Average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Elk Grove Post Acute during CMS and state inspections, most recent first.
A facility failed to remove discontinued medications from use when medications belonging to discharged residents were found stored with active residents' medications. An LN confirmed a vial of regular insulin in the medication room refrigerator belonged to a discharged resident, and another LN confirmed dexamethasone oral solution and ipratropium bromide-albuterol sulfate inhalation solution in a med cart also belonged to discharged residents. The DON stated these medications should have been removed, disposed of, or stored separately from medications assigned to active residents.
A facility staff member did not follow recipe measurements when preparing pureed pork and cornbread for multiple residents. During observation, the staff member added unmeasured amounts of water and milk instead of using the specified amounts, and the RD confirmed the pureed cornbread was too thick and stiff for residents with swallowing problems and that excess liquids could affect nutrient intake.
Kitchen Food Storage and Sanitation Deficiencies: Staff failed to keep kitchen floors dry over multiple observations, with water trails and wet shoe prints seen in food service areas. Frozen waffles were left unsealed in a reach-in refrigerator, food boxes were stored on the freezer floor and on upside-down milk crates near rusty shelving, steam table pans were stored wet or with residue, and spice bottles were left with open lids. The DM and RD stated these items should have been stored and handled properly to prevent contamination.
Uncovered dumpsters and debris in the garbage storage area were observed over multiple days. One recycle dumpster was overfilled so the lid could not close, and two garbage dumpsters were left open with empty boxes and buckets on the ground nearby. The MS, IP, and ADM confirmed the dumpsters remained uncovered, and the facility policy stated dumpster lids should be covered when not in use.
Broken Dishwasher Thermometer: A damaged thermometer was used on the automatic dishwashing machine while dishware was being washed. The machine thermometer stayed at 110 degrees Fahrenheit during multiple cycles, below the stated minimum of 120 degrees Fahrenheit needed for proper sanitizing, and the RDM later used a new thermometer that registered 137.7 degrees Fahrenheit during the rinse cycle. Facility records and P&P required low-temp chemical sanitizing and proper maintenance of kitchen equipment.
Resident struck by another resident: A resident with dementia-related diagnoses was hit twice on the lower leg by another resident with dementia after the other resident blocked the doorway to the room and would not move when redirected. CNA, LPN, and DON interviews confirmed the physical altercation, and the facility policy defined hitting as physical abuse.
A resident’s MDS entry and discharge assessments were completed and transmitted to CMS more than 14 days after discharge. The ADON confirmed the assessments shared the same ARD, and the DON stated staff were expected to follow the required MDS submission timeframes. The facility policy required these assessments to be completed by the end of day 14.
A resident with quadriplegia had a physician DNR order and a POLST indicating DNR, but the MDS documented full resuscitation instead. The MDS-RN confirmed the error, and the ADM also acknowledged the inaccurate MDS documentation of the resident’s resuscitation status.
A resident’s BP medication via g-tube was administered later than the ordered time, and staff confirmed it was outside the scheduled window. Another resident had an indwelling urinary catheter in place for months, but the chart contained no order for the catheter. Staff confirmed the missing order, and the DON/ADON acknowledged the medication timing expectation and the absent catheter order.
Menu items were omitted from lunch meals for two residents. One resident with DM2 and dysphagia on a carb-controlled diet was not served Mandarin oranges listed on the meal ticket, and another resident with DM2, malnutrition, and a renal carb-controlled diet was served a pork chop without the gravy listed on the menu. Staff confirmed the missing items, and the RD stated that leaving items off the menu could decrease intake of needed nutrients.
Call lights were not within reach for two residents. One resident with quadriplegia had a touch pad call light clipped near the left hip despite limited movement and inability to use the left arm, and another resident with hemiplegia/hemiparesis was yelling for help while the regular call light was clipped beside the pillow on the left side. Staff and leadership confirmed both call lights were not accessible to the residents.
A resident with impaired memory and no capacity for medical decision-making had their eyeglasses lost, and the facility did not replace them or reimburse the cost in a timely manner. The RP reported the missing glasses, and the SSA stated that a theft and loss form was supposedly completed, but neither the SSA nor the DON could locate this documentation. The SSA could not specify when the glasses were lost, only that it occurred over several months, and later records showed the resident declined new glasses despite lacking decision-making capacity, with no notification to the RP. The facility’s own theft and loss policy requiring prompt investigation, documentation, and notification of the resident or representative was not followed.
Two residents with histories of cerebral infarction, mobility limitations, and differing cognitive status became involved in a physical altercation when one, who had moderate cognitive impairment, grew impatient while trying to pass the other, who was seated in a wheelchair in their shared doorway. The impatient resident pushed the wheelchair into the hallway despite the seated resident’s resistance and then struck the seated resident in the eye. The seated resident responded by swatting back, causing scratches to the other resident’s face and neck. Witnesses, including another resident and a CNA, confirmed the hitting and scratching, and clinical assessments documented a subconjunctival eye injury for one resident and superficial facial and neck scratches for the other.
The facility failed to maintain a safe, clean, and homelike environment in resident shower rooms when three of five shower areas were found unclean and in disrepair. A cognitively intact resident with Type 2 DM reported that the shower rooms were dirty and caused discomfort. Surveyor observations, confirmed by LNs, the IP nurse, and the DON, identified mold on shower curtains, used bandages on the floor and shelves, hair on drains, an overfilled sharps container with razors protruding, cracked shelves, cracked tiles, peeled paint, and one shower room out of order. These conditions did not meet the facility’s own policy requiring a clean, sanitary, and orderly homelike environment.
Surveyors found that multiple shower rooms were left unclean and poorly maintained, with mold on curtains and tiles, used bandages (including one with dried blood) on floors and shelves, hair on drains, cracked tiles, peeled paint, overflowing trash with uncovered soiled items, and overfilled sharps containers with razors sticking out or overflowing. An LPN and the IP nurse confirmed these conditions in several shower rooms that are used by most residents, and acknowledged that the rooms were dirty and that improper cleaning and sharps disposal could spread infectious organisms or cause injury. The IP nurse also stated she did not conduct daily checks of the shower rooms, and the DON confirmed that staff were expected to clean shower rooms after each use and that overflowing sharps could have spread infectious organisms, contrary to the facility’s infection control and sharps disposal policies.
Two residents with intact cognition and mobility impairments, including hemiplegia, CHF, COPD, muscle weakness, and difficulty walking, were housed in a shared room that became cluttered and unsanitary when a third roommate packed belongings into multiple boxes stacked in front of beds and along the path to the bathroom, with additional personal items, towels, an empty soda can near a power cord, and overripe bananas left in the area. Both residents had care plans requiring a clutter-free environment due to fall risk, yet one resident’s family reported the room as very unsanitary and requested a room change, and the other resident recalled the room being cluttered and unclean without explanation from staff. After reviewing photos and video, housekeeping staff, CNAs, and LNs acknowledged the room was not kept clean or clutter-free, described it as unsafe, a potential fire hazard, and not homelike, and the administrator confirmed that residents are entitled to a safe, clean, and homelike environment under facility policy.
A cognitively intact resident with a wedge compression fracture reported that a CNA kissed the resident’s forehead and pushed the resident’s behind during incontinent care without any consent or warning, causing the resident to feel violated and disrespected. In a subsequent interview, the CNA admitted to kissing the resident’s forehead without asking permission while providing care and removing food from the bed. The DON acknowledged that residents have the right to be free from abuse, and facility policy states that residents must be free from abuse, neglect, misappropriation of property, and exploitation, making this conduct inconsistent with established resident rights.
A resident with end stage renal disease and moderately impaired cognition, who was care planned as being at risk for elopement due to wanting to go home, left the facility without staff knowledge or a Leave of Absence order and walked about 15 minutes to a local coffee shop. Staff only became aware of the resident’s location when an off-duty staff member called the on-duty nurse, prompting a missing-resident code and the resident’s return within a short time. The DON confirmed that facility staff did not know when the resident left, and a CNA reported finding the resident sitting on a bench at the coffee shop. Facility policy required identification of residents at risk for wandering/elopement and inclusion of safety strategies and interventions in the care plan.
Two residents with severe cognitive impairment were involved in an altercation when a CNA, after briefly checking on a yelling resident and leaving the room, returned minutes later to find another resident forcefully gripping the first resident’s throat. Documentation and interviews confirmed that the resident reported his neck and hands had been squeezed and continued to have hand pain afterward, and he stated he felt safe only when away from his former room. The DON acknowledged that the resident should not be subjected to physical abuse, and the facility’s abuse prohibition policy states that abuse is prohibited and that an abuse prevention program will be implemented.
Resident-to-resident abuse was not prevented when one resident threw a water pitcher toward another resident after an argument. The affected resident was cognitively intact and had MDD, while the other resident was cognitively intact and had paraplegia. The resident reported threats from the other resident’s family member and said water splashed onto him, and a CNA witnessed the pitcher being thrown and had to intervene when the resident moved toward the other resident’s bed.
Failure to Provide Written Bed Hold Notice: A resident admitted with diverticulitis was transferred to the hospital, and the MDS showed the resident was cognitively intact. Progress notes documented the hospital transfer and a call with the resident's daughter, but the DON confirmed there was no documented evidence that a written bed hold notice was provided to the resident or family as required by regulation and the facility's Bed-Hold and Returns policy.
Failure to supervise a known elopement-risk resident: A cognitively intact resident with Type 2 DM and independent wheelchair mobility left the facility unaccompanied on two occasions. Staff observed the resident outside in a wheelchair, could not locate him during searches, and contacted law enforcement after he had already gone out of sight; the DON confirmed the resident eloped twice without informing staff.
A resident with cognitive impairment and significant physical disabilities was pushed to the floor by a roommate with dementia after rummaging through the roommate's closet, despite verbal warnings. The incident escalated with both residents using profanity and one attempting to retaliate with a cane before staff intervened. Facility records and staff interviews confirmed that the push was deliberate and that the facility did not prevent the physical altercation, resulting in a failure to protect the resident from abuse.
A resident with paraplegia and urinary retention did not receive a full dose of Bethanechol as ordered when an LPN crushed the medication without a physician order and left it in unlabeled cups at the bedside. The resident, not approved for self-administration, was unaware of the medication's purpose, and the DON confirmed this practice did not meet professional standards.
A resident with diabetes experienced a hypoglycemic episode resulting in unresponsiveness and required emergency intervention. Facility staff did not inform the resident or her family member about the change in condition or the treatment provided, and there was no documentation of such communication or education, despite facility policy requiring immediate notification and documentation.
A resident with CHF, diabetes, and schizoaffective disorder left the facility unnoticed and was missing for over 24 hours, during which time she did not receive nursing care and was exposed to unsafe conditions. Staff failed to provide adequate supervision, did not follow or report the resident's departure, and the facility's front door lacked an alarm, allowing the resident to exit without detection.
A resident with severe cognitive impairment and a history of wandering eloped from the facility despite wearing a Wanderguard bracelet. The resident exited through a door that lacked a Wanderguard sensor, and there was no person-centered care plan in place to address elopement risk prior to the incident. The resident was later found outside the facility.
A resident with a recent hip fracture and multiple comorbidities did not receive prescribed Norco for moderate to severe pain for two days after admission due to a delay in obtaining a signed prescription, resulting in unmanaged pain and reduced participation in therapy. Staff and therapy notes documented high pain levels, and the medication was not available from the emergency kit without pharmacy authorization.
A resident with multiple complex diagnoses became lethargic during therapy sessions, and both PT and OT staff notified nursing staff of this change. Despite these notifications, there was no documented nursing assessment or vital signs recorded until several hours later, when the resident was found to have significantly decreased oxygen saturation and increased lethargy. The DON confirmed the lack of timely assessment and the facility could not provide a policy for change of condition assessment.
A CNA was observed changing linen for a resident with an indwelling catheter under Enhanced Barrier Precautions without wearing a gown, as required by facility policy. The CNA acknowledged the omission, and the Infection Preventionist confirmed that both gloves and a gown are necessary PPE for such high-contact care activities.
Three residents with significant physical or cognitive impairments were found with long, untrimmed nails, despite care plans and facility policy requiring staff to assist with nail care as part of ADLs. Staff and the DON confirmed that nail care was not consistently provided, and residents reported their nails had not been trimmed since admission.
A resident with diabetes and paraplegia did not receive timely podiatry care, resulting in long, debris-laden toenails and dry, crusted feet. Despite requests from the resident and his family, no podiatry consult was initiated, and staff confirmed that the required referral process was not followed according to facility policy.
A resident with mild memory impairment and multiple medical conditions sustained a burn injury when another resident, known for verbally aggressive behavior and a mental health disorder, threw a cup of hot coffee during a verbal altercation. The incident occurred after the injured resident entered the aggressor's room and did not leave when asked, resulting in hot coffee splashing onto the resident's arm and hand. Staff and medical records confirmed the injury and the sequence of events, indicating a failure to protect residents from physical abuse.
The facility failed to meet professional standards of care for several residents, including a resident performing self-catheterization without a physician's order, another missing doses of prescribed antibiotics, and a resident wearing a mouth guard during meals against recommendations. Additionally, there was inconsistent documentation of urine output for a resident with a catheter.
The facility failed to maintain pharmacy services for two residents. Expired controlled medications were not removed from the medication cart for seven days, risking drug diversion. Additionally, a resident's Physician Order for an IV antibiotic was not followed, resulting in six omitted doses, putting the resident at risk for further infection complications.
The facility failed to properly store and label medications, as an opened bottle of oseltamivir was found without an expiration date, and staff personal belongings were stored in the medication room. LN 1 and the DON acknowledged these issues, which contradict the facility's policies requiring proper labeling and storage practices.
The facility's kitchen staff demonstrated deficiencies in competencies and hygiene practices, including incorrect dish machine temperature settings, improper sanitizer concentration testing, and inadequate hand hygiene. Additionally, a cook used the wrong cutting board, risking cross-contamination. These failures could potentially lead to foodborne illness for residents.
The facility failed to maintain food safety and sanitation standards, with issues such as improper food labeling, unsanitary kitchen conditions, and inconsistent use of hairnets. Food items were found without proper labels, and the kitchen had rust, dirt, and worn equipment. Additionally, food was transported uncovered, and maintenance work was conducted over food production areas, risking contamination.
The facility failed to maintain effective infection control, with staff not adhering to PPE protocols for residents on enhanced barrier precautions, improper storage and labeling of respiratory equipment, and inadequate hand hygiene practices. A CNA entered a droplet isolation room without full PPE, and a nasal cannula found on the floor was reused without replacement.
The facility failed to maintain essential kitchen equipment, including a leaking ice machine, a non-functional dish machine temperature gauge, and an unstable tray line rack, potentially compromising food safety for 125 residents. Ice build-up in the freezer and mold-like substance on the ice machine pipe were also observed.
The facility failed to ensure the call light system was accessible for four residents, potentially preventing them from communicating their needs for assistance. Residents with various physical and cognitive impairments were observed with call light buttons out of reach, contrary to facility policies. Staff confirmed the inaccessibility and acknowledged the importance of having call lights within reach.
Two residents were not treated with respect and dignity during meal assistance. A CNA stood over Resident 8, who has chronic pain and depression, causing emotional distress. Similarly, Resident 20, with hemiplegia and dementia, was fed by a CNA standing over him. The facility's policy requires feeding with attention to dignity, which was not followed.
A resident with hemiplegia, dementia, and contractures was unable to use the call light system due to its inaccessibility and unsuitability. Despite staff awareness of the resident's inability to use the standard call light button, an appropriate alternative, such as a soft touch pad, was not provided, contrary to facility policy.
The facility failed to provide adequate nail care for two residents, resulting in long and potentially harmful nails. One resident with multiple sclerosis and quadriplegia had long, jagged nails that could cause self-scratching, while another resident with hemiplegia and hemiparesis had sharp nails that cut into her hand. The facility's policy required regular nail care, but this was not adequately provided, leading to the deficiency.
A resident with senile degeneration of the brain and hearing impairment was not provided with resident-centered activities or communication aids, leading to feelings of loneliness and isolation. Despite requests for assistance and the importance of reading materials noted in the care plan, no accommodations were made. Staff interviews revealed a lack of communication tools and activities, and the facility's policy on activity programs was not effectively implemented.
Two residents in the facility did not receive consistent monitoring of their low-air loss mattresses (LALM) as per physician's orders, which were intended to aid in wound healing. Resident 44, with severe cognitive impairment and at risk for pressure ulcers, and Resident 59, with a Stage 4 pressure ulcer, both had gaps in the monitoring of their LALM settings over several shifts. The ADON and DON confirmed the inconsistency, which was against the facility's policy and procedure.
A facility failed to follow a physician's order for a resident's oxygen therapy, delivering oxygen at 1.5 LPM instead of the ordered 3 LPM. The resident had respiratory failure and COPD, requiring continuous oxygen therapy. Staff confirmed the discrepancy, and the DON acknowledged the risk of shortness of breath if the order is not followed.
A resident with multiple diagnoses, including diabetes and osteoarthritis, did not receive appropriate pain management as the facility failed to follow the physician's order for Percocet, which was to be given only for severe pain. The medication was administered on several occasions for moderate or mild pain, as confirmed by the ADON and DON, contrary to the facility's pain management policy.
A resident on a No Added Salt (NAS) diet received two salt packets with their meal, contrary to the physician's orders. The resident, who has dementia and hypertension, did not request the salt. Staff interviews confirmed the error, and facility policy requires dietary checks that were not followed.
A facility failed to administer PRN Clonidine HCl to a resident with high blood pressure as per physician's orders. Despite the resident's systolic blood pressure exceeding 170 on two occasions, the medication was not given, and the Medication Administration Record showed no indication of administration. Interviews revealed that the LVN did not follow the protocol of reassessing blood pressure and administering the PRN medication accordingly.
Discontinued Medications Stored With Active Residents' Medications
Penalty
Summary
The facility failed to remove discontinued medications from use for a census of 129 residents when medications belonging to discharged residents were stored with active residents' medications. During a concurrent observation and interview on 5/14/26 at 8:32 a.m. inside the medication room at nurses' station one, LN 8 confirmed that a vial of regular insulin was found in the refrigerator and stated that it belonged to a resident who had been discharged from the facility. During a concurrent observation and interview on 5/14/26 at 11:55 a.m., LN 4 inspected the southeast medication cart and confirmed that a bottle of dexamethasone oral solution and a pack of ipratropium bromide-albuterol sulfate inhalation solution were stored in the cart. LN 4 stated that these medications belonged to residents who had been discharged from the facility. During an interview on 5/14/26 at 2 p.m., the DON stated that medications belonging to discharged residents should have been removed, disposed of, or stored separately from those assigned to active residents to prevent medication administration errors.
Pureed Meal Preparation Did Not Follow Recipe Measurements
Penalty
Summary
The facility failed to follow the recipe for pureed meals for nine residents when C 1 added unmeasured amounts of water and milk while preparing lunch. The lunch menu included barbeque pork ribs, baked or mashed potatoes, collard greens, cornbread, and Texas sheet cake, and the facility’s recipes specified maximum measured amounts of hot water for 12 servings of pureed pork and warm milk for 12 servings of pureed cornbread. During a concurrent observation and interview, C 1 was seen preparing 12 servings of pureed meals and measured the pork into a blender, then added warm water in increments using two different sized eating spoons and a Styrofoam cup rather than following the recipe. C 1 also prepared the cornbread by adding four cups of warm milk in increments and alternating with an unmeasured amount of milk six times, resulting in a thick and stiff mixture. The RD confirmed C 1 did not follow the recipe and stated the cornbread’s consistency was inadequate for residents with swallowing problems and that residents on pureed diets might not get essential nutrients if the food had excess liquids.
Kitchen Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain proper kitchen and food safety measures for a census of 129 residents when kitchen floors were observed wet over multiple days. During observations with the Dietary Manager, a water trail was seen leading from the main kitchen area, a trail of water was noted in front of the hot steam table, and later a worker pushed a cart loaded with dishes through a water trail in front of the dishwasher. Another observation showed a wet floor extending approximately 40 feet from the dirty dishes counter to the entrance door, with wet shoe prints indicating someone had walked through the water. The Dietary Manager confirmed the floors should not be wet and stated kitchen crew should promptly mop up spills; the facility policy also stated the kitchen should be properly maintained and wet floor signs and mats used as appropriate. Additional kitchen storage and sanitation issues were observed. A large bag of frozen waffles was found unsealed in the reach-in refrigerator, 11 boxes of food were stored directly on the freezer floor, six boxes were stored on upside-down milk crates, and a metal shelving unit in the walk-in freezer had a reddish-brown material resembling rust on the bottom shelf and corner pole. Four quarter-sized steam table pans were stored wet, and one half-sized steam table pan had a soft, clumpy beige residue on the outside. Four spice bottles were also found with open lids. The Dietary Manager and Registered Dietician stated food, pans, and spices should be stored properly and protected from contamination, and the facility policies required food to be wrapped or in covered containers, stored six inches above the floor, and dishware to be air dried and properly stored.
Uncovered dumpsters and debris in garbage storage area
Penalty
Summary
The facility failed to ensure sanitary conditions were maintained in the garbage storage area when garbage dumpsters were left uncovered for three consecutive days for a census of 129 residents. During an observation on 5/11/26 at 7:38 a.m. in the backyard of the facility, one recycle dumpster was observed overfilled to the point that the lid could not close, with empty boxes on the ground next to it. Two garbage dumpsters were also observed left open, with a few empty boxes and buckets on the ground around them, and no staff was seen using the dumpsters. On 5/12/26 at 10:40 a.m. and again on 5/13/26 at 11:15 a.m., the Maintenance Supervisor and then the Maintenance Supervisor with the Infection Preventionist confirmed that the recycling and garbage dumpsters were left open. The Infection Preventionist stated that all dumpster lids should remain closed when not in use. On 5/14/26 at 11:30 a.m., the Administrator confirmed the dumpsters had been left uncovered for three consecutive days and stated staff were expected to close the lids immediately after use to prevent pests infestation and spreading infection in the facility. The facility policy titled, Dispose of Garbage and refuse, revised 2/2025, stated that the area surrounding the exterior of the dumpsters is to be maintained free of rubbish or other debris and that all trash is to be properly disposed of in external receptacles with lids covered when not in use.
Broken Dishwasher Thermometer
Penalty
Summary
The facility failed to maintain safe operating condition for kitchen equipment when a damaged thermometer was used for the automatic dishwashing machine. During a concurrent observation and interview with a Dietary Aide and the Regional District Manager, dishware was run through the dishwasher while the machine's thermometer remained at 110 degrees Fahrenheit throughout three cleaning cycles and during nonuse. The Regional District Manager stated the water temperature for both wash and rinse cycles needed to be at a minimum of 120 degrees Fahrenheit to properly sanitize dishware, and then obtained a new dishwasher thermometer that registered 137.7 degrees Fahrenheit during the rinse cycle. The Regional District Manager stated the thermometer on the dishwasher was broken and kitchen staff would not know if dishware was washed at the designated temperature to properly sanitize them for resident use. Facility records showed the dish machine log required low-temperature chemical sanitizing with wash and rinse temperatures of 120-140 degrees Fahrenheit, and the facility's policies required dish machine water temperatures to be maintained per manufacturer recommendations and kitchen equipment issues to be promptly reported and recorded.
Resident struck by another resident
Penalty
Summary
The facility failed to ensure that Resident 37 was free from abuse when Resident 117 struck Resident 37 during a physical altercation. Resident 37 was admitted with diagnoses including Alzheimer's disease, dementia, anxiety disorder, and major depressive disorder. Resident 117 was admitted with a diagnosis of dementia. According to the facility's Report of Suspected Dependent Adult/Elder Abuse, Resident 117 became involved in a physical altercation with Resident 37 after blocking the entrance to Resident 37's room. During interviews, CNA 1 stated that Resident 117 was sitting in a wheelchair in the doorway of Resident 37's room, would not move when redirected, and then stood up and hit Resident 37 twice on the lower right leg with a closed left fist after Resident 37 told her to put a shirt on. LN 2 stated CNA 1 reported that Resident 117 hit Resident 37, and LN 1 stated she received a report that Resident 117 hit Resident 37 at night. The DON confirmed that Resident 37 was hit twice by Resident 117 while lying in bed and stated that all residents should be free from any type of abuse. The facility's Abuse Prohibition Policy and Procedure stated that health care centers prohibit abuse, mistreatment, neglect, misappropriation of resident property, and exploitation for all residents, and defined physical abuse to include hitting.
Late MDS Submission for Discharged Resident
Penalty
Summary
The facility failed to submit a Minimum Data Set (MDS) assessment in a timely manner for one sampled resident, Resident 17. Resident 17 was admitted and discharged on the same date, and during a concurrent interview and record review on 5/12/26, the Assistant Director of Nursing confirmed that the resident’s MDS entry and discharge assessments shared the same assessment reference date but were completed and transmitted to CMS on 12/11/25, more than 14 days later. The Director of Nursing stated on 5/14/26 that staff were expected to follow the required timeframes for MDS submission. The facility’s policy titled Comprehensive Assessments, revised in 10/2023, stated that assessments for residents admitted and discharged with return anticipated must be completed by the end of day 14.
Inaccurate MDS Documentation of Resuscitation Status
Penalty
Summary
The facility failed to ensure an accurate MDS assessment for one resident, identified in the report as Resident 140. Resident 140 was admitted with a diagnosis of quadriplegia. A review of the resident’s OSR showed a physician order for DNR, and the resident’s POLST also indicated DNR. During a concurrent interview and record review with the MDS-RN, the resident’s POLST and MDS were compared, and the MDS dated [DATE] was found to document full resuscitation instead of DNR. The MDS-RN confirmed the resuscitation instructions were documented incorrectly and stated that inaccurate documentation might compromise the resident’s rights and disregard the family’s wishes. The Administrator also confirmed the resuscitation instructions were documented inaccurately in the MDS and expected staff to maintain accurate documentation for the resident’s care and treatment.
Medication Given Late and Urinary Catheter Lacked Order
Penalty
Summary
Resident 139 had an order for isosorbide mononitrate 10 mg via g-tube three times daily at 9 a.m., 1 p.m., and 5 p.m., but during a concurrent observation, interview, and record review, the medication was prepared and administered later than the scheduled 9 a.m. time. The nurse confirmed the blood pressure medication was given after the ordered time. The DON stated nurses were expected to administer medications according to physician instructions, especially when prescribed multiple times daily, and the facility policy stated medications are to be administered within 60 minutes of the scheduled time. Resident 1, who had diagnoses including UTI and severe chronic kidney disease and had intact cognition on the MDS, was observed with an indwelling urinary catheter draining urine from the bedside. Resident 1 stated he had the catheter for almost three months, and the care plan indicated the catheter had been in place since 2/12/26. However, the medical record had no order for the catheter. Staff confirmed the missing order, and the ADON stated nurses missed the order and that without an order, staff would not know when the catheter was inserted. The facility policy for physician orders required complete and accurate orders, and the urinary catheter policy stated there must be a valid medical justification for use of an indwelling catheter.
Menu Items Omitted From Resident Lunch Meals
Penalty
Summary
The facility failed to follow the menu for two residents when food items were omitted from lunch meals. Resident 72, who had diagnoses including type 2 diabetes and dysphagia, was on a carbohydrate-controlled diet with soft and bite sized texture and thin liquids. During a concurrent observation, interview, and record review in the dining room, Resident 72 was served lunch, and her meal ticket listed Mandarin oranges as part of the noon meal. Resident 72 stated she was not served the Mandarin oranges, and RNA 1 stated she should have been served them. Resident 6, who had diagnoses including type 2 diabetes and moderate protein-calorie malnutrition, was prescribed a carbohydrate-controlled, renal diet with regular texture, thin liquids, and a 1500 ml fluid restriction. During a concurrent observation, interview, and record review in the kitchen, Resident 6's noon meal ticket listed a pork chop with gravy, noodles, collard greens, bread, Texas sheet cake, and a beverage. Resident 6 was served his pork chop without gravy, and DA 2 and the RDM stated he was supposed to get gravy on his pork chop. The RD stated that leaving out items of the menu could decrease a resident's intake of needed nutrients. The facility policy stated menus would be planned in advance to meet residents' nutritional needs and served as written.
Call Lights Not Within Reach for Two Residents
Penalty
Summary
The facility failed to ensure call lights were available within reach for two residents. One resident with quadriplegia, admitted in April 2014, was observed with a touch pad call light clipped to the gown and positioned next to the left hip. The resident stated the call light could not be reached because of complete weakness in the left arm and very little movement in the right hand. The CNA confirmed the call light was not within reach and stated it should have been placed on the resident’s chest near the right hand. The DON also confirmed the call light was not within reach and expected staff to place it near the resident’s right hand. Another resident, admitted in August 2019 with hemiplegia and hemiparesis following cerebral infarction affecting the left side, was observed yelling for help from bed while the regular call light was clipped and placed to the left side of the pillow. The resident stated the call light could not be reached because of weakness in the left arm. The UC confirmed the call light was not within reach, and the ADM later confirmed it was placed on the left side and not within reach. The ADM stated call lights should be placed near the resident’s right hand and that call lights should be within residents’ reach to meet their needs.
Failure to Replace Lost Eyeglasses and Notify Resident Representative
Penalty
Summary
The facility failed to protect a resident’s personal belongings when the resident’s eyeglasses were lost and not replaced in a timely manner. The resident was admitted in late 2025 with a diagnosis that included a brain disease impairing memory, and an Order Summary Report dated 9/17/25 documented that the resident did not have capacity to make medical decisions. The resident’s responsible party (RP) reported that the facility had lost the resident’s glasses and had neither replaced them nor reimbursed the cost of replacement. The Social Service Assistant (SSA) stated that the usual process for a lost item was to complete a theft and loss form, communicate with family, and have the facility pay for the lost item if it was not located, with a copy of the form kept in the social services office. During interviews and record review, the SSA recalled that the RP had reported the glasses missing and that the facility had met with the RP to discuss the loss, and she stated that a theft and loss form had been completed. However, the SSA and DON were unable to locate any theft and loss form for the lost glasses, and the SSA could not identify the exact date the glasses were lost, only that it occurred sometime between September and December 2025. An eye exam form dated 1/22/26 showed the resident declined new eyeglasses after the exam, but the SSA confirmed the resident lacked capacity to make medical decisions and that the RP should have been notified, which did not occur. The SSA confirmed that nothing further had been done to replace the glasses and acknowledged that glasses were important to help residents see. The facility’s policy on investigating incidents of theft and loss required prompt and thorough investigation of theft or misappropriation, prompt response to complaints, and notification of the resident and/or representative of investigation results and corrective action, which was not demonstrated in this case.
Resident-to-resident altercation resulting in physical abuse and injury
Penalty
Summary
The deficiency involves the facility’s failure to protect residents’ right to be free from physical abuse when two roommates became involved in a physical altercation. One resident, with a history of cerebral infarction resulting in hemiplegia, hemiparesis, and difficulty walking, and with intact cognition (BIMS 15/15), was seated in a wheelchair in the doorway of the shared room. The other resident, who also had a history of cerebral infarction with hemiplegia and hemiparesis, dementia, communication deficit, difficulty walking, and a history of falls, and who had moderate cognitive impairment (BIMS 10/15), attempted to pass through the doorway and became impatient when unable to do so. According to interviews and documentation, the resident with moderate cognitive impairment pushed the wheelchair of the other resident in an effort to get past. The resident in the wheelchair reported telling the other resident to wait, but the pushing continued, moving the wheelchair into the hallway while the seated resident was resisting. During this interaction, the resident attempting to pass struck the resident in the wheelchair in the right eye, and the resident in the wheelchair responded by reaching back and swatting, which resulted in scratching the other resident. Witness accounts and clinical records confirmed the physical contact and resulting injuries. A fellow resident stated that one resident hit the other in the doorway and that the other resident “clawed back” and scratched the first resident’s face. A CNA reported seeing one resident hitting the other and observed bleeding from scratches on the forehead and neck of the resident with dementia. Change of Condition evaluations documented superficial scratches to the forehead and neck of the resident with dementia and subconjunctival redness of the right eye of the resident in the wheelchair, confirming that both residents sustained physical injury during the altercation.
Unclean and Non-Homelike Shower Rooms
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment when three of five shower rooms were found unclean and unsanitary. A cognitively intact resident with Type 2 diabetes mellitus reported that the shower rooms were dirty and unclean, and stated feeling uncomfortable at the facility and wanting to leave. Surveyor observations, corroborated by staff, identified multiple issues in the South Station shower room, including mold on the shower curtain, a used tan bandage on the shower floor, a ball of hair on the shower drain, a used bandage on the shelf adjacent to the shower, and an overfilled sharps container with razors sticking out. Cracked, exposed shelves in the shower room were also noted as not homelike. Further observations and staff interviews revealed that the northwest shower room was out of order, mold was present in the northeast shower room, and cracked tiles and peeled paint were present in the north station shower room. Licensed nurses and the Infection Prevention Nurse confirmed that the shower rooms in use were unclean and did not represent a homelike environment for residents. The DON stated that the facility’s expectation was for staff to clean shower rooms after each use and acknowledged that the current condition of the shower rooms did not meet this expectation. Review of the facility’s “Home-like Environment” policy indicated residents are to be provided with a safe, clean, comfortable, and homelike environment, including a clean, sanitary, and orderly setting, which was not met in these shower areas.
Failure to Maintain Clean Shower Rooms and Proper Sharps Disposal
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to unclean and poorly maintained shower rooms. Observations with a licensed nurse in the South Station shower room revealed mold on the shower curtain and tiles, used bandages (including one with dried blood) on the shower floor and adjacent shelf, a ball of hair on the drain, broken tiles, and an overfilled sharps container with razors sticking out. In the East Station shower room, the same nurse confirmed an overflowing trash bin with bagged soiled items and no cover, an overfilled sharps container with razors overflowing, a dirty yellow PPE gown on the floor, another gown on a bedside table, and an open air freshener can on the floor. The nurse stated the rooms were dirty, that most residents used these shower rooms, and that residents or staff could be hurt by the exposed sharps and that the rooms could have spread infectious organisms to residents. Further observations with another licensed nurse showed the northwest shower room was out of order, mold was present in the northeast shower room, and cracked tiles and peeled paint were present in the north station shower room, which the nurse confirmed was unclean and should have been cleaned after each use. The infection prevention nurse confirmed the presence of mold, cracked tiles, dirty bandages, dark mold on the shower curtain, overflowing sharps containers with razors sticking out and on top, used and packaged PPE gowns left in the shower rooms, an open air freshener can on the floor, and an overflowing trash bin with uncovered soiled items. The infection prevention nurse stated the shower rooms were dirty, that improper cleaning practices can lead to spread of infections, and that improper disposal of full sharps containers can result in cuts and transmission of infectious organisms. The infection prevention nurse also confirmed she did not perform daily checks of the shower rooms to ensure proper cleaning. The DON confirmed the expectation that shower rooms be cleaned after each resident use and acknowledged that overflowing sharps in the shower rooms could have spread infectious organisms to staff and residents, in contrast to the facility’s written infection prevention and sharps disposal policies.
Cluttered, Unsanitary Shared Room Compromises Homelike Environment
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, comfortable, and homelike environment for two residents whose room became cluttered and unsanitary. One resident, admitted in January 2026 with hemiplegia and hemiparesis following cerebrovascular disease, required assistance with personal care and had a care plan identifying risk for falls and impaired mobility, with an intervention to maintain a clutter-free environment. This resident’s daughter reported that during a visit the room was cluttered with multiple boxes and was very unsanitary, and she requested a room change. Photos and video from that visit showed multiple brown boxes stacked in front of the residents’ beds and along the path to the bathroom, personal items piled on the boxes, an empty box on a wheelchair, two white towels and an empty soda can near a power cord in front of the television, and overripe bananas and other personal items in front of one bed. The second resident, admitted in November 2025 with congestive heart failure, COPD, muscle weakness, difficulty walking, and a need for assistance with personal care, also had a care plan identifying risk for falls related to impaired mobility, with an intervention to maintain a clutter-free room. This resident recalled that the room had been cluttered with many boxes and was not clean during the prior week, and stated that staff did not explain the purpose of the boxes. The resident expressed dislike of the cluttered and unclean condition and stated that staff should have tidied and cleaned the room so it would be safe. Multiple staff interviews confirmed the cluttered and unsanitary condition of the room and acknowledged it was inappropriate. A housekeeper, after viewing the photos and video, stated staff should have tidied and cleaned the room and that the clutter could cause an accident. A nurse explained that the third roommate was moving out and packing personal items, which led to the accumulation of boxes, but agreed the room should not have been left cluttered and unsanitary due to resident safety and infection control concerns and that the environment was not homelike for the other two residents. Another nurse stated it was acceptable for the moving resident to have personal items but not to the extent of compromising roommates’ space, and noted the clutter could cause infection control and safety issues, especially in emergencies. A CNA stated the roommates had the right to a clean, home-like environment and that she would speak up if she saw such clutter. Another nurse reported seeing the room cluttered and unsanitary, describing it as unsafe and a potential fire hazard. The administrator acknowledged that the family requested a room change because the room was cluttered and unsanitary and affirmed residents’ rights to a safe, clean, and homelike environment, consistent with the facility’s homelike environment policy requiring a clean, sanitary, and orderly setting.
Failure to Obtain Consent Before Physical Contact During Care
Penalty
Summary
The deficiency involves a failure to protect a resident’s rights to dignity, respect, and freedom from abuse when a CNA kissed the resident’s forehead without consent. The resident had been admitted with a wedge compression fracture and had intact cognition per the MDS assessment. During an IDT conference, it was documented that the resident alleged inappropriate conduct by staff, including that a staff member kissed his forehead and pushed his behind during care. In a subsequent interview, the resident stated he felt violated, trashed, helpless, and disrespected, and reported that he had not consented to the kiss and had not been warned it would occur. In a telephone conversation, CNA 1 admitted to kissing the resident’s forehead without asking for consent while providing incontinent care and removing food from the bed. The DON confirmed that residents in the facility have the right to be free from any form of abuse by staff, visitors, or any individuals. Review of the facility’s Resident Rights policy indicated that federal and state law guarantee residents the right to be free from abuse, neglect, misappropriation of property, and exploitation. The CNA’s admitted action of kissing the resident without consent, in the context of hands-on care, conflicted with these stated resident rights and facility policy.
Failure to Supervise Elopement-Risk Resident Who Left Facility Unnoticed
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe environment and provide adequate supervision for a resident identified as at risk for elopement. The resident was admitted with end stage renal disease and had moderately impaired cognition per the MDS. A care plan dated late November indicated the resident was at risk of elopement related to wanting to go home or leave the facility, with directions to continue monitoring for elopement risk behaviors and to reassess elopement risk as needed. A progress note from early December documented that the resident was discussed in IDT due to being identified as an elopement risk based on history. Despite this identified risk and care plan, the resident left the facility without staff knowledge or a Leave of Absence order and walked to a local coffee shop unaccompanied. A progress note from early January documented that staff saw the resident at the coffee shop and brought the resident back, and that the resident verbalized persistent desires to go home and was still requesting discharge. During interviews, the p.m. shift nurse stated that the facility was notified by an off-duty staff member around mid-afternoon that the resident was at the coffee shop, after which a code for a missing resident was initiated and the resident was returned within about 30 minutes. The DON confirmed that staff did not know when the resident left the facility and could not provide an exact time of departure, and that the resident had no LOA order and did not notify staff when leaving. A CNA reported finding the resident sitting on a bench at the coffee shop and stated the walk from the facility to the coffee shop was approximately 15 minutes. The facility’s wandering and elopement policy stated that residents at risk for wandering or elopement would be identified and their care plans would include strategies and interventions to maintain safety.
Failure to Protect Resident From Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident’s right to be free from physical and mental abuse when one cognitively impaired resident forcefully grabbed another resident by the throat during an altercation. Resident 1, admitted in January 2023 with generalized weakness and Alzheimer’s disease, had a BIMS score of 3 indicating severe mental and cognitive impairment. Resident 2, admitted in December 2024 with dementia and a BIMS score of 4, also had severe cognitive impairment. On 12/26/25 at approximately 3 a.m., a CNA responded to Resident 1 yelling and asked if he needed to be changed; Resident 1 declined, and the CNA left to another room. After approximately 5–6 minutes, the CNA again heard Resident 1 yelling and, upon re-entering the room, observed Resident 2’s hand forcefully gripping Resident 1’s throat and immediately separated the residents. Nursing documentation for 12/26/25 reflected the CNA’s report that Resident 2’s hands were on Resident 1’s neck and that Resident 1 stated Resident 2 had been squeezing his hand and neck. During a later interview, Resident 1 reported that someone had grabbed his neck and hands, rubbed his wrists, and stated his hands had been hurting since the incident, and further indicated he felt safe only when not near his old room. The DON acknowledged that the facility was considered Resident 1’s home and that he should not be subjected to physical abuse. The facility’s Abuse Prohibition Policy and Procedure, revised 2/21, stated that the center prohibits abuse, mistreatment, neglect, misappropriation of resident property, and exploitation for all residents and that it will implement an abuse prohibition program through prevention of occurrences; however, the incident demonstrated that the resident was not protected from physical abuse by another resident.
Resident-to-Resident Abuse Not Prevented
Penalty
Summary
The facility failed to ensure that one of four sampled residents, Resident 3, was free from abuse when Resident 2 threw a water pitcher toward Resident 3. Resident 3 was admitted in September 2025 with a diagnosis of Major Depressive Disorder and was cognitively intact per the 9/26/25 MDS. Resident 2 was also admitted in September 2025 with a diagnosis of paraplegia and was cognitively intact per the MDS. A review of Resident 2’s progress note dated 2/21/25 indicated Resident 2 grabbed an empty plastic water cup and threw it at Resident 3. During interview, Resident 3 stated he told his roommate, Resident 2, to quiet down, after which Resident 2’s mother approached him and threatened him, saying he was going to die anyway. Resident 3 stated Resident 2 then threw a water pitcher toward him, causing water to splash onto him, and that Resident 2 and the family member said they were going to have other people come into the facility to hurt him. CNA 1 stated he witnessed Resident 2 throw a plastic water pitcher at Resident 3’s bed, saw water hit Resident 3, and had to take a chair handle away from Resident 2 when Resident 2 was moving toward Resident 3’s bed. The DON stated resident-to-resident abuse is not tolerated at the facility. The facility policy defined abuse as willful infliction of injury and verbal abuse as disparaging or derogatory language toward patients or their families.
Failure to Provide Written Bed Hold Notice
Penalty
Summary
The facility failed to provide a written bed hold notice when Resident 4 was transferred to the hospital. Resident 4 was admitted in August 2025 with diverticulitis of the large intestine, and the MDS dated 8/21/25 indicated the resident was cognitively intact. Progress notes dated 9/13/25 documented that the resident was admitted to the hospital, and a progress note dated 9/14/25 documented that staff received a call from the resident's daughter, who verbally understood the situation and agreed with the plan of care to send the resident to the ER for evaluation. During interview and concurrent record review on 9/24/25, the DON confirmed there was no documented evidence that a written bed hold notice upon transfer to the hospital was provided to the resident or family as required by regulation. The facility policy titled Bed-Hold and Returns, dated October 2022, stated that multiple attempts to provide the resident representative with notice should be documented if staff were unable to reach and notify the representative timely.
Failure to Supervise Known Elopement Risk
Penalty
Summary
The facility failed to ensure adequate supervision for a resident identified as a known elopement risk. The resident was admitted in September 2025 with a diagnosis of Type 2 Diabetes Mellitus and was assessed on the MDS as cognitively intact and independent with wheelchair mobility up to 150 feet. The care plan for the resident, titled "The resident is non compliant," included frequent safety checks and monitoring the resident's whereabouts and any attempts to leave the facility without staff knowledge. On 9/13/25, staff observed the resident outside in a wheelchair in the parking lot, and the resident stated he was going to the grocery store and heading down the street. Staff attempted to speak with him, but he was already out of sight; law enforcement was contacted, and the resident was later returned to the facility. On 9/14/25, staff could not locate the resident in his room, bathroom, or activity room, and a facility-wide search was started and extended to surrounding streets. Law enforcement was contacted after the resident had placed a 911 call, and officers later made contact with him after staff observed him wheeling away from the facility. CNA and LN interviews confirmed staff were unable to locate the resident during both incidents, and the DON confirmed the resident was a known elopement risk and left the facility twice without informing staff.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from abuse when an altercation occurred between two residents sharing a room. One resident, who had a history of moderate cognitive impairment, left femur shaft fracture, hemiplegia, hemiparesis, and a malignant brain tumor, was found sitting on the floor after being pushed by his roommate. The incident began when the first resident was rummaging through the roommate's closet, despite being told to stop. The roommate, also with moderate cognitive impairment and dementia, admitted to pushing the first resident in an attempt to stop him from going through his belongings. Multiple staff notes and interviews confirmed that the push resulted in the resident falling to the floor. The situation escalated further when the resident who was pushed attempted to retaliate with a cane, but staff intervened before any further physical contact occurred. Both residents were observed using elevated voices and profanity during the altercation, and the staff documented that the resident who pushed did so deliberately after verbal warnings were ignored. The facility's policy prohibits all forms of abuse, including the willful infliction of injury. Despite this, the incident was not prevented, and the resident was not protected from physical abuse by another resident. The deficiency was identified through observation, interviews, and record reviews, which consistently indicated that the facility did not ensure the safety of the resident involved in the altercation.
Medication Administration Not Performed as Ordered and Medication Left at Bedside
Penalty
Summary
A deficiency occurred when a resident with a history of complete thoracic spinal cord lesion, paraplegia, depression, and urinary retention did not receive medication as ordered. The resident had an intact cognitive status and was not approved to self-administer medications. Physician orders specified that Bethanechol 25 mg, two tablets by mouth three times daily, was to be administered for urinary retention. However, observation revealed two unlabeled medication cups containing crushed and powdered yellow medication left at the resident's bedside. The resident reported that the nurse left the medication earlier and was unaware of its purpose. Further investigation confirmed that the nurse had crushed the Bethanechol without a physician order to do so and left it at the bedside, resulting in the resident not receiving the full dose. The facility's policy required medications to be administered as prescribed, with staff ensuring the full dose is ingested and not left at bedside, especially for residents not approved for self-administration. The DON and the nurse both confirmed that the medication was not administered according to professional standards and facility policy.
Failure to Notify Resident and Family of Change in Condition and Treatment
Penalty
Summary
The facility failed to inform a resident and her family member about a significant change in her medical condition and the subsequent plan of treatment following an episode of hypoglycemia. The resident, who was cognitively intact and had multiple diagnoses including diabetes, was found unresponsive and lethargic with a blood sugar level of 41 mg/dl. Staff attempted to administer sugar orally but were unsuccessful, and emergency services were called. Paramedics administered IV dextrose, after which the resident's blood sugar increased and she returned to her baseline condition. Despite the severity of the incident, there was no documentation that the resident or her family member was notified about the change in condition or the treatment provided. Interviews with nursing staff and the Assistant Director of Nursing (ADON) revealed that the facility's policy required immediate notification of the resident and their representative in the event of a significant change in condition. However, the ADON and nursing staff acknowledged that this communication and documentation did not occur as required. The facility's policies also mandated that residents be informed of their medical condition and participate in care planning, which was not followed in this case. Record reviews and staff interviews confirmed that there was no evidence in the progress notes or other documentation that the resident or her family member was educated or informed about the hypoglycemic episode or any changes to the care plan. The ADON and nursing staff admitted that information should have been provided and documented, but this was not done. The failure to communicate and document the change in condition and treatment plan constituted a violation of the facility's own policies and federal requirements regarding resident rights and notification.
Resident Elopement Due to Inadequate Supervision and Lack of Door Alarms
Penalty
Summary
A deficiency occurred when a resident left the facility unnoticed and remained missing for over 24 hours, resulting in the resident not receiving nursing care and being exposed to an unsafe environment. The resident, who had diagnoses including congestive heart failure, type II diabetes mellitus, and schizoaffective disorder, was assessed as cognitively intact. On the day of the incident, the resident was last seen in her room in the morning and was later observed by staff walking toward the front of the facility with her walker and personal belongings. Despite being seen by a CNA, the staff member did not follow or report the resident's departure, assuming others were aware. The facility's front door was not alarmed, and the resident was able to exit without staff intervention. The resident spent the night outside, sleeping in front of a library, and was returned to the facility the following evening by a neighbor. Upon return, the resident was found to be tachycardic, confused, and dehydrated, requiring emergency room evaluation and fluids. Interviews with staff revealed that the resident had asked for the facility's address and phone number prior to leaving, and that supervision was sometimes needed due to fall risk. The facility's policies required a safe environment and supervision to prevent elopement, but these were not followed, resulting in the resident's unsupervised exit and prolonged absence.
Resident Elopement Due to Inadequate Wanderguard Coverage and Lack of Care Plan
Penalty
Summary
A resident with diagnoses of Alzheimer's Disease and dementia, and documented severe cognitive impairment, was admitted to the facility and wore a Wanderguard monitor bracelet. Despite this, the resident was able to elope from the facility premises. The resident was found sitting on a sidewalk three houses down from the facility. Review of the resident's records showed that there was no documented evidence of a person-centered care plan addressing the risk of elopement prior to the incident, despite the resident's known cognitive impairments and risk factors. Further investigation revealed that although the resident was wearing a Wanderguard bracelet, the North-north exit door used by the resident to leave the facility did not have a Wanderguard system sensor installed. The Director of Nursing confirmed that the purpose of the Wanderguard system is to alert staff when a resident at risk for wandering approaches or exits through a monitored door, but this system was not in place on the door used during the elopement. Facility policy required adequate supervision and care planning for residents at risk of elopement, which was not implemented prior to the incident.
Failure to Provide Timely Pain Management Due to Medication Unavailability
Penalty
Summary
A deficiency occurred when a resident admitted with multiple complex diagnoses, including a left hip fracture, did not receive prescribed pain medication for moderate to severe pain upon admission. The resident had a physician's order for acetaminophen-hydrocodone (Norco) to be administered every four hours as needed for pain, but the medication was not available or administered for two days after admission. During this period, the resident experienced significant pain, with documented pain levels as high as 9 out of 10, both at rest and with movement, as recorded by therapy staff. The resident's pain was severe enough to limit participation in physical and occupational therapy, as noted in therapy encounter notes. Despite the presence of an order for Norco, the medication was not given until two days after admission, and only a one-time dose of Tylenol was administered in the interim. Interviews with staff revealed that the Norco was not available because the pharmacy had not received a signed prescription from the physician, and the emergency kit could not be accessed for Norco without this authorization. Communication lapses were identified, as the pharmacy was not contacted to obtain the necessary script until the resident's pain was reported at a high level. The facility's pain management policy required prompt assessment and treatment of pain, including obtaining necessary medication orders and ensuring availability of prescribed medications. However, the process for securing the Norco prescription was delayed, resulting in the resident experiencing unmanaged pain and decreased comfort and participation in therapy. Staff interviews confirmed that the Norco was not administered until the required prescription was obtained from the physician and processed by the pharmacy.
Failure to Timely Assess Change of Condition After Therapy Notification
Penalty
Summary
Nursing and therapy staff identified a change in condition for a resident with multiple complex diagnoses, including a recent hip fracture, pneumonia, COPD, malnutrition, and schizoaffective disorder. On the day in question, both physical and occupational therapy staff documented that the resident was lethargic and notified nursing staff of this change. Despite these notifications, there was no documented nursing assessment or vital signs recorded by nursing staff after the initial reports of lethargy until several hours later. The clinical record showed that the resident's oxygen saturation dropped from 95% in the morning to 87% in the evening, at which point nursing staff finally documented an assessment noting lethargy, shortness of breath, and low oxygen saturation. The Director of Nursing confirmed that no change of condition assessment was documented after therapy staff notifications and stated that nurses are expected to assess residents after such notifications. Additionally, the facility was unable to provide a policy and procedure for assessment after a change of condition when requested by surveyors.
Failure to Use Required PPE During Linen Change in EBP Room
Penalty
Summary
A Certified Nursing Assistant (CNA) failed to follow required infection control practices while changing linen in the room of a resident who was under Enhanced Barrier Precautions (EBP). The CNA was observed changing the linen without wearing a gown, which is required PPE for high-contact care activities in EBP rooms. The CNA acknowledged not wearing the gown and stated she should have worn both a gown and gloves during the task. The resident involved had a history of renal and ureteral calculous obstruction and had an indwelling catheter in place. Facility policy, as well as the Infection Preventionist, confirmed that gloves and a gown are required PPE when changing linen in EBP rooms, especially for residents with indwelling catheters. The failure to use appropriate PPE was directly observed and confirmed by both the CNA and the Infection Preventionist.
Failure to Provide Required Nail Care for Dependent Residents
Penalty
Summary
The facility failed to provide adequate assistance with nail care for three out of five sampled residents who required help with activities of daily living (ADLs). Observations and interviews revealed that these residents had long, untrimmed fingernails or toenails, with one resident having visible debris and crusted areas on their feet, and another with nails digging into their wrist and palm. Staff interviews confirmed that nail care had not been performed as required, and residents reported that their nails had not been trimmed or cared for since admission. Care plans for all three residents indicated a need for assistance with personal hygiene and ADLs, but this assistance was not provided. The residents involved had significant medical conditions, including diabetes with poor wound healing, paraplegia, hemiplegia, hemiparesis, and chronic leg weakness, which increased their dependence on staff for personal care. Facility policy required daily cleaning and regular trimming of nails to prevent infection and injury, and staff were expected to check and provide nail care on shower days. Despite these policies, staff and the Director of Nursing acknowledged that nail care was not consistently performed, resulting in residents being left with long, untrimmed nails.
Failure to Provide Timely Podiatry Services for Diabetic Resident
Penalty
Summary
A resident with multiple diagnoses, including type 2 diabetes mellitus and paraplegia, was admitted to the facility and required assistance with personal care. Despite being cognitively intact, the resident did not receive timely podiatry services, resulting in long toenails with visible debris and dry, crusted areas on both feet. The resident reported discomfort and stated that neither he nor his sister's requests for podiatry treatment had been addressed since admission. Observations and interviews with facility staff, including CNAs, a licensed nurse, and the social service assistant, confirmed the resident's toenails were overgrown and that no podiatry consult had been scheduled. Staff acknowledged that diabetic residents require professional foot care and that the process for referral to a podiatrist had not been initiated. The facility's policy required referrals for residents with foot disorders or medical conditions associated with foot complications, but this was not followed in the resident's case.
Failure to Protect Resident from Physical Abuse During Resident-to-Resident Altercation
Penalty
Summary
A deficiency occurred when a resident with a history of mild memory impairment and multiple medical conditions, including chronic kidney disease and thrombotic disorders, sustained a burn injury after another resident threw a cup of hot coffee at him. The incident followed a verbal altercation between the two residents, during which the aggressor, who had a documented history of verbally aggressive behavior and schizotypal disorder, became upset when the injured resident entered his room and did not leave after being asked. The aggressor then threw a coffee cup, resulting in hot coffee splashing onto the other resident's right arm and hand, causing redness and a bruise. Medical records and staff interviews confirmed the sequence of events, with the injured resident reporting the incident to a treatment nurse, who observed scalding on the right arm. The aggressor admitted to throwing the coffee cup after repeated requests for the other resident to leave his room were ignored. Documentation in both residents' care plans and progress notes described the altercation and the resulting injury, with the aggressor's care plan noting a history of behaviors that could increase the risk of conflict with peers. The facility's policy on abuse prohibition defines abuse as the willful infliction of injury, and staff interviews, including with the DON, confirmed that the injury was the result of a willful act. The failure to prevent this resident-to-resident altercation resulted in physical harm and demonstrated a lapse in protecting residents from abuse as required by facility policy.
Deficiencies in Care Planning and Medication Administration
Penalty
Summary
The facility failed to meet professional standards of care for several residents, leading to potential health complications. Resident 21, who was admitted with paraplegia and a history of urinary tract infections, was observed performing self-catheterization without a physician's order or a care plan in place. Despite the resident's cognitive ability to understand the procedure, the lack of formal documentation and oversight from the facility posed a risk to the resident's health. The Director of Nursing (DON) confirmed the absence of a physician's order and care plan, which was against the facility's policy. Resident 27, admitted with an ulcer of the right lower extremity, did not receive the full course of prescribed antibiotics for cellulitis. The Medication Administration Record (MAR) showed that six out of 21 doses were missed, which the DON acknowledged. This oversight in medication administration was contrary to the facility's policy and placed the resident at risk for further infection complications. The presence of discontinued medications in the storage room further highlighted lapses in medication management. Resident 92, who was cognitively impaired and required assistance with meals, was observed wearing a mouth guard during feeding, contrary to the recommendations of the Speech Therapist (ST). The failure to remove the mouth guard before meals increased the risk of aspiration and bacterial growth. The DON confirmed that a care plan addressing the use of the mouth guard was not in place. Additionally, Resident 82, with an indwelling catheter, had inconsistent and inaccurate documentation of urine output, which was essential for monitoring the catheter's effectiveness. The DON confirmed that the documentation did not meet the required standards, as it lacked specific measurements necessary for proper assessment and reporting to the physician.
Failure to Maintain Pharmacy Services and Follow Physician Orders
Penalty
Summary
The facility failed to maintain proper pharmacy services for two residents, leading to potential risks. In the first instance, expired controlled medications belonging to a resident were not removed from the medication cart for seven days, creating an opportunity for drug diversion. The Director of Nursing (DON) acknowledged that 20 controlled medications, which expired on February 17, were not brought to her office for destruction until February 24. The facility's policy requires that discontinued medications be promptly removed and secured for future destruction, but this was not followed. In the second instance, Resident 27's Physician Order for an IV antibiotic to treat cellulitis was not followed, resulting in six omitted doses. The medication, which was supposed to be administered every eight hours for seven days, was found in the medication room, and the last dose was recorded on February 18. The DON confirmed that the expectation was for staff to follow all medication orders as prescribed and to remove discontinued medications. The failure to administer the antibiotic as ordered put Resident 27 at risk for further complications of infection.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications, as observed during a survey. An opened multi-dose bottle of oseltamivir oral suspension was found in the refrigerator without an expiration date. Licensed Nurse (LN) 1 acknowledged the absence of the expiration date and stated that the expectation is for staff to label all medications with appropriate open and expiration dates to maintain potency and effectiveness. The Director of Nursing (DON) confirmed that medications should be labeled when opened to avoid administering expired medications. The facility's policy and procedure, as well as the package insert for oseltamivir, both indicated the necessity of labeling with an expiration date. Additionally, the survey revealed that staff personal belongings were stored in the medication storage room, which is against the facility's policy. LN 1 observed personal items in the medication storage room and acknowledged that staff are provided with lockers for personal storage. The DON confirmed that only medications and related supplies should be stored in the medication storage room to prevent infection transmission and drug diversion. The facility's policy emphasized that medication storage areas should be clean and free of clutter.
Deficiencies in Kitchen Staff Competency and Hygiene Practices
Penalty
Summary
The facility failed to ensure that the kitchen staff had the appropriate competencies and skill sets to safely carry out the functions of the food and nutrition service. During an observation, a dietary aide was unable to correctly identify the necessary dish machine temperature for effective cleaning, initially stating an incorrect range and then adjusting the response to match the incorrect gauge reading. The dish machine logbook showed consistent entries below the required temperature, indicating a lack of understanding of the proper operation specifications as outlined in the facility's sanitation policy and the FDA Food Code. Additionally, a prep cook demonstrated improper testing of sanitizer concentration in red buckets, initially testing for an incorrect duration and obtaining a reading that was significantly above the safe range. This was confirmed by the registered dietician, who noted that the high concentration could be harmful to residents. The facility's sanitation policy requires that service area wiping cloths be placed in a chemical sanitizing solution of appropriate concentration, which was not adhered to in this instance. Further observations revealed lapses in hand hygiene practices. A prep cook and diet aide were seen handling soiled equipment and engaging in activities that contaminated their hands without performing the necessary hand hygiene before returning to their duties. This was acknowledged by the dietary manager as a failure to follow the facility's infection control policy. Moreover, a cook was observed using a yellow cutting board, designated for raw poultry, to cut cooked roast beef, instead of the appropriate brown board, increasing the risk of cross-contamination. The dietary manager confirmed the importance of using the correct cutting board colors to prevent such risks.
Food Safety and Sanitation Deficiencies in Facility
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by multiple deficiencies observed during a survey. Food items were found without proper labeling, including ice cream cups and supplemental shakes lacking use-by dates, and thickened apple juice and cottage cheese with incomplete dates. The Dietary Manager confirmed these labeling issues, acknowledging that labels are crucial for determining food safety. The FDA Food Code requires proper labeling and dating to ensure food safety, which was not followed in this instance. The kitchen environment was found to be unsanitary, with rust and dirt observed in various areas, including the ice machine, dry storage racks, and walk-in freezer. The stove and oven were discolored, and the food serving area was dirty. The can opener tip had dark spots, and plastic bowls were worn and scratched, making them unsanitary. The facility's sanitation policy requires all kitchen areas and equipment to be clean and in good repair, which was not the case. Additionally, clean plates were found with food residue and a sugar packet, and steam table pans were stored wet, which could lead to bacterial growth. Hairnets were not consistently used by kitchen staff and visitors, increasing the risk of contamination. Food items were transported uncovered, and maintenance work was conducted over food production areas, both of which could lead to cross-contamination. The facility's policies and FDA Food Code require hair restraints and covering of food items to prevent contamination, but these standards were not met. These failures had the potential to lead to foodborne illness for the 125 residents consuming facility-prepared meals.
Infection Control Deficiencies in PPE Use and Equipment Storage
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple instances of staff not adhering to required personal protective equipment (PPE) protocols. In one instance, a Certified Nurse Assistant (CNA) was observed changing the briefs of a resident on enhanced barrier precautions (EBP) without wearing a gown, despite signage indicating the necessity of both gloves and a gown for high-contact activities. Similarly, another CNA was seen transferring a resident on EBP without wearing a gown, contrary to the facility's policy and procedures. Additionally, the facility did not properly store and label respiratory equipment, increasing the risk of cross-contamination. A resident's nasal cannula was found uncovered and unlabeled on a bedside drawer, and another resident's nebulizer face mask was similarly stored without proper labeling. The Director of Staff Development (DSD) and the Director of Nursing (DON) confirmed that respiratory equipment should be stored in infection control pouches and labeled with the date of first use to ensure timely replacement. Further deficiencies were noted in the facility's handling of droplet isolation precautions and hand hygiene practices. A CNA entered a droplet isolation room wearing only a face mask, despite the requirement for full PPE, including an N95 mask, gloves, gown, and face shield. Additionally, a Licensed Nurse (LN) failed to perform hand hygiene between administering medications, and a nasal cannula found on the floor was placed back on a resident without being replaced, contrary to the facility's infection control policies.
Deficiencies in Kitchen Equipment Maintenance
Penalty
Summary
The facility failed to maintain essential kitchen equipment in safe operating condition, which could potentially lead to foodborne illness for the 125 residents consuming meals prepared by the facility. The deficiencies observed included ice build-up on the floor of the walk-in freezer due to a leak from the ice machine, which was not addressed promptly. Additionally, the ice machine itself was leaking, and a bucket was placed underneath to catch the water. A black, mold-like substance was observed on the pipe connected to the ice machine, indicating a lack of proper maintenance and cleaning. Further issues were identified with the dish machine, where the temperature gauge was not functioning, preventing the monitoring of water temperature necessary for proper sanitation. This led to the decision to use paper plates for serving meals. Additionally, the tray line rack used in food service was not holding its position and was temporarily secured with plastic wrap, resulting in a tray falling during meal service. These observations highlight the facility's failure to maintain equipment in good repair and in accordance with the Food and Drug Administration (FDA) Food Code 2022, which could compromise the safety and sanitation of food services provided to residents.
Inaccessible Call Light System for Residents
Penalty
Summary
The facility failed to ensure that the call light system was accessible for four residents, which could prevent them from communicating their needs for assistance. Resident 41, who was admitted with hemiplegia and hemiparesis, had her call light button pinned to the top of the bed, out of reach. CNA 3 confirmed this observation and acknowledged that Resident 41 would not have been able to ask for help if needed. Similarly, Resident 11, with muscle weakness and reduced mobility, had her call light button pinned behind the bed, making it inaccessible. CNA 12 confirmed that Resident 11 could not reach it and would not have been able to call for help. Resident 52, who required assistance with personal care, had her call light button on the floor, which CNA 13 confirmed should have been within reach. Resident 20, with severe cognitive impairment and multiple physical limitations, was observed with his call light button hung on the wall and later on the floor, both out of reach. CNA 9 confirmed that the call light button should be accessible to Resident 20. The facility's policies and procedures require that each resident be provided with a means to call staff directly for assistance from their bed, and that the call light should be accessible when in bed. The Director of Nursing confirmed the expectation for call lights to always be within reach, acknowledging the potential for residents to be unable to call for assistance if the call lights are not accessible.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to uphold the rights of two residents to be treated with respect and dignity during meal assistance. Resident 8, who has chronic pain syndrome, weakness, contracture, and major depressive disorder, was observed being fed by a CNA who stood over her. This action caused Resident 8 to feel disrespected and emotionally distressed. The resident's care plan indicated the need for assistance with meals, but the manner in which the assistance was provided did not align with the facility's policy of treating residents with kindness, respect, and dignity. Similarly, Resident 20, who has hemiplegia, hemiparesis, dementia, and requires full assistance with meals, was also fed by a CNA standing over him. The CNA believed this was acceptable, despite the facility's policy stating that residents should be fed with attention to safety, comfort, and dignity. The Director of Nursing acknowledged that a more person-centered approach, such as sitting and facing the resident, should be used to maintain respect and dignity during meal assistance.
Inadequate Call Light System for Resident with Disabilities
Penalty
Summary
The facility failed to provide reasonable accommodation for a resident's needs when the call light system was not appropriate and not within reach. The resident, who was admitted in January 2025, had multiple diagnoses including hemiplegia, hemiparesis, dementia, contractures, and muscle weakness, and was dependent on assistance for personal care. Observations revealed that the resident's call light button was either hung on the wall next to the door or on the floor, making it inaccessible. The resident was unable to use the call light button due to hand contractures, and a soft touch pad, which would have been more suitable, was not provided. Interviews with staff confirmed that the resident was given a call light button despite being unable to use it. A Licensed Nurse and the Director of Nursing acknowledged the need for an alternative call system, such as a soft touch pad, but it was not implemented. The facility's policy required that an alternative means of communication be provided if a resident could not use the standard call system, but this was not documented in the care plan. The resident's progress notes indicated an inability to use the call light due to physical and cognitive limitations, highlighting the facility's failure to accommodate the resident's needs appropriately.
Failure to Provide Adequate Nail Care for Residents
Penalty
Summary
The facility failed to provide adequate nail care for two residents, Resident 24 and Resident 47, as part of their Activities of Daily Living (ADLs). Resident 24, who has multiple sclerosis and quadriplegia, was found with long and jagged nails on her left hand, which she confirmed were bothersome and could cause self-scratching. Similarly, Resident 47, who has hemiplegia and hemiparesis, was observed with long nails on both hands, which she stated were sharp and painful as they cut into her hand. Both residents' conditions were confirmed by licensed nurses, who acknowledged the potential for the nails to cause injury. The Director of Nursing (DON) stated that staff are expected to provide nail care as needed and check nails on residents' shower days. However, the care plans for both residents indicated that nail care should be performed on bath days and as necessary. The facility's policy and procedure on nail care emphasized the importance of regular trimming to prevent infections and injuries. Despite these guidelines, the facility did not ensure that the residents received the necessary assistance with nail care, leading to the deficiency.
Failure to Provide Resident-Centered Activities for Hearing-Impaired Resident
Penalty
Summary
The facility failed to provide resident-centered activities for one resident, identified as Resident 13, who was admitted with a diagnosis of senile degeneration of the brain. Observations and interviews revealed that Resident 13 expressed feelings of loneliness and a desire to communicate with others, but faced difficulties due to a hearing impairment. Despite requests for hearing assistance, no activity tools such as magazines, music players, or communication aids were present in the resident's room. The care plan for Resident 13 indicated the importance of having reading materials, yet these were not provided, and no accommodations for hearing loss were documented. Interviews with staff, including a Certified Nurse Assistant, Licensed Nurse, and the Social Services Director, highlighted a lack of communication tools and activities for Resident 13. The Activities Assistant noted that Resident 13 had not participated in group activities and no translation devices were used. The Director of Nursing acknowledged the expectation for residents' needs and preferences to be supported, but the facility's policy on activity programs was not effectively implemented for Resident 13. The absence of a care plan addressing communication strategies and the lack of engagement in activities contributed to the resident's isolation and unmet needs.
Inconsistent Monitoring of Low-Air Loss Mattresses
Penalty
Summary
The facility failed to ensure that two residents, Resident 44 and Resident 59, received treatment and care in accordance with professional standards of practice and the facility's policy and procedure. Both residents had physician's orders for low-air loss mattresses (LALM) to aid in wound healing, with specific instructions to monitor the settings and functioning every shift. However, the monitoring was not consistently performed, as evidenced by gaps in the treatment administration records for both residents over several shifts in January and February 2025. Resident 44, who was admitted in April 2020, had diagnoses including dementia, major depressive disorder, weakness, and malnutrition. The resident was at risk of developing pressure ulcers and was using a pressure-reducing device for the bed. Despite the physician's order to check the LALM settings every shift, there were multiple instances where this was not done, potentially impacting the resident's wound healing process. The Assistant Director of Nursing (ADON) confirmed the inconsistency in monitoring during a record review. Similarly, Resident 59, admitted in July 2022, had diagnoses including rheumatoid arthritis, failure to thrive, major depressive disorder, and contracture. The resident had a Stage 4 pressure ulcer and was also using a LALM for wound healing. The treatment administration records showed that the LALM settings were not monitored consistently, as required by the physician's order. The ADON and the Director of Nursing (DON) both acknowledged the failure to adhere to the monitoring schedule, which was crucial for ensuring the proper functioning of the LALM and the residents' well-being.
Failure to Follow Physician's Order for Oxygen Therapy
Penalty
Summary
The facility failed to ensure proper delivery of respiratory care for one resident, as the physician's order for oxygen therapy was not followed. The resident, who was admitted in April 2021, had diagnoses including respiratory failure, chronic obstructive pulmonary disease, weakness, and major depressive disorder. The resident's care plan required oxygen therapy as ordered by the physician, which was continuous oxygen at 3 liters per minute (LPM) via nasal cannula. However, observations on multiple occasions revealed that the oxygen concentrator was set at 1.5 LPM, contrary to the physician's order. Interviews with facility staff, including a Certified Nurse Assistant and the Director of Nursing, confirmed the discrepancy in oxygen delivery. The Director of Nursing acknowledged the risk of shortness of breath if oxygen is delivered at a lower setting than ordered and emphasized the importance of following the physician's order. The facility's policy on oxygen administration also required reviewing the physician's orders and the resident's care plan to assess any special needs, which was not adhered to in this case.
Failure to Follow Pain Medication Orders
Penalty
Summary
The facility failed to provide appropriate pain management services for one resident, identified as Resident 17, by not adhering to the physician's order for pain medication. Resident 17, who was admitted in May 2023, had diagnoses including diabetes mellitus, neuropathy, osteoarthritis, and low back pain. The resident's cognitive assessment indicated intact cognition. The physician's order, dated August 22, 2023, specified that Percocet should be administered only for severe pain levels of 7 to 10. However, the medication administration records for February 2025 showed that Percocet was given on multiple occasions when the resident's pain levels were recorded as moderate or mild, contrary to the physician's order. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) confirmed that the physician's order was not followed, and the DON acknowledged the risk of medication overdose if the order was not adhered to. The facility's policy on pain management, dated August 25, 2021, emphasized the need for pain management to be consistent with professional standards and the resident's care plan. The failure to follow the physician's order for pain medication administration had the potential to affect the resident's well-being.
Failure to Adhere to Prescribed NAS Diet for a Resident
Penalty
Summary
The facility failed to adhere to the physician's prescribed diet for Resident 16, who was on a No Added Salt (NAS) diet. During a lunch meal, Resident 16 received two packets of iodized salt on their meal tray, despite the meal ticket indicating an NAS diet. Resident 16, who has a history of dementia, malnutrition, hypokalemia, and hypertension, did not request the salt packets. The oversight was confirmed by a Certified Nurse Assistant (CNA) who acknowledged that the resident should not have been given additional salt. Interviews with the Dietary Manager and the Director of Nursing revealed that residents on an NAS diet should not receive salt packets, and staff are expected to follow diet orders to prevent adverse health effects. The facility's policy requires the Food Services Manager or supervisor to check trays for correct diets before transport, and nursing staff to verify the diet before serving. However, these procedures were not followed, leading to the dietary error for Resident 16.
Failure to Administer PRN Clonidine HCl as Ordered
Penalty
Summary
The facility failed to follow physician's orders for administering PRN Clonidine HCl to a resident with a history of hemiplegia, hemiparesis, chronic kidney disease, and hypertensive heart disease. The resident was admitted with an order for Clonidine HCl to be given as needed for systolic blood pressure (SBP) of 170 or greater. However, on two occasions, the resident's SBP exceeded 170, and the PRN medication was not administered as per the physician's order. The Medication Administration Record (MAR) for November 2024 showed no indication that the medication was given on these dates. Interviews and record reviews revealed that the Licensed Vocational Nurse (LVN) did not follow the protocol of administering the PRN medication after reassessing the blood pressure 30 minutes to an hour after giving routine blood pressure medications. The facility's policy on medication administration requires adherence to physician's written orders, which was not followed in this case. This oversight had the potential to negatively impact the resident's health condition and well-being.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Elk Grove
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bruceville Terrace - D/p Snf Of Methodist Hospital | 4.7 mi | ★★★★★ | 18 | 0 |
| City Creek Post Acute | 6.7 mi | ★★★★★ | 0 | 0 |
| Bridgewood Post Acute | 8.3 mi | ★★★★★ | 2 | 0 |
| Double Tree Post Acute Care Center | 8.3 mi | ★★★★★ | 22 | 0 |
| Capital Post Acute | 9 mi | ★★★★★ | 28 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.