Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Foundation Skilled Nursing during CMS and state inspections, most recent first.
Surveyors found that the facility failed to maintain a functioning call light system for 11 of 59 beds, with several residents lacking working call lights or any call light device at their bedside. One cognitively intact resident with muscle weakness and a history of repeated falls reported his call light had worked intermittently since admission, had stopped working again, and that he had previously gotten out of bed and yelled for help and once waited about an hour for incontinence care due to the nonfunctioning call light. In another room, a resident reported having no call light, and her roommate had only a small silver bell despite hand deformities that made its use difficult. The DOM and staff identified loose wall connections, missing cords, and long-standing issues in multiple rooms, with some residents given bells or portable call buttons instead of functioning call lights, while CNAs, an LVN, the scheduler, and the DON gave conflicting accounts of their awareness of these ongoing problems and the reporting process.
Failure to Provide Adequate Fall Supervision and Monitoring: A resident with dementia, poor safety awareness, unsteady gait, and repeated unwitnessed falls was kept on 15-minute fall checks even though staff said the monitoring was not effective and one-on-one supervision was needed. The resident continued unsafe self-transfers, wheelchair use, and wandering, while the facility did not complete the medication review after the first fall or reflect the identified fall interventions in the care plan. The resident later sustained a right hip/femur fracture requiring hospital transfer and ORIF.
Admission Medications Not Available as Ordered: A resident admitted after a hospital stay with multiple chronic conditions, including ESRD, cirrhosis, HTN, DM2, and depression, did not receive several ordered admission meds on time. Records showed multiple meds pending delivery or unavailable, including rifaximin, lactulose, bumetanide, diltiazem ER, sertraline, folic acid, and gabapentin, and the EMAR documented missed doses due to medication not being available. Staff and the pharmacy manager confirmed meds should have been available by the next dose and that the delays were not acceptable.
Food and Nutrition Services Menu Not Followed: A Dietary staff member and the DM did not follow the lunch menu when preparing a turkey croissant sandwich, using available ingredients instead of the listed items and serving two garlic bread sticks instead of one. The RD stated the DM forgot to order the correct ingredients and that the kitchen staff did not follow the correct menu, which would not meet residents' nutritional needs.
Menu Not Followed During Lunch Service: Dietary staff did not follow the planned lunch menu when preparing a turkey croissant deluxe sandwich, using available ingredients instead of the ordered menu items and serving two garlic bread sticks instead of one. The DM stated the correct ingredients were not ordered, and the RD stated the kitchen used whatever was available rather than a substitute menu, which did not follow the facility’s menu requirements.
Failure to follow up on a positive PASARR Level I screening for a resident with bipolar disorder, schizoaffective disorder, anxiety, and dementia. The screening required a Level II MH evaluation, but the evaluation was not completed after facility staff were unresponsive to attempts to communicate. The IP and MDSC confirmed the Level II was incomplete and was not followed up, and the DON stated PASARRs were expected to be reviewed for accuracy and completed as needed.
A facility emergency medication kit containing three vials of insulin was found opened with red tags, but no form documented who opened it, when it was opened, or what medication was removed. The IP, LVN, RNS, and DON all stated the required withdrawal form should be completed and faxed to the pharmacy, but no completed form was found and the kit had not been replaced.
Medication Error Rate Exceeded Limit Due to Expired Folic Acid and Incorrect Inhaler Dose. An LPN prepared an expired Folic Acid dose without checking the expiration date and administered only one inhalation of a Tiotropium Bromide Monohydrate inhaler when two inhalations were ordered. The resident had anemia, COPD, and severe cognitive impairment, and the DON stated the nurse did not follow the ordered dose or expiration-date check requirements.
Two residents' discontinued chlorhexidine gluconate bottles were found mixed with active meds in a med cart. An LVN identified the bottles as belonging to the residents, while another LVN said she did not know whether the meds were still being given. Record review showed both orders were time-limited and had ended, and the DON confirmed discontinued meds should be removed from the cart and separated from active meds per facility policy.
A facility failed to maintain infection control during resident care, equipment handling, and water management. A CNA provided direct care to a resident on EBP for ESBL without the required gown, a housekeeper used the same gloves while touching two residents’ blankets, and an LVN did not properly disinfect a shared glucometer before placing it in the med cart. The facility also did not follow its Legionella water management and testing policy, with staff relying on quarterly outside testing instead of the required monitoring and documentation.
Mechanical lifts were not functional because of battery problems, and a resident who required a mechanical lift transfer remained in bed while a CNA stated the resident should have been up in a chair for meals. The RNA said there was no back-up battery, the borrowed lift was not operating safely when tested, and monthly resident weights were delayed because the lifts could not be used as scheduled. The DON and ESM both stated resident care equipment should be maintained in working condition.
An effective pest control program was not maintained when flies were observed in a resident room and the dining room, including flies landing on a resident’s clothing and curtain, flying around uncovered food, and moving from table to table during meals. Staff, including an LVN, CNA, RNA, IP, ESM, DON, and the ADM, acknowledged the flies were present in the facility and around residents’ food, and the facility was using a fly swatter rather than an effective pest control program.
Dirty Floor Mattress in Resident Room: A resident’s mattress placed on the floor beside the bed was observed dirty with brownish buildup, and an LVN stepped on it during the room observation. The resident had severe cognitive impairment, and multiple staff members, including the RNA, HS, ESM, and DON, stated the mattress was dirty, posed an infection control issue, and should be cleaned and disinfected; staff also noted the resident often rolled from the bed onto the floor mattress.
A resident with schizoaffective disorder, subdural hemorrhage, and muscle weakness was ordered olanzapine 5 mg at bedtime, but no behavior monitoring was in place after the psychotropic medication was started. The IP and RNS confirmed the lack of behavior monitoring, and the DON stated monitoring should begin when the medication is initiated so the resident's response can be documented.
Failure to Document and Notify Staff for AMA Discharge: A resident with spinal stenosis, muscle weakness, and gait impairment left AMA, but the record lacked documentation of the discharge and there was no documentation that the MD, ADM, or DON were notified. Interviews confirmed staff expected the AMA form, progress note documentation, and notification of leadership and the MD, but these were not documented in the resident’s record.
Inaccurate MDS Coding for Mood Stabilization Medication: A resident with Alzheimer’s disease and dementia was observed in bed during tour, and record review showed he was prescribed Divalproex for mood stabilization. The MDS nurse confirmed the resident was taking the medication but did not code the related mood disorder in Section I of the MDS, and the DON stated MDS assessments were expected to be accurate.
Failure to update PASARR screening after mental health changes: The facility did not complete new PASARR Level I screenings for three residents after psychotropic meds were started and mental health diagnoses were identified. Records showed psychosis, schizophrenia, schizoaffective disorder, depression, and related orders for olanzapine, quetiapine, paroxetine, and aripiprazole. The MDSC stated updated PASARR reviews should have been completed, but none were found.
A resident with schizoaffective disorder, psychoactive substance abuse, and traumatic brain injury had an order for olanzapine 5 mg at bedtime, but the record did not contain a care plan for the psychotropic medication. The IP and MDSC both confirmed the missing care plan, and the DON stated psychotropic orders were expected to be added right away so staff could monitor for side effects and follow the plan of care.
A facility failed to provide nail care for two residents who depended on staff for ADLs. One resident with dementia was observed with long, dirty fingernails with debris under the nails while eating, and the RNA stated the resident touched food with her hands and needed trimmed, cleaned nails. Another resident with hemiplegia, hemiparesis, DM, HTN, and polyneuropathy was observed with long fingernails, and staff stated nail care was the responsibility of CNAs or licensed nurses depending on the resident. The facility policy required daily cleaning and regular trimming of nails.
Failure to implement an ophthalmology referral for a resident with cataracts and retinal detachment. The resident, who was alert and oriented, reported worsening L eye vision, black circles, and repeated requests for an eye specialist after a prior eye evaluation recommended ophthalmology follow-up. MDS and nursing staff confirmed the resident had impaired vision and that the referral should have been arranged through SSD, but the referral was not carried out as documented.
A resident with hemiplegia and hemiparesis after a cerebral infarction did not receive timely restorative nursing support after PT and OT ended, and staff did not implement the resident’s left hand splint and left leg boot program as ordered for contracture management. The resident reported feeling weaker, said the splint and boot had been missing for over a month, and was observed with left-sided weakness and flaccidity while staff confirmed there was a delay in transitioning from skilled therapy to RNA services.
Failure to provide dental evaluation for a resident with toothache. A cognitively intact resident with hemiplegia/hemiparesis following cerebral infarction reported ongoing tooth pain and said she had been asking for a dental exam but had not seen a dentist since admission. Staff confirmed there was no dental assessment or dentist evaluation completed, despite facility policy requiring dental requests and acute dental pain to be referred for immediate dental care.
A facility failed to ensure that three bedrooms did not exceed the maximum occupancy limit. Surveyors observed that Rooms 1, 2, and 14 each contained six beds, although the report noted the rooms met residents’ needs, had sufficient space for nursing care and ambulation, and included adequate storage and accessible wheelchair and toilet facilities.
A facility area contained accident hazards and staff did not provide adequate supervision to prevent accidents, as observed by surveyors. These lapses resulted in a deficiency related to environmental safety and resident supervision.
A resident with severe cognitive impairment and multiple risk factors for falls experienced three unwitnessed falls within two weeks due to the facility's failure to provide adequate supervision and timely, effective fall prevention interventions. Despite being identified as high risk and requiring supervision while ambulating, the resident was only checked every 15 minutes rather than receiving direct in-room supervision, and interventions were not adjusted after repeated falls.
A resident with moderate cognitive impairment was left at a doctor's office for several hours without a meal due to a failure in transportation arrangements. The resident was ready to return to the facility by noon but was not picked up until the evening, resulting in emotional distress and hunger. The facility's process for managing appointments was not followed, and the Social Services Director did not ensure the resident's timely return.
A resident at high risk for falls was not properly placed on the facility's Red Sneaker Program, a fall prevention initiative. Despite having a fall risk score indicating high risk, the necessary visual symbols and red bracelet were missing, contrary to the facility's policy. The resident's medical history included conditions like osteomyelitis and muscle weakness, but their MDS indicated no cognitive impairment. Interviews with the DON and an LVN confirmed the oversight in implementing the required interventions.
A resident with Alzheimer's and severe cognitive impairment, identified as a high fall risk, experienced an unwitnessed fall resulting in a skin tear. Despite being part of a fall prevention program, the resident was left unsupervised after breakfast, leading to the incident. Staff interviews confirmed the resident's need for supervision, especially when tired, was known but not adequately provided.
The facility failed to maintain a safe and comfortable environment for residents when the dining room temperature fell below the acceptable range of 71 to 81 degrees Fahrenheit. Three residents, including one with dementia and another with COPD, expressed discomfort due to the cold conditions. The Director of Maintenance confirmed the low temperatures, and the Director of Nursing emphasized the importance of maintaining the specified temperature range to ensure a homelike setting.
The facility failed to implement comprehensive care plans for three residents, leading to potential health risks. A resident's medication refusal was not addressed in their care plan, another resident's skin assessments were not conducted, and a third resident's call light was not within reach, contrary to their care plan. These oversights indicate a failure to adhere to care planning policies.
The facility failed to meet professional standards by not explaining medications to residents during administration, not notifying a physician of a resident's medication refusal, and not performing current vital assessments before a hospital transfer. Nurses admitted to not informing residents about their medications, and outdated assessments were used for a resident with shortness of breath.
A resident was given divalproex without a specific diagnosed condition documented in their clinical record. The medication was used off-label for mood disorders, despite effective non-pharmacological interventions. The resident had a history of dementia and other mental health issues, and the facility's policy required a specific diagnosis before administering psychotropic medications.
The facility failed to maintain the required temperature in the high temperature dishwasher, with readings below the necessary 155 degrees Fahrenheit during the wash cycle. This failure could potentially expose 52 out of 55 highly susceptible residents to foodborne illnesses due to cross-contamination. Staff interviews confirmed the importance of correct temperatures for sanitation, and the facility's policy emphasized adherence to manufacturer's recommendations.
The facility failed to maintain an effective pest control program, as flies were observed in the kitchen on two consecutive days. The Certified Dietary Manager acknowledged the lack of a fly light trap and recognized the infection control issue posed by flies. The Registered Dietician expected a pest-free kitchen, emphasizing the risk of illness for residents. The facility did not provide a specific pest control policy, and a review of the FDA Food Code highlighted the need to protect food establishments from pests.
The facility was found to have three rooms (Rooms 1, 2, and 14) each accommodating six residents, exceeding the regulatory limit of four residents per room. Despite this, the rooms were noted to have sufficient space and facilities to meet the residents' needs, and the health and safety of the residents were not deemed to be adversely affected by this arrangement.
A resident at high risk for falls, with severe cognitive impairment and multiple medical conditions, was left unattended by a CNA assigned to provide one-on-one supervision. The CNA briefly left the resident's side to assist another CNA, resulting in the resident falling and sustaining head injuries. The facility lacked a specific policy for one-on-one supervision, contributing to the deficiency.
Failure to Maintain Functioning Call Light System for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain a functioning resident call light system in multiple rooms and beds, including bathrooms and bathing areas, leaving residents without a reliable means to summon staff assistance. Surveyors observed that 11 of 59 beds (8A, 8B, 11A, 11B, 11C, 14A, 14B, 15A, 15B, 17B, 17D) had nonfunctioning or missing call lights. In one room, a resident reported that his call light had worked intermittently since admission and had stopped working again the day before the survey; when he pressed the button, there was no light above the door and no sound or light at the bed station panel. The panel had a splitter adapter with two cords plugged in, but the system did not activate. This resident stated he had previously gotten out of bed on his own and gone to the door to yell for help and that on one occasion he waited about an hour to be cleaned after a bowel movement because the call light was not working. The same resident’s records showed diagnoses including mastoiditis, Bell’s palsy, muscle weakness, and repeated falls, and his MDS BIMS score indicated he was cognitively intact. He reported that the Director of Maintenance (DOM) had attempted to fix the call light about three weeks earlier but was unsuccessful, and that the DOM had said he ordered the wrong part or that parts were not coming in. During the interview, the DOM entered the room with a call light cord, stating he had a work order to replace the cord, but then left the room without replacing it. Later, the DOM stated there were five call lights not working in the facility and that he had received work orders for rooms 8, 11, and 14 on a recent Sunday, and he asserted it was the first time he had heard that the resident’s call light had been intermittently nonfunctional for approximately six weeks. In another room shared by two residents, one resident stated she did not have a call light and believed it had been stolen; surveyors confirmed there was no call light near her bed. The other resident in the same room had a small silver bell on her overbed table instead of a call light, and she had partial deformity of her hands, making use of the bell difficult. Additional observations with the DOM showed that call lights in multiple rooms and beds did not activate when pressed, including beds 8A, 8B, 11C, 14A, 14B, 15A, 15B, 17B, and 17D, and that beds 11A and 11B had no call lights at all. In some cases, the DOM identified loose plugs or bad connections in the wall panels and noted that silver bells or portable call buttons had been used when the call lights were not working. Staff interviews revealed inconsistent awareness and reporting of the call light problems. A CNA assigned to affected rooms stated she was unaware the call lights were not working and that the previous shift had not reported any issues. Another CNA reported that one room’s call light would not work at times because the cord would come slightly out of the panel and had to be pushed back in. An LVN stated she did not know that call lights in a particular room were not working, while another LVN reported that call lights in one room had not worked for about two months and that portable call buttons had been provided. The scheduler, who conducted Angel Rounds for certain rooms, stated that call lights in one room had not been working for approximately two months and that residents were initially given silver bells and later portable call buttons, but she was unaware that one resident in that room did not have a call light or bell. The DON stated that call lights in one room had not been working since January and that portable call lights were given due to connection issues, and she was unaware that a resident in another bed did not have a call light. Review of maintenance request forms showed repeated reports of call light problems over several weeks, including nonworking call lights in room 14 for all beds, a bad wall connection in room 8B, a need for call lights for both beds in another room, and a missing call light in bed 11A. Some forms documented completion dates and comments that call lights were working again or that parts such as split connectors had been ordered. Angel Rounds documentation for certain dates noted a broken call light button in room 11. The facility’s call light policy stated that staff would be educated on proper use of the call system, ensure resident access to call lights, and report problems to a supervisor or maintenance director, and the maintenance director’s job description required maintaining the building and equipment in safe order and ensuring a safe and secure environment for staff, residents, and guests. Despite these policies, survey findings showed multiple nonfunctioning or missing call lights and inconsistent communication and follow-through regarding identified call light issues.
Failure to Provide Adequate Fall Supervision and Monitoring
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents for a resident with Alzheimer’s disease, severe cognitive impairment, poor safety awareness, unsteady gait, and repeated falls. The resident was identified as high risk for falls on quarterly assessment and had multiple unwitnessed falls while attempting to self-transfer, ambulate without assistance, or while found on the floor in the room or hallway. The resident also had diagnoses including COPD, malnutrition, CHF, anxiety, depression, anemia, hypertension, osteoarthritis, chronic pain syndrome, scoliosis, generalized weakness, gait abnormalities, spinal stenosis, and repeated falls. After the resident’s falls, the facility used its Red Sneaker fall monitoring program at Level 2, which was described as every 15-minute checks. Staff interviews and record review showed the resident continued to fall while on this monitoring level, and multiple staff stated the resident needed one-on-one supervision because the 15-minute checks were not effective and were not consistently completed when assigned staff were also caring for other residents. The resident was observed self-propelling a wheelchair, stating she was lost, and staff reported unsafe transfers, failure to lock the wheelchair, wandering, and inability to reliably use the call light. Record review also showed the facility did not complete or act on a medication regimen review after the first fall, despite medications including clonazepam, melatonin, and later tramadol being identified as possible contributors to falls. The resident’s fall care plan and IDT fall review documentation did not reflect the new interventions identified after the falls, including medication review, therapy referral, and monitoring for UTI. The resident sustained four unwitnessed falls, and after the final fall was sent to the hospital with severe right hip pain and inability to bear weight, where a periprosthetic right hip fracture was diagnosed and ORIF of the right femur was performed.
Admission Medications Not Available as Ordered
Penalty
Summary
The facility failed to ensure that Resident 64’s admission medications were available by the next dose as ordered by the physician. Resident 64 was admitted after a hospital stay following a fall at home with a pelvic fracture and had diagnoses including end stage renal disease, chronic kidney disease, alcoholic cirrhosis of the liver, anemia, essential hypertension, type 2 diabetes mellitus, and major depressive disorder. During an interview, Resident 64 stated she had not received her medications since arriving at the facility because she did not bring her medical card. Record review showed multiple admission medications were documented as pending delivery or not available, including folic acid, bumetanide, diltiazem ER, sertraline, rifaximin, lactulose, and gabapentin. The Orders-Administration Notes documented delays across several days, including medications pending delivery, faxed to pharmacy, not available in the e-kit, and rifaximin pending authorization. The EMAR showed rifaximin doses on multiple days marked with a notation indicating the medication was not available. Interviews with nursing and pharmacy staff confirmed that medications should have been available on the next dose and that delays in delivery were occurring. The RNS stated the resident’s medications should be available to prevent complications and that rifaximin should have been available to manage the resident’s cirrhosis. The DON stated new admission residents should have medications available the next day or next dose, and the PGMO stated it was not acceptable for medications to be unavailable and that she needed to investigate the delay. Facility policies required medications to be administered in a safe and timely manner and that pharmacies provide 24-hour emergency service with delivery seven days a week.
Food and Nutrition Services Menu Not Followed
Penalty
Summary
The facility failed to employ sufficient staff with appropriate competencies and skill sets to carry out food and nutrition services when two kitchen staff members, the Dietary staff member and the Dietary Manager, did not follow the lunch menu. During a concurrent observation and interview in the kitchen, the Dietary staff member was preparing a turkey croissant sandwich using ingredients that were available in the facility rather than the ingredients listed on the menu. The Dietary staff member stated the menu for the lunch sandwich was not followed and that she had informed the Dietary Manager, who stated she forgot to order the correct ingredients for the croissant sandwich. The Dietary staff member also served two garlic bread sticks instead of one. Review of the facility menu for the turkey croissant deluxe sandwich showed ingredients including lettuce, oven roasted tomatoes, pickled red onions, turkey breast, sliced cheddar cheese, mozzarella, bacon onion marmalade, and avocado, while the diet spreadsheet listed lunch as homestyle bread with one slice of garlic bread. The Registered Dietician stated the Dietary Manager forgot to buy the correct ingredients, the kitchen used whatever was available, and the kitchen staff did not follow the correct menu; the RD also stated that if the menu was not followed it would not meet residents' nutritional needs.
Menu Not Followed During Lunch Service
Penalty
Summary
The facility failed to employ sufficient staff with appropriate competencies and skill sets to carry out food and nutrition services when the lunch menu was not followed for a turkey croissant deluxe sandwich. During a concurrent observation and interview in the kitchen, Dietary staff prepared a lunch item using ingredients that were not the same as those listed on the facility menu. Dietary staff stated the correct ingredients were not available because the Dietary Manager had not ordered them, and the Dietary Manager stated she forgot to order the correct ingredients for the croissant sandwich. The observed lunch service included a croissant sandwich with turkey breast, fresh tomatoes, cheddar cheese, regular bacon, and lettuce, while the facility menu for the meal listed lettuce, oven roasted tomatoes, pickled red onions, turkey breast, sliced cheddar cheese, mozzarella, bacon onion marmalade, and avocado. Dietary staff also served two garlic bread sticks instead of one. The Registered Dietician stated the kitchen staff did not follow the correct menu, used whatever ingredients were available, and should have used a substitute menu instead of omitting ingredients. The facility policy stated meals are to meet nutritional needs and menus are to be approved by the Registered Dietician before each quarterly menu cycle.
Failure to Follow Up on Positive PASARR Screening
Penalty
Summary
The facility failed to follow up on a positive PASARR Level I screening for Resident 7, whose screening dated 4/8/25 indicated that a PASARR Level II mental health evaluation was required. A Notice of Attempted Evaluation dated 4/12/25 stated that the Level II evaluation was unable to be completed because facility staff were unresponsive to two or more separate attempts of communication within 48 hours of the Level I screening. Resident 7 was admitted with diagnoses including bipolar disorder, schizoaffective disorder, anxiety, and dementia. The resident's MDS dated 10/2/25 showed a BIMS score of 3 out of 15, indicating severe cognitive impairment. During observation on 12/2/25, Resident 7 was standing outside her room, dressed appropriately, stated she liked to keep her door closed, and was observed ambulating in the hallway with a steady gait. During interviews and record review, the IP stated that Resident 7's PASARR Level I was positive and needed a Level II assessment, but the Level II was incomplete and should have been followed up and was not. The MDSC stated she did not know who received the PASARR Level II and filed in the record without reviewing it. The DON stated the MDS, business office manager, medical records, and admission director were responsible for ensuring PASARR was completed and reviewed for accuracy prior to admission.
Opened Emergency Medication Kit Without Required Documentation
Penalty
Summary
The facility failed to provide pharmaceutical services to ensure appropriate administration of medications when the refrigerator emergency kit was found opened and no form was available showing the date, time, or name of the person who opened it. During observation and interview, the kit had red tags indicating it had already been opened, but staff could not determine when it was accessed or what medication had been taken. The facility’s pharmacy policy required staff who broke the tamper-evident seal to record the nurse’s name, the date and time the kit was accessed, and fax the emergency kit withdrawal communication form to the pharmacy. During interviews, the IP, LVN, RNS, and DON each stated the expected practice was to complete the form when the emergency kit was opened and fax it to the pharmacy, but no completed form was found. Staff also stated they did not know who opened the kit, when it was opened, or how long it had been open. The DON stated there was no medicine missing from the kit and was not sure why it was opened, and the pharmacy had not replaced the kit. The emergency kit contained three vials of insulin.
Medication Error Rate Exceeded Limit Due to Expired Folic Acid and Incorrect Inhaler Dose
Penalty
Summary
The facility failed to keep the medication error rate below 5 percent; surveyors calculated an 8 percent medication error rate based on 25 opportunities for error and two medication errors involving one resident. During an observation and interview, an LVN prepared five tablets of Folic Acid 1 mg for a resident and did not check the expiration date before medication administration. The medication card was later found to have an expiration date of 11/5/25, and the LVN stated the medication had been expired and that she was not checking expiration dates during the medication pass. The same resident also received an incorrect dose of Tiotropium Bromide Monohydrate inhalation medication. During the medication pass, the LVN asked the DON how to prepare the inhaler medication and stated she had not received training on it. The LVN administered one inhalation to the resident and later signed the EMAR indicating all morning medications had been given. When questioned, she stated she had mistakenly administered only one inhalation instead of the ordered two inhalations and acknowledged that the resident did not receive the full dosage. The resident involved had diagnoses of anemia and COPD and a BIMS score of 4, indicating severe cognitive impairment. The DON stated it was her expectation that licensed nurses check expiration dates before administering medications and follow physician orders so residents receive the full effectiveness of prescribed medications. The facility policy required medications to be administered as prescribed, with the label checked three times and the expiration or beyond-use date checked prior to administration.
Discontinued Mouthwash Left in Medication Cart
Penalty
Summary
The facility failed to ensure proper storage and disposal of medications and biologicals in accordance with facility policy and procedures when discontinued bottles of Chlorhexidine Gluconate were found in side 1's medication cart mixed with active medications. During a concurrent observation, interview, and record review, two bottles of Chlorhexidine Gluconate were observed in the cart with medications that were in use for residents. LVN 1 identified the bottles as belonging to Resident 17 and Resident 45, and LVN 2 stated she did not know whether the residents were still receiving the medication because she did not administer it. Record review showed Resident 17's chlorhexidine order was for 14 days, with administration from 11/14/25 through 11/27/25 and a one-time dose on 11/28/25, while Resident 45's chlorhexidine order was also for 14 days and was administered from 11/14/25 through 11/27/25. LVN 2 stated both residents' medications should have been removed from the medication cart because they were no longer active orders, and that discontinued and expired medications should be pulled right away to prevent medication errors. The DON stated discontinued medications should be removed from the cart because they are no longer active, and the facility policy required discontinued medications to be removed from the resident's medication supply and placed in a designated secure location marked for discontinued medications.
Infection Control Failures in Resident Care, Equipment Disinfection, and Water Management
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program during multiple observed events involving resident care, equipment cleaning, and water management. On 12/3/25, a CNA provided direct care to a resident who was on enhanced barrier precautions for a known history of ESBL-producing bacteria in urine. The CNA entered the room to perform a brief change and linen change without wearing the required gown and did not close the privacy curtain. She was observed carrying one bag containing a diaper and another containing clean linen, and later stated she did not check the sign by the door and was not aware the resident was on enhanced barrier precautions. Facility staff and the Infection Preventionist stated that gown and gloves were expected for this type of high-contact care activity. On 12/2/25, a housekeeping staff member was observed in a resident room where one resident was on enhanced barrier precautions due to a dialysis catheter and the roommate was not on enhanced barrier precautions. The housekeeper touched and covered the resident’s blanket, continued mopping the resident’s floor area, then went to the roommate and touched and covered the roommate’s blanket while wearing the same pair of gloves. The housekeeper later acknowledged she used the same gloves for both residents and stated she should have changed gloves between residents. Facility staff and the DON stated gloves must be changed between resident care to avoid cross contamination. The facility also failed to properly disinfect a glucometer after use. An LVN was observed wiping the glucometer for 2 seconds, placing it in a cup to air dry, and then securing it inside the medication cart. The LVN stated the same glucometer would be used for other residents and later acknowledged she did not disinfect it according to the required wet time. In addition, the facility did not follow its water management and testing policy for Legionella. The Infection Preventionist stated Environmental Services Maintenance was responsible for testing and monitoring water, but the ESM stated the facility only relied on quarterly outside testing and had not implemented the policy’s monthly testing, weekly flushing, temperature monitoring, or documentation requirements.
Mechanical Lifts Not Functional Due to Battery Problems
Penalty
Summary
The facility failed to maintain resident care equipment in safe operating condition when both mechanical lifts were not functional because of battery problems. During observations, a resident who required a mechanical lift transfer was found lying in bed, and a CNA stated the resident should be up in a chair during meals but the facility’s mechanical lift was not working and a new battery had been ordered. The RNA stated the two mechanical lifts were not working due to battery problems, there was no back-up battery, and the borrowed lift was not functioning properly when tested because it was stacked in the air and could not move to its normal position. The RNA also stated monthly resident weights were scheduled to be obtained by the fifth of the month and that the weights were due on 12/5/25, but the facility had not been able to complete them as scheduled because the lift was not functional. The DON stated the two mechanical lifts were not functional because the battery was not charging and that residents who required mechanical lift transfers could not get up, resulting in them staying in bed. The ESM stated he was responsible for monitoring resident care equipment, checked the lift batteries weekly, and that the batteries did not arrive as expected.
Pest Control Program Not Effective
Penalty
Summary
The facility failed to maintain an effective pest control program when flies were observed inside a resident room and the resident dining room. On 12/2/25, multiple flies were seen in a resident room landing on a resident’s clothing and privacy curtain, and an LVN confirmed flies were flying around inside the room and stated there should be no flies inside residents’ rooms or the facility. Later that day, a resident’s food tray was left uncovered on a bedside table while two flies were flying around the food. On 12/3/25, a CNA was observed giving a resident a carton of house supplement while two flies were flying around the resident, and the CNA stated she did not know what to do. In the dining room, the Administrator was observed swinging his hand to keep flies away from residents’ food and asked the RNA to remove and replace a food tray. The RNA stated flies were transferring from one table to another and that flies were seen there once in a while. A CNA later stated she saw a fly around residents’ food and water pitcher during lunch. The IP stated the facility was using a fly swatter to eliminate flies, and the ESM and DON both stated flies should not be inside the facility and can transfer germs into residents’ food. The facility policy stated it shall maintain an effective pest control program.
Dirty Floor Mattress in Resident Room
Penalty
Summary
The facility failed to provide and maintain a safe, clean, and sanitary environment for one resident when the resident’s mattress on the floor beside the bed was observed dirty with brownish dirt built up on the top surface. During the observation, an LVN stepped on the mattress while in the resident’s room. The LVN stated the mattress was dirty and should be cleaned by housekeeping and covered with a bed sheet. The LVN also stated the resident had episodes of purposely rolling from the bed to the mattress on the floor, and that the floor mattress should remain clean to prevent infection. The resident’s MDS dated 10/9/25 showed a BIMS score of 4, indicating severe cognitive impairment. During interviews, the RNA, HS, ESM, and DON all stated the mattress on the floor was dirty and identified it as an infection control issue. They stated the mattress should be cleaned and disinfected, and that staff walking on it could harbor germs or bacteria. Facility policy on Standard Precautions and Cleaning and Disinfection of Resident-Care Items and Equipment stated resident-care equipment must be handled, cleaned, and disinfected in a manner that prevents contamination and transfer of microorganisms.
Failure to Monitor Behavior for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that one of five sampled residents, Resident 13, was free from unnecessary psychotropic medication use when behavior monitoring was not attempted or implemented for olanzapine. Resident 13 was observed ambulating inside the room with a steady gait and was appropriately dressed. During interview, Resident 13 stated he had been in an acute care hospital for a week before admission to the facility, was there to work with therapy to get stronger, and planned to eventually go home. He also stated he did not know anyone in the facility but felt safe. Record review showed Resident 13 was admitted with diagnoses including schizoaffective disorder, subdural hemorrhage, and muscle weakness. A physician order dated 11/26/25 directed olanzapine 5 mg by mouth at bedtime related to schizoaffective disorder. During interviews and record review, the IP and RNS stated Resident 13 was receiving a psychotropic medication and that no behavior monitoring was in place. The DON stated behavior monitoring should have been started as soon as the psychotropic medication was started, and that the licensed nurse receiving the order was responsible for ensuring it was initiated. Facility policy stated psychotropic drugs are not given unless necessary for a specific condition and beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response.
Failure to Document and Notify Staff for AMA Discharge
Penalty
Summary
The facility failed to follow its discharge policy for one resident who left against medical advice. Resident 61 was admitted with diagnoses including spinal stenosis, muscle weakness, and abnormalities of gait and mobility, and was discharged AMA. During record review and interviews, there was no documentation that the resident’s discharge was completed in the record and no documentation that the medical doctor, administrator, or director of nursing were notified when the resident left. During interviews, the MDS nurse stated the resident was AMA and that the MD, ADM, and DON should have been notified, but there was no documentation. The medical records person stated she audits discharges for signatures, remembered providing a copy to the nurse on duty, and assumed the process was completed, but the record still lacked documentation that the MD was notified the day of the AMA discharge. The DON stated licensed nurses should ensure the AMA form is signed and that the MD, ADM, and DON should be notified and documented in the progress note. The ADM stated he was aware the resident left AMA but was not sure when he was notified, and he was not aware there was no documentation that the resident was discharged and the MD was not notified that day.
Inaccurate MDS Coding for Mood Stabilization Medication
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) accurately reflected one resident’s health and functional status when the resident’s use of Divalproex was incorrectly coded. During an initial tour, the resident was observed lying in bed with a blanket over him and a lunch tray on the over-bed table; he stated he had already eaten and refused further questions. The admission record showed diagnoses including Alzheimer’s disease, muscle weakness, and dementia. An IP later confirmed the resident was confused and had Alzheimer’s disease, and that Divalproex had been ordered for mood stabilization. During record review with the MDS nurse, the resident’s admit MDS was reviewed and it was noted that Section N reflected the medication use, but Section I was not marked for the related active diagnosis. The MDS nurse stated the resident was taking medication for mood stabilization and that she did not code him as having a mood disorder, but she should have. The DON stated the expectation was for MDS assessments to be accurate, and that missing or inaccurate MDS assessments are reviewed by the MDS and IDT. The facility’s MDS Coordinator job description stated the role includes coordinating completion of the resident assessment in accordance with federal and state rules and ensuring timely electronic submission of all MDSs, and the facility’s MDS Error Correction policy addressed modification requests when information in the record contains clinical or demographic errors.
Failure to Update PASARR Screening After Mental Health Changes
Penalty
Summary
The facility failed to complete a new PASARR Level I screening and notify the state mental health or intellectual disability authority promptly after significant changes for three residents. The deficiency involved Residents 1, 3, and 6, whose records showed mental health diagnoses and psychotropic medication use that were not reflected in updated PASARR review. The report states this failure had the potential for these residents to not receive appropriate services related to their mental disorders. Resident 1’s record showed diagnoses including psychosis and psychoactive substance abuse, and the PASARR Level I screening dated 11/4/25 indicated that a Level II mental health evaluation was not required. The order summary showed olanzapine was started on 11/11/25 for psychosis. During interview, the MDSC stated a new PASARR Level I screening should have been completed after the psychotropic medication was started, but none was found. Resident 3’s record showed diagnoses including schizophrenia, schizoaffective disorder, and anxiety. The PASARR Level I screening dated 10/14/25 was documented as negative for serious mental illness, intellectual disability, developmental disability, and related condition, and stated the resident did not have serious mental illness and was not taking psychotropic medications. However, the order summary showed paroxetine and quetiapine were prescribed. Resident 6’s record showed diagnoses including schizophrenia, depression, and psychosis, while the PASARR Level I dated 3/14/25 was negative for serious mental illness and related conditions. The order summary showed aripiprazole and trazodone were ordered. The MDSC stated new PASARR Level I screenings should have been completed for Resident 3 and Resident 6 when their conditions and psychotropic medications were identified, but none were completed.
Missing Care Plan for Psychotropic Medication
Penalty
Summary
A comprehensive, person-centered care plan was not developed and implemented for Resident 13 to address the use of olanzapine. Resident 13 was admitted with diagnoses including schizoaffective disorder, psychoactive substance abuse, and traumatic brain injury. The resident's MDS assessment showed a BIMS score of 15, indicating no cognitive deficit. The physician's pharmacy order dated 11/26/25 included olanzapine 5 mg tablet at bedtime for schizoaffective disorder, but the resident's record did not contain a care plan for this psychotropic medication. During record review and interviews, the Infection Preventionist stated she did not find a care plan for Resident 13's olanzapine and said one should have been initiated as soon as the order was received to direct staff on how to care for the resident. The MDS Coordinator also reviewed the record and stated she could not find a care plan for the resident's use of olanzapine, noting that a care plan was important to monitor for side effects of medications and to ensure all staff were aware of the plan of care. The DON stated care plans were to be initiated on admission and that psychotropic medication orders should be added right away by the licensed nurse receiving the order to monitor for possible side effects.
Failure to Provide Nail Care for Two Residents
Penalty
Summary
The facility failed to provide nail care for two residents who were dependent on staff for activities of daily living. Resident 51 was observed in the dining room with long fingernails on both hands that were dirty and had brownish to blackish dirt built up underneath the nails while handling bread and eating. During a later observation, the RNA again noted that Resident 51 had long and dirty fingernails and stated the resident touched food with her hands. The RNA also stated that CNAs were responsible for weekly nail care and that Resident 51's nails should have been trimmed and cleaned to prevent infection. Resident 4 was observed with long fingernails on both hands while the RNA was applying a splint to the resident's right hand. The RNA checked both hands, confirmed the fingernails were long, and stated the resident agreed to nail care. Resident 4 was dependent on staff for ADLs. LVN 3 stated licensed nurses were responsible for Resident 4's nail care because the resident had DM, and that weekend desk nurses were responsible for checking and providing nail care for residents with DM to keep nails trimmed and cleaned. Record review showed Resident 51 was admitted with dementia. Resident 4 was admitted with hemiplegia, hemiparesis following cerebral infarction, type 2 DM, HTN, and polyneuropathy, and had a BIMS score of 14. The care plan for Resident 4 included nail care as needed. The facility policy stated nail care includes daily cleaning and regular trimming, and that trimmed and smooth nails help prevent accidental scratching and infections. The DON stated long fingernails can harbor microorganisms and cause infection and self-inflicting skin injuries.
Failure to Implement Ophthalmology Referral for Resident with Vision Impairment
Penalty
Summary
The facility failed to assist a resident in gaining access to vision services when an eye specialist referral dated 5/30/25 was not implemented for Resident 33. During observation and interview, Resident 33 was awake in bed, alert and oriented x4, and stated she had been at the facility for over a year with concern about her left eye vision. She reported a left eye cataract and a right eye retinal detachment, said her personal doctor had scheduled cataract surgery before admission, and stated she had repeatedly reminded facility staff and the doctor about needing a referral for an eye specialist. Resident 33 stated she could still see shadow-like shapes when admitted but now saw black circles, and she wanted the cataract removed so she could improve her vision and enjoy watching her tablet again. The MDS Coordinator stated Resident 33’s MDS assessments showed highly impaired vision and a BIMS score of 14, indicating cognitive intactness. The MDS Coordinator also stated Resident 33 had cataract and retinal detachment diagnoses on admission and should be referred to an eye specialist related to vision impairment. The Registered Nurse Supervisor reviewed the record and stated Resident 33 had an ophthalmologist referral on 12/2/25 and should have been referred by Social Services to evaluate her vision. The DON reviewed the 5/30/25 eye evaluation, which documented cataracts in both eyes and recommended an ophthalmology referral for optic OS pallor with treatment goals within 2 months. The DON stated the referral should have been implemented and followed through, and the facility policy required timely eye care services, coordination with external providers, documentation, and follow-up for residents needing vision care.
Delay in restorative nursing and missing splint/boot application
Penalty
Summary
The facility failed to provide appropriate services, equipment, and assistance to maintain or improve mobility for one resident with left-sided weakness after a cerebral infarction. The resident was admitted with hemiplegia and hemiparesis affecting the left dominant side, had a BIMS score of 14, and stated she had been receiving therapy for a massive stroke but was getting weaker and wanted more physical therapy. She also stated that her left hand splint and left leg boot had been missing for more than a month and that she had not received restorative nursing programs for more than a month. Record review showed the resident’s restorative nursing programs dated 5/28/25 included assistance with application of a left upper extremity resting hand splint to be removed after 6 to 8 hours and a left lower extremity boot up to 6 hours. The resident’s RNA programs were later discontinued on 10/2/25, and staff stated the resident was not currently on RNA programs. The MDS coordinator stated the resident had previously been on RNA programs for the left hand splint, left leg boot, AROM, and PROM, but no RNA referral had been received from therapy at that time. Therapy records showed PT ended on 10/23/25 and OT ended on 11/12/25, but the restorative nursing referral for bed mobility was not accepted until 12/4/25. The Director of Rehabilitation stated there was a delay of more than a month in transitioning to RNA programs and that the expectation was for the transition to occur on the day of or the day after discharge from skilled services. During observation, the resident was found in bed with left lower extremity weakness and flaccidity, and the RNA stated the left hand splint was found in the bedside drawer while the left leg boot remained missing. Staff also stated there was no RNA referral for the left hand splint and left leg boot application, despite acknowledging that the resident should continue RNA programs for contracture management.
Failure to Provide Dental Evaluation for Resident With Toothache
Penalty
Summary
The facility failed to ensure dental services were provided for one of seven sampled residents, a resident with hemiplegia and hemiparesis following cerebral infarction and a BIMS score of 14, indicating cognitive intactness. During observation and interview, the resident was lying in bed and complained of a toothache, stating pain medication had relieved the pain and that she needed to see a dentist. The resident stated she had been at the facility for eight months and had not seen a dentist, and said she had been asking nurses for a dental examination while the SSD was not always available when asked about a dentist. Record review and staff interviews showed there was no dental assessment or evaluation completed by the dentist since the resident’s admission. The RNS stated the facility had a dentist who visits the facility and that the resident should have been seen and evaluated by the dentist. The DON stated the resident should have been evaluated by the dentist from admission and as needed, and that the resident’s complaint of toothache should be assessed by a dentist to prevent infection. The resident’s care plan included oral care assistance and dental exams as necessary, and facility policy required dental requests to be referred to the Resident Services Director and acute dental pain to be reported for immediate arrangement of dental care.
Excess Residents in Multiple Bedrooms
Penalty
Summary
The facility failed to ensure each bedroom accommodated no more than four residents in three of 19 rooms, specifically Rooms 1, 2, and 14. During the initial tour, surveyors observed that each of these rooms had six beds. The report states that although the bedrooms accommodated more than four residents, each room met the particular needs of each resident, there was sufficient room for nursing care and for residents to ambulate, adequate closet and storage space was available, bedside stands were available for each resident, and wheelchair and toilet facilities were accessible. The report also states that the health and safety of residents would not be adversely affected by the continuance of this waiver.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Provide Adequate Supervision and Fall Prevention for High-Risk Resident
Penalty
Summary
A deficiency occurred when a facility failed to provide adequate supervision and implement effective fall prevention interventions for a resident assessed as high risk for falls. The resident, who had diagnoses including osteoporosis, type 2 diabetes, dementia, gait abnormalities, and muscle weakness, was severely cognitively impaired and required supervision while ambulating. Despite being identified as high risk through multiple fall risk assessments and care plans, the resident experienced three unwitnessed falls within a two-week period. The facility's care plans and fall prevention program, including the Red Sneaker Program, outlined interventions such as supervision, environmental safety checks, and regular monitoring. However, the resident was placed on Level 2 supervision, which involved staff checking every 15 minutes, rather than direct in-room supervision, even after repeated falls. The care plans included interventions like assessing dizziness, monitoring for injury, and providing education, but staff acknowledged that the resident's dementia prevented retention of safety education or reminders. Interviews and record reviews revealed that the interdisciplinary team (IDT) did not increase the level of supervision to direct, in-room monitoring until after the third fall. The Director of Nursing confirmed that Level 2 supervision was not effective for this resident, as evidenced by the repeated falls. The facility's own policies required individualized, resident-centered interventions and modification of interventions if falls recurred, but these were not implemented in a timely manner for this resident.
Resident Left at Doctor's Office Due to Transportation Failure
Penalty
Summary
The facility failed to ensure adequate transportation for a resident returning from a doctor's appointment, resulting in the resident being left at the doctor's office for several hours without a meal. The resident, who was moderately cognitively impaired, was admitted with conditions including cellulitis, muscle weakness, and mobility issues. On the day of the incident, the resident was picked up for a morning appointment and was ready to return to the facility by noon, but was not picked up until the evening. Interviews and record reviews revealed that the facility's process for managing resident appointments was not followed. The scheduler received a call from the doctor's office at 12:30 p.m. indicating the resident was ready to be picked up and forwarded the call to the Social Services Director (SSD). The SSD provided the doctor's office with a phone number for transportation but did not follow up to ensure the resident was picked up. The Director of Nursing (DON) later stated that the facility was ultimately responsible for ensuring the resident had something to eat and drink. The incident was documented in the resident's records, noting the delay in transportation and the resident's return to the facility. The facility's policy indicated that social services representatives were responsible for assisting with transportation arrangements, but this was not effectively executed. The resident experienced emotional distress, hunger, and was without a jacket in cold weather, highlighting the facility's failure to uphold the resident's right to dignity and adequate care.
Failure to Implement Fall Prevention Program for High-Risk Resident
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for a resident identified as being at high risk for falls. The resident, who had a history of falls both at home and within the facility, was not properly placed on the facility's Red Sneaker Program (RSP), a fall prevention initiative. Despite the resident's fall risk care plan being updated after a recent fall, the necessary interventions outlined in the RSP were not executed. This included the absence of visual symbols such as red sneakers by the resident's name placard outside their room, above their bed, and the lack of a red bracelet on the resident. Interviews with the Director of Nursing (DON) and a Licensed Vocational Nurse (LVN) revealed that the resident had a fall risk score of 13, indicating a high risk of falls. The facility's policy required that residents on the RSP be identified with specific symbols and a red bracelet to alert staff of their fall risk. However, during observations, these indicators were missing, and the resident was not wearing the required red bracelet. The DON acknowledged the oversight and confirmed that these measures should have been in place as per the resident's care plan and the facility's fall prevention policy. The resident's medical history included conditions such as osteomyelitis of the vertebra, muscle weakness, cognitive communication deficit, and end-stage renal disease. Despite these conditions, the resident's Minimum Data Set (MDS) indicated no cognitive impairment. The facility's policies on comprehensive person-centered care plans and safety and supervision of residents emphasized the need for targeted interventions to reduce individual risks, which were not adequately implemented in this case.
Inadequate Supervision Leads to Resident Fall
Penalty
Summary
The facility failed to provide adequate supervision to a resident identified as a high fall risk, resulting in an unwitnessed fall. The resident, who has a history of falls and a known behavior of placing herself on the floor when tired, was found on the floor with a skin tear on her right elbow. The incident occurred after the resident ambulated unattended from the dining room, where she had been left unsupervised by a CNA who was assisting another resident. The resident's medical history includes Alzheimer's Disease, Type 2 Diabetes Mellitus, muscle weakness, and dementia, with a severe cognitive impairment as indicated by a BIMS score of 01 out of 15. The resident was part of the facility's Red Sneaker Program, which identifies individuals at high risk for falls. Despite this, the resident frequently walked unsupervised, and staff acknowledged that she required supervision, especially when tired, to prevent falls. Interviews with facility staff, including CNAs, an LVN, the MDS Coordinator, the DON, and the Administrator, revealed that the resident's need for supervision was well-known. The facility's policy emphasized the importance of individualized safety measures and adequate supervision for residents at risk of falls. However, the resident's care plan and fall risk assessments were not effectively implemented, leading to the unwitnessed fall and subsequent injury.
Facility Fails to Maintain Safe Temperature in Dining Room
Penalty
Summary
The facility failed to maintain a safe, comfortable, and homelike environment for three residents when the dining room temperature was below the acceptable range of 71 to 81 degrees Fahrenheit. This deficiency was observed during a survey where residents expressed discomfort due to the cold temperature in the dining room. Resident 22, who has a history of dementia, muscle weakness, and falls, mentioned needing a coat because the dining room was always cold. Resident 29, who is cognitively intact and has conditions such as shortness of breath and osteoarthritis, also reported that the dining room was too cold while wearing a sweater. Resident 42, with chronic obstructive pulmonary disease (COPD) and asthma, stated that the dining room was cold even at night and had previously contracted pneumonia. The Director of Maintenance confirmed the low temperatures in the dining room, with readings of 69, 67, and 69 degrees Fahrenheit. The Director acknowledged that closing the dining room door before meals contributed to the cold environment and emphasized the importance of maintaining the temperature within the specified range to ensure a homelike setting. The Director of Nursing also stated that the facility's expectation was to keep the temperature between 71 and 81 degrees Fahrenheit to provide a safe and comfortable environment for residents. The facility's policy on providing a homelike environment includes maintaining comfortable and safe temperatures. Professional references cited in the report highlight the negative impact of low indoor temperatures on residents, particularly those with dementia and respiratory conditions. These references indicate that deviations from the recommended temperature range can lead to increased agitation and respiratory issues, underscoring the importance of maintaining appropriate indoor temperatures for the well-being of residents.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents, leading to potential risks for their health and safety. Resident 13's care plan did not include interventions for his refusal of medications, which was not documented or communicated to the attending physician. This oversight occurred despite multiple refusals of his inhaler, which could exacerbate his Chronic Obstructive Pulmonary Disease (COPD). The Licensed Vocational Nurse (LVN) and the Minimum Data Set Nurse (MDSN) acknowledged the absence of a specific care plan addressing the medication refusal, indicating a failure to adhere to the facility's care planning policy. Resident 8's care plan was not implemented for skin assessments, resulting in a lack of monitoring for skin tears, bruising, or wounds. During observations, a wound was noted on Resident 8's forearm, which she reported was not being treated by the staff. The Registered Nurse Supervisor (RNS) confirmed that there was no documentation of the wound in Resident 8's medical record, and the care plan did not include wound care for the forearm. The facility's policy required daily skin checks during activities of daily living and showers, but these were not consistently documented or communicated to the nursing staff. Resident 16's care plan was not followed regarding the placement of the call light within reach, which is crucial for a resident with a history of falls and severe cognitive impairment. The call light was observed out of reach, and the resident expressed difficulty in accessing it. The Activity Assistant and Certified Nursing Assistant (CNA) confirmed the call light was not within reach, contrary to the care plan's intervention to prevent falls. The Director of Nursing (DON) stated that the call light should always be within reach, highlighting a failure to implement the care plan as intended.
Failure to Meet Professional Standards in Medication Administration and Resident Assessment
Penalty
Summary
The facility failed to provide services that met professional standards of practice for several residents. Registered Nurse (RN) 1 and Licensed Vocational Nurse (LVN) 1 did not explain the medication names and indications to multiple residents during medication administration. This oversight was observed during medication pass observations, where medications were administered without informing the residents about the medications they were receiving. Interviews with the nurses confirmed that they did not explain the medications, acknowledging that residents have the right to know the medications they are receiving. The facility also failed to notify the attending physician of a resident's ongoing refusal of a prescribed inhaler. The resident had multiple episodes of refusal, which were not documented or communicated to the physician as required by the facility's policy. This lack of communication and documentation could potentially affect the resident's health condition, as the inhaler was prescribed to manage a chronic lung disease. Additionally, the facility did not perform current oxygen saturation and respiration assessments on a resident before transporting them to the hospital for shortness of breath. The assessments used were outdated, and there was no documentation of vital signs taken prior to the hospital transfer. The Registered Nurse Supervisor acknowledged that vital signs should have been checked and documented before the transfer, as per the facility's policy.
Unnecessary Psychotropic Medication Administration
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medications. Resident 39 was administered divalproex, an anticonvulsant medication, without a specific condition diagnosed and documented in the clinical record. The medication was prescribed for an unspecified mood disorder manifested by irritability and abusive language, despite the fact that non-pharmacological interventions had been documented as effective. The Pharmacist Consultant acknowledged that divalproex was being used off-label for mood disorders and that other medications could have been used on-label for the resident's diagnoses. Observations and interviews revealed that Resident 39 had bruising on her forehead, nose, and around her left eye, and had fallen out of bed. The resident had a history of dementia, muscle weakness, unspecified psychosis, and unspecified mood disorder. The Director of Nursing stated that divalproex was being used as a mood stabilizer and acknowledged that the expectation was for residents to have a specific diagnosis before administering psychotropic medications. The facility's policy indicated that medications should not be administered without a clinical indication to treat a specific condition, and non-pharmacological approaches should be used to minimize the need for medications.
Dishwasher Temperature Deficiency
Penalty
Summary
The facility failed to adhere to professional standards for food service safety when the high temperature dishwasher did not reach the required temperature during the wash cycle. Observations revealed that the dishwasher's temperature was below the necessary 155 degrees Fahrenheit, with readings as low as 145 degrees Fahrenheit. Dietary Aide 1, responsible for operating the dishwasher, incorrectly stated that the wash cycle temperature should be above 135 degrees Fahrenheit, while the actual requirement was 155 degrees Fahrenheit as per the dishwasher's data plate. This discrepancy in temperature could potentially expose 52 out of 55 highly susceptible residents to foodborne illnesses due to cross-contamination. Interviews with various staff members, including the Certified Dietary Manager and the Registered Dietician, confirmed the importance of maintaining the correct dishwasher temperatures for sanitation and infection control. The facility's policy and procedure for dishwashing emphasized the need for the dishwasher to operate within the manufacturer's recommended temperatures, and if not achievable, to resort to manual dishwashing. Despite these guidelines, the dishwasher was not consistently reaching the required temperatures, posing a risk to resident safety.
Deficiency in Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of flies in the kitchen area on two consecutive days. On the first day, a fly was observed flying around the food serving area. The following day, two flies were seen in the kitchen by the food serving and dishwasher areas during an observation and interview with the Certified Dietary Manager (CDM). The CDM acknowledged the presence of a fly fan at the back entrance but noted the absence of a fly light trap to attract and eliminate flies. The CDM also mentioned that pest control services were scheduled once a month and recognized that flies posed an infection control issue, potentially leading to illness among residents consuming food from the kitchen. The Registered Dietician (RD) expressed an expectation for the kitchen to be free of flies and pests, emphasizing the risk of residents becoming ill. The RD indicated that the CDM was responsible for ensuring the kitchen's cleanliness and pest-free status. A review of the facility's infection control policy highlighted the goal of maintaining a safe, sanitary, and comfortable environment to prevent disease transmission. However, the facility did not provide a specific policy for pest control or kitchen sanitation upon request. Additionally, a professional reference from the FDA Food Code 2022 underscored the importance of protecting food establishments from insects and rodents to prevent contamination of food and food-contact surfaces.
Exceeding Resident Capacity in Rooms
Penalty
Summary
The facility failed to comply with the regulation that limits the number of residents per room to a maximum of four. During the survey conducted from August 19 to August 23, 2024, it was observed that three rooms (Rooms 1, 2, and 14) each accommodated six residents, exceeding the allowed capacity. Despite this non-compliance, the report notes that the rooms were adequately equipped to meet the residents' needs, providing sufficient space for nursing care, ambulation, and storage. The report also mentions that the health and safety of the residents would not be adversely affected by the continuance of this waiver, suggesting that the facility had previously been granted a waiver for this requirement.
Inadequate Supervision Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to ensure adequate supervision for a resident who was at high risk for falls, resulting in the resident falling and sustaining injuries. The resident, who had severe cognitive impairment and multiple medical conditions including dementia and muscle weakness, was assessed to require one-on-one observation for safety. Despite this assessment, a CNA left the resident unattended to assist another CNA with a different resident, leading to the resident's fall. The incident occurred during the night shift when the resident was restless and attempting to get out of bed frequently. The resident had been given medications for anxiety and pain, which could cause drowsiness and unsteady gait, increasing the risk of falls. The CNA assigned to the resident's one-on-one care left the resident's side briefly, believing the resident was asleep, and closed the curtain for privacy while assisting another resident. During this time, the resident fell and sustained lacerations and contusions to the head, necessitating transfer to the emergency department. Interviews with facility staff, including the Administrator, LVN, and DON, confirmed that the resident's one-on-one supervision was not maintained as required. The facility did not have a specific policy and procedure for one-on-one supervision, which contributed to the failure in providing adequate supervision. The DON acknowledged that the CNA should not have left the resident unattended, and the lack of a policy for one-on-one supervision was noted as a deficiency.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 216 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Fresno
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Veterans Home Of California - Fresno | 3.9 mi | ★★★★★ | 13 | 0 |
| Fresno Postacute Care | 4.6 mi | ★★★★★ | 16 | 0 |
| Healthcare Centre Of Fresno | 5 mi | ★★★★★ | 3 | 0 |
| Community Subacute And Transitional Care Center | 5.9 mi | ★★★★★ | 12 | 0 |
| Oakwood Gardens Care Center | 6.4 mi | ★★★★★ | 2 | 0 |
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