facility
Penalty
Summary
Surveyors observed multiple failures in infection prevention and control practices within the facility. A Licensed Vocational Nurse (LVN) was seen not performing hand hygiene between tasks, such as moving between resident rooms and handling items like used cups, which was confirmed by the LVN during an interview. Additionally, a licensed nurse did not change gloves between tasks while preparing and administering intravenous medication, a fact acknowledged by the nurse and the Director of Nursing (DON). Equipment used for respiratory therapy was not properly managed. One resident's nasal cannula and nebulizer mask were found undated and not properly stored, with the DON confirming these observations and stating that such items should be stored in a designated bag. Another resident's nasal cannula was undated, the humidifier was outdated, and the oxygen concentrator filter was visibly dusty with an accumulation of whitish-grayish substances. The DON confirmed these findings, and facility policy required regular dating, changing, and cleaning of such equipment. Environmental cleanliness was also lacking, as dark brownish substances were observed on top of the medication storage cabinets in the medication storage room. Both the DON and the housekeeping manager confirmed that the area should have been kept clean, in accordance with facility policy. These observed failures in hand hygiene, glove use, equipment management, and environmental cleanliness were documented through direct observation, interviews, and review of facility policies.
Failure to Assess and Authorize Resident Self-Administration of Medications
Penalty
Summary
The facility failed to implement its policy regarding self-administration of medications for one resident. Specifically, a resident with multiple diagnoses, including diabetes mellitus, peripheral vascular disease, obesity, hypothyroidism, and hyperlipidemia, was observed to have five medication bottles at his bedside. These included Simethicone Tablets, PB8 Probiotic, Maximum Strength Ultra-Zyme, and Say Yes to Beans. The resident stated that he used these medications for stomach issues. Review of the resident's Minimum Data Set indicated a BIMS score of 9, reflecting moderate cognitive impairment. Upon review, the DON confirmed that there was no physician's order, no assessment for self-administration, and no care plan developed for the resident to self-administer medications or to keep medications at the bedside. The facility's policy requires that the attending physician and the interdisciplinary care planning team determine a resident's capacity to self-administer medications safely before allowing self-administration. These steps were not followed, resulting in the deficiency.
Residents Not Informed of Survey Results or Binder Location
Penalty
Summary
The facility failed to ensure that residents were aware of and had access to the results of previous state recertification surveys and the corresponding plans of correction. During a resident council meeting, four residents, all of whom were alert, oriented, and verbally responsive, stated they were not aware of the survey results or the location of the survey results binder. These residents had various primary diagnoses, including incomplete paraplegia, idiopathic peripheral autonomic neuropathy, and unspecified cord compression. None of the residents interviewed could identify where to find the survey results or had been informed about them. Further interviews with facility staff, including the director of activities (DOA), administrator (ADM), and director of nursing (DON), revealed that the DOA was also unaware of the location of the survey results binder and had not informed residents about it. The facility's policy requires that survey reports and plans of correction be readily accessible to residents, family members, and the public, and that residents be able to examine the most recent survey results and plans of correction. However, this policy was not followed, resulting in residents not being informed or reminded about the survey outcomes.
Failure to Maintain Advance Directive Documentation
Penalty
Summary
The facility failed to ensure that an advance directive or a Physician Orders for Life-Sustaining Treatment (POLST) form was completed and available in the clinical record for one of two sampled residents. Review of the resident's clinical record showed no completed POLST form, despite the resident's admission to the facility. During an interview and concurrent record review, the DON confirmed the absence of the POLST form in the resident's records and suggested it may have been misplaced. Facility policy requires that information about whether a resident has executed an advance directive be displayed prominently in the medical record, and that a copy of the POLST form be retained in the patient's medical record.
Inaccurate Discharge MDS Coding
Penalty
Summary
The facility failed to accurately complete the discharge Minimum Data Set (MDS) for one of three reviewed residents. Specifically, a resident who was discharged home with home health services was incorrectly coded on the discharge MDS as having been discharged to an acute hospital. This error was confirmed during an interview and record review with the MDS Coordinator, who acknowledged that the discharge status was inaccurately recorded on the MDS. According to the CMS Resident Assessment Instrument (RAI) Manual, the discharge status should have been coded as discharge to the community when the resident was sent home.
Failure to Develop and Implement Activity Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, resident-centered care plan for one resident regarding her activities. During an observation and interview, the resident was found to be alert, oriented, and actively participating in a resident council meeting, and she identified herself as the current resident council president who regularly attends meetings. Review of her admission record showed she was readmitted with a primary diagnosis of idiopathic peripheral autonomic neuropathy, and her order summary allowed participation in activities as long as they did not conflict with her treatment plan. Despite these findings, a review of her care plans revealed that there was no activity care plan in place for her, nor were there any documented interventions or updates regarding the effectiveness of her current activities. Both the director of activities and the DON confirmed that the resident did not have an activity care plan, which was inconsistent with the facility's policy requiring comprehensive, person-centered care plans with measurable objectives and timetables for each resident.
Failure to Follow Physician Orders and Proper Medication Transcription
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards of practice for two residents. For one resident with a history of muscle weakness, bilateral knee osteoarthritis, and a left artificial knee joint, physician orders required the application of a foam dressing to the left heel on specific days and the use of offloading booties at all times while in bed to prevent further skin breakdown. During observation, the resident was found in bed without the prescribed foam dressing and booties, and a deep tissue injury with dark purple discoloration was noted on the left heel. Both the LVN and Treatment Nurse confirmed that the required interventions were not in place at the time of observation. For another resident with diagnoses including diabetes, infection related to cardiac and vascular devices, and a recent dental extraction, the facility failed to accurately transcribe a physician's order for Chlorhexidine Gluconate mouth rinse. The hospital discharge summary specified a 0.12% solution for oral use, but the order was incorrectly transcribed as a 4% solution, which is intended for external wound care. This error was confirmed by the DON, MDS Coordinator, and Consultant Pharmacist, who stated that the 4% solution is not appropriate for oral use and may cause adverse effects such as bitter taste, dry mouth, and oral irritation.
Failure to Provide Timely and Accurate Pharmaceutical Services
Penalty
Summary
The facility failed to provide adequate pharmaceutical services in two separate incidents involving two residents. In the first case, a resident who had recently undergone a dental extraction was prescribed Chlorhexidine Gluconate Oral Rinse for post-extraction care. Despite a physician's order dated the day after hospital discharge, the medication was not available or administered for five consecutive days. The nurse confirmed the medication was unavailable since the order date, and the medication administration record showed no doses given during this period. The medical director stated that the order had been sent to the pharmacy, but there was no communication from the pharmacy regarding the delay or non-delivery. In the second incident, a resident with diabetes was prescribed insulin lispro to be administered per a sliding scale. During medication administration, the nurse administered insulin aspart instead, as insulin lispro was not available. The electronic medication administration record incorrectly documented the administration of insulin lispro, and the nurse explained that the pharmacy had linked both an insulin aspart sliding scale order and an inappropriate fixed-dose lispro order under the original lispro order. The consultant pharmacist confirmed that insulin aspart and insulin lispro are different medications and that a new physician order is required to substitute one for the other. The assistant director of nursing acknowledged that the pharmacy's action to auto-link these orders was inappropriate and not based on the resident's actual orders. A review of facility policy indicated that the provider pharmacy is responsible for accurately dispensing prescriptions based on authorized prescriber orders and ensuring timely delivery of medications. The pharmacy is also required to screen new medication orders for appropriate indications and communicate with nursing staff if additional information is needed before administration. In both incidents, the pharmacy failed to meet these requirements, resulting in missed and incorrect medication administration.
Medication Error Rate Exceeds Acceptable Threshold Due to Missed and Incorrect Medication Administration
Penalty
Summary
A medication error rate of 7.14% was identified during survey observations, with two errors out of 28 opportunities involving two residents. In the first instance, a Licensed Vocational Nurse (LVN) failed to administer Chlorhexidine Gluconate Oral Rinse to a resident as ordered. The nurse confirmed during interview that the medication had not been available since the order was placed several days prior, resulting in the resident not receiving the prescribed oral rinse. In the second instance, another LVN administered insulin aspart (Novolog) to a resident instead of the ordered insulin lispro (Humalog) before lunch, following a sliding scale for blood glucose management. The nurse stated she believed the two insulins were equivalent and administered the available medication without obtaining a new physician order. The facility's consultant pharmacist confirmed that the two insulins are different medications and a new order is required for substitution. The facility's policy requires medications to be administered in accordance with prescriber orders.
Resident's Right to Dignity Violated During Room Transfer
Penalty
Summary
The facility failed to honor a resident's right to dignity and self-determination when they moved Resident 1 to another room against her wishes. Resident 1, who was admitted with diagnoses including encephalopathy and a psychotic disorder with delusions, had requested a room change following the death of her previous roommate. However, when the Social Worker Staff returned to have her sign the notice of room change, Resident 1 had already been moved without her consent, and she refused to sign the notice. During the move, Resident 1 became upset, screaming and crying, expressing her desire not to be moved. Despite objections from the Housekeeping Staff and Transportation Staff, the Assistant Director of Nursing insisted on proceeding with the move. The Director of Nursing later acknowledged that the move should not have been executed under those circumstances and that Resident 1's rights should have been respected, as the facility is considered her home. The facility's policies emphasize treating residents with dignity and respect, which was not upheld in this instance.
Failure to Conduct Weekly Pressure Ulcer Assessments
Penalty
Summary
The facility failed to ensure that pressure ulcers for four residents were assessed weekly, as required. Resident 1, who was admitted with severe obesity, muscle weakness, and cognitive communication deficit, had a stage 2 pressure ulcer on her sacrum that was not assessed from November 8 to December 2, 2024. Resident 2, with diagnoses including muscle weakness, difficulty in walking, iron deficiency, vitamin deficiency, and dementia, had an unstageable pressure ulcer on his sacrum that was not assessed during the same period. Resident 3, admitted with severe obesity, muscle weakness, and peripheral vascular disease, had a deep tissue pressure injury on her right lateral foot that also went unassessed from November 13 to December 2, 2024. Resident 4, who was admitted with muscle weakness, difficulty in walking, and sepsis, had a stage 3 pressure ulcer on his sacrum that was not assessed from August 13 to August 29, August 31 to September 12, and September 14 to October 21, 2024. The Director of Nursing confirmed these lapses in assessment during an interview, acknowledging that the residents' pressure ulcers should have been assessed weekly. The progress notes from the physician assistant-certified from Professional Wound Specialists indicated that the residents' pressure ulcers required follow-up, assessment, and evaluation every seven days.
Infection Control Lapses by CNAs
Penalty
Summary
The facility failed to implement proper infection control practices as observed in the actions of three certified nursing assistants (CNAs). CNA A was seen working with a resident and, after removing her gloves, she exited the resident's room and walked into the hallway without sanitizing or washing her hands. During an interview, CNA A acknowledged that she should have sanitized or washed her hands upon leaving the resident's room. Similarly, CNA B was observed leaving another resident's room with gloves on, discarding them in a hallway hamper, and then walking in the hallway without sanitizing or washing her hands. CNA B admitted during an interview that she should have removed and discarded her gloves inside the resident's room and sanitized or washed her hands afterward. CNA C was also seen exiting a resident's room with gloves on and discarding them in a hallway hamper. She acknowledged in an interview that she should have removed and discarded her gloves inside the resident's room. The backup infection preventionist confirmed that staff should remove gloves inside residents' rooms and sanitize or wash their hands upon exiting.
Unattended Unlocked Medication Cart
Penalty
Summary
The facility failed to ensure proper medication storage when a registered nurse (RN A) left an unlocked medication cart unattended in the hallway while attending to a resident's knee in their room. This oversight was observed during an interaction with RN A, who acknowledged the mistake and confirmed that the cart should have been locked before leaving it unattended. The director of nursing (DON) also confirmed that the medication cart should be locked when not attended. The facility's policy, dated August 2014, mandates that medication rooms, carts, and supplies must be locked when not attended by authorized personnel.
Uncertified CNA Provided Resident Care
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA), referred to as CNA A, had a current CNA certificate during her employment from August 2023 to April 2024. CNA A began working as a CNA after passing the knowledge and skill portions of the CNA exam in August 2023, but she did not receive her CNA certificate. Despite this, she provided care to multiple residents. The facility's job description for a CNA requires that the individual must be a licensed Certified Nursing Assistant. Interviews with the Director of Nursing (DON) and the Director of Staff Development (DSD) confirmed that CNA A had not obtained her CNA certificate while providing care. The DSD acknowledged that CNA A should not have provided direct care until she obtained her certification. CNA A was eventually removed from the work schedule at the beginning of May 2024. The lack of certification documentation in CNA A's employee file and the facility's failure to verify her certification status contributed to this deficiency.
Failure to Conduct Weekly Wound Assessments
Penalty
Summary
The facility failed to ensure that residents received the necessary care and services for wound management. Specifically, four residents did not receive weekly wound assessments as required by the facility's policy. Resident 2 had a sacrococcygeal wound and only received one Comprehensive Skin Evaluation/Assessment and one Skin and Wound Evaluation during his stay. Resident 3 had a pressure injury on her left buttock but did not receive any Comprehensive Skin Evaluation/Assessment or Skin and Wound Evaluation. Resident 4 had a pressure injury on his coccyx and received only one Comprehensive Skin Evaluation/Assessment and no Skin and Wound Evaluation. Resident 5 had a wound on her right coccyx buttocks and received no Comprehensive Skin Evaluation/Assessment and only one Skin and Wound Evaluation during her stay. The Director of Nursing (DON) confirmed these deficiencies during an interview, acknowledging that the required weekly wound assessments were not conducted for these residents. The facility's policy, dated 9/8/22, mandates that a weekly skin assessment should be completed to describe the current condition of the patient's skin. The failure to adhere to this policy resulted in undetermined wound status for the affected residents, which could negatively impact their wound healing progress.
Failure to Ensure Safe Discharge for Resident
Penalty
Summary
The facility failed to provide a safe discharge for a resident who was discharged home without a caregiver readily available, despite the physician's indication that the resident could not be discharged home for self-care. The resident, who had moderately impaired cognition as indicated by the Minimum Data Set (MDS), was admitted to the facility and later discharged. The physician's notes specified that the resident needed a safe placement and could not manage self-care at home. However, the social service director (SSD) only provided pamphlets on caregiving services and did not confirm that these services were set up before the discharge. This oversight was confirmed by the SSD during an interview, acknowledging that the caregiving services should have been confirmed prior to the resident's discharge.
Failure to Apply Prescribed Triamcinolone Cream
Penalty
Summary
The facility failed to follow the care plan and physician's order to apply Triamcinolone cream to a resident with a diagnosis of rash and other nonspecific skin eruptions. The physician's order, dated 11/29/22, specified that the cream should be applied to the affected areas twice daily. However, a review of the resident's electronic treatment administration record (eTAR) from February to April 2024 revealed multiple instances where the treatment was not documented as applied, nor were there any records of refusal by the resident. Specifically, the cream was not applied on several dates in February, March, and April 2024. During interviews, both the registered nurse and the resident confirmed that the cream had not been applied as prescribed on multiple occasions. The director of nursing (DON) and the assistant director of nursing (ADON) acknowledged the lapses in treatment application. The ADON confirmed that the staff should have followed the physician's order and that the treatment nurse or floor nurse was responsible for applying the cream. The facility's policy and procedure for registered nurses, dated 9/2018, indicated that medication passes and treatment schedules should be monitored to ensure treatments are provided as scheduled. Despite this policy, the resident's treatment was not consistently administered, leading to a potential delay in the improvement of the resident's skin condition.
Failure to Develop and Implement Dysphagia Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with a newly added diagnosis of dysphagia following a hospital admission. The resident, who had severe psychiatric issues and refused the majority of care for chronic medical conditions, was at high risk of aspiration pneumonitis. Despite recommendations from a Speech and Language Pathologist (SLP) for a puree diet and nectar thick liquids, the facility did not create a care plan to address the resident's dysphagia status to prevent aspiration or choking. Observations and interviews revealed that the resident often stayed in bed during meals and experienced coughing during mealtime. The resident preferred to keep her bed in a flat position, which further increased the risk of aspiration. The Director of Nursing (DON) and the Assistant Director of Nursing (ADON) confirmed that no care plan had been developed for the resident's dysphagia, acknowledging that a comprehensive person-centered care plan with appropriate interventions should have been implemented following the resident's discharge from the hospital.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 173 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Monterey
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Monterey Post Acute | 0.1 mi | ★★★★★ | 4 | 0 |
| Canterbury Woods | 1.5 mi | ★★★★★ | 11 | 0 |
| Forest Hill Manor Health Center | 1.5 mi | ★★★★★ | 2 | 0 |
| Oceanview Post Acute | 1.8 mi | ★★★★★ | 15 | 0 |
| Westland House | 1.9 mi | ★★★★★ | 6 | 0 |
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