Average — CMS composite of the measures below.
The next survey window likely opens around January 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 Fair Oaks Healthcare Center during CMS and state inspections, most recent first.
A resident with CKD and dependence on dialysis had Sevelamer HCL ordered three times daily with meals, but the facility did not assess the resident for self-administration before staff sent the medication with the resident to dialysis. The MAR showed inconsistent documentation for the midday dose on dialysis days, and staff gave conflicting accounts about whether the dose was held or sent with the resident. The DON acknowledged there was no physician order to send the medication, no self-administration assessment, and no care plan addressing safe self-administration.
A resident with CHF, muscle weakness, asthma, and moderate cognitive impairment was incorrectly deemed to lack decision-making capacity when an ADON entered an order stating she could not understand choices or make health care decisions, relying on hospital documentation that only described her capacity as limited and requiring surrogate input for complex decisions. The physician’s H&P and MDS indicated she could make some choices, and she clearly expressed a desire to go out with a friend and to change her DPOA due to family restrictions, but the facility did not inform Social Services to review or update her DPOA. A MoCA score later showed mild impairment, and facility materials described MoCA as only a screening tool, yet there was no documented comprehensive capacity evaluation before the facility restricted her rights, resulting in a failure to support her self-determination and exercise of rights.
Failure to promptly address a room change grievance: A resident with Alzheimer's disease and severely impaired cognition was placed with a roommate who repeatedly yelled at her and caused distress. The RP reported the resident was afraid, unable to rest or sleep, and was being moved between a couch in the common area and her bed at night. Staff were aware of the concerns, the DON and SSD knew about the request for a different room, but the transfer had not been completed and the grievance was still pending.
Medication storage and administration practices were deficient when a resident mouth guard, a nurse’s purse, a resident’s cigarettes, and a non-cleanable cloth BP cuff were kept in medication carts. The IP confirmed the personal items and cloth cuff did not belong there, and the cuff could spread infection. The facility also stopped twice-daily temperature monitoring for the staff vaccine refrigerator, and a resident with intact cognition was found with morning meds left unattended at bedside instead of being directly observed taking them.
Therapeutic diet orders were not followed for four residents with fortified meal tickets. During meal observations, kitchen staff failed to add the fortified items to three residents’ lunch trays, and one resident received a regular dessert instead of the ordered soaked and drained dessert. The CDM confirmed the missed items, and the RD stated that all kitchen staff were expected to follow therapeutic diet orders.
Unsafe food storage and temperature control were observed in the kitchen. Eight sandwiches were found in unsealed plastic bags, a container of black olives was left uncovered, two boxes of black and brown bananas were present, and cooked Brussel sprouts on the last tray tested at 125 degrees, below the required 140 degrees holding temp. The CDM confirmed each finding.
A resident with a coccyx pressure ulcer received wound care after bowel contamination when the TN and CNA did not perform hand hygiene or change gloves appropriately. Staff also entered rooms without required PPE or hand hygiene for residents on contact precautions and EBP, left IV tubing hanging and unlabeled after antibiotic use, kept a dirty urinal in use for months, and failed to follow infection control practices during insulin preparation and glucometer cleaning.
Missing Resident Packages Not Safeguarded: A cognitively intact resident with MS and heart disease did not receive two packages sent by family after they were delivered to the facility. Staff said mail and packages were taken from the main desk to residents, but the LTC had no tracking log, mail was sometimes lost, and no investigation was conducted to locate the missing items.
Noise Disrupted Resident Sleep and Rest: A resident with kidney disease, dialysis dependence, anxiety, and depression reported that loud yelling from a neighboring resident repeatedly woke her at night, prevented her from returning to sleep, and caused her panic attacks to return. Surveyors observed the yelling on multiple occasions, and staff acknowledged the noisy behaviors and the resident's grievance about the disruption.
A resident with anxiety disorder and intact cognition received Lorazepam PRN, with the dose later increased, but the record contained no physician orders or MAR documentation for target behavior or side effect monitoring. The DON confirmed the medication was given and acknowledged there was no care plan for the antianxiety medication use, despite facility policy requiring psychotropic medication monitoring and documentation.
Nursing staff failed to follow professional standards during medication administration for two residents. An LPN handled hazardous transplant medications without gloves while preparing and giving them to a resident with a prior kidney transplant. Another LPN gave Metoprolol to a resident with a BP hold parameter without checking the resident’s current BP, despite a CNA reading earlier in the shift showing a systolic BP below the ordered hold threshold.
A resident dependent on ADL assistance was observed with long, thickened, discolored toenails after nursing staff repeatedly noted on shower sheets that toenails needed clipping. An LPN confirmed the resident had long nails, and the DON stated the resident was diabetic, did not have a current podiatry order, and was not on the podiatry list, despite the facility policy requiring residents unable to perform ADLs independently to receive needed grooming and hygiene services.
Failure to Use LAL Mattress for Pressure Injury Healing: A resident with impaired mobility, incontinence, and fragile skin developed worsening coccyx and buttock pressure injuries that progressed from Stage 1 to Stage 2, then to Stage 3 and Stage 4. The wound care physician recommended aggressive offloading, q2h turning, and a LAL mattress, but the facility did not document use of the LAL mattress for months after the recommendation. Staff interviews and record review showed the mattress was started only after the wound had already advanced.
A resident with intact cognition and C. difficile infection had diarrhea and loose stools for weeks, yet Senna ordered for bowel management with a hold parameter for loose stools was still administered on multiple days. The resident reported staff were giving the laxative while she was having diarrhea, and the DON and NC confirmed the medication was given despite the loose stools.
A resident on O2 had a nasal cannula on the floor while the concentrator remained on, and an LPN wiped the cannula with an alcohol pad and reapplied it even though the IP and DON stated it should be replaced. Another resident’s CPAP mask and tubing were left on the nightstand without an infection control bag, and a third resident’s nebulizer mouthpiece and tubing were also left out after use instead of being stored in a bag. Staff and the IP confirmed the equipment was not handled or stored as expected for infection control.
A resident with spinal infection and intact cognition did not receive ordered IV Cefazolin doses as scheduled, with multiple MAR entries left unsigned and a missed evening dose later documented by nursing. The resident, LN, ADON, DON, and a nurse consultant all confirmed the antibiotic was not administered as ordered, and the chart lacked documentation explaining several missed doses.
Laundry Area Environment and Clean Linen Protection: The facility failed to maintain the laundry area in a safe and sanitary condition when a shattered window was covered with cardboard, another window was cracked and taped, and the clean linen cart cover had a tear. Laundry staff reported the damaged windows had been present for months and that the torn cover could allow dust into clean linen sent to the nursing station. The ED stated the windows had been damaged for about a year and no replacement had been ordered, while the IP stated the torn cover should be replaced and the cardboard could not be cleaned properly.
A resident with significant medical needs and cognitive intactness reported to family that a CNA handled her roughly during incontinence care. The family notified staff, but no investigation, interviews, or documentation occurred, and the only action taken was to remove the CNA from working with the resident, contrary to facility grievance policy.
A resident with a history of aggressive behavior and dementia physically assaulted another resident in the dining room when staff failed to provide required supervision, despite care plans and staff awareness of the risk. The assaulted resident, who had major depression and intact memory, reported feeling scared and confirmed previous attacks by the same individual. Staff interviews and records indicated that the aggressive resident had a pattern of altercations and required frequent supervision, which was not consistently provided.
A resident with severe cognitive and physical impairments, identified as high risk for falls, was injured after sliding off the edge of a low bed while being assisted with dressing by a CNA who used a Chux pad, making the surface slippery. The resident sustained a right hip fracture, and staff interviews revealed improper positioning and inadequate supervision during care, as well as inconsistent documentation and pain assessment.
A resident with multiple diagnoses, including diabetes and heart disease, was not provided with STAT blood tests as ordered by a physician to evaluate treatment for a UTI. The facility's records lacked evidence of the tests being completed, and the resident was later hospitalized with acute encephalopathy due to an untreated infection. Interviews revealed that the facility did not follow proper procedures for STAT orders, contributing to the resident's condition worsening.
A resident with multiple health issues, including a UTI, had STAT blood tests ordered to assess treatment response. The facility failed to document the completion, cancellation, or rescheduling of these tests, and did not record the resident's refusal or physician notification. This led to confusion among staff about whether the tests were performed.
The facility failed to maintain accurate medication reconciliation and storage, leading to loose pills in medication drawers and misplaced blister packs. A resident's controlled medication records did not reconcile between the CDR and MAR, posing a risk of medication diversion. The DON and staff acknowledged these discrepancies, which violated the facility's policies on medication management.
The facility failed to properly label and store medications, including an expired lidocaine bottle and an unlabeled glucagon kit, as well as an open bottle of glucose test strips without an open date label. These issues were confirmed by LNs and the DON, violating the facility's medication policies.
The facility was found deficient in food storage and staff hygiene practices. Raw ground beef was stored above vegetables, and dry foods were left unsealed, risking contamination and pest attraction. A Restorative Nursing Assistant entered the kitchen without washing hands or wearing hair restraints, and a Dietary Aide did not cover facial hair, both violating infection control protocols.
The facility failed to maintain effective infection control, with staff removing N95 masks inside isolation rooms, visitors entering COVID rooms without proper PPE, and staff lacking N95 fit tests. Additionally, residents' medical equipment was improperly handled, and a staff member provided care without required PPE.
A facility failed to provide an accurate MDS assessment for a resident, leading to incorrect health status data. The resident, admitted with orthopedic aftercare and pain, was inaccurately recorded as not receiving pain medication, despite records showing administration of Norco and Tylenol. Interviews with the resident and staff confirmed the oversight, with the MDS Coordinator acknowledging the error.
A facility failed to consistently monitor a resident's intake and output for enteral feeding as per physician's orders. The resident, with a nasogastric tube and diagnoses including cerebral infarction and aphasia, had missing records for intake and output monitoring on two shifts. Interviews confirmed the oversight, highlighting the importance of following orders to ensure adequate nutrition and fluid balance.
A resident with a history of cerebral infarction, muscle weakness, Parkinson's disease, and osteoarthritis did not receive appropriate pain management due to the facility's failure to follow physician's orders. Despite the resident's moderate pain levels, Acetaminophen was administered instead of the prescribed Acetaminophen-Codeine. Interviews with staff confirmed the oversight, highlighting a breach in the facility's pain management and medication administration protocols.
A resident's antipsychotic medication was discontinued without notifying their representative, leading to behavioral changes and family frustration. The facility's policy required notification of such changes, which was not followed, as confirmed by staff and the Director of Nursing.
A resident with parkinsonism and ataxia suffered burns on her fingers after attempting to eat hot cereal without adequate supervision. A CNA, unfamiliar with the resident's care needs, microwaved the cereal and left it unattended, leading to the incident. The facility's policy required supervision for residents with such needs, which was not provided in this case.
A resident with parkinsonism and ataxia suffered burns to her fingers after attempting to feed herself without assistance. The facility failed to promptly notify the resident's family, as required by their policy. The family was informed four days later, contrary to the facility's procedures for notifying resident representatives of accidents or incidents resulting in injury.
A resident with parkinsonism and ataxia sustained burns on two fingers after spilling hot cereal. The facility failed to ensure timely and accurate assessments by an RN, resulting in inconsistent evaluations and delayed treatment. LVNs documented the incident but acknowledged their limitations in performing assessments, which are the responsibility of RNs. The facility did not adhere to Nursing Practice guidelines, leading to inadequate assessment and treatment of the resident's injuries.
A resident with parkinsonism and ataxia sustained burns while attempting to self-feed without CNA assistance, leading to a delay in care plan revision. The incident was documented, and new orders were issued, but the care plan was not updated until several days later. The DON confirmed the delay, which contradicted the facility's policy requiring timely updates.
A resident with diabetic foot ulcers did not receive wound care as ordered, with missing documentation for several shifts. The facility's policy required accurate documentation of services, but this was not followed, and no progress notes explained the omissions. The DON confirmed the lack of documentation, and the facility could not provide a policy for following physician orders.
A resident with a history of diabetes and peripheral vascular disease developed a wound on the right foot second toe, which was not properly monitored or documented by the facility. The resident missed multiple podiatry appointments due to a failure in arranging transportation services. These deficiencies led to the worsening of the wound and ultimately resulted in a partial foot amputation.
The facility failed to ensure a qualified Infection Preventionist (IP) was available to meet all requirements for a census of 141 residents. The IP left in January 2024, worked zero hours in February, and did not attend the quarterly QA meeting. The Director of Staff Development (DSD) was not certified to perform IP duties, leaving the facility without a qualified IP, which decreased the potential to prevent infection spread.
A facility failed to maintain effective infection control during a wound treatment for a resident with PVD and diabetes. The nurse did not clean bandage scissors, placed supplies on the bed, and did not perform hand hygiene, increasing the risk of cross-contamination and infection.
Medication Sent With Resident to Dialysis Without Self-Administration Assessment
Penalty
Summary
The facility failed to ensure that one resident was assessed for the ability to self-administer medications before medications were sent with the resident to dialysis treatment. The resident was admitted with chronic kidney disease and dependence on renal dialysis, and the MDS dated 4/8/26 showed mild cognitive impairment with a score of 11 out of 15. The resident’s active orders included Sevelamer HCL 600 mg three times daily with meals, and the dialysis care plan initiated on 1/7/26 was not revised after this medication was prescribed on 4/7/26 and did not address the medication. The resident’s MAR showed Sevelamer scheduled for 8 a.m., 12 p.m., and 5 p.m., while nursing notes indicated the resident left the facility for dialysis every Monday, Wednesday, and Friday around 10:15 a.m. The MAR for May 2026 showed inconsistent documentation for the 12 p.m. dose on dialysis days: on some dates the dose was documented as administered while the resident was out at dialysis, and on other dates it was documented as not administered because the resident was out of the facility. During interview, the resident stated that on dialysis days medications were given in the morning and after returning from dialysis, and that she received a snack during dialysis but could not remember whether Sevelamer was sent with her. Staff interviews showed conflicting practices and understanding. One nurse stated the 12 p.m. dose was held when the resident was out at dialysis and that the medication was not sent with the resident. Another nurse stated she sent Sevelamer with the resident to dialysis because it had to be taken with food, and said she did so after the DON directed her to send it. The DON stated the nurses were supposed to send the medication with the resident because lunch was taken at dialysis, but also acknowledged there was no physician order to do so, that the resident had not been assessed for self-administration, and that there was no care plan addressing the resident’s ability to self-administer medications safely. The MD stated that prior to sending medications with a resident, the resident must be evaluated for self-administration to ensure it is safe and appropriate.
Improper Capacity Determination and Failure to Support Resident in Changing DPOA
Penalty
Summary
The facility failed to honor a resident’s right to a dignified existence, self-determination, and exercise of rights by improperly determining that the resident lacked capacity without adequate clinical assessment or legal authority, and by not supporting her in updating her Durable Power of Attorney (DPOA). The resident was admitted with diagnoses including congestive heart failure, muscle weakness, and asthma. Hospital SNF orders documented that her capacity for medical decision making was “limited,” stating she seemed able to make very basic medical decisions and that more complex decisions would require input from a surrogate. Despite this, the Assistant Director of Nursing entered a facility order stating the resident did not have the capacity to understand choices and make health care decisions, based solely on the hospital documentation, which did not support a finding of incapacity. The ADON had no legal authority to determine capacity, and there was no documentation showing the resident lacked capacity. The physician’s History & Physical documented that the resident could make some choices, and the admission MDS showed a BIMS score of 10 (moderate cognitive impairment) with no delirium or behavioral symptoms. The DON could not explain why the order declaring no capacity was created and incorrectly stated that a BIMS score less than 9 would mean a resident did not have capacity. The resident reported wanting to go out to lunch with a friend but said her family would not allow it, became emotional and cried, and stated she wanted to change her DPOA because of her family’s actions. A physician visit note documented that the physician reviewed the resident’s record, found an advance directive listing a granddaughter as DPOA, and intended for the social worker to review the document with the resident to see if she wanted to update it, indicating the physician considered her capable of reviewing and updating her DPOA. The Social Services Director stated she was never informed she needed to review the DPOA with the resident. A subsequent change-in-condition note showed the physician wrote that the resident was “felt to lack capacity” and requested a MoCA to confirm; the MoCA score was 15/30, and the DON stated a score below 10 would indicate lack of capacity, but there was no documentation that the physician further evaluated the resident after the MoCA. Facility educational material stated the MoCA was a screening tool and might not accurately diagnose cognitive impairment. Later physician documentation, provided after the survey, stated that the MoCA score was consistent with mild dementia and that the resident did not have capacity for medical decision making, along with a new diagnosis of major neurocognitive disorder, but the report shows that during the survey period the facility had already treated the resident as lacking capacity without adequate assessment or proper support for her expressed wish to change her DPOA, contrary to the facility’s Resident Rights policy.
Failure to Promptly Address Room Change Grievance
Penalty
Summary
The facility failed to promptly act on a grievance and request for a room change for Resident 151, whose responsible party repeatedly asked that she be moved away from her roommate. Resident 151 was admitted in January 2026 with diagnoses including Alzheimer's disease and traumatic brain bleed, and her MDS dated 1/11/26 indicated severely impaired cognition. Her care plan identified communication problems and psychosocial well-being concerns related to facility placement, with interventions to anticipate needs, monitor for discomfort, discuss family concerns, and provide opportunities for family participation in care. During observation on 2/10/26, loud yelling was heard coming from Resident 151's room, and staff identified Resident 131 as yelling toward Resident 151, who then left the room and walked into the hallway. In interview, Resident 151's RP stated that the roommate had been screaming when anyone entered the room, had yelled at Resident 151 to get out of the room for over 30 minutes on one occasion, and that Resident 151 became afraid, cried, and refused to return to the room. The RP also stated that since the room change, Resident 151 had been walking all day, unable to rest or sleep at night, and was being placed on a couch in the common room at night before being moved back to bed later. A nursing progress note documented that the RP expressed concerns about the current room and roommate and requested transfer because Resident 151 could not get adequate rest, and that the DON and Social Services were notified. The DON acknowledged awareness of Resident 131's verbally aggressive behavior, the couch sleeping arrangement, and the RP's request for a different room, and stated the facility had plans to transfer Resident 151 but had not done so yet. The SSD stated the RP requested a room change the prior week and that the facility was still working on it, telling the RP that Resident 151 would be moved when a bed became available. The facility's grievance and resident rights policies stated residents and representatives have the right to voice grievances and that the Administrator and staff will make prompt efforts to resolve grievances.
Medication Storage and Administration Deficiencies
Penalty
Summary
The facility failed to ensure proper medication storage when multiple non-medication items were kept inside medication carts and a non-cleanable blood pressure cuff used on residents was stored with medications. During observation, a resident mouth guard was found inside a medication cart in the B Wing, and a nurse’s personal purse was also stored in the cart. In the A Wing, a resident’s cigarettes were observed in a medication cart, along with a cloth blood pressure cuff bearing a nurse’s name that was used on residents. The Infection Preventionist confirmed that the cigarettes and personal blood pressure cuff should not have been stored in the medication cart and stated the cloth cuff was not cleanable and could spread infection from one resident to another. The facility also did not monitor the staff vaccine refrigerator temperatures twice daily as required. The Infection Preventionist stated temperature monitoring for the staff vaccine refrigerator stopped in 11/2025, and the facility did not have documentation showing twice-daily temperature checks. In addition, Resident 57, who had diagnoses including anxiety disorder, atherosclerosis, and osteoporosis and a BIMS score of 15/15, was observed with two morning medications left in a clear plastic cup on the overbed table in the resident’s room. The resident stated the nurse had dropped off the medications and she would take them throughout the morning. The nurse confirmed the medications were the resident’s morning medications and stated they should not have been left unattended at bedside; the ADON also stated medications should not be left at bedside and that the nurse was expected to stay and watch residents take the pills.
Therapeutic Diet Orders Not Followed for Four Residents
Penalty
Summary
Therapeutic diets were not followed for four sampled residents whose meal tickets indicated fortified diet orders. Resident 75’s lunch meal ticket indicated a fortified diet order, but during observation on 2/11/26 at 11:54 a.m., [NAME] 1 did not add the fortified item to the lunch tray before kitchen staff placed the tray on the cart. The RD confirmed at 11:55 a.m. that Resident 75 did not receive the fortified item, and the facility’s fortified lunch menu showed the expected fortified items for that meal. Resident 109’s lunch meal ticket indicated an easy to chew, fortified diet order, but during observation on 2/11/26 at 12:07 p.m., [NAME] 1 did not add the fortified item to the tray and DA 1 placed the regular dessert on the tray instead of the soaked and drained dessert listed on the winter menu spreadsheet. Resident 111’s lunch tray was observed at 12:25 p.m. without the fortified item, and Resident 166’s lunch tray was observed at 12:39 p.m. without the fortified item. The CDM confirmed that Residents 109, 111, and 166 did not receive the fortified items, and the RD stated at 3:36 p.m. that it was his expectation that all kitchen staff follow therapeutic diet orders for all residents. The facility policy stated therapeutic diets are prescribed by the attending physician to support the resident’s treatment and plan of care.
Unsafe Food Storage and Temperature Control
Penalty
Summary
Food was not safely stored and distributed in accordance with professional standards in the kitchen for a census of 147 residents. During observation and interview with the Certified Dietary Manager (CDM), eight sandwiches were found in the refrigerator in unsealed plastic bags, and a container of black olives was found in the refrigerator with the lid not closed. The CDM confirmed both findings and stated the bags and container should have been sealed. During the same kitchen observations, two boxes of black and brown bananas were found and the CDM stated they should have been thrown out. On a later observation, the last tray of food was checked for temperature and cooked Brussel sprouts were measured at 125 degrees. The CDM confirmed the temperature and agreed it was below the appropriate holding temperature of 140 degrees. Facility policies reviewed stated food and supplies will be stored properly and in a safe manner, food should be covered, produce should be rotated to assure fresh product is used, and hot foods should be held at 140 degrees or above.
Infection Control Failures During Wound Care, Isolation, Equipment Handling, and Medication Administration
Penalty
Summary
The facility failed to maintain an effective infection control program during wound care for a resident with a coccyx pressure ulcer and bowel movement contamination. The resident was admitted with dementia and lumbar spinal stenosis, and the care plan identified a pressure ulcer to the coccyx with a goal to remain free from infection. During treatment, the treatment nurse and a CNA cleaned the resident after a bowel movement, and the nurse then proceeded with wound care after removing and replacing gloves without performing hand hygiene in between. The CNA handled the soiled wipes and did not change gloves after contact with the contaminated material. The nurse and CNA later acknowledged the actions, and the IP and DON stated that hand hygiene was expected before and after glove use and after bowel care. The facility also failed to follow isolation and barrier precaution practices for multiple residents. A resident with C. diff was on contact precautions, with signage at the door directing staff to perform hand hygiene and wear gown and gloves before entry and exit, yet staff were observed entering the room without proper PPE, including a CNA carrying a meal tray and another CNA and an OT inside the room without PPE. A resident with a PICC line was identified in the care plan as requiring EBP, but staff entered the room and provided care without gowns, and staff stated the posted signage was for the roommate rather than that resident. The DON stated staff should wear gown and gloves for residents on contact precautions and EBP, while the IP stated staff should not cross the threshold without PPE. Additional infection control failures involved equipment and medication practices. In one resident’s room, unlabeled IV tubing remained hanging on the IV pole after antibiotic administration, with the distal end exposed to air, and the MAR did not show the tubing change was signed on the day it should have been changed. Another resident had a urinal dated five months earlier that remained in use and appeared dirty and discolored. For another resident on EBP for a G-tube, a CNA entered and exited the room without using hand sanitizer despite signage directing hand hygiene. During medication administration, a nurse drew up Novolog insulin and placed the syringe back into its wrapper with the needle exposed while waiting for the meal tray, and the glucometer was not disinfected with the manufacturer-approved wipe after use. The IP and ADON stated the syringe should have been discarded and the glucometer should have been disinfected between uses.
Missing Resident Packages Not Safeguarded
Penalty
Summary
The facility failed to provide a safe and secure environment to ensure that one cognitively intact resident received her mail when two packages addressed to her and delivered to the facility were not safeguarded. The resident, admitted in 2017 with diagnoses including multiple sclerosis and heart disease, stated that her sister sent two packages about 1.5 to 2 months earlier, one by USPS and one by FedEx, but she never received them. She reported that activity staff told her there were two packages in her name, but when they went to retrieve them, they were gone. She also stated she had informed the Activity Director and Social Services Assistant about the missing packages and had not heard back about what happened to them. Facility staff described a process in which mail and packages were delivered to the main desk and then taken to residents by activity staff, but the facility did not have a log to track mail or package deliveries. The Activity Director stated that mail was sometimes lost and that he would look around for it if reported missing. The Social Services Assistant stated the facility did not conduct an investigation to find the missing packages, and the Social Services Director stated the facility would request confirmation of receipt and reimburse the value of missing items if reported. The facility was asked to provide a policy regarding missing mail and/or packages, but none was provided.
Noise Disrupted Resident Sleep and Rest
Penalty
Summary
The facility failed to provide a comfortable, home-like environment for Resident 70 when low sound levels were not maintained during hours of sleep. Resident 70 was admitted in 2022 with diagnoses including kidney disease, dependence on renal dialysis, anxiety, and depression. Her MDS dated 11/25/25 indicated she was cognitively intact and independent in decision making. Her care plan identified use of antidepressant medication due to inability to sleep, with goals and interventions to monitor for lack of sleep, depression, sadness, withdrawal, and to notify the physician if these signs were observed. Another care plan identified her as at risk for psychosocial well-being related to depression and anxiety. During interview and observation, Resident 70 stated the facility was too noisy at night because the resident next door was yelling at her roommate day and night. She reported that the screaming caused her panic attacks to return, prevented her from sleeping at night, and left her unable to rest during the day; she also stated she missed therapy because she was too tired from lack of sleep. Loud yelling from the neighboring room was observed multiple times by surveyors on 2/10/26 and 2/11/26. Staff interviews confirmed awareness that Resident 131 was yelling and noisy, that redirection had not always been effective, and that the facility had received Resident 70's grievance about the noise. The DON stated yelling and screaming could disrupt residents' sleep at night, and the SSD stated the facility had to be vigilant and find solutions to ensure residents were free from unwanted noises.
Unmonitored Lorazepam Use Without Care Plan
Penalty
Summary
The facility failed to ensure one sampled resident was free from unnecessary psychotropic medication use when Lorazepam was administered without appropriate target behavior monitoring and without side effect monitoring. The resident was admitted with a diagnosis of anxiety disorder, had intact cognition on the MDS, and did not exhibit behaviors directed toward self or others. The MAR showed an order for Lorazepam 0.5 mg, 1/2 tablet by mouth every 12 hours as needed for anxiety manifested by inability to relax for 14 days, and the dose later increased from 0.25 mg to 1 mg. The resident received Lorazepam on multiple dates, but the electronic clinical record contained no physician orders or MARs for monitoring target behavior or side effects related to the medication. The record review also showed no care plan developed for the resident's use of antianxiety medication. During interview, the DON stated residents on psychotropic medication are monitored for target behaviors and side effects and that such monitoring should be documented on the MAR and weekly charting summary. The DON confirmed the Lorazepam orders and administration, acknowledged there were no orders or MARs for target behavior and side effect monitoring, and confirmed there was no care plan for the antianxiety medication use. The facility policy identified anti-anxiety medications as psychotropic medications subject to prescribing, monitoring, and review requirements and stated residents receiving psychotropic medication are monitored and the response to treatment is documented.
Unsafe Medication Handling and Failure to Verify Vital Signs
Penalty
Summary
Nursing services were not provided in accordance with professional standards of practice for two residents. For Resident 185, who had a previous kidney transplant, LN 1 prepared and administered Mycophenolate Sodium 180 mg and Tacrolimus 1 mg on 2/4/26 at 8:38 a.m. without wearing gloves. During the observation, LN 1 handled the hazardous medications with bare hands during preparation and administration. For Resident 172, LN 2 administered Metoprolol 100 mg by mouth on 2/4/26 at 9:05 a.m. without obtaining the resident’s blood pressure at the time of administration. The medication order directed the nurse to give one tablet twice daily for hypertension and to hold the medication for systolic blood pressure less than 110 or heart rate less than 55. The resident’s blood pressure had been recorded at 107/63 at 7 a.m. by a CNA. During interview, LN 2 stated she accepted blood pressure results obtained by CNAs and would only recheck blood pressure herself if the reading was really high or really low.
Failure to Provide Toenail Care for Dependent Resident
Penalty
Summary
The facility failed to provide ADL care for one resident who was dependent on assistance when Resident 30’s toenails were not trimmed after multiple requests from nursing staff. During observation, Resident 30 was seen with long, thickened, discolored toenails. A Licensed Nurse stated that Resident 30 did have long nails, and the resident’s shower sheets dated 1/15/26, 2/1/26, and 2/5/26 each indicated that toenails needed clipping. During interview and record review, the DON stated that when a resident is referred for nail clipping, the resident would need an order for the podiatrist because that is how reimbursement is handled. The DON also stated that Resident 30 did not have an order to see the podiatrist and was not currently on the list to see the podiatrist, and that the last podiatry order was in December 2025. The facility policy stated that residents unable to carry out ADLs independently will receive services necessary to maintain good nutrition, grooming, and personal and oral hygiene.
Failure to Use Low Air Loss Mattress for Worsening Pressure Injury
Penalty
Summary
The facility failed to ensure necessary treatment and services were implemented to promote healing and prevent worsening of a pressure injury for one resident with multiple medical conditions, including heart disease, kidney disease, chronic pain syndrome, and widespread edema. On admission, the resident had coccyx redness with intact skin, and the MDS later identified the resident as dependent for personal hygiene, toileting, mobility, turning and repositioning, and transferring, with risk for developing pressure injuries. The care plan identified the resident as at risk for further skin breakdown related to impaired mobility, bowel and bladder incontinence, advanced age, and the presence of a coccyx pressure injury. The resident’s skin condition worsened over time. An IDT note documented that the resident developed a new coccyx pressure injury and a right buttock pressure injury, both with partial thickness skin loss and scant sanguineous drainage. The care plan for these wounds directed staff to encourage turning and repositioning, encourage getting out of bed periodically, administer treatments, and monitor wound healing weekly, but it did not include use of a low air loss mattress. The wound care physician later evaluated the resident, documented that the coccyx wound had increased in size and was a Stage 3 pressure injury, and performed excisional debridement. The wound care physician recommended aggressive offloading, turning every 2 hours, and a low air loss mattress. The facility did not document that it followed the wound care physician’s recommendation for a low air loss mattress for more than two months after that recommendation was made. The resident’s records showed the low air loss mattress order was not obtained until later, and the resident’s coccyx wound worsened further and was later classified as a Stage 4 pressure injury after another excisional debridement. During interviews, CNA staff and nursing staff stated the resident was on a low air loss mattress and needed frequent repositioning, while the treatment nurse confirmed the facility generally used low air loss mattresses for residents with skin issues and that the resident’s mattress was started only after the wound had already advanced. The DON reviewed the records and stated the facility should have used the low air loss mattress when the resident developed Stage 2 pressure injuries, but could not find documentation that it had been ordered and used during the earlier wound management period.
Laxative Given Despite Diarrhea and C. difficile Infection
Penalty
Summary
The facility failed to ensure appropriate treatment to restore normal bowel function for a resident with bowel incontinence when the resident received Senna, a laxative ordered for bowel management with instructions to hold for loose stools, while the resident was having diarrhea and loose stools related to a C. difficile infection. The resident was admitted in January 2026 with diagnoses including cellulitis of the right lower limb, severe sepsis with septic shock, and depression, and the MDS indicated intact cognition. The care plan noted the resident had C. difficile infection and directed staff to give medications and IV therapy as ordered. The resident stated during interview that she had been diagnosed with C. difficile and had diarrhea for three weeks, and that staff were giving a laxative while she was having the infection and diarrhea. The physician order for Senna 8.6 mg twice daily for bowel management included a hold parameter for loose stools, and the bowel and bladder task documented loose stools and diarrhea from 1/22/26 to 2/12/26. The MAR showed Senna was administered on multiple days during that period. The DON confirmed the resident had C. difficile infection and stated laxatives were held for residents having diarrhea because they can trigger more diarrhea, and NC 2 confirmed Senna was given while the resident had loose stools and diarrhea.
Respiratory equipment not stored or handled per infection control expectations
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not maintained for three sampled residents. Resident 124 had diagnoses including hemiplegia, hemiparesis following cerebrovascular disease, and polyneuropathy, and had moderate cognitive impairment with a BIMS score of 12. The resident had an order for oxygen at 2 liters per minute via nasal cannula for shortness of breath, chest pain, or oxygen saturation less than 90%. During observations, the resident was in bed with the oxygen concentrator running at 2L/min while the nasal cannula was on the floor, and staff observed the same condition again later. A nurse wiped the cannula with an alcohol prep pad and reapplied it, while the IP and DON stated the cannula should be replaced when it is on the floor and that alcohol prep pads are not sufficient for sanitizing it. Resident 144 was admitted with diagnoses including pneumonia and muscle weakness and had impaired cognition with a BIMS score of 9. The resident had an active order for CPAP at bedtime for sleep apnea. During observation, the resident’s CPAP mask and tubing were lying on the nightstand and were not placed into an infection control bag, and there was no infection control bag in the room for CPAP storage. CNA 1 confirmed the equipment was not in a bag and stated it should be stored in one. The ADON reviewed a photograph of the CPAP mask left on the nightstand and stated CPAP masks and nebulizer mouthpieces should be stored in a bag after use for infection control purposes. Resident 188 was admitted with diagnoses including COPD and muscle weakness and had an active order for levalbuterol inhalation nebulization twice daily for COPD. During observation, the resident’s nebulizer mouthpiece and tubing were left on top of the nebulizer machine on the nightstand and were not placed in an infection control bag after use. LN 1 confirmed the equipment was not in a bag and stated it should be placed in one. The IP stated all respiratory masks, nebulizer mouthpieces, and tubing should be placed in a bag, and the facility policy indicated respiratory equipment should be stored in a plastic bag marked with the resident’s name between uses.
Missed IV antibiotic doses not administered as ordered
Penalty
Summary
The facility failed to ensure that a resident with osteomyelitis of the vertebra and intact cognition received Cefazolin as ordered for treatment of a spinal infection. The resident was admitted in January 2026 and had a care plan directing staff to administer antibiotic therapy as prescribed. Review of the MAR showed Cefazolin 2 grams IV every 8 hours in January 2026, but doses were not signed as given on 1/8/26 and 1/29/26. In February 2026, the order was changed to Cefazolin 2 grams IV three times a day, and the MAR showed the dose was not signed as given on 2/11/26. Nursing documentation stated the resident missed the 8 p.m. IV antibiotic dose on 2/11/26, and pharmacy was called for advice. A subsequent note documented physician orders to ask pharmacy to expedite delivery of IV Cefazolin and give it when available. During interviews, the resident stated staff forgot to give the antibiotic and the timing had to be changed. LN 15 stated the resident was supposed to receive the dose in the evening but did not, and the ADON stated there was no information explaining why it was not given within one hour before or after the scheduled time. The DON stated the reason for the missed dose was not indicated in the progress notes and believed the medication was not delivered on time. A nurse consultant also confirmed that the January doses not signed on the MAR meant the doses were not given and noted there was no documentation explaining those missed doses.
Laundry Area Environment and Clean Linen Protection
Penalty
Summary
The facility failed to maintain a safe and sanitary environment in the laundry area when the glass windows were cracked and shattered and the clean linen cart cover had a rip/tear. During a concurrent observation and interview in the clean side of the laundry area, a cardboard was taped over a broken glass window, another window was cracked with blue tape on the cracks, and the clean linen cover had a linear tear on the top portion. Laundry Staff 1 stated the cardboard had been placed to prevent cold air from coming into the room and that the windows had been in that condition for 2 to 3 months. Laundry Staff 1 also stated the Environmental Director knew about the rip on the clean linen cover. Laundry Staff 2 stated that if the clean linen cart cover had a rip, dust could get into the clean linen, and that the cart goes to the nursing station. The Environmental Director stated the cracked windows had been like that for the whole year and no replacement had been ordered, and said he did not notice the rip on the clean linen cover because it was folded open when he saw it. The Infection Preventionist reviewed the pictures from the laundry room and stated the ripped linen cover should be replaced, the cardboard taped over the shattered window could not be cleaned properly, and the crack in the window was a safety hazard. Facility policy stated maintenance service shall keep the building in good repair and free from hazards, and the laundry and linen policy stated clean linen should remain hygienically clean through measures designed to protect it from environmental contamination, such as covering clean linen carts.
Failure to Investigate and Document Resident Grievance of Rough Handling
Penalty
Summary
The facility failed to properly investigate a complaint of mistreatment involving a resident who was cognitively intact and required maximal assistance for toileting hygiene due to multiple medical conditions, including malignant neoplasm of the cauda equina, COPD, neuromuscular bladder dysfunction, and anxiety disorder. The resident's family member reported to facility staff that the resident had been handled roughly by a CNA during incontinence care. Despite this report, there was no documentation in the resident's chart regarding the complaint, the reporting of the incident, or any follow-up actions taken by staff. Interviews with facility staff, including licensed nurses, the Director of Nursing (DON), Assistant Director of Nursing (ADON), Social Services Director (SSD), RN Case Manager (CM), and Director of Staff Development (DSD), revealed that none of them conducted interviews with the resident or the CNA involved regarding the alleged rough handling. The SSD and CM acknowledged that they did not document the complaint or any follow-up actions. The DSD confirmed that no one spoke to the CNA about the incident, and no disciplinary counseling, education, or in-service was conducted in response to the complaint. The facility's policy required that all grievances or complaints be investigated, documented, and responded to both verbally and in writing, with a written summary provided to the resident or their representative. However, the facility did not follow these procedures, as there was no investigation, documentation, or communication of findings to the resident or family. The only action taken was to remove the CNA from working with the resident, without any formal investigation or staff education.
Failure to Prevent Resident-to-Resident Physical Abuse Due to Lack of Supervision
Penalty
Summary
The facility failed to provide a safe and protective environment free from physical abuse for one of three sampled residents when a resident with a history of aggressive behavior and dementia physically assaulted another resident in the dining room. The resident who was assaulted had a diagnosis of major depression and intact memory, while the aggressor had moderately impaired cognition and a documented history of physical altercations, poor impulse control, and anger. The care plan for the aggressive resident specified the need for staff supervision in the dining room, but this supervision was not provided at the time of the incident. Multiple staff interviews confirmed that the aggressive resident had been involved in previous altercations and required frequent supervision, which was not consistently implemented. The incident occurred when the assaulted resident attempted to move a chair to sit with a friend, prompting the aggressive resident to hit her in the arm and back of the head. The assaulted resident reported feeling scared and stated this was not the first time she had been attacked by the same individual. Observations and interviews with staff and other residents confirmed ongoing aggressive behavior by the resident with dementia, and that the lack of supervision allowed for repeated incidents of physical abuse. The facility's policy states that residents have the right to be free from all forms of abuse, but this was not upheld in this case.
Failure to Prevent Resident Injury During Bedside Care
Penalty
Summary
A deficiency occurred when a resident with significant cognitive and physical impairments, including severe cognitive impairment, hemiplegia, hemiparesis, osteoporosis, and a high risk for falls, was not adequately protected from accident hazards during care. The resident required maximal assistance for activities of daily living and was dependent for bed mobility. While being assisted with dressing by a CNA, the resident was positioned at the edge of a low bed with a Chux pad underneath, which contributed to the resident sliding off the bed and onto the floor. The CNA acknowledged that sitting the resident at the edge of the bed with a Chux pad was a mistake, as it made the surface slippery and difficult to control the resident's movement. Following the incident, the resident initially did not complain of pain, but later developed significant right hip pain. Assessment and interviews revealed that the resident had sustained a minimally displaced right intertrochanteric hip fracture as a result of the fall. The resident's care plan had identified a high risk for falls and set a goal to prevent falls, but the interventions in place were not sufficient to prevent this incident. Staff interviews indicated that the bed was kept in a low position during care, which made it difficult for the CNA to maintain balance and safely assist the resident, and that the use of a Chux pad further increased the risk of sliding. Documentation and communication following the fall were inconsistent, with pain medication administered "in case" of pain and pain levels documented that did not match the resident's reported symptoms at the time. The facility's policies and procedures on fall risk and prevention emphasized the need for individualized interventions and proper assessment of risk factors, but these were not effectively implemented in this case. The failure to provide adequate supervision and to ensure a safe environment directly resulted in the resident's injury, decreased mobility, and increased pain.
Failure to Perform STAT Blood Tests Leads to Resident Hospitalization
Penalty
Summary
The facility failed to provide nursing services in accordance with professional standards of practice for a resident when it did not follow a physician's order to perform laboratory blood tests. The resident, who was admitted in 2023 with multiple diagnoses including diabetes mellitus, lung, and heart diseases, was diagnosed with dehydration and a urinary tract infection (UTI). The physician ordered two blood tests to be completed immediately (STAT) to evaluate the resident's response to treatment for the UTI. Despite the physician's order, there was no documented evidence that the blood tests were carried out on the specified date or at any later time. The facility's Patient Service Log did not show if the tests were completed, canceled, or rescheduled. Interviews with nursing staff revealed that the STAT order required immediate action, including entering the order into the computer and notifying the laboratory. However, the Director of Nursing confirmed that the tests were not performed and that there was no documentation of the physician being notified of the resident's refusal to undergo the tests. The resident experienced a change in condition and was sent to the emergency department, where they were diagnosed with acute encephalopathy secondary to an acute urinary infection. The resident was hospitalized for nine days and received treatment with multiple antibiotics. The facility's failure to carry out the physician's order for STAT blood tests potentially contributed to the resident's continued infection and subsequent hospitalization.
Failure to Document Blood Test Orders and Physician Notification
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, leading to confusion among staff regarding the completion of ordered blood tests. The resident, who was admitted with multiple diagnoses including diabetes mellitus, lung, and heart diseases, was diagnosed with a urinary tract infection. A physician ordered two STAT blood tests to assess the resident's response to treatment for the infection. However, there was no documentation in the resident's medical records indicating that the tests were performed, canceled, or rescheduled, nor was there evidence that the physician was notified of the resident's refusal to undergo the tests. Interviews with facility staff revealed that the nurse failed to document the resident's refusal and the subsequent notification to the physician, as well as the rescheduling of the tests. The Director of Nursing confirmed the absence of documentation and acknowledged that the tests were not carried out as ordered. The facility's policies on telephone orders and charting and documentation require that all services, changes in condition, and communications with physicians be accurately recorded in the resident's medical records, which was not adhered to in this case.
Medication Reconciliation and Storage Deficiencies
Penalty
Summary
The facility failed to maintain proper pharmacy services, resulting in discrepancies in medication reconciliation and storage. During observations, loose medications were found in the medication drawers of carts in different wings, which were verified by licensed nurses. These loose pills were not supposed to be there, and the staff acknowledged the need for proper disposal. The Director of Nursing (DON) demonstrated the medication retrieval and destruction process, emphasizing that loose pills should be removed to prevent medication errors. The facility's policy on medication labeling and storage requires medications to be stored in an orderly manner to prevent mixing. Additionally, a medication blister pack with a resident label was found misplaced at the back of a medication drawer. The DON confirmed that the medication should not have been stored in this manner, as it led to the staff being unable to locate it, necessitating an early reorder against the pharmacist's advice. This incident highlights the facility's failure to adhere to its policy of orderly medication storage, which is crucial for ensuring that each resident's medications are correctly managed and accessible. Furthermore, the facility did not reconcile controlled medication records for a resident, as evidenced by discrepancies between the Controlled Drug Record (CDR) and the Medication Administration Record (MAR). The resident, who had an intact cognitive status, was receiving pain medication, but the administration was not documented on the MAR on two occasions, despite being signed out from the CDR. The DON and a nurse consultant confirmed that both records should match to ensure accountability for controlled medications, as per the facility's policies. This failure posed a risk of medication diversion and highlighted the need for accurate documentation.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications, which was observed during a survey. An expired medication was found stored in a treatment cart alongside active medications, specifically a multi-dose bottle of liquid lidocaine with an expiration date of January 2024. This was confirmed by a Licensed Nurse (LN) who acknowledged that the medication should have been discarded according to the facility's policy. Additionally, an emergency glucagon kit was found without a resident-specific pharmacy label, which was also confirmed by the LN and the Director of Nursing (DON) as a violation of the facility's medication labeling policy. Furthermore, an open bottle of glucose test strips was found without an open date label, which is necessary to ensure the strips are used within the manufacturer's recommended timeframe. This was verified by another LN, who confirmed the absence of the open date label. The DON also stated that the open date label is required to prevent the use of expired strips. These deficiencies in medication management increased the risk of administering expired or incorrectly labeled medications, potentially compromising resident safety.
Deficiencies in Food Storage and Staff Hygiene Practices
Penalty
Summary
The facility failed to adhere to safe food storage and handling practices, as observed during a survey. Raw ground beef was improperly stored above vegetables in the kitchen's walk-in freezer, which the Dietary Manager acknowledged could lead to contamination from meat drips. Additionally, in the dry pantry, uncooked lasagna pasta, polenta powder, and chocolate chips were found unsealed, which the Dietary Manager confirmed should have been stored in food-grade plastic bags to prevent pest attraction. Furthermore, there were lapses in personal hygiene and safety protocols among staff. A Restorative Nursing Assistant entered the kitchen without washing hands or wearing hair and facial hair restraints, which he admitted was against infection control practices. The Dietary Manager stated that only kitchen staff should enter the kitchen, and the RNA should have waited outside for his meal tray. Additionally, a Dietary Aide was observed with a long mustache and beard not covered by a facial hair restraint, which he acknowledged was required while working in the kitchen.
Infection Control Deficiencies in PPE Use and Equipment Handling
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several observed deficiencies. Two staff members were seen removing their N95 masks inside a droplet isolation precaution room before exiting, contrary to the facility's guidelines and CDC recommendations. The Infection Preventionist and Director of Nursing confirmed that the practice should be to remove the N95 mask after leaving the room and closing the door. Additionally, two visitors entered a COVID isolation room without the required PPE, wearing only surgical masks, despite the facility's policy requiring adherence to transmission-based precautions by visitors. Further deficiencies were noted in the fit testing of N95 masks for staff. Four out of five sampled staff members, including a Licensed Nurse, Certified Occupational Therapist Assistant, Unit Secretary, and Certified Nurse Assistant, had not undergone the required N95 fit testing upon hire, as confirmed by the Infection Preventionist and Director of Nursing. This lack of fit testing contravenes OSHA requirements and compromises the expected level of protection for staff working in environments with potential exposure to airborne pathogens. Additional infection control issues were observed with residents' medical equipment. Resident 395's nasal cannula was found on the floor and uncovered, which the Infection Preventionist and Director of Nursing acknowledged as a contamination risk. Similarly, Resident 120's urinary drainage bag was observed on the floor on two occasions, posing a risk of infection due to potential backflow. Lastly, a staff member provided care to Resident 42, who was on Enhanced Barrier Precautions, without wearing the required gown and gloves, as confirmed by the facility's policy and the Nurse Consultant.
Inaccurate MDS Assessment for Pain Management
Penalty
Summary
The facility failed to provide an accurate Minimum Data Set (MDS) assessment for one resident, identified as Resident 131, which led to inaccurate health status data. Resident 131 was admitted in September 2024 with diagnoses including orthopedic aftercare, pain in the right lower leg, and diabetes mellitus. The MDS assessment, dated 9/9/24, inaccurately indicated that Resident 131 did not receive scheduled and PRN pain medication in the last five days, despite records showing that the resident had been receiving pain medication, including Norco and Tylenol, since admission. Interviews with Resident 131 and facility staff, including the MDS Coordinator and the Director of Nursing, confirmed the inaccuracy in the MDS pain management assessment. The MDS Coordinator acknowledged the oversight, stating that the pain management questions might have been missed. The Director of Nursing also expressed the expectation for MDS assessments to be accurate to ensure the facility has an accurate resident health status. The facility's policy requires staff to certify the accuracy of the MDS assessments, which was not adhered to in this case.
Failure to Monitor Enteral Feeding Intake and Output
Penalty
Summary
The facility failed to provide appropriate care and services for a resident with enteral feeding, specifically regarding the monitoring of intake and output as per the physician's orders. Resident 396, who was admitted with diagnoses including cerebral infarction, muscle weakness, and aphasia, was observed to have a nasogastric tube for feeding. The physician's order required intake and output monitoring every shift, but this was not consistently followed, as evidenced by missing records on the night shift of October 10 and the day shift of October 13. Interviews with the licensed nurse and the Director of Nursing confirmed the oversight in monitoring, emphasizing the importance of adhering to the physician's orders to ensure adequate fluid balance and nutrition for the resident. The facility's policy on enteral nutrition also highlighted the need for monitoring to detect signs of inadequate nutrition and altered hydration. This lapse in monitoring increased the potential for inadequate care and compromised the resident's well-being.
Failure to Follow Pain Management Protocols
Penalty
Summary
The facility failed to provide appropriate pain management services for a resident, identified as Resident 69, by not adhering to the physician's orders for pain medication. Resident 69, who was admitted in August 2024, had a history of cerebral infarction, muscle weakness, Parkinson's disease, and osteoarthritis, conditions that can cause significant pain. The resident's cognitive assessment indicated intact cognition, and she reported experiencing pain for which she took medication. The physician's orders specified the administration of Acetaminophen for mild pain and Acetaminophen-Codeine for moderate to severe pain. However, the Medication Administration Record (MAR) showed that Acetaminophen was administered on several occasions when the resident's pain level was recorded as moderate, according to the facility's pain scale protocol. Interviews with facility staff, including a Licensed Nurse (LN) and the Director of Nursing (DON), confirmed that the physician's orders were not followed on specific dates when the resident's pain was assessed as moderate. The facility's policy and procedure for pain management and medication administration require adherence to prescriber orders and assessment of pain intensity using a numeric scale. The failure to follow these protocols resulted in the potential for the resident not to achieve relief from pain and not attain her highest practicable well-being.
Failure to Notify Resident's Representative of Medication Change
Penalty
Summary
The facility failed to ensure timely notification of a resident's representative when an antipsychotic medication, Seroquel, was discontinued for a long-term resident with diagnoses including memory problems with agitation, anxiety disorder, and legal blindness. The resident's medical record indicated that Seroquel was discontinued without notifying the resident's representative or family members, leading to a change in the resident's behavior, including screaming and refusing to listen to family members during visits. The family was not informed of the medication change until it was reinstated, causing frustration and confusion about the resident's altered behavior. Interviews with the resident's family and facility staff confirmed that the facility did not follow its policy of notifying the resident's representative of changes in the resident's care, including medication changes. The Director of Nursing acknowledged that the resident's representative should have been informed when Seroquel was discontinued. The lack of notification resulted in the family being unaware of the medication change and its impact on the resident's behavior, which was only resolved when the medication was reinstated.
Resident Burned Due to Inadequate Supervision During Meal
Penalty
Summary
The facility failed to ensure the safety of a resident during breakfast, resulting in burns and blisters on two of the resident's fingers. The resident, who was admitted with diagnoses including parkinsonism and ataxia, required assistance with eating due to tremors. On the day of the incident, a CNA, who was not familiar with the resident's care, microwaved the resident's hot cereal and left it unattended on the tray. The resident attempted to check the temperature of the cereal, resulting in the hot cereal spilling on her hand and causing burns. The CNA admitted to not testing the temperature of the cereal before serving it and acknowledged that it was likely too hot. Despite the presence of a thermometer and instructions to ensure liquids do not exceed 145 degrees, the CNA did not use the thermometer. The Director of Nursing confirmed that the resident required supervision during meals due to her inability to feed herself. The facility's policy on safety and supervision emphasized the need for resident supervision based on individual needs and environmental hazards.
Failure to Notify Family of Resident's Injury
Penalty
Summary
The facility failed to promptly notify the responsible party or family member of a resident when the resident experienced burns to two fingers. The resident, who was admitted in May 2020 with diagnoses including parkinsonism and ataxia, attempted to feed herself without CNA assistance and spilled hot cereal, resulting in burns to her left hand. A nurse's progress note documented the incident, but there was no evidence that the resident's responsible party or family member was notified at the time of the injury. The deficiency was further highlighted during a review of the resident's change of condition evaluation, which showed that the family member was only notified four days after the incident. Interviews with the Director of Nursing and a licensed nurse confirmed that the facility's policy required prompt notification of the resident's representative in such cases, but this was not adhered to. The facility's policy, revised in February 2021, clearly stated the requirement for prompt notification in the event of an accident or incident resulting in injury.
Failure to Ensure Timely and Accurate Resident Assessment
Penalty
Summary
The facility failed to ensure accurate and timely assessments of a resident's injuries, leading to inconsistent evaluations and a delay in appropriate treatment. The resident, who was admitted with diagnoses including parkinsonism and ataxia, sustained burns on two fingers of the left hand after spilling hot cereal due to tremors. Despite the incident being documented by various Licensed Vocational Nurses (LVNs) over several days, there was no documented assessment by a Registered Nurse (RN), Nurse Practitioner (NP), or Physician on the day of the injury. This lack of assessment resulted in the absence of a diagnosis regarding the severity of the burns. Interviews with staff revealed that LVNs acknowledged their limitations in performing physical assessments and diagnosing injuries, which are responsibilities designated to RNs. The Director of Nursing confirmed that RNs are expected to conduct assessments. The report highlights that the facility did not adhere to the Nursing Practice guidelines, which stipulate that only RNs can perform comprehensive assessments, analyze data, and formulate nursing diagnoses. This oversight led to the resident's injuries being inadequately assessed and treated.
Delayed Care Plan Revision After Resident Injury
Penalty
Summary
The facility failed to revise a resident's care plan in a timely manner after the resident sustained an injury. The resident, who was admitted in May 2020 with diagnoses including parkinsonism and ataxia, attempted to feed themselves without CNA assistance, resulting in hot cereal spilling and causing burns to two fingers on their left hand. A nurse progress note documented the incident, and a Nurse Practitioner wrote new orders to monitor the burn site. Despite the incident occurring on April 22, 2024, the care plan was not updated until April 26, 2024. During an interview and record review on June 5, 2024, the Director of Nursing confirmed that the care plan had not been revised promptly, stating that care plans should be updated the day of or the next day at the latest. The facility's policy, revised in March 2022, emphasizes that care plans should be revised as residents' conditions change, highlighting the deficiency in this case.
Failure to Follow Physician Orders for Wound Care
Penalty
Summary
The facility failed to ensure that physician orders for wound care treatment were followed for a resident with open wounds on both lower legs, diabetes mellitus, and atherosclerosis. The resident was admitted with specific orders for monitoring and treating diabetic foot ulcers on both legs. However, the Treatment Administration Record (TAR) for April 2024 showed that monitoring was not documented for 20 out of 70 shifts, and wound care treatment was not documented for several shifts on both legs. The absence of documentation and progress notes indicated that the treatments were either not performed or not recorded, as confirmed by the Licensed Nurse and the Director of Nursing. The facility's policy required all services provided to residents to be documented accurately in their medical records, but this was not adhered to in the case of the resident. The Director of Nursing confirmed the lack of documentation and progress notes explaining why the treatments were not completed. Additionally, the facility could not provide a policy and procedure regarding the standard for following physician orders, which is a legal duty for licensed nurses according to the California Nursing Act.
Failure to Provide Proper Foot Care Leads to Amputation
Penalty
Summary
The facility failed to ensure proper foot care for a resident, leading to a partial right foot amputation. The resident, who had a history of peripheral vascular disease, diabetes, heart failure, peripheral neuropathy, and a previous partial left foot amputation, developed a wound on the right foot second toe. There was a lack of documentation indicating that the wound was being assessed per nursing standards, and the resident missed multiple podiatry appointments due to a failure in arranging transportation services. These missed appointments and inadequate wound monitoring contributed to the worsening of the resident's condition, ultimately resulting in the need for surgical intervention. The resident's care plan included monitoring for signs of skin breakdown and ensuring podiatry consultations as ordered. However, the facility's records showed no documented evidence of consistent wound assessments or discussions in weekly wound meetings. The wound on the resident's right second toe persisted from December 2023 to February 2024 without proper documentation of its progress or any significant intervention. The treatment nurse admitted to not closely monitoring the wound, and the Director of Nursing confirmed that the lack of documentation made it impossible to determine if the wound was improving. Interviews with staff revealed a breakdown in communication and responsibility regarding the resident's care. The Social Services Coordinator was responsible for arranging transportation to outside appointments but failed to do so, leading to missed podiatry visits. The nursing staff did not adequately document or monitor the resident's wound, and the physician was not notified of the wound's lack of healing in a timely manner. This series of failures in communication, documentation, and care ultimately led to the resident's partial foot amputation.
Failure to Maintain Qualified Infection Preventionist
Penalty
Summary
The facility failed to ensure an Infection Preventionist (IP) was available to meet all the requirements of the position for a census of 141 residents. The Executive Director (ADM) stated that the full-time IP left in January 2024 and worked part-time during February 2024. However, time sheets indicated the IP worked zero hours from 2/1/24 to 2/15/24, and no time sheets were provided for the latter half of February. The ADM confirmed that no further time sheets were sent to the Department, and the IP did not attend the facility's quarterly Quality Assurance (QA) meeting on 1/25/24. The Director of Nursing (DON) acknowledged the importance of having an IP present in the building and at QA meetings. The Resource Nurse Consultant (RNC) initially indicated that the Director of Staff Development (DSD) was performing IP duties, but later confirmed that the DSD was not certified to perform the role of an IP and was not acting as the facility's IP. The facility's policy and procedure for the Infection Prevention and Control Program, revised in October 2018, stated that the program should be coordinated and overseen by an infection prevention specialist. The ADM and other staff interviews confirmed that the facility did not have a qualified IP in place during the period in question, which decreased the facility's potential to prevent the spread of infection among staff and residents. The ADM acknowledged the absence of an IP and the failure to provide necessary documentation to the Department, highlighting a significant gap in the facility's infection control measures.
Infection Control Deficiency During Wound Treatment
Penalty
Summary
The facility failed to maintain an effective infection prevention program for one resident when the Treatment Nurse did not follow proper infection control practices during a wound treatment. The nurse did not clean bandage scissors before or after cutting a soiled wound dressing, placed treatment supplies directly on the resident's bed, and did not perform hand hygiene during the procedure. These actions were observed during a bandage change for a resident with peripheral vascular disease and diabetes, conditions that slow the body's ability to heal wounds. During the bandage change, the nurse placed a plastic bin of treatment supplies and a box of disposable gloves directly on the resident's bed and put on gloves without performing hand hygiene. The nurse used uncleaned bandage scissors to cut off the old bandages, placed the scissors on the bed, and removed the soiled bandages without changing gloves or performing hand hygiene. The nurse then picked up a cup with bandages soaking in a reddish-brown liquid and planned to apply povidone-iodine to the wound without changing gloves. The procedure was stopped for safety concerns, and the nurse acknowledged not changing gloves or performing hand hygiene. Upon resuming the bandage change, the nurse put on new gloves without performing hand hygiene, applied povidone-iodine, and continued to wrap the wound. After completing the procedure, the nurse did not clean the bandage scissors before putting them back in the pouch and returned the supplies to the treatment cart. The Assistant Director of Nursing and the Director of Staff Development both stated that the nurse's actions did not follow the facility's infection control practices, which require hand hygiene, clean surfaces for supplies, and cleaning of reusable equipment to prevent cross-contamination and infection.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Fair Oaks
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Citrus Heights Post Acute | 1.3 mi | ★★★★★ | 13 | 0 |
| Manzanita Healthcare Center | 3.8 mi | ★★★★★ | 17 | 0 |
| Sacramento Post-acute | 4.3 mi | ★★★★★ | 16 | 0 |
| American River Center | 4.6 mi | ★★★★★ | 12 | 0 |
| Casa Coloma Health Care Center | 4.6 mi | ★★★★★ | 1 | 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.