Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Desert Canyon Post Acute, Llc during CMS and state inspections, most recent first.
Oxygen Concentrator Not Inventoried in Resident Property Record: A resident with CHF, OSA, and atrial fibrillation had an oxygen concentrator from home at the bedside, but it was not listed in the resident's clothing and possessions inventory. The resident said he used the concentrator himself when needed and that his belongings record had not been updated after returning from the hospital. The LVN and DON confirmed there was no documentation of the concentrator in the inventory or nursing notes.
Oxygen Therapy Provided Without Order or Monitoring: A resident with CHF, OSA, and atrial fibrillation was observed using a home oxygen concentrator with nasal cannula tubing at the bedside, and he stated he applied and turned on the oxygen himself when short of breath. Record review found nursing documentation showing oxygen via NC on several occasions, but no physician order for oxygen therapy and no monitoring documentation. The LVN and DON stated oxygen should be ordered, assessed, and monitored, and the facility’s policy required a physician order with device, flow rate, duration, target saturation, and assessment before and during oxygen use.
Failure to Provide Requested Medical Records: A resident with epilepsy, DM2, COPD, and severely impaired cognition had an authorized RP request copies of medical records by eFax, but the facility did not send the records until well after the requested release timeframe. The MRD acknowledged the delay, and the ADM stated the records should have been available within two working days after request.
Hot Water Not Maintained at Resident Bathroom Sinks: Two residents reported that bathroom water stayed cold and took too long to warm for bathing. During observation, the MD measured sink water at 81 degrees F after running it for five minutes and said the issue was related to the building setup and laundry use. Resident Council members also confirmed the hot water problem affected bathing and other ADLs, and facility records noted hot water was lacking in most resident rooms.
The facility used physical restraints for several residents without proper documentation or authorization. A resident had bilateral bolsters tucked under the sheet and staff said they were used to keep the resident from getting out of bed and falling; another resident had a low air loss mattress with bolsters tucked under the sheets for fall prevention without the required restraint documentation; a resident used a pommel wedge cushion in a wheelchair without an order, restraint assessment, or informed consent; and two other residents had bolsters used without a completed restraint assessment and with orders that did not clearly state the indication for use.
Unsafe resident environment and supervision failures were identified for multiple residents. A resident with dementia and high fall risk had a side table and wheelchair placed on top of floor mats, another resident with dementia had an opened A&D ointment left at the bedside despite no order and inability to self-administer meds, a resident had a call light with frayed exposed wires, and another resident with a limp was seen pushing a maintenance trolley in the hallway without supervision.
Failure to Rotate Subcutaneous Injection Sites: A resident receiving insulin lispro had repeated injections documented in the same arm areas despite an order to rotate sites, and an ADON confirmed the staff did not follow the order. Another resident receiving enoxaparin had consecutive injections given in the right arm/right shoulder, and an LVN acknowledged he did not check the prior site before administration. The facility’s records and policies required site rotation for these subcutaneous medications.
Dietary staff failed to demonstrate competency with IDDSI testing for a resident’s pureed meal. A resident with dysphagia, chronic respiratory failure, and COPD was ordered a pureed, mildly thick diet, but the lunch tray included pureed broccoli with watery separation. The DS, cook, and other dietary staff stated they were not familiar with IDDSI spoon tilt testing, and the RD and DS stated no in-service or competency evaluation had been provided for IDDSI standards.
Modified diets were not prepared in the correct texture for several residents with dysphagia. A resident on a pureed diet was served broccoli with separating liquid and staff did not perform IDDSI testing; another resident on a minced and moist diet received pureed bread and pasta that were too thin and did not hold shape; and a third resident on a soft and bite sized diet was served pasta pieces that were not bite sized. Staff and the RD confirmed the meals did not match the ordered textures.
Unsafe food storage and handling practices were observed in the kitchen. Used towels were left in the prep sink, on the tray line, and in the dirty dish area instead of being stored in sanitizer buckets or dirty towel bins. Surveyors also found frozen pizzas without labels or dates, an unsecured cereal bin lid, expired English muffins still available, sprouting potatoes without a date, and fruits and vegetables stored outside the refrigerator despite facility policy requiring refrigeration for most produce.
Missing QAPI Plan and Incomplete QAPI Data Review: The facility failed to maintain documentation and evidence of an ongoing QAPI program. During survey, the ADON stated the QAPI Plan in the binder was outdated, she did not have access to the current plan, and the ADM and DON were unavailable. The ADON described the QAPI Plan as the written guide for identifying problem care areas, reviewing data, and discussing issues such as falls, but the facility did not provide documentation of regular data collection and analysis for falls, which had been identified as a problem area.
The facility failed to follow its infection prevention and control program when a resident’s call light was found inside a trash can and returned without sanitizing, another resident’s call light was picked up from the floor and handed back without being wiped, and a CNA provided ADL care to a resident on EBP without wearing a gown. The residents involved had diagnoses including PVD ulcer, cellulitis, dementia, and a GT, and staff stated the call lights should have been cleaned and gown use was required for high-contact care.
A facility failed to keep call lights within reach for two residents. One resident with muscle weakness, difficulty walking, major depressive disorder, and high fall risk had a call light dangling inside a trash can, while another resident with muscle weakness, difficulty in walking, and depression had a call light resting on the floor by the bed. Staff stated the call lights should have been within reach so the residents could call for help when needed.
Missing POA Documentation in Resident Record: The facility failed to ensure a resident’s POA document was current and included in the EHR. The resident had diagnoses including dementia, metabolic encephalopathy, epilepsy, and DM, and records showed the resident could understand others and make himself understood. Although the chart listed a POA and other records referenced an advance directive, RN and SS staff found no POA document in the EHR, and the SS Coordinator stated there was no documented follow-up to obtain it. The POA also stated the documents had already been provided to the facility.
A resident with metabolic encephalopathy, cerebral infarction, major depressive disorder, and moderate cognitive impairment fell while being assisted in bed. The RN documented no pain, no visible injury, and baseline VS, but the record did not show that the resident’s representative was notified. The representative later stated she was upset because she was not informed and later learned the resident had a hip fracture after transfer to the hospital.
Missing monitoring orders for clonazepam use: A resident with CVA, epilepsy, and generalized weakness received clonazepam 1 mg TID for anxiety manifested by restlessness, but the record lacked a physician order for behavior monitoring, adverse side effect monitoring, and documentation of non-pharmacological interventions each shift. The ADON confirmed the missing orders during record review, even though the care plan referenced GDR, side effect monitoring, and non-pharmacological approaches.
A resident with sepsis, acute respiratory failure, CHF, and severely impaired cognition was transferred to the hospital after an abnormal BUN and NP order for ER evaluation. Although the resident left via gurney and the RP was notified, the facility did not document that the nurse provided the receiving hospital with the necessary medical information or telephone handoff report as required by policy.
PASRR Screening Not Completed Accurately for Resident With Mental Health Diagnoses: A resident admitted with major depressive disorder, anxiety disorder, and PTSD was taking escitalopram, but the PASRR Level I Screening stated the resident did not have a diagnosed serious mental illness and had not been prescribed psychotropic medications for serious mental illness. An LVN confirmed the screening was not completed accurately, and no corrected or second PASRR screening was submitted.
A resident with metabolic encephalopathy, cerebral infarction, and major depressive disorder had a witnessed fall after sliding off the bed. RN assessed the resident and found no pain or injuries, but the chart did not show an actual care plan for the fall. The ADON stated licensed staff should have developed and implemented a care plan after the accident to ensure the resident received needed care.
Failure to Maintain Nail Care and Personal Hygiene: Two residents did not receive needed grooming and hygiene assistance. One resident with dementia and total dependence had overgrown fingernails despite a care plan directing staff to check, trim, and clean nails, and staff gave conflicting accounts about who was responsible. Another dependent resident was observed with dirt accumulated under the free edges of the right-hand fingernails, and staff acknowledged the nails needed cleaning before meals.
Unlabeled and Overdue Urinal Care: A resident who was incontinent of urine had two urinals at the bedside, including one that was unlabeled and another that was labeled with an old date. CNA and DON staff stated the urinals should have been labeled with the resident’s name or room number and the date last changed, and that the dated urinal was very old and should have been changed per facility practice to reduce cross-contamination concerns.
A resident with a g-tube, GERD, and dysphagia had a reusable piston syringe left in use beyond the 24-hour replacement interval. The OSR directed daily syringe changes, and the care plan called for enteral feeding containers and administration sets to be discarded every 24 hours. During observation, staff found the syringe still dated from the prior day, and the MDSC and ADON stated it should have been discarded and replaced by the night LPNs per facility policy.
Unlabeled Peripheral IV Dressing: A resident with a peripheral IV for IV therapy had a dressing on the right arm that was not labeled with the date and initials of the nurse who inserted the IV or last changed the dressing. RN observed the IV covered with Kerlix without required labeling, and the DON/ADON stated licensed staff are responsible for keeping the site current and labeled per policy.
Respiratory care equipment was not maintained consistently for three residents. A resident using BiPAP had mask and tubing stored in a clear bag without a resident name or date, a resident receiving nebulizer treatments had mask and tubing that remained dated beyond the expected replacement interval, and a resident on continuous O2 had NC tubing touching the floor. Staff stated the equipment should be labeled, replaced on schedule, and kept off the floor to reduce contamination and respiratory infection risk.
Pain medication was not managed according to the physician’s order for a resident with Parkinsonism, HF, and HTN. An LVN gave PRN tramadol for pain after the resident reported a pain level of 7, even though the order was for moderate pain only, and she did not contact the MD. The LVN also failed to sign the controlled substance receipt record after administration, and the DON/ADON noted the record is used to ensure accurate controlled substance counts and that the order parameters were for pain levels 4 to 6.
A resident with ESRD and dependence on HD did not receive required nursing assessment and communication related to dialysis care. Staff did not document a post-HD assessment or the resident’s return time after one HD session, and on another occasion the HD communication form was left blank before transport to HD. RN and ADON interviews confirmed the form should have included the nurse’s assessment, vital signs, access site information, and communication with the HD center.
A resident with Parkinsonism, HF, and HTN had a PRN tramadol order for moderate pain, but an LVN administered the dose and did not sign the controlled substance receipt record after giving it. During review, the LVN said she forgot to document the dose, and the ADON stated the record is used to ensure accurate counting of controlled meds and that missing documentation could lead to a double dose.
Pureed Menu Not Followed and IDDSI Testing Not Performed: A resident with dysphagia, chronic respiratory failure with hypoxia, and COPD was ordered a pureed, mildly thick diet, but dietary staff served pureed broccoli that was watery and separating from liquid. During tray line, the cook did not use the pureed broccoli recipe, the recipe was not available in the kitchen, and staff stated they were unfamiliar with IDDSI testing and did not perform the required appearance, fork drip, or spoon tilt checks.
Failure to Honor Resident Food Preferences: A resident with DM, sepsis, and muscle weakness, who had moderate cognitive impairment but could make decisions, was on a CCHO diet with an order to honor food preferences. During breakfast observation, the resident received eggs cooked over hard and burnt toast instead of the requested over easy eggs and toast, and the DS and ADON both confirmed the meal was not prepared as ordered and was not appealing.
A resident with Guillain-Barre Syndrome and hypertension was discharged to recuperative care without written confirmation of acceptance, resulting in the resident being denied by the receiving facility and subsequently left at a hospital. Facility staff confirmed that only verbal and email communications were obtained, and no official documentation of acceptance was present, contrary to facility policy requiring proper preparation and confirmation for safe discharge.
Failure to monitor and treat a worsening buttocks wound: A resident with DM, hemiplegia, hemiparesis, and contractures had a left buttocks wound that progressed from MASD to an unstageable wound. The record showed a missed weekly wound assessment, a five-day gap with no documented wound care on the TAR, and no documented COC for the wound increase. The TN stated the wound enlarged and that the MD and RP were not notified, and the DON stated the increase should have had its own COC.
Failure to Notify MD and RP of Worsening Wound Change of Condition: A resident with DM, hemiplegia, hemiparesis, and contractures developed MASD on the left buttocks that later increased in size and was treated as a wound/pressure injury. The TN stated the wound enlargement was a COC, but the TN did not notify the MD or RP, and the DON stated the wound size increase should have had its own COC.
A resident with pneumonia, bronchiectasis, dysphagia, and continuous O2 via NC had a bedside fan observed with thick gray dust. The resident said staff were supposed to dust it but had not, and said the dust may be contributing to his coughing. The DON later observed the fan and confirmed dust accumulation, stating it was dirty and not consistent with a homelike environment.
Improper Labeling and Storage of Resident Food: A resident's outside food was found in a nurses' station refrigerator with an identifier and date, but the opened cheese and salami had no open date and a partially erased use-by date. The DON stated opened items must be labeled with received and open dates and discarded within 48 hours, and that the items should have been thrown away because they were opened.
Failure to Enforce Masking During Respiratory Virus Season: Staff did not consistently wear masks inside the facility during respiratory virus season. An AD was observed with her nose exposed while interacting with a resident, and a HSK and CNA were observed without masks in the hallway, with the CNA entering two residents’ rooms unmasked. The IP, DON, and ADON stated masking was mandatory, and the residents involved had significant medical conditions, including impaired cognition in two residents and RSV risk in one resident.
The facility failed to follow its infection prevention and control and reporting policies after bed bugs were discovered in a shared room occupied by three cognitively intact residents with multiple comorbidities and varying dependence on staff for ADLs. A CNA and an LVN observed insects on a resident’s bed, and the IP later confirmed that a pest management company identified bed bugs on one mattress. Despite acknowledging that bed bugs can be transferred via clothing and linens and can cause skin reactions, the IP reported that no contact tracing was initiated, no systematic assessment of other residents for bites or rashes was conducted, and no surveillance or monitoring system for bed bugs was developed. Facility leadership and policy documents characterized bed bugs as an unusual occurrence with potential impact on resident safety and health, yet the facility did not report this event to the Department of Public Health as required by its own outbreak and reportable disease policies.
The facility failed to revise comprehensive care plans for three cognitively intact residents sharing a room after bed bugs were discovered on one resident’s mattress. CNAs observed small red insects on the resident’s bed during personal care, and an LVN confirmed the presence of insects and completed a skin assessment that showed no bites at that time. A pest management company later confirmed bed bugs in the room and performed heat treatment. Despite this, the residents’ care plans were not updated to include monitoring for skin issues or other complications related to potential bed bug exposure, contrary to the facility’s policy requiring person-centered care plans that address medical, physical, mental, and psychosocial needs.
A resident with severe cognitive impairment and high fall risk was found with the call light on the floor and out of reach after ADL care was provided. Staff interviews confirmed that facility policy and the resident's care plan required the call light to be accessible, but this was not followed, resulting in a deficiency related to reasonable accommodation of resident needs.
Two residents were subjected to physical restraint practices without proper assessment or documentation. One resident's bed was placed against the wall without the required quarterly restraint assessments, and another had pillows tucked under the fitted sheet as a restraint, which was not ordered or care planned. These actions did not comply with facility policy and restricted the residents' freedom of movement.
Three residents were moved to new rooms without receiving written notice or an explanation for the change, as required by facility policy. One resident, who is blind, struggled to adapt to a smaller, less accessible room, while another felt disregarded after being moved without consultation or documentation. A third resident was relocated after complaining about a roommate, without being oriented to the new environment. The Social Service Director confirmed that no written notifications were provided to the residents or their representatives.
Three residents were moved to new rooms without receiving written notification or explanation as required by facility policy and regulatory guidance. One resident, who was blind and had diabetes, was not oriented to her new room and struggled with the new environment. Another resident, dependent on staff due to cerebral infarction, was moved without being consulted or given documentation. A third resident, who had a UTI and required substantial assistance, was relocated after complaining about a roommate, without orientation or choice. The facility's governing body did not ensure that policies were updated or followed.
A resident who needed substantial assistance with ADLs and had an intact thought process was not fully covered while walking in the hallway with a physical therapist student, resulting in exposure of the incontinence brief. The PT student and DON both acknowledged the importance of maintaining resident dignity by ensuring full coverage, as required by facility policy.
A Hoyer lift was found parked in front of an emergency exit, with an emergency crash cart and two wheelchairs also obstructing the hallway. An LVN and the DON confirmed that these items were improperly placed, blocking exits and hallways, contrary to facility policy requiring a safe and accessible environment.
A resident with muscle weakness and paraplegia experienced an unwitnessed fall, but the subsequent Fall Risk Evaluation inaccurately recorded a lower risk score. The nurse failed to document the fall, note the need for assistive devices, and incorrectly indicated no falls in the last three months, leading to a deficiency in the facility's documentation practices.
Two residents in an LTC facility engaged in a verbal altercation, exchanging derogatory words, which was witnessed by staff members. Despite facility policies on abuse prevention, the incident was considered verbal abuse, highlighting a failure to protect residents from mistreatment. Both residents had cognitive impairments and required assistance with daily activities.
The facility employed an Activity Director (AD) who did not meet the qualifications outlined in the job description. The AD, hired in October 2024, lacked the required certification in long-term care specialization and did not maintain written records of residents' attendance at activities. The DON and ADM confirmed the AD's hiring and training, but the ADM admitted the AD was likely not qualified according to the job description.
A resident with sepsis, diabetes, and end-stage renal disease refused multiple medications over several days, but the facility failed to develop a care plan to address this. Despite the resident's capacity to make decisions, the facility did not create a care plan after the resident refused medication three times, as required by policy. The DON acknowledged the oversight during a review.
A facility failed to provide a resident-centered activity program for a resident with dementia and other health issues. The resident was not assessed for activities upon admission, and there was no documentation of activity participation. Interviews revealed miscommunication and lack of documentation, contrary to the facility's policy requiring assessment of residents' interests and preferences.
A resident with cognitive capacity and specific activity preferences was not offered a resident-centered activity program, as required by the facility's policy. Despite the resident's ability to make decisions, there was no documented activity attendance, and the resident expressed that they were not asked about their daily preferences. Interviews revealed a lack of implementation of a personalized activity plan.
A facility failed to implement infection control measures for a resident on enhanced barrier precautions (EBP). A nurse did not wear a protective gown while providing wound care, despite the resident having a diabetic foot ulcer and a dialysis port. The facility's policy required gown use during high-contact care activities for residents with wounds or indwelling devices. Observations and interviews confirmed the nurse's non-compliance with EBP requirements.
Oxygen Concentrator Not Inventoried in Resident Property Record
Penalty
Summary
The facility failed to ensure a resident was treated with respect and dignity by not ensuring the resident's oxygen concentrator was inventoried in the Resident's Clothing and Possessions record. The resident was admitted with diagnoses including heart failure, obstructive sleep apnea, and atrial fibrillation. The H&P indicated the resident had capacity to make decisions, and the MDS indicated the resident could make himself understood and understand others. During observation, the resident was seen in his room with an oxygen concentrator turned off at the right side of the bed with nasal cannula tubing attached. The resident stated he brought the concentrator from home, had used it for a long time, and could apply the tubing and turn it on himself when needed. He also stated he had asked if it was okay to bring it in and said no one had updated his personal belongings after he returned from the hospital. Record review showed the resident's chart contained no order for oxygen therapy administration or monitoring, while the Weights and Vitals Summary documented oxygen via nasal cannula on several dates. The LVN stated there was no mention of the oxygen concentrator in the nursing notes or the Resident's Clothing and Possessions form, and the DON stated the inventory should be updated on the day of admission or after admission. The DON also stated the inventory protects residents' property rights and helps prevent misappropriation of property.
Oxygen Therapy Provided Without Physician Order or Monitoring
Penalty
Summary
The facility failed to ensure respiratory care was provided in accordance with professional standards of practice for one resident who was admitted with diagnoses including heart failure, obstructive sleep apnea, and atrial fibrillation. The resident’s H&P indicated he had the capacity to make decisions, and the MDS indicated he could make himself understood and understand others. The care plan for congestive heart failure included oxygen therapy as ordered as an intervention, but the record review found no physician order for oxygen therapy administration. During observation, the resident was in bed awake with an oxygen concentrator at the bedside and nasal cannula tubing attached. The resident stated he had brought the concentrator from home, had used oxygen at home for a long time, and would apply the cannula and turn on the concentrator himself when he felt short of breath. He also stated he would call for help only if the concentrator was too far to reach. The concentrator was observed turned off at the right side of the bed. Record review showed nursing documentation of oxygen via nasal cannula on several occasions, and the LVN stated that such documentation meant oxygen had been administered. However, the LVN also stated there was no order for oxygen therapy administration and no monitoring. The DON stated oxygen therapy should be preceded by an order and assessment, and that the resident should be monitored for respiratory status and signs or symptoms of distress. The facility’s oxygen therapy policy required a physician order with specific parameters and assessment and documentation before and while oxygen was being administered, and stated only RNs and respiratory therapists or respiratory care practitioners may initiate or titrate oxygen.
Failure to Provide Requested Medical Records
Penalty
Summary
The facility failed to provide requested medical records to the responsible party of one sampled resident. Resident 1 was admitted on 11/29/2016 with diagnoses including epilepsy, type 2 diabetes mellitus, and COPD. The resident’s 9/4/2024 MDS indicated severely impaired cognitive skills for daily decision making. On 2/25/2026, an Authorization for the Release of Medical Information named RP 2 as the recipient authorized to receive Resident 1’s health information, business office files, billing records, and writings pertaining to medical history and treatment. The facility received RP 2’s request for Resident 1’s medical records by eFax on 4/23/2026. The Medical Records Director stated she received the request that day and emailed RP 2 on 5/6/2026 stating the records would be available at the end of that week. The requested records were not sent until 5/11/2026, which was 16 days after the date the records were supposed to be released. The facility’s policy stated discharged residents or their authorized representatives may request and receive a copy of the medical record within 15 days, and the Administrator stated the State Operation Manual indicated the facility must allow the resident to obtain a copy of the records or any portions thereof upon request and two working days advance notice to the facility.
Hot Water Not Maintained at Resident Bathroom Sinks
Penalty
Summary
The facility failed to honor residents’ right to a safe, clean, comfortable, and homelike environment by not maintaining hot water at resident-use bathroom sinks within the stated range of 105 to 120 degrees F for two sampled residents. For Resident 46, the record showed admission and readmission with diagnoses including anxiety disorder, anemia, and a history of falling. The resident’s H&P indicated decision-making capacity, and the MDS indicated the resident could make self-understood and understand others with intact cognition. During interview, Resident 46 stated the bathroom water was cold, uncomfortable for bathing, and took a long time to warm up, and said the facility was aware of the issue. During a concurrent observation and interview in Resident 46’s bathroom, the Maintenance Director ran the sink faucet for five minutes before it began to warm, and the water temperature measured 81 degrees F. The MD stated the issue was caused by the building setup and that hot water was being pulled to the laundry room when washers were used. The MD stated he was aware of the issue and could not do anything about it. The same condition was observed for Resident 85, whose record showed diagnoses including hypothyroidism, depression, and overactive bladder. Resident 85’s H&P indicated decision-making capacity, and the MDS indicated the resident could make self-understood and understand others with intact cognition. Resident 85 also stated the bathroom water was cold, uncomfortable for bathing, and took time to warm up, and said the facility was aware of the issue. The Resident Council meeting confirmed the concern was not isolated. Five of five residents attending stated the hot water in the facility was not warm enough and was very uncomfortable for bathing and other ADLs, and they said the facility had known about the concern for months. Facility-provided Resident Council minutes documented that hot water was lacking in the majority of residents’ rooms. The ADON and GBC both stated the hot water should be maintained between 105 and 120 degrees F for resident comfort, and the GBC stated the issue should be fixed regardless of the age of the building and the laundry-related water pull. The facility’s Homelike Environment policy and Maintenance Services-Water Temperature policy both stated resident-use water temperatures should be maintained between 105 and 120 degrees F and variances corrected promptly.
Physical restraints used without proper orders, assessments, or consent
Penalty
Summary
The facility failed to ensure five sampled residents were free from the use of physical restraints unless needed for medical treatment. For Resident 63, the record showed an order for bilateral bolsters to define the parameters of the bed, an informed consent for bilateral bolsters with a target behavior of sliding off the bed for fall risk, and a restraint assessment that referenced climbing out of bed, confusion, and sliding or leaning. During observation, the resident was seen with the bilateral bolsters tucked under the sheet, and staff stated the bolsters were being used to prevent the resident from getting out of bed and falling. The ADON stated the physician order and consent did not match and that the use of the bolsters to prevent the resident from getting out of bed was a restraint. For Resident 41, the record showed an order for a low air loss mattress with bolsters every shift for skin maintenance, while the care plan reflected use of the mattress with bolsters for fall risk. During observation, the resident had the bolsters tucked under the sheets, and staff stated this was done because the resident was high risk for falls and to make it harder for the resident to remove them. The ADON stated there was no informed consent, restraint assessment, or care plan on the use of the low air loss mattress with bolsters for restraint purposes, and stated the facility was using it for fall prevention. The facility-provided information also stated roll-control bolsters are not substitutes for bed side rails. For Resident 3, the resident was observed multiple times seated in a wheelchair with a pommel wedge cushion. The record review and staff interview showed there was no physician order, restraint assessment, or informed consent completed before the cushion was used. The ADON stated the pommel wedge cushion is a restraint, that the resident should have been assessed as a candidate, and that the responsible party should have been informed and asked for an order if they wanted the cushion used. For Resident 76 and Resident 56, the records showed orders for bilateral bolsters or a low air loss mattress with bolsters, but the ADON stated the orders did not specify the indication for use and that no device/physical restraint assessment had been completed prior to application. Observations showed Resident 76’s bolsters were tucked under the fitted sheet and Resident 56’s bolsters were inside the mattress and zippered, with staff stating the devices were used to prevent sliding and falls.
Unsafe Resident Environment and Supervision Failures
Penalty
Summary
The facility failed to keep the resident environment free of accident hazards for four sampled residents. Resident 63, who was admitted with muscle weakness, dementia, and altered mental status and was assessed as having severely impaired cognition and high fall risk, had bilateral floor mats in place, but a side table and a wheelchair were observed on top of the floor mat on the right side of the bed. The resident’s care plan called for a safe environment with floors free of clutter and personal items within reach, and the landing mat owner’s manual stated that objects should not be placed on the product during storage. Resident 77, who was admitted with dementia, depression, and cerebral infarction, was assessed as not able to self-administer medications. During observation in the resident’s room, an opened A&D ointment was found on the side table at the bedside even though there was no order for the ointment in the resident’s record. The resident’s care plan included promoting a safe environment, and the facility’s medication storage policies required safe and secure storage of medications and biologicals. Resident 41, who had diagnoses including psychosis and major depressive disorder, had a call light button cable with frayed and exposed wires near the call light console. The maintenance director and MDS coordinator both observed the condition, and the MDS coordinator stated exposed wires on the call light could cause electrocution. Resident 21, who was admitted with cerebral infarction, difficulty walking, and aphasia, was observed walking in the hallway with a slight limp while pushing a maintenance trolley. CNA 3 stated the resident was not supposed to be pushing the trolley and was unsteady, and the ADON stated all residents are supposed to be supervised and that the resident could trip and fall while pushing the equipment.
Failure to Rotate Subcutaneous Injection Sites
Penalty
Summary
The facility failed to ensure that subcutaneous insulin was administered with rotation of injection sites for a resident with type 2 diabetes mellitus, end stage renal disease, and encephalopathy. The resident’s orders included insulin lispro before meals and at bedtime with instructions to rotate the site, and the care plan also directed insulin administration as ordered. The location of administration record showed repeated use of the same general areas, including the left upper arm/rear upper arm on multiple occasions and the left arm/forearm on multiple occasions, rather than rotating sites as ordered. During a concurrent interview and record review, the ADON confirmed that there were multiple instances where licensed staff did not rotate the resident’s insulin administration sites as reflected in the record. The ADON stated there was an order to rotate the administration sites and that the staff did not follow the physician’s order, constituting a medication error. The ADON also stated that failure to rotate insulin injection sites can lead to lipodystrophy. The facility’s insulin administration policy stated that injection sites should be rotated to reduce the risk of damaging skin tissue, and the medication errors policy defined significant medication errors as administration not in accordance with the prescriber’s order, manufacturer’s specifications, or accepted professional standards. The facility also failed to rotate subcutaneous enoxaparin administration sites for another resident admitted with a displaced fracture of the right femur and ordered enoxaparin 40 mg subcutaneously daily for post-operative prophylaxis with instructions to rotate sites. The location of administration record showed enoxaparin given on consecutive days at the right arm. During direct observation, an LVN prepared and administered the enoxaparin injection to the resident at the right shoulder, then later checked the electronic record and found the last site had also been the right arm. The LVN stated he should have checked the record for the last administration site before giving the medication and acknowledged that not rotating the site was a medication error. The ADON also stated the injection should have been rotated and that staff should check the history of the last site in the electronic record before administering subcutaneous medications that require rotation.
Dietary Staff Lacked IDDSI Competency for Pureed Foods
Penalty
Summary
The facility failed to provide sufficient support personnel with the appropriate skills and competencies to carry out food and nutrition services when kitchen staff did not demonstrate knowledge of or competency with IDDSI testing for mechanically altered diets. On 2/23/2026, during tray line, the Dietary Supervisor, a cook, and other dietary staff prepared a puree meal for Resident 25 without performing IDDSI testing on the puree foods. The resident’s lunch tray included puree broccoli, puree pasta, and puree bread, and the broccoli was observed with a green-tinted, water-like liquid surrounding it. The staff member plating the meal stated the broccoli was separating and should not have water, and then stirred and replated the meal. Resident 25’s record showed admission on 11/6/2025 with diagnoses including dysphagia, chronic respiratory failure with hypoxia, and COPD. The resident’s MDS dated 2/4/2026 indicated the resident required supervision or touching assistance with eating and oral hygiene and was on a mechanically altered and therapeutic diet. The physician’s order summary dated 2/26/2026 showed an order for a consistent carbohydrate, no added salt, pureed texture, mildly thick consistency, fortified diet. The facility’s lunch menu for that day listed pureed seasoned fresh broccoli florets as part of the pureed meal. During interviews and record review, the Dietary Supervisor, the cook, and another dietary staff member stated they were not familiar with the term IDDSI spoon tilt test. One staff member stated the broccoli was prepared by placing an unmeasured amount of cooked broccoli and an unmeasured amount of cooking water into the blender. The Dietary Supervisor stated the facility had implemented the menu and recipe system with IDDSI about a year earlier, but no in-service had been provided to kitchen staff and no competency evaluations had been completed for IDDSI testing. The Registered Dietitian stated he was responsible for making sure kitchen staff were competent, but he had not provided an in-service or competency evaluation for the Dietary Supervisor. The Speech-Language Pathologist stated puree level 4 should be like a pudding texture and should pass visual checks, the spoon tilt test, and the fork drip test. The Assistant Director of Nursing and Governing Body Chair both stated the staff did not demonstrate competency with IDDSI standards, and the Governing Body Chair stated there was no documentation that the Administrator provided competency evaluations for the Dietary Supervisor.
Modified Diets Served in Incorrect Texture
Penalty
Summary
Food was not prepared in a form designed to meet individual resident needs for multiple residents on modified diets. During tray line observation, a resident on a pureed diet was served broccoli that was separating and surrounded by a green, water-like liquid, and staff did not perform IDDSI testing on the prepared pureed foods. Staff stated the broccoli had been made by blending cooked broccoli with an unmeasured amount of cooking water, and the dietary supervisor, cooks, and other staff stated they were not familiar with the term IDDSI spoon tilt test. The facility’s diet manual and recipe materials described the use of IDDSI testing for pureed foods, but staff did not demonstrate that testing during service. A second resident with dysphagia and an order for a minced and moist diet was served pureed garlic bread and penne pasta with mushroom sauce that was not runny and did not hold its shape during dining observation. The CNA stated the pureed bread and pasta were runny, and liquid was separating from the broccoli. The RD and ADON reviewed the tray and meal ticket and stated the resident was served food that was too thin and did not hold its shape for the ordered diet. The resident’s record showed diagnoses including dysphagia and the resident required assistance with eating and other ADLs. A third resident with dysphagia and an order for a soft and bite sized diet was served pasta with mushroom sauce that was finely chopped and minced rather than bite sized. CNAs observed that the noodles were soft but not bite sized, and one CNA stated the tray should be replaced with bite-sized pasta. The RD and ADON later reviewed the tray and stated the noodles were not bite-sized pieces, with most pasta pieces at least 1 inch in length. The resident’s record showed dysphagia, dementia, and dependence for multiple ADLs, and the meal served did not match the ordered texture.
Unsafe food storage and handling practices
Penalty
Summary
Safe and sanitary food storage and food preparation practices were not maintained in the kitchen during the survey observation. During an initial kitchen tour with the Dietary Supervisor, surveyors observed a damp white towel placed in the kitchen prep sink, a soiled white towel placed under a plate of parsley on the tray line, and a damp soiled towel left on top of dirty dishes in the dirty dish area. The Dietary Supervisor stated the towels were dirty and should not have been left in those locations. The Registered Dietician stated kitchen towels are kept in sanitation solution buckets and then used one time before being placed in the dirty towel bin, and that towels should not be left on kitchen surfaces because staff could grab and re-use dirty towels. Surveyors also observed multiple food storage problems in the Dry Food Storage Area, Ice Cream Freezer, and Dry Can Storage Area. In the Ice Cream Freezer, a clear plastic bag containing two frozen pizzas was observed without labels for the contents or date after removal from the original container. In the Dry Can Storage Area, a clear plastic bin of dry cereal had a lid that was not secured, and a package of English muffins labeled with a best if used by date of 2/11/2026 was still available. In the Dry Food Storage Area, a box of sprouting potatoes was not labeled with a date, and the Dietary Supervisor stated he was not sure when the potatoes arrived because the box was not dated. The Dry Food Storage Area also contained fruits and vegetables that the Dietary Supervisor stated should have been stored in the refrigerator per facility policy, including cabbage, green bell peppers, cantaloupes, cucumbers, and honey dew melons. The area had no thermometer and no temperature monitoring logs. The Dietary Supervisor stated the facility policy required all vegetables and fruits except potatoes, onions, and bananas to be stored at 41 degrees Fahrenheit in the refrigerator. The facility policies reviewed also stated that foods should be labeled and dated, opened products should be stored in containers with tight fitting lids, and perishable foods should be covered, labeled, and dated when stored in the refrigerator or freezer.
Missing QAPI Plan and Incomplete QAPI Data Review
Penalty
Summary
The facility failed to maintain documentation and demonstrate evidence of an ongoing QAPI program. During the Entrance Conference on 2/23/2026, the Assistant Director of Nursing (ADON) was given the Entrance Conference Worksheet, which included a request for the QAPI Plan. On 2/26/2026, during a concurrent interview and record review with the ADON, the survey binder and Entrance Conference Worksheet were reviewed, and the ADON stated the QAPI Plan in the binder was not the correct one and was dated 1/26/2023. The ADON stated she did not have access to the current QAPI Plan, and also stated the Administrator was unable to be reached and the Director of Nursing was not available. The ADON stated the QAPI Plan is a written plan used to identify problem care areas, discuss and fix them, and that it contains data, logs, in-services, meeting minutes, and analysis during QAPI meetings by the DON. The facility’s policy titled Quality Assurance Performance Improvement (QAPI), last reviewed 10/23/2025, stated the facility maintains documentation and demonstrates evidence of its ongoing QAPI program and that the QAPI plan is a written plan describing the process for conducting QAPI/QAA activities. The report also states the facility failed to provide documentation of data collection and analysis at regular intervals for falls, which the facility had identified as a problem issue.
Infection Control Failures With Call Lights and EBP PPE Use
Penalty
Summary
The facility failed to maintain its infection prevention and control program when a resident’s call light was observed dangling inside a trash can and was handed back for use without being sanitized. Resident 41 was admitted and later readmitted to the facility, had diagnoses including muscle weakness, difficulty walking, and major depressive disorder, and was assessed as cognitively intact but dependent to needing set-up assistance with mobility and ADLs. The resident was on enhanced barrier precautions for a left heel PVD ulcer, and the care plan directed environmental cleaning of the resident’s room, equipment, and devices. During observation, the MDS Coordinator saw the call light inside the trash can and stated it should not have been there and should have been sanitized before being returned to the resident. The facility also failed to sanitize Resident 37’s call light after it was found on the floor before handing it back to the resident. Resident 37 had diagnoses including cellulitis of both lower limbs, local infection of the skin and subcutaneous tissue, and depression, and the MDS indicated intact cognition with dependence to needing set-up assistance for mobility and ADLs. During observation, a CNA picked up the call light from the floor and handed it to the resident without wiping it with an antiseptic wipe. The CNA stated the call light should have been wiped before being returned to the resident, and the ADON stated the call light should not have been on the floor and should have been wiped prior to being handed back. The facility further failed to ensure CNA 10 wore a gown while providing ADL care to Resident 4, who was on enhanced barrier precautions. Resident 4 had a GT, dementia, generalized muscle weakness, severely impaired cognition, and was totally dependent on staff for all ADLs. The resident’s orders included GT care and EBP due to the GT and a right third toe ulcer, and the care plan included teaching about proper hand hygiene and PPE use. During observation, CNA 10 performed hand hygiene and put on gloves but did not put on a gown before starting ADL care, and later stated she had just finished care without wearing a gown. The ADON stated the signage indicated staff were to perform hand hygiene and put on gown and gloves for high-contact care activities for residents with wounds and indwelling medical devices such as a GT.
Call Light Not Kept Within Reach for Two Residents
Penalty
Summary
The facility failed to keep the call light within reach for two sampled residents. For one resident, the record showed diagnoses including muscle weakness, difficulty walking, and major depressive disorder, with intact cognition and dependence to set-up assistance for mobility and ADLs. That resident was identified as high risk for falls, and the care plan included keeping the call light within reach and encouraging use of it for assistance as needed. During a concurrent observation and interview, the resident’s call light button was seen dangling inside the trash can. The MDSC stated the call light should not be dangling inside the trash can because it would be hard for the resident to reach when needing help, and the resident could fall while reaching for it. During later interview and record review, the ADON stated the resident was at high risk for falls and that the call light should not be dangling on the trash can because it would be hard to reach and the resident would not be able to call for help when needed. For the second resident, the record showed diagnoses including muscle weakness, difficulty in walking, and depression, with intact cognition and dependence to set-up assistance for mobility and ADLs. The resident’s care plan included anticipating and meeting needs and keeping the call light within reach, although the fall risk evaluation indicated the resident was not at risk for falls. During observation, the resident’s call light was resting on the floor at the right side of the bed. CNA 4 stated the call light should always be within the resident’s reach so the resident can call for help when needed, and the ADON later stated the call light should not be resting on the floor because it would be hard for the resident to reach.
Missing POA Documentation in Resident Record
Penalty
Summary
The facility failed to ensure Resident 2’s medical record was updated with a current copy of the resident’s Durable Power of Attorney (POA) document. Resident 2 was admitted with diagnoses including metabolic encephalopathy, dementia, major depressive disorder, epilepsy, and diabetes mellitus. The record showed the resident had a POA listed as Friend 1, and the resident’s assessment and history and physical indicated the resident was able to understand others, make himself understood, and had capacity to make decisions. The resident’s care plan identified the resident as full code and full treatment unless rescinded by the resident, responsible party, or surrogate decision maker. A POLST signed by Resident 2 indicated the resident did not have an advance directive, while the psychosocial assessment/social history/discharge planning form indicated the resident had completed an advance directive and identified it as a POA. During interview and record review, RN 1 stated there was no documented evidence of the POA in the EHR and that Social Services kept POA documentation. The Social Services Coordinator stated the POA should have been uploaded into the EHR, but Friend 1 had not provided the document and there was no documented evidence the facility followed up to obtain it. Friend 1 stated he was Resident 2’s POA and that the documents had already been provided to the facility. The Assistant Director of Nursing reviewed the facility’s advance directives policy and stated the POA document communicates a resident’s wishes when the resident can no longer do so, that Social Services follows up to obtain and place the document in the chart, and that the facility’s policy was not followed. The policy stated the medical record should document whether the resident has an advance directive and that the facility will request a copy when the resident states one exists and periodically during care conferences if it has not been provided.
Failure to Notify Resident Representative After Fall
Penalty
Summary
The facility failed to document and communicate a significant change of condition for a resident who had a high fall risk and multiple diagnoses including metabolic encephalopathy, cerebral infarction, and major depressive disorder. The resident’s records showed the resident had a witnessed fall while being assisted in bed, with the RN documenting that the resident was found sitting on the floor, denied pain, had normal range of motion, baseline vital signs, and no visible injuries. The change of condition form listed the family/health care agent notification as self-monitoring rather than identifying a notified representative or family member. The resident’s history and physical later indicated the resident was transferred to acute care for worsening confusion and a fall, and the resident had capacity to make decisions. The minimum data set showed moderate cognitive impairment and dependence or need for supervision with mobility and activities of daily living. The care plan included interdisciplinary team, resident representative, and physician involvement, but the record reviewed did not show that the resident’s representative was informed of the fall. During interview, the resident representative stated she was upset because she was not notified when the resident fell at the facility and later learned the resident had been transferred to the hospital, where a broken hip was found. The CNA involved stated she could not remember whether the representative was informed, and the RN supervisor stated she could not remember calling the family member and acknowledged she should have informed the resident representative of the accident because it was facility policy to notify family members or resident representatives when accidents occur.
Missing monitoring orders for clonazepam use
Penalty
Summary
The facility failed to ensure Resident 12’s drug regimen was free from unnecessary drugs and that the use of clonazepam was monitored in accordance with facility policy and procedures. Resident 12 was admitted with diagnoses including cerebral infarction, epilepsy, and generalized muscle weakness. The resident’s H&P indicated the resident had capacity to make decisions, and the MDS indicated intact cognition and that the resident could understand others and make needs known. The record showed a physician’s order dated 1/12/2026 for clonazepam 1 mg by mouth three times daily for anxiety manifested by restlessness. However, the Order Summary Report did not include a physician’s order to monitor episodes of anxiety manifested by restlessness, monitor for adverse side effects, or document non-pharmacological approaches attempted every shift for the clonazepam use. The informed consent showed the resident’s responsible party consented by telephone for clonazepam for anxiety manifested by restlessness. The care plan for clonazepam use, initiated on 1/31/2025 and revised on 2/4/2026, included interventions to review medication use for gradual dose reduction, monitor and document side effects and effectiveness, and use non-pharmacological approaches. During interview and record review, the ADON stated there was no physician’s order to monitor the behavior manifestation, adverse side effects, or non-pharmacological interventions every shift, and stated such monitoring should have been in place so the physician, pharmacist, and IDT could know whether the medication was effective and tolerated.
Failure to Communicate Transfer Information to Receiving Hospital
Penalty
Summary
The facility failed to follow its transfers and discharge policy by not ensuring that necessary medical information was communicated to the receiving hospital when Resident 90 was transferred. Resident 90 was admitted with diagnoses including sepsis, acute respiratory failure, and CHF, and the MDS indicated severely impaired cognition, inability to understand others or make needs known, and total dependence on staff for all ADLs. On 1/21/2026, the resident had an abnormal BUN of 202 mg/dl, the NP was notified, and an order was given to transfer the resident to the ER via non-emergent transportation. The responsible party was notified, and the resident left the facility by gurney at 4:35 a.m. on 1/22/2026. During interview and record review, the ADON stated the facility practice for hospital transfers was to send the admission record and current physician orders with the resident and for licensed staff to give a telephone report to the receiving hospital, documenting it in the Health Status Notes. The ADON stated there was no documentation that the nurse provided the hospital with the necessary medical information when Resident 90 was transferred, and that the licensed nurse who transferred the resident should have called the hospital and documented the report. The facility policy stated that residents are transferred or discharged in a safe manner, the transfer or discharge is documented in the medical record, and appropriate information is communicated to the receiving healthcare institution or provider when a resident is transferred.
PASRR Screening Not Completed Accurately for Resident With Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure the PASRR was completed accurately for one sampled resident who was admitted with major depressive disorder, anxiety disorder, and PTSD. The resident’s admission record showed the resident was admitted on 2/11/2025, and the history and physical dated 2/15/2025 stated the resident had the capacity to make decisions. The MDS dated 2/18/2025 identified the resident as cognitively intact and listed active diagnoses of anxiety disorder, depression, and PTSD. The order summary report dated 2/11/2025 showed escitalopram oxalate 10 mg daily for depression manifested by persistent feeling of worthlessness. The PASRR Level I Screening dated 2/13/2025 stated the resident did not have a diagnosed serious mental illness and had not been prescribed psychotropic medications for serious mental illness. During interview and record review, the LVN reviewed the resident’s admitting diagnoses and physician orders and stated the PASRR Level I Screening was not completed accurately. The LVN also stated there was no correction or second PASRR Level I Screening submitted after 2/13/2025. The ADON stated the PASRR should be accurately completed to ensure the outcome is correct and the resident is evaluated and receives specialized services if required.
Failure to Develop Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident 5 after the resident had a fall on 10/31/2025. Resident 5 was admitted on 2/2/2024 and readmitted on 11/11/2025 with diagnoses including metabolic encephalopathy, cerebral infarction, and major depressive disorder. The H&P dated 11/12/2025 indicated the resident had the capacity to make decisions, and the MDS dated 11/18/2025 indicated the resident could make self-understood and understand others, with moderately impaired cognition. Resident 5’s MDS also indicated dependence to needing supervision assistance with mobility and ADLs, and the FRE dated 9/24/2025 identified the resident as high risk for falls. The COC dated 10/3/10225 documented a witnessed fall at around 8 p.m., when CNA 5 lowered Resident 5 while the resident was sliding off the bed. RN 2 assessed the resident, found the resident sitting on the floor, noted no pain, normal ROM, baseline vital signs, and no injuries, then assisted the resident back to bed and notified the PMD. During interview and record review, the ADON stated she was not able to see an actual care plan for the resident’s fall and stated licensed staff should have developed and implemented a care plan on the resident’s actual fall to ensure the resident got all needed care and prevent delays of care.
Failure to Maintain Nail Care and Personal Hygiene
Penalty
Summary
The facility failed to provide necessary grooming and personal hygiene services for two residents who were dependent on staff for care. One resident had diagnoses including vascular dementia, major depressive disorder, Alzheimer’s disease, and schizoaffective disorder, and the MDS indicated she was completely dependent on staff for eating, toileting, bathing, dressing, personal and oral hygiene, and mobility. Her care plan directed staff to check nail length and trim and clean nails on bath day and as necessary, and to communicate with the family regarding her needs. During observation, the Assistant Director of Staff Development was seen trimming the resident’s fingernails at the bedside. At that time, two nails on the left hand had been trimmed and three remained untrimmed; the untrimmed nails were white, overgrown to about one inch past the fingertip, and curling inward. The ADSD stated she noticed the nails were long while making rounds and said the LN or CNA was responsible for trimming them. The CNA present stated she had not cared for the resident in over a week and had not noticed the nails were long. The resident’s family member stated the nail length was an ongoing issue discussed with facility staff every time he spoke with them and said the nails were long and pressing into the resident’s palms. Staff interviews showed conflicting understanding about responsibility for nail care. One CNA stated she had never cut the resident’s fingernails because she believed CNAs do not cut nails for residents with DM, while the DSD stated the resident did not have DM and CNAs were responsible for cutting her fingernails. The ADON reviewed the facility policy and stated the resident’s nails should not have been kept long unless the family wanted them that way, and that the policy was not followed. The report also identified a second resident with COPD, anemia, and HTN who was dependent on staff for personal hygiene. That resident was observed with black dirt accumulated under the free edges of the right-hand fingernails, and a CNA stated the dirt was from scratching and wheelchair use and that she would clean the resident’s hands before he ate. The ADON stated CNAs should check fingernails before meals and offer to clean them, and the facility policy required staff to provide hygiene, including grooming and oral care.
Unlabeled and Overdue Urinal Care
Penalty
Summary
The facility failed to ensure that a resident who was incontinent of bladder received appropriate urinal care. Resident 40 was admitted with diagnoses including bipolar disorder, cognitive communication deficit, and generalized muscle weakness. The resident’s H&P did not indicate capacity to understand and make decisions, and the MDS indicated moderately impaired cognition, that the resident could understand others and make needs known, required assistance with toileting hygiene and personal hygiene, and was always incontinent of urine and occasionally incontinent of bowel. The resident’s care plan for preference to hang a personal urinal on the trash can directed staff to observe the urinal frequently for cleanliness, ensure it was emptied, disinfect it after each use, and replace it as needed if soiled. During observation in the resident’s room, two urinal bottles were present at the bedside. One urinal hanging at the bed headboard had no label, and the other urinal in a holder on the right side of the bed was labeled with the date 1/12/2026. CNA 12 stated the unlabeled urinal should have had the resident’s name or room number and the date it was last changed, and stated the dated urinal was very old and should have been changed. The ADON stated the facility practice was to change urinals at least weekly and that the urinal dated 1/12/2026 was very old and should have been changed. The ADON also stated the unlabeled urinal should have had the resident’s name or room number and the date it was last changed to prevent it from being switched with another resident’s urinal and to prevent cross-contamination. The facility’s policies on cleaning and disinfection of resident care items and infection prevention and control stated that reusable resident equipment is to be cleaned and disinfected and that standard precautions include cleaning and disinfection of reusable resident medical equipment.
Feeding Tube Syringe Not Replaced Every 24 Hours
Penalty
Summary
The facility failed to ensure proper care for a resident with a feeding tube by not discarding a reusable piston syringe after 24 hours of use. Resident 6 was admitted and later readmitted with diagnoses including gastrostomy, GERD, and dysphagia. The resident’s H&P indicated the resident had capacity to make decisions, and the MDS indicated the resident usually could make self-understood and understand others, had intact cognition, and was dependent to needing partial assistance with mobility and ADLs. The MDS also indicated the resident had a feeding tube. The resident’s OSR directed enteral feeding every day shift and to change the syringe daily. The care plan included an intervention to discard continuous enteral feeding containers and administration sets every 24 hours. During observation on 2/23/2026, the resident’s piston syringe was seen hanging on the feeding pole stand in a plastic pouch dated 2/22/2026. The MDSC stated the syringe should have been discarded by the night shift licensed nurses and replaced with a new syringe dated 2/23/2026. The ADON later stated the night licensed nurses should have discarded the syringe and replaced it with a new one, and that the facility’s Enteral Feeding- Syringe policy was not followed because syringes should be replaced every 24 hours.
Unlabeled Peripheral IV Dressing
Penalty
Summary
The facility failed to ensure parenteral fluids were administered consistent with professional standards of practice for one resident reviewed for hydration. Resident 5 was admitted with diagnoses including type 2 DM, ESBL resistance, and major depressive disorder, and the H&P indicated the resident had the capacity to make decisions. The MDS indicated the resident could make self-understood and understand others and had moderately impaired cognition. The resident had an order for peripheral IV therapy to monitor the IV site every shift and as needed for signs of infiltration or phlebitis, and to flush with 5 cc NS before and after medications and every shift as needed. During an interview and observation, Resident 5 stated the peripheral IV in the right arm had been inserted at another facility and that the resident could not remember when the dressing was last changed by facility staff. RN 1 observed the resident had a gauge 22 peripheral IV on the right arm covered with Kerlix without the date and initials of the licensed nurse who inserted the IV or changed the dressing. RN 1 stated peripheral IV dressings should be changed weekly and as needed. The ADON stated licensed staff are responsible for changing the peripheral IV dressing and ensuring the site is current and labeled with the date it was inserted or last changed and the initials of the licensed nurse. The facility policy stated peripheral IV dressings should be labeled with the date and time of dressing placement, initials, gauze size, and length of catheter.
Respiratory Equipment Not Maintained in a Clean and Labeled Condition
Penalty
Summary
The facility failed to ensure respiratory care equipment was maintained in accordance with professional standards for three residents. For one resident with diagnoses including acute respiratory failure with hypoxia, chronic diastolic heart failure, and obstructive sleep apnea, the chart showed an order for BiPAP use at night and as needed for respiratory distress, along with an order to replace mask and tubing accessories as needed due to device degradation. During observation, the resident’s BiPAP/CPAP mask and tubing were found in a clear plastic bag with no resident name and no date indicating when the equipment was provided. The RN stated the bag should have been labeled with the resident’s name and date provided, and the ADON stated the mask and tubing should be changed every 30 days and as needed to prevent respiratory infection. For another resident with diagnoses including acute respiratory failure with hypoxia, gastrostomy, and major depressive disorder, the record showed an order for ipratropium-albuterol nebulizer treatments as needed for shortness of breath or wheezing. During observation, the resident’s nebulizer mask and tubing were found in a clear plastic bag dated 2/10/2026. The MDSC stated the nebulizer mask and tubing should have been discarded by the night shift nurses, and that the equipment should be changed every seven days and labeled with the date it was provided. The ADON also stated the nebulizer mask and tubing should be changed every seven days and as needed to prevent respiratory infection. For a third resident with diagnoses including acute respiratory failure, adult failure to thrive, and generalized muscle weakness, the record showed an order for oxygen at 2 L/min via nasal cannula continuously with oxygen saturation monitoring every shift. During observation, the resident was asleep in bed with the nasal cannula tubing touching the floor. The LVN stated staff were supposed to ensure the oxygen tubing was not touching the floor at any time because the floor is dirty and can contaminate the tubing. The ADON stated the tubing should not touch the floor because contamination or bacteria can travel up the tubing and the resident can inhale the bacteria.
Pain Medication Given Outside Ordered Parameters
Penalty
Summary
Safe, appropriate pain management was not provided for a resident who had diagnoses including Parkinsonism, heart failure, and hypertension and was documented as having decision-making capacity. The physician ordered tramadol 50 mg by mouth every six hours as needed for moderate pain, and also ordered pain monitoring every shift using a 0 to 10 scale, with 4 to 6 defined as moderate pain and 7 to 10 as severe pain. The resident’s care plan for tramadol included black box warning interventions related to addiction, abuse, misuse, and life-threatening respiratory depression. During a concurrent interview and record review, an LVN stated she administered tramadol at 10 a.m. but did not sign the controlled substance receipt record at the time of administration. She stated she forgot to sign the record after giving the medication and acknowledged that she should have signed it as soon as she administered it to ensure the medication was given and to prevent a miscount. The ADON stated the controlled substance receipt record is used for documentation and accurate counting of controlled medications, and that failure to sign it could allow a double dose to be given. During follow-up interview, the LVN stated the resident reported pain levels of 6 and 7 and that she chose the higher level of 7. She stated tramadol was ordered for moderate pain and that she should have called the physician because the resident reported severe pain. She also stated she thought a pain level of 7 was moderate pain and did not contact the physician at that time. The ADON stated the physician parameters for tramadol were for moderate pain only, and that the resident reported a pain level of 7, which is severe pain. The facility’s policies stated medications must be administered in accordance with orders, controlled substances must be reconciled with the MAR and resident controlled substance record, and PRN controlled substance orders must clearly identify the condition for which they are administered.
Dialysis assessments and communication not completed
Penalty
Summary
The facility failed to ensure safe, appropriate dialysis care for a resident with ESRD who received hemodialysis. The resident was admitted with diagnoses including ESRD, dependence on renal dialysis, HTN, and hemiplegia/hemiparesis following CVA. The care plan identified the resident as having potential complications related to ESRD/HD and included interventions to assess the left arm AV shunt, communicate with the HD center using the HD communication form, and call the physician for changes in condition. The physician orders included HD with pre- and post-HD vital signs on Tuesday, Thursday, and Saturday. During review of the resident's records and interviews with nursing staff, the facility did not document a post-HD assessment after the resident returned from HD on one occasion, and there was no documented time of return from HD. RN 1 stated the resident should have been assessed and documented upon return to ensure stability and to monitor for bleeding or blood pressure changes. On another occasion, the HD Communication Record form was left blank and the pre-HD facility assessment was not completed. LVN 2 stated she did not complete the form, and RN 1 stated the form should have included the resident's vital signs, access site information, and the nurse's name and date. The ADON reviewed the facility dialysis policy and stated the process required completion of the HD Communication Record form with the nurse's assessment and ongoing communication with the HD center before and after dialysis. The ADON stated the facility process after HD was for the nurse to assess the resident upon return because of possible high blood pressure or bleeding. The ADON stated the facility policy and procedure was not followed for this resident.
Controlled Medication Not Properly Documented
Penalty
Summary
The facility failed to accurately account for one dose of tramadol for Resident 95 in Medication Cart 1. Resident 95 was admitted and later readmitted to the facility and had diagnoses including Parkinsonism, heart failure, and hypertension. The resident’s H&P dated 2/25/2026 indicated the resident had the capacity to make decisions. A physician order dated 2/24/2026 directed tramadol hydrochloride 50 mg, one tablet by mouth every six hours as needed for moderate pain. During a concurrent interview and record review on 2/25/2026 at 11:20 a.m., LVN 2 reviewed the MAR and the Drug Control Receipt Record/Disposition Form for tramadol and stated she administered the medication at 10 a.m. but forgot to sign the Drug Control Receipt Record after giving it. LVN 2 stated the signature should be completed as soon as the medication is administered to ensure it was given and to prevent a miscount. During an interview on 2/26/2026 at 12:58 p.m., the ADON stated the drug control receipt record is used to document and ensure correct and accurate counting of controlled medications, and that failure to sign it could allow a resident to overdose because a licensed nurse may give a double dose. The facility’s policy stated controlled substances are reconciled to the MAR and the individual resident’s controlled substance record, and that medications must be administered according to orders using the pour, pass, chart standard of practice.
Pureed Menu Not Followed and IDDSI Testing Not Performed
Penalty
Summary
The facility failed to prepare and follow the pureed menu for a resident on a pureed diet by not having the pureed broccoli recipe available during lunch service and by not performing IDDSI testing on the prepared food. The resident had diagnoses including dysphagia, chronic respiratory failure with hypoxia, and COPD. The resident’s MDS indicated the resident required supervision or touching assistance with eating and oral hygiene and was on a mechanically altered and therapeutic diet. A physician’s order dated 2/23/2026 specified a consistent carbohydrate, no added salt, pureed texture, mildly thick consistency, fortified diet. During tray line observation, the resident’s lunch tray was prepared with pureed broccoli, pureed pasta, and pureed bread. When the plate cover was removed, the broccoli was observed with a green tinted, water-like liquid surrounding it. The cook stated the broccoli was separating and should not have water, and then stirred and replated the meal. The cook did not perform IDDSI standardized testing on the prepared pureed foods during tray line. The cook stated the broccoli had been prepared by blending cooked broccoli with an unmeasured amount of cooking water, and the dietary supervisor stated the pureed broccoli recipe was not with the printed recipes and had to be printed. Interviews with dietary staff showed they were not familiar with IDDSI testing, including the spoon tilt test. One cook stated there had never been printed pureed menus available in the kitchen and that he did not follow a recipe to determine how much water or thickener to add to pureed foods. The dietary supervisor stated the pureed recipes should be printed, in the kitchen, and followed when preparing meals, and that the cooks did not have the recipes during lunch service. The speech-language pathologist and dietary supervisor stated level 4 pureed foods must meet IDDSI appearance, fork drip, and spoon tilt testing standards, and the dietary supervisor stated the watery broccoli could potentially cause liquid going to the lungs, coughing, and aspiration when served to residents.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to ensure that Resident 44 received food that accommodated the resident’s preferences and was appealing. Resident 44 was admitted with diagnoses including type 2 DM, sepsis, and muscle weakness, and the H&P indicated the resident had the capacity to make decisions. The MDS showed the resident could make self-understood and understand others, with moderate cognitive impairment, and the resident was on a mechanically altered and therapeutic diet. The OSR ordered a CCHO diet with regular texture, thin liquids, double protein with meals, and no potatoes, peas, or corn. The care plan included an intervention to provide and honor food preferences. During dining observation, Resident 44 stated the kitchen did not know how to cook the eggs and that the food was drowned with gravy, and the oatmeal was stone cold during breakfast. On 2/25/2026, the resident stated he was upset because he had asked for over easy eggs and toast for breakfast, but the tray contained two eggs cooked over hard and two burnt toasts instead of the ordered three over easy eggs and bacon with milk listed on the meal tray ticket. The Dietary Supervisor reviewed the tray photo and stated the toast was burnt and the eggs were not cooked over easy, and the ADON also confirmed the eggs were not over easy and the toast was burnt.
Failure to Confirm Acceptance Prior to Resident Discharge
Penalty
Summary
The facility failed to ensure a safe and orderly transfer or discharge for a resident diagnosed with Guillain-Barre Syndrome and hypertension, who required partial assistance with activities of daily living and had no cognitive impairment. The resident was initially admitted and later readmitted to the facility, with discharge planning indicating a return to recuperative care upon discharge. However, the facility discharged the resident to recuperative care without obtaining written confirmation that the receiving facility would accept the resident. On the day of discharge, the resident left the facility with all medications and belongings, but shortly after, the outside social service worker (OSSW) notified the facility that recuperative care would not accept the resident due to their medical condition. The resident returned to the facility parking lot and requested assistance, after which the assistant social worker (ASSW) accompanied the resident to a hospital and left the resident in the hospital parking lot. The resident then walked into the emergency room independently. Interviews with facility staff, including the ASSW, social service worker, administrator, and director of nursing, confirmed that there was no written or official confirmation from recuperative care regarding acceptance of the resident. The facility relied on verbal and email communication from the OSSW and did not have documentation of acceptance. Facility policy required sufficient preparation and orientation to ensure safe and orderly transfer or discharge, which was not followed in this instance.
Failure to Monitor and Treat Worsening Buttocks Wound
Penalty
Summary
The facility failed to provide necessary wound monitoring and treatment for a resident with diabetes, hemiplegia, hemiparesis, and contractures who was admitted with orders for a low air loss mattress with bolsters for skin maintenance. The resident’s record showed a wound on the left buttocks that was first documented as moisture-associated skin damage, with the MD notified and treatment ordered per facility protocol. A Wound Weekly Monitoring Assessment dated 9/9/2025 documented the wound at 3 cm by 3.5 cm by 0.2 cm. The record review showed there was no Wound Weekly Monitoring Assessment completed for the week of 9/23/2025. The Treatment Administration Record also showed no wound care treatment was provided from 9/24/2025 through 9/28/2025. On 9/29/2025, the wound was documented as 6 cm by 4 cm with depth unable to determine, and the Order Summary Report then included wound care orders for cleansing with normal saline, applying dermaseptine for MASD, and applying medihoney for pressure injury with a foam dressing. During interview, the treatment nurse stated the wound had initially been MASD, then opened up and became unstageable, and that the wound increase in size would be considered a change in condition. The nurse stated the missing weekly assessment could have delayed recognition of the change and that the five-day break in documented wound care meant the care could not be confirmed as provided. The nurse also stated he did not notify the MD or resident representative of the change in condition. The DON stated the wound increase should have had its own change in condition documentation and that without it, the resident could not be properly monitored and the MD and resident representative could not be confirmed as notified.
Failure to Notify MD and RP of Worsening Wound Change of Condition
Penalty
Summary
The facility failed to inform the attending physician and the resident's responsible party when a resident experienced a change of condition involving a worsening wound on the left buttocks. The resident was admitted with diagnoses including type 2 DM, hemiplegia, hemiparesis following cerebral infarction, and contracture of muscle in multiple sites. The resident's MDS indicated the resident could understand and be understood, but was dependent for eating, oral hygiene, toileting, showering, dressing, footwear, and personal hygiene. Record review showed the resident had an order for a low air loss mattress with bolsters every shift for skin maintenance. The wound documentation showed the left buttocks area was first documented as MASD with no open skin, discharge, or bleeding, and the MD was made aware with the RP also documented as made aware. Subsequent wound monitoring documented the area at 3 cm by 3.5 cm by 0.2 cm on 9/9/2025 and again on 9/16/2025. On 9/29/2025, the wound monitoring assessment documented the left buttocks wound had increased to 6 cm by 4 cm with depth unable to determine, and treatment orders were entered for cleansing, topical products, and foam dressing for MASD and pressure injury. During interview, the treatment nurse stated the wound had increased in size and this would be considered a COC, but he did not notify the MD or RP of the COC and could not recall whether the RN supervisor was notified. The DON stated the wound size increase should have had its own COC and that without it, the facility could not monitor the wound properly and could not say the RP and MD were made aware of the resident's COC.
Dusty bedside fan in resident room
Penalty
Summary
The facility failed to maintain a clean and sanitary environment for Resident 4 when the resident’s bedside fan was observed with thick gray dust. Resident 4’s admission record showed diagnoses including pneumonia, bronchiectasis, and dysphagia. The MDS dated 8/30/2025 indicated the resident could understand and be understood, but was dependent for eating, oral hygiene, toileting, showering, upper and lower body dressing, putting on and taking off shoes, and personal hygiene. The resident’s order summary dated 11/5/2025 also showed oxygen at 2 LPM via nasal cannula continuously, with oxygen saturation to be monitored and documented every shift and maintained above 91%. During a concurrent observation and interview on 12/1/2025 at 10:37 a.m., Resident 4 stated the fan at the side of the bed belonged to him and that staff were supposed to dust it but had not. The resident stated the dust was probably why he coughed so much and described the dust on the fan as thick and gray and disgusting. Later that day, the DON observed the fan and stated there was accumulation of dust on it, that it should not be like this because it could be a potential for respiratory issues, and that it would not be providing a homelike environment because it was dirty. The facility policy stated staff are responsible for creating a homelike environment and promptly addressing cleaning needs, and that the resident has a right to a safe, clean, comfortable, and homelike environment.
Improper Labeling and Storage of Resident Food
Penalty
Summary
The facility failed to ensure safe and sanitary practices were followed for food brought from outside the facility for one sampled resident. Resident 4 was admitted with diagnoses including pneumonia, bronchiectasis, and dysphagia, and the MDS indicated the resident could understand and be understood but was dependent for eating, oral hygiene, toileting, showering, dressing, shoes, and personal hygiene. During interview, Resident 4 stated he buys food and staff place it in the refrigerator at Nurses Station 2, and that his food is usually kept there for one week. During observation of the Station 2 resident refrigerator, Resident 4's food was found in a Ziplock bag labeled with the resident's identifier and a date of 10/26/2025. Inside the bag were opened sliced pepper jack cheese with no open date and opened hard salami with no open date and a partially erased use-by date that could not be determined. The DON stated resident food is stored in Nurses Station 2, that opened items must be thrown away within 48 hours, and that resident food items must be labeled with received date, opened date, and resident identifier. The DON reviewed the items and stated the cheese and salami should have been discarded on 10/29/2025 because they were opened, and that food not properly labeled and not discarded within 48 hours can become spoiled and cause food borne illness.
Failure to Enforce Masking During Respiratory Virus Season
Penalty
Summary
The facility failed to implement its infection control measures during respiratory virus season by not ensuring that staff wore masks properly or at all while inside the building. The deficiency involved three sampled residents: one resident admitted with diabetes mellitus, generalized muscle weakness, and aphasia who had intact cognitive skills and capacity to understand and make decisions; a second resident admitted with respiratory tract disease, generalized muscle weakness, and hypertension who had severely impaired cognitive skills and was identified as at risk for RSV; and a third resident admitted with urinary tract infection, generalized muscle weakness, and hypertension who also had severely impaired cognitive skills. During observation in the hallway, the Activity Director was seen wearing a mask with her nose exposed while interacting with the first resident and giving the resident a high five. The Activity Director later stated she had adjusted her mask and forgot to cover her nose before interacting with the resident. She acknowledged that it was mandatory for staff and visitors to wear a mask inside the facility and stated the resident could get infected with influenza because the mask was not worn properly. Additional observations showed a Housekeeping staff member walking in the hallway without a mask and a CNA walking in the hallway and entering the rooms of the second and third residents without a mask. Both staff members stated they had forgotten to wear their masks and acknowledged they had been informed that masking was mandatory inside the facility to prevent spread of infection. The IP, DON, and ADON all stated that staff had to wear masks inside the facility during respiratory virus season, and the DON stated the residents could have been exposed to respiratory illness because the staff did not wear masks properly or at all.
Failure to Implement Bed Bug Surveillance and Reporting Under Infection Control Program
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program and related policies when bed bugs were identified in a shared resident room. On 10/9/2025, a CNA assisting a resident in Room A around 4 a.m. observed several small red insects on the white linen covering the resident’s mattress and notified another CNA, who then informed an LVN. The LVN went to Room A, confirmed the presence of small insects on the resident’s bed, notified an RN, and completed a skin assessment that did not show signs of bed bug bites. The Infection Preventionist (IP) was later informed by a supervisor that a bed bug had been seen in Room A and went to assess the residents in that room, again not observing signs of bed bug bites. Resident records showed that three cognitively intact residents with varying levels of dependence for activities of daily living were residing in Room A. One resident had diagnoses including type 2 diabetes mellitus, cerebral infarction, and cardiomegaly and was dependent on staff for toileting hygiene, personal hygiene, showers, and dressing. A second resident had type 2 diabetes mellitus, osteomyelitis, and muscle weakness, required supervision for toileting and personal hygiene, and needed assistance for showers, dressing, and ambulation. A third resident had a history of cerebrovascular accident with right-sided hemiplegia, end-stage renal disease, and dependence on dialysis, and required moderate to maximal assistance with hygiene and dressing but was independent in wheelchair mobility. A pest management company inspected Room A later that morning and positively identified bed bugs on one mattress, with a recommendation for heat treatment. The IP stated that bed bugs can be transferred via clothing and linens and can cause bites, allergic reactions, rash, itchiness, and welts, but acknowledged that the facility did not initiate contact tracing between residents in Room A and staff assigned to that room, nor between those staff and other residents. The IP further stated that residents outside Room A were not assessed for bed bug bites or skin rashes, and that the facility failed to develop a surveillance and monitoring system for bed bugs after the incident. The Maintenance Supervisor confirmed that the pest control company conducts monthly inspections and that the 10/9/2025 bed bug finding was not a usual occurrence. The Administrator and Assistant Director of Nursing both indicated that bed bugs were not a usual occurrence in the facility and that failure to thoroughly inspect the facility and residents for bed bugs had the potential to affect resident safety. Review of facility policies showed that the Infection Prevention and Control Program policy required the facility to identify, investigate, control, and prevent infections and to maintain a safe, sanitary, and comfortable environment. A separate Bed Bugs policy stated its purpose was to ensure the facility takes precautions needed to prevent, control, and manage a bed bug infestation. The facility’s Reportable Diseases and Communicable Diseases–Outbreak policies defined “unusual occurrences” as events such as epidemic outbreaks or other occurrences that threaten the welfare, safety, or health of patients, personnel, or visitors, and indicated that such occurrences should be promptly identified and reported. The Administrator stated that bed bugs were not a usual occurrence in the facility and that their identification had the potential to negatively affect resident safety and health, but the facility did not contact the Department of Public Health to report this unusual occurrence, contrary to its policies.
Failure to Revise Care Plans After Bed Bug Infestation in Shared Room
Penalty
Summary
The deficiency involves the facility’s failure to review and revise the comprehensive care plans for three cognitively intact residents sharing the same room after bed bugs were identified on one resident’s mattress. Resident 1, originally admitted in 2022 and readmitted in 2025 with diagnoses including DM II, cerebral infarction, and cardiomegaly, was dependent on staff for toileting hygiene, personal hygiene, showers, and dressing. Resident 2, admitted in July 2025 with DM II, osteomyelitis, and muscle weakness, required supervision or moderate assistance for hygiene and dressing. Resident 3, admitted in February 2025 with CVA, right-sided hemiplegia, end stage renal disease, and dependence on dialysis, required moderate to maximal assistance with hygiene and dressing. All three residents had documented capacity to make decisions and intact cognitive functioning. On the early morning of 10/9/2025, CNA 1, while assisting Resident 1 with perineal care, observed several small red insects on the white linen covering Resident 1’s mattress near the resident’s head. CNA 2 informed LVN 1, who then went to the room between 4 a.m. and 5 a.m. and also observed small insects on Resident 1’s bed. LVN 1 notified an RN and completed a skin assessment on Resident 1, noting no signs of bed bug bites such as red bumps or rash at that time. The room, shared by Residents 1, 2, and 3, was subsequently inspected by a pest management company, which confirmed bed bugs on one mattress and recommended heat treatment. Service notifications from the pest management company documented a positive identification of bed bugs in Room A on 10/9/2025 and completion of heat treatment on 10/10/2025. Despite these findings and the shared occupancy of the room by three residents, the facility did not revise or update the comprehensive care plans for Residents 1, 2, and 3 to address monitoring for skin problems or other complications related to potential bed bug bites. In an interview, the ADON acknowledged that the care plans were not revised after the bed bugs were found and stated that the care plans should have been updated with interventions for staff to monitor for skin problems and report issues to the physician. The facility’s own policy on developing and implementing comprehensive, person-centered care plans requires addressing each resident’s medical, physical, mental, and psychosocial needs.
Call Light Not Placed Within Reach for High-Risk Resident
Penalty
Summary
The facility failed to provide reasonable accommodation of resident needs and preferences by not ensuring that the call light was within reach for a resident with significant cognitive impairment and high fall risk. The resident, who had diagnoses including sepsis, schizoaffective disorder bipolar type, dementia, and major depressive disorder, was unable to make decisions or communicate needs effectively. The resident required substantial to total assistance with activities of daily living and was assessed as high risk for falls. The care plan specifically directed staff to keep the call light within easy reach and encourage its use to minimize fall risk. During an observation, the resident was found asleep in bed with the call light on the floor at the foot of the bed, out of reach. A CNA acknowledged that after providing ADL care, she should have ensured the call light was within reach, as required by facility policy and the resident's care plan. Both the ADON and DON confirmed that staff are expected to place call lights within reach after care, and failure to do so could result in unmet needs and increased risk for the resident. The facility's policy also stated that the call system must be accessible to residents while in bed.
Failure to Ensure Residents' Right to Be Free from Physical Restraints
Penalty
Summary
The facility failed to ensure that residents were free from the use of physical restraints unless required for medical treatment, as evidenced by the care of two residents. For one resident with schizoaffective disorder, major depressive disorder, and seizures, the facility placed the bed against the wall as a fall prevention measure. Although there was a physician's order for this intervention, the facility did not complete the required quarterly restraint assessments to evaluate the continued appropriateness of this measure, as mandated by facility policy and the resident's care plan. The only documented restraint assessment was from several months prior, and both the Assistant Director of Nursing and the Director of Nursing confirmed that quarterly assessments were not performed as required. Another resident, diagnosed with sepsis, schizoaffective disorder, dementia, and major depressive disorder, was found with pillows tucked under the fitted sheet on one side of the bed, with the bed itself against the wall on the other side. This intervention was implemented by a CNA to prevent falls, but there was no physician's order or care plan documentation supporting this practice. The CNA stated that they believed this was not a restraint, but facility policy and the ADON clarified that tucking pillows under the fitted sheet is considered a restraint and is not permitted, as it restricts the resident's freedom of movement. Both cases demonstrated a lack of adherence to the facility's own policies and procedures regarding the use of physical restraints. The required interdisciplinary team discussions, documentation, and ongoing evaluations were not completed for the use of the bed against the wall, and unauthorized restraint practices were implemented without proper assessment or documentation for the use of pillows under the fitted sheet. These actions resulted in the restriction of residents' freedom of movement and did not honor their right to be free from physical restraints.
Failure to Provide Written Notice and Orientation for Room Changes
Penalty
Summary
The facility failed to provide written notice indicating the reason for room changes for three residents, as required by its own policy and federal regulations. Each resident was moved to a different room without receiving written documentation explaining the reason for the change. Interviews revealed that one resident, who is blind and had been in her previous room for over a year, was moved to a smaller room at the far end of the building, which made it difficult for her to navigate and caused her distress. Another resident reported being moved without being asked or given any documentation, leading her to feel disregarded and unable to exercise her right to make decisions about her living arrangements. A third resident, after complaining about a noisy roommate, was told she had to move because she was the complainant, and was not oriented to her new room or roommate. Review of facility policy confirmed that written notice, including the reason for the room change, should be provided to residents, and that social services staff are responsible for assisting with orientation to the new room and roommate. The Social Service Director acknowledged that no written notifications were given to the affected residents or their responsible parties. The lack of written notice and orientation resulted in the residents feeling their rights were violated and left them feeling upset and disempowered.
Failure to Provide Written Notification and Explanation for Room Changes
Penalty
Summary
The facility failed to update and implement its policy and procedure regarding room changes, affecting three residents who were moved without proper written notification or explanation. The facility's current policy required written notice for room or roommate changes, including the reason for the move, but this was not followed in practice. The Social Service Director confirmed that no written notifications were provided to the residents or their responsible parties, and the Director of Nursing acknowledged that the policy did not align with regulatory guidance requiring written explanations for such moves. Resident 1, who was blind and had type 2 diabetes mellitus, was moved from her room of over a year to a new location designated for isolation purposes. She reported not being oriented to the new room, experiencing difficulty navigating the space, and feeling that her needs were disregarded due to the room's location and size. Resident 2, with a diagnosis of cerebral infarction and dependent on staff for activities of daily living, stated that staff moved her without asking for her input or providing any documentation or explanation for the change, leaving her feeling disrespected and unable to exercise her rights. Resident 3, who had a urinary tract infection and required substantial assistance, was moved after complaining about a noisy roommate. She reported that staff informed her that the complainant would be the one moved, and she was not oriented to her new room or roommate. She felt forced to move and believed the process was unfair. The facility's governing body was found to be responsible for ensuring policies were updated and implemented, but failed to do so in accordance with regulatory requirements.
Resident's Dignity Compromised Due to Inadequate Coverage During Hallway Walk
Penalty
Summary
A deficiency occurred when a resident, who required substantial assistance with activities of daily living and had an intact thought process, was not fully covered while walking in the hallway with a physical therapist student. During the walk, the resident's gown was pulled upward, exposing the incontinence brief. The physical therapist student acknowledged that the resident's brief was exposed and stated the importance of keeping the resident covered to maintain dignity and comfort. The Director of Nursing confirmed that staff are required to ensure residents are fully covered at all times in public areas to protect their dignity. Facility policy on dignity and respect, reviewed on 10/30/2024, also states that residents must be treated with dignity and respect at all times, including assistance in maintaining self-esteem and self-worth. The failure to keep the resident covered in the hallway constituted a lack of dignity and respect as required by facility policy.
Obstructed Emergency Exit and Hallway by Equipment
Penalty
Summary
Surveyors observed that a Hoyer lift was parked directly in front of and close to an emergency exit door, an emergency crash cart was parked beside the utility room, and two wheelchairs were parked along the right side of the hallway in Station A. During the tour, a Licensed Vocational Nurse confirmed that these items were blocking the hallways and the exit door, acknowledging that such placement was inappropriate. The Director of Nursing also stated that emergency exits should not be blocked, as this could prevent residents from exiting during an emergency. Review of the facility's policy indicated that the environment should be safe, clean, comfortable, and not pose a safety risk, with the physical layout maximizing resident independence.
Inaccurate Fall Risk Assessment Documentation
Penalty
Summary
The facility failed to accurately document a Fall Risk Assessment for a resident after the resident experienced a fall. The resident, who was admitted with diagnoses including muscle weakness, difficulty in walking, and paraplegia, was identified as being at risk for falls due to gait and balance problems. Despite this, after an unwitnessed fall where the resident was found on the floor, the subsequent Fall Risk Evaluation inaccurately recorded a lower fall risk score. This was due to the nurse not marking the fall, not noting the need for assistive devices, and incorrectly indicating that the resident had not fallen in the last three months. The Director of Nursing acknowledged that the Fall Risk Evaluation was inaccurately documented, which could affect the nursing interventions provided to the resident. The facility's policy requires that fall risk assessments incorporate information from various sources, including the Minimum Data Set and Care Area Assessments, to ensure accurate and reliable evaluations. However, the failure to document the fall and update the risk assessment accordingly represents a deficiency in the facility's adherence to its own policies and procedures.
Verbal Altercation Between Residents Leads to Abuse Deficiency
Penalty
Summary
The facility failed to protect two residents from verbal abuse, which occurred when both residents engaged in a verbal altercation. Resident 2, admitted with diagnoses including muscle weakness, hypertension, and end-stage renal disease, had intact cognitive skills for daily decision-making but required assistance with various activities of daily living. Resident 3, admitted with major depressive disorder, anxiety disorder, and hypertension, had moderately impaired cognitive skills and also required assistance with daily activities. On the day of the incident, Resident 2 and Resident 3 exchanged derogatory words in the activity room after a male resident called Resident 2 over to his table, where Resident 3 was sitting. The incident was witnessed by several staff members, including the Infection Preventionist, Activities Assistant, and Social Services Director, who all confirmed the verbal exchange between the two residents. The staff members described the situation as verbal abuse, noting that the derogatory language used could lead to emotional and mental distress for the residents involved. The Director of Nursing, although not present during the incident, also acknowledged that such behavior constitutes verbal abuse and should not occur among residents. The facility's policies and procedures on abuse prevention and prohibition were reviewed, indicating that each resident has the right to be free from mistreatment and neglect. Despite these policies, the incident highlights a failure in the facility's responsibility to maintain an environment free from abuse, as both residents were subjected to verbal abuse while under the facility's care.
Unqualified Activity Director Employed
Penalty
Summary
The facility failed to employ a qualified Activity Director (AD) who met the qualifications as per the facility's job description. During interviews and record reviews, it was revealed that the AD, hired in October 2024, did not maintain a written record of residents' attendance at activities and lacked the required certification in long-term care specialization. The Director of Nursing (DON) and the Administrator (ADM) confirmed that the AD was hired by the ADM and received training and orientation upon hiring. However, the ADM acknowledged that the AD was probably not qualified based on the facility's job description, which required a current Activities Director certification in long-term care specialization.
Failure to Develop Care Plan for Medication Refusal
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident who refused medication, which was identified during a survey. The resident, admitted with diagnoses including sepsis, diabetes mellitus, and end-stage renal disease, had the capacity to understand and make decisions. Despite this, the resident refused multiple medications over several days in January 2025, including those for high blood pressure, cholesterol, depression, and other conditions. The Medication Administration Record documented these refusals, but no care plan was created to address the medication refusal. During an interview and record review, the Director of Nursing acknowledged the absence of a care plan for the resident's medication refusal. The facility's policy required a care plan to be created after a resident refused medication three times, but this was not done. The policy also emphasized the importance of a person-centered, comprehensive care plan developed by the interdisciplinary team, including the resident's participation. The lack of a care plan for the resident's medication refusal was identified as a deficient practice with the potential for delayed provision of necessary care and services.
Failure to Provide Resident-Centered Activity Program
Penalty
Summary
The facility failed to provide an ongoing, resident-centered activity program for a resident who was admitted with diagnoses including an unspecified fracture of the right patellar, unspecified dementia, and a history of falls. Upon review, it was found that the resident's cognitive skills for daily decisions were severely impaired, and they were dependent on staff for toileting and showering. Despite these needs, the resident had not been assessed for activities, and there was no documented activity participation or attendance since their admission. Interviews with the Director of Nursing (DON) and the Activity Director (AD) revealed a lack of communication and documentation regarding the resident's activity assessment and participation. The DON acknowledged that the resident should have been assessed within three days of admission, and the AD admitted to a miscommunication about the necessary steps to complete the assessment. The facility's policy requires that residents be assessed upon admission to identify their interests and preferences, but this was not done for the resident in question, leading to a deficiency in meeting their psychosocial needs.
Failure to Provide Resident-Centered Activity Program
Penalty
Summary
The facility failed to provide a resident-centered ongoing activity program for a resident, which had the potential to affect the resident's sense of self-worth and psychosocial well-being. The resident was admitted with diagnoses including sepsis, diabetes mellitus, and end-stage renal disease. Despite having the cognitive capacity to understand and make decisions, the resident was not offered activities that aligned with their preferences, such as movies, outdoor time, eating snacks, and playing with their phone. The resident expressed that they were not asked about their daily activity preferences. Interviews with the Activity Director and the Director of Nursing revealed that the resident preferred staying in their room and did not like sitting on a chair for long periods. However, there was no documented activity attendance for the resident in November and December. The facility's policy stated that an ongoing activities program should support residents' physical, mental, and psychosocial well-being, but the activity staff failed to document or implement a resident-centered activity plan for the resident.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement its infection control measures for a resident who was on enhanced barrier precautions (EBP). Treatment Nurse 1 (TN 1) did not wear a protective gown while providing wound care to the resident, who had a diabetic foot ulcer and a dialysis port. The resident was admitted with diagnoses including sepsis, diabetes mellitus, and end-stage renal disease. The facility's policy required the use of gowns and gloves during high-contact care activities for residents with wounds or indwelling medical devices, even if they were not known to be infected with multidrug-resistant organisms. During observations and interviews, it was noted that TN 1 exited the resident's room wearing gloves and a mask but without a protective gown, despite the EBP signage indicating the requirement for gown use. The Admissions Director, Director of Staff Development, and Director of Nursing all confirmed that the protective gown should have been worn to prevent the transmission of infection. The facility's policy on EBP, dated April 2024, outlined the necessity of using personal protective equipment during care activities that could transfer multidrug-resistant organisms to staff hands and clothing.
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Illustrative
What surveyors actually found near you
We read the 133 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
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Illustrative
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Nursing homes near Lancaster
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mirage Post Acute | 0.1 mi | ★★★★★ | 73 | 0 |
| Antelope Valley Care Center | 0.2 mi | ★★★★★ | 21 | 0 |
| The Ellison John Transitional Care Center | 0.9 mi | ★★★★★ | 39 | 0 |
| Santa Clarita Post-acute Care Center | 30 mi | ★★★★★ | 21 | 0 |
| Mountain View Conv Hosp | 30.2 mi | ★★★★★ | 39 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.