Average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Fulton Gardens Post Acute, Llc during CMS and state inspections, most recent first.
Food service safety deficiencies were observed in the kitchen when an ESD entered without a beard restraint, multiple opened food items were not labeled or sealed correctly, frozen foods showed freezer burn or were exposed to air, and the dry storage floor was worn and discolored. Staff also stored dirty or wet equipment in ready-to-use areas, two cutting boards had deep gouges, an apron contacted cooked fish and broccoli during meal prep, and resident lunches were served in disposable clamshell containers after standard heated dish plates ran out.
Oxygen humidification was not maintained for two residents. One resident with COPD had an empty humidifier bottle that was labeled RX but had no MD order for its use, and staff stated it should not have been allowed to run dry. Another resident with COPD and serious infections was observed with an empty, unlabeled humidifier bottle. An LPN, the IP, and the DON all confirmed the bottles were ineffective when empty and needed to be labeled with the date and time of setup.
Pureed Rice Pilaf Prepared Incorrectly: A cook did not follow the recipe for pureed lemon rice pilaf when preparing puree-texture food for several residents. Instead of adding the prescribed milk, the cook used unmeasured chicken broth, then added thickener after the texture test was not correct. The RD stated the recipe was not followed and that the added thickener was not indicated in the recipe.
Unlabeled urinals were observed in two residents’ rooms, including one resident with hemiplegia, hemiparesis, and cognitive communication deficit and another with severe infectious diagnoses. In a separate room, a resident with COPD, DM2, and prostate cancer had multiple boxes of soda stored directly on the floor with visible dust, and the floor had dark brown/black stains; staff stated the resident often retrieved soda from the boxes himself and that the boxes made cleaning underneath difficult.
A Diet Aide discarded resident tray tickets in the regular trash while cleaning meal trays, and the DON confirmed the tickets contained resident identifiers and diet-related health information such as names, room assignments, diet orders, allergies, and texture requirements. The DON, DS, and RD acknowledged the tickets should have been protected and not placed in garbage where unauthorized individuals could access them; the facility policy stated resident medical information shall not be in public view.
Failure to Update Respiratory Care Plan and Develop Dialysis Care Plan: A resident with COPD and shortness of breath was receiving O2, but the care plan was not updated to include the new oxygen therapy intervention. Another resident with ESRD had multiple hemodialysis orders, including access-site monitoring and pre/post dialysis vital signs, but no dialysis care plan was created. Staff interviews confirmed care plans were expected to be person-centered, individualized, and used to guide nursing care.
A resident with ESRD, PVD, anemia in CKD, and existing buttock pressure injuries was observed on a low-air loss mattress set to 120 lbs., even though the resident’s current post-dialysis weight was 142 lbs. Staff confirmed the mattress setting did not match the resident’s weight, and the care plan called for a pressure-relieving mattress for both pressure injury risk and an actual stage 2 PI on the left buttock. Interviews with an LN, Tx Nurse, ESD, and DON confirmed the mattress should have been adjusted according to the resident’s weight and manufacturer guidance.
Improper Lidocaine Patch Use: A resident with back and knee pain received lidocaine patch orders that were not followed as written and did not match FDA labeling. The MAR showed the patch was scheduled every 12 hours without a drug-free period, while the order history reflected changes from once-daily use to twice-daily use. An LPN entered the last order but could not explain why it changed and had not contacted the MD, and the resident reported the patch was not helping with knee pain.
Medication administration errors exceeded the allowed rate when nurses gave medications contrary to label instructions and ordered directions. One resident received doxycycline at the same time as calcium, iron, and a multivitamin containing zinc; another received Linzess after breakfast despite an empty-stomach instruction; and a third received an incorrect vitamin D dose instead of the ordered 5,000 units. The DON confirmed the doxycycline timing issue and the dose discrepancy.
Unsafe Storage of Expired and Single-Use Medications and Supplies: A treatment cart contained an opened single-use normal saline bottle and expired wound care supplies, and a medication cart stored a fleet enema in the same bin as oral meds. An LPN confirmed the findings, and the DON stated single-use items should be discarded after use and the enema should be stored separately from oral meds.
Failure to monitor and care plan long-term antibiotic use for a resident with chronic right knee PJI and wound issues. The resident remained on doxycycline 100 mg BID for an extended period, with repeated courses and an indefinite order noted in the record. The IP sought orthopedic review, but there was no response or documented clinical justification, and the nursing care plan did not address the antibiotic therapy or the chronic wound infection. The DON and ADM confirmed there was no antibiotic care plan, and the MD stated the facility did not escalate the issue or obtain further reassessment.
Failure to maintain a homelike environment occurred when a resident with severe cognitive impairment, blindness, dementia, schizophrenia, and a history of aggression repeatedly yelled day and night, disturbing nearby residents and staff. The resident’s behavior care plan was not specific or person centered, and staff reported the resident needed close reassurance, soft voices, music, and one-on-one attention to stay calm. Several residents said the constant yelling disrupted sleep, caused frustration, and led to conflicts with other residents.
Failure to protect a vulnerable resident from roommate assault: A bedbound resident with paraplegia and limited hand use was placed with a cognitively impaired, legally blind resident with a history of yelling, aggression, and wandering to roommates’ sides of the room. The roommate repeatedly entered the resident’s space, removed his call light, and choked him while the resident called for help and said he felt trapped and feared for his life. The roommate’s behavior plan was incomplete and nonspecific, and the ADON acknowledged the resident was unpredictable and did not have constant 1:1 supervision.
A facility failed to maintain a safe environment and provide adequate supervision for two residents with SUD histories and homelessness. One resident with osteomyelitis, DM, and a PICC line eloped in a wheelchair during the night and left before completing IV ABT, while assessments incorrectly missed his meth use, smoking, homelessness, and elopement risk. Another resident with psychoactive substance abuse and homelessness had no substance-use care plan, and her boyfriend—reportedly under the influence of drugs—entered the room, assaulted her, and caused visible facial discoloration.
A resident's medications were left unattended at her bedside, and a diagnostic test to determine the cause of her illness was delayed. The resident, with type 2 diabetes and hypertension, was unable to take her medications due to coughing, and the LN left them assuming it was permissible. The facility's policy required timely administration and completion of diagnostic services, which was not adhered to, leading to potential risks.
The facility did not follow the planned menu and recipes during lunch preparation, affecting 94 residents. The DSS substituted ingredients without RD approval, using insufficient cucumbers and unapproved items for the Asian Cucumber Salad. The Asian [NAME] Rice was served without necessary ingredients, and the Asian Smooth Sauce was not prepared, impacting residents needing specific food consistencies.
The facility failed to provide meals according to the dietary needs of 94 residents during a lunch meal. Residents on various diets, including regular, chopped, pureed, large portion, CCHO, and fortified diets, received incorrect portion sizes or missing items. These deficiencies were observed during a lunch tray line and confirmed through staff interviews and document reviews.
The facility failed to maintain proper food safety and sanitation standards, with issues including unclean kitchen equipment, improper food storage, and inadequate temperature monitoring. Spoiled produce and food stored beyond use-by dates were found, and a visibly ill employee prepared food without proper hand hygiene. Unwashed mushrooms were also served, increasing the risk of foodborne illness for residents.
The facility failed to implement proper infection control measures, including the use of PPE and EBP signage, for residents with indwelling devices. A nurse did not wear a gown while providing G-tube care, and another stored an open sterile dressing improperly. Additionally, a resident's room lacked EBP signage and PPE supplies, and a nurse did not wear a gown when accessing a PICC line, all of which increased the risk of infection.
The facility failed to follow its Antibiotic Stewardship Program, resulting in deficiencies in monitoring and optimizing antibiotic use. A resident was prescribed antibiotics without following the McGeer Criteria, as no laboratory specimen was sent for testing. The facility's documentation was incomplete, lacking details on the duration of antibiotic therapy and outcomes. The Pharmacist Consultant highlighted the risk of antibiotic resistance due to the lack of diagnostic tests, which could lead to incorrect medication prescriptions.
A resident's right to dignity was violated when two CNAs spoke a foreign language over her while providing care, making her feel uncomfortable. The facility's policy required staff to speak English to ensure residents' emotional comfort, which was not adhered to in this instance.
Two residents permitted to self-administer medications had their medications stored unsafely, with expired and unsecured medications accessible at the bedside and in a tote bag. The facility failed to follow its policy requiring medications to be stored in a locked container, increasing the risk of overdose and reduced efficacy. The residents' cognitive impairments and the presence of other residents with wandering behavior further heightened the risk.
A facility failed to implement an individualized care plan for a resident with dementia and schizophrenia by not incorporating PASRR Level II recommendations. The PASRR Level II screening was completed but not uploaded to the resident's EMR, and the recommendations were not included in the care plan, posing a risk of not receiving necessary specialized services.
A resident with a history of stroke and aphasia did not receive consistent Assisted Active ROM (AAROM) services as required by their care plan. The resident's right hand was contracted, and documentation of AAROM was often marked as 'Not Applicable' or missing. Staff interviews confirmed the inconsistency in performing and documenting AAROM, and the Therapy Director noted the need for a splint. The facility's leadership acknowledged the failure to adhere to policies, which could have affected the resident's hand function and quality of life.
Three shaving razors were left unattended on the counter in a shared bathroom used by four residents, posing a risk of injury and infection. A nurse confirmed the hazard, and interviews with the Director of Staff Development and the DON highlighted the violation of facility policy, which requires the containment of hazards to protect residents.
The facility failed to ensure safe pharmaceutical services by not replacing an opened emergency kit and inaccurately documenting narcotic medication use for a resident with intervertebral disc degeneration. The emergency kit was not replaced in a timely manner, and the required confirmation fax was not found. Additionally, the Medication Administration Record did not reflect the narcotic dosages signed out for the resident, indicating a failure to follow facility policy.
A resident was prescribed Ciprofloxacin for a UTI without meeting the McGeer Criteria for continued use, as no urine specimen was collected. The facility's policies on infection prevention and antibiotic stewardship were not followed, leading to unnecessary antibiotic use. The absence of urinalysis results and physician progress notes further highlighted the deficiency.
The facility failed to secure liquid controlled substances in a locked refrigerator, as required by policy, increasing the risk of unauthorized access. A nurse found the refrigerator unlocked and secured it immediately. The DON confirmed the policy breach, which mandates controlled medications be stored securely with limited access.
The facility failed to maintain closed garbage bins, as observed during an inspection with the Dietary Service Supervisor (DSS). The bins were found open, contrary to the facility's policy on sanitary garbage disposal, which aims to prevent pest infestations. The DSS confirmed that the dumpsters should be kept closed to avoid attracting pests.
A resident's medical records were mistakenly placed in another resident's EHR, breaching confidentiality. The Director of Medical Records and the Administrator confirmed the error, acknowledging it as a HIPAA issue. Despite using a software program to manage records, the facility failed to follow its Privacy and Confidentiality Policy, leading to potential exposure of private information.
A facility failed to coordinate care with a hospice agency for a resident receiving end-of-life care. After an incident involving the resident, the IDT recommended a medication review by hospice, but the facility did not follow up, leaving the review undocumented in the resident's record. The hospice agency confirmed the review was done and faxed to the facility, but it was not received due to staff oversight during shift changes. The DON admitted the facility's service agreement and policy for hospice services were not followed.
A resident experienced a delay in receiving physician-ordered Tramadol for pain management due to pharmacy prescription requirements, despite its availability in the E-kit. The resident endured moderate pain levels, and Tylenol was provided as an inadequate substitute.
Two residents did not receive scheduled showers, with one going a week and the other six days without one. Despite needing assistance, the facility failed to provide showers as per policy, leading to family members intervening. Staff confirmed the oversight and lack of documentation for missed showers.
Food Storage, Equipment Sanitation, and Meal Service Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 103 residents. During kitchen observations, the Environmental Services Director was seen in the kitchen without a beard restraint while working on a leaking drainpipe in the floor sink. Facility staff, including the Infection Preventionist, Dietary Supervisor, and Registered Dietitian, acknowledged that hair restraints and beard covers were expected in the kitchen to prevent contamination of food. In dry storage, several opened food items were not labeled or stored correctly. A previously opened cake mix had an open date and use-by date, but the use-by date did not match the food storage chart. Olive oil had an open date but no use-by or discard date and remained in dry storage even though the chart indicated it should have been refrigerated after opening. Five opened bags of pasta were found on a shelf; four were closed but lacked use-by or discard dates, and one bag was partially open to air and not securely sealed. A previously opened bag of shredded cheese had an open date and use-by date that did not match the recommended storage time frame. The dry storage floor was also observed worn with black discoloration. Frozen food storage and equipment sanitation were also deficient. Frozen hotdogs in the reach-in freezer had visible ice crystal buildup or freezer burn, frozen turkey in the walk-in freezer had heavy ice crystal buildup or freezer burn, and frozen pork chops were not securely closed and were exposed to air with freezer burn present. In the cook’s area, a fry pan had whitish residue and worn surfaces, a steam table pan and three muffin tins had dried residue and discoloration, and a blender was stored wet with pooled water around the blade assembly. Two cutting boards used for food preparation had multiple deep gouges. During meal preparation, CK 1’s apron ties contacted cooked fish twice, and the apron contacted broccoli while plating a resident meal. During lunch service, the facility ran out of standard heated dish plates with covers, and the last four resident lunches were served in disposable clamshell food containers instead of the standard dishware.
Oxygen Humidifier Bottles Left Empty and Unlabeled
Penalty
Summary
Supplemental oxygen was not maintained in accordance with professional standards of practice for two residents. Resident 19 had diagnoses including COPD with acute exacerbation and type 2 diabetes mellitus, and was ordered oxygen at 1 L/min via nasal cannula as needed for shortness of breath to keep oxygen saturation above 90%. During observation, Resident 19’s oxygen concentrator had an empty humidifier bottle, and the bottle was labeled with a date of 4/7/26. A nurse later confirmed the bottle was empty and stated humidifier bottles should be replaced when they were no longer bubbling and should not be allowed to become completely empty before replacement. Resident 19’s record did not contain a physician order for the humidifier bottle, even though the bottle was labeled RX. The medical director stated that items labeled RX should have a physician’s order before use, and that she had overlooked the absence of an order for the oxygen humidifier bottle. The infection preventionist stated nurses were expected to check oxygen humidifier bottles every 24 hours, replace them according to manufacturer guidelines, and use a humidifier for comfort and moisture when indicated. Resident 19’s care plan also included an intervention to change the oxygen humidifier in accordance with manufacturer’s guidelines. Resident 80, who had diagnoses including necrotizing fasciitis, Fournier gangrene, and COPD, was observed with an oxygen humidifier bottle that was empty and not labeled with the date it was set up. A nurse acknowledged the bottle was empty and unlabeled and stated it should have been replaced and properly labeled. The infection preventionist and DON both stated that an empty humidifier was ineffective and that the bottle needed to be labeled with the date and time so the length of use could be determined. The facility policy stated oxygen humidification must be provided, maintained, and replaced to prevent infection, ensure proper device function, and comply with manufacturer instructions and accepted standards of practice, and that a prefilled humidifier should be replaced whenever the sterile water is empty.
Pureed Rice Pilaf Prepared Incorrectly
Penalty
Summary
The facility failed to conserve the nutritive value and flavor of pureed food for six residents who received puree textures, including Residents 6, 9, 15, 63, 64, and 112, when it did not follow the recipe for pureed lemon rice pilaf. During observation in the kitchen, a cook measured ten and a half cups of rice pilaf from the steam table pan into a blender container, then added unmeasured amounts of thin yellow liquid identified as chicken broth and blended the mixture briefly. The cook repeated the addition of chicken broth, then tested the texture and stated it needed thickener, after which two large scoops of thickener were added and the mixture was blended again. The Registered Dietitian performed IDDSI testing and stated the texture for the pureed rice pilaf was not correct. Review of the recipe for pureed lemon rice pilaf showed that the prepared product was to be placed in a blender or food processor and that 2 tablespoons of milk were to be added for each portion. The Registered Dietitian stated the recipe was not followed because unmeasured chicken broth was used instead of the required milk, and the recipe did not indicate a need for thickener. During interview, the Dietary Supervisor and Registered Dietitian acknowledged that not following the recipe could affect the nutritive value, flavor, and consistency of the food. The facility policy on assisted nutrition and hydration stated the intent was to provide staff guidelines to help maintain acceptable nutritional and hydration status and to provide therapeutic diets when there is a nutritional indication.
Infection Control Lapses With Unlabeled Urinals and Unclean Resident Room
Penalty
Summary
The facility failed to follow infection prevention and control practices when urinals in two residents’ rooms were observed without labels identifying the resident to whom each urinal belonged. One resident had diagnoses including hemiplegia, hemiparesis, and cognitive communication deficit, and the other resident had diagnoses including necrotizing fasciitis, Fournier gangrene, and cellulitis of the corpus cavernosum and penis. During observation, each urinal was found on a bedside surface without any identifying label, and an LN confirmed both were unlabeled. The Infection Preventionist stated the urinals should have been labeled because there was no way to know who they belonged to without proper identification, and another resident could inadvertently use them. The DON also stated that failing to label the urinal was a concern because there was no way to determine ownership and another individual might use it. The facility policy indicated the infection prevention and control program was intended to provide a safe, sanitary, and comfortable environment and help prevent the development and transmission of communicable diseases and infections. The facility also failed to maintain one resident’s room in a clean condition when multiple boxes of soda were observed stored directly on the floor, with several boxes open and visible dust accumulation on them. The resident had diagnoses including COPD, type 2 diabetes mellitus, and malignant neoplasm of the prostate. Staff stated the resident often requested soda from the boxes and was able to independently retrieve cans while seated in his wheelchair, and the resident stated he could do so himself. The floor in the room was also observed to have multiple dark brown/black stains near the bedside area, and staff stated the boxes on the floor made it difficult to clean underneath them because the resident did not want them moved.
Resident Tray Tickets Discarded in Regular Trash
Penalty
Summary
The facility failed to protect resident privacy and confidentiality when three tray tickets were discarded in the regular trash for a census of 103 residents receiving facility-prepared meals. During the initial kitchen tour, the Diet Aide removed trays from the cart and dumped leftover food and paper products, including at least three residents' tray tickets, into the garbage can before separating items for washing. The Diet Aide stated that dirty and/or wet tray tickets were placed in the garbage without any other destruction occurring. During record review and interviews, the DON confirmed that the tray tickets contained resident identifiers and diet-related health information, including names, unit/room/bed, date, diet orders, food allergies, food and beverage texture requirements, and notes such as assistive devices, portion sizes, and dislikes. The DON stated that these tray tickets should be protected, shredded before disposal, and not placed in regular garbage where unauthorized individuals could access them. The Dietary Supervisor and RD also acknowledged that placing the tray tickets in the garbage was not appropriate. The facility policy stated that resident medical information shall not be in public view.
Failure to Update Respiratory Care Plan and Develop Dialysis Care Plan
Penalty
Summary
The facility failed to develop and update comprehensive care plans for 2 of 29 sampled residents. For one resident with diagnoses including COPD and a personal history of pulmonary embolism, the record showed a physician order for oxygen therapy at 2 liters per minute via nasal cannula to maintain an oxygen saturation level of 90%, started on 3/17/26. During observation, a sign outside the resident’s room indicated oxygen was in use, and the resident was confirmed to be receiving oxygen for shortness of breath. However, review of the active care plans showed that oxygen therapy was not included as an intervention for shortness of breath or respiratory distress, and the care plan had not been updated to reflect the initiation of oxygen therapy. For the second resident, the admission record showed diagnoses including ESRD and DM2. The resident stated she was going to dialysis and reported dialysis treatments every Tuesday, Thursday, and Saturday. The order summary included multiple dialysis-related orders, including hemodialysis three times per week, no restriction of fluids, no blood pressure or blood draws on the left arm, monitoring of the left upper AV fistula for redness, swelling, drainage, and pain, monitoring intake and output every shift, monitoring for bruit and thrill every shift, and pre- and post-dialysis vital signs. Despite these orders, the care plan report showed no dialysis care plan had been created or initiated to address the resident’s dialysis needs. Interviews with LN 6, LN 4, the ADON, and the DON confirmed that care plans were expected to be individualized, person-centered, and used as a guide for nursing care and communication. The facility’s policies also stated that comprehensive care plans were to be developed and implemented to meet residents’ medical, physical, mental, and psychosocial needs, and that dialysis care required a comprehensive person-centered care plan. The record review and staff interviews showed that these care plans were not in place or updated for the two residents.
Low-Air Loss Mattress Not Set According to Resident Weight
Penalty
Summary
The facility failed to provide adequate care and services to promote healing and prevent a pressure injury for one resident with existing buttock wounds. The resident was admitted with diagnoses including end stage renal disease, peripheral vascular disease, and anemia in chronic kidney disease. The resident was observed lying in bed on a low-air loss mattress that was set to 120 lbs., while the resident’s most recent post-dialysis weight was documented as 142 lbs. The resident stated the mattress was being used because of pressure injuries to the buttocks to promote wound healing and prevent further skin breakdown. During the observation, an LN confirmed the resident was on a low-air loss mattress adjusted to 120 lbs. and stated nurses were responsible for checking the setting each shift and adjusting it according to the resident’s actual weight. The LN acknowledged the resident had existing wounds on the buttocks and confirmed the mattress setting did not reflect the resident’s current weight. The record review showed care plans for pressure injury risk and for an actual stage 2 pressure injury on the left buttock, both identifying the need for a pressure relieving/reducing low-air loss mattress. Additional interviews showed the Tx Nurse stated the mattress was intended to relieve pressure, promote wound healing, and prevent further skin breakdown, and that a setting lower than the resident’s current weight could provide insufficient support. The ESD stated he would set the mattress pressure according to the resident’s current weight and, if an exact setting was unavailable, would choose the next highest setting; he said that for a weight of 142 lbs. he would have selected 160 lbs. The DON stated she expected nurses to adjust the mattress pressure according to the manufacturer’s guidelines and the resident’s comfort level, and acknowledged that a lower setting could delay wound healing or worsen the wound condition. The facility’s mattress manual stated the air mattress should be adjusted to the desired firmness according to the patient’s weight.
Improper Lidocaine Patch Use
Penalty
Summary
The facility failed to ensure the safe use of medications for one sampled resident with back and knee pain when the resident’s lidocaine patch order was not followed as written and did not match the manufacturer’s directions for use. The hospital discharge orders indicated a lidocaine 5% patch was to be applied once daily and removed after 12 hours, but the resident’s MAR later showed a lidocaine 4% patch ordered every 12 hours with no drug-free period. The order history also showed changes from a once-daily schedule to twice-daily use, and the nurse who entered the last order stated she could not recall what prompted the change and had not called the doctor to change the order. During interview, the resident stated the pain patch was placed on the right knee and had not been effective or helpful in managing knee pain. The MD stated she had not closely monitored the resident and did not recall signing the monthly order review sheet. The DON stated nursing staff were expected to discuss medication timing or changes with the care team and medical provider, and that excessive use of lidocaine could affect the medication’s effectiveness and safety. The DailyMed drug information reviewed by surveyors stated the patch should be removed after at most 8 hours of application.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure safe medication administration practices when the medication error rate exceeded 5%, with 3 errors identified out of 32 opportunities during medication administration observations. The observations involved 3 residents and showed that medications were administered in ways that did not match label instructions, MAR directions, or the ordered dose. The facility-wide medication error rate was calculated at 9.38%. For one resident, a nurse administered doxycycline at the same time as calcium, iron, and a multivitamin containing zinc, even though the doxycycline label stated it should be taken at least 2 hours before or after products containing calcium, iron, or zinc. The MAR showed these medications were all scheduled for 9 AM, and the nurse stated the doxycycline should have been scheduled earlier or the administration time changed. For another resident, a nurse gave Linzess after the resident had already eaten breakfast, even though the medication label stated it should be taken on an empty stomach at least 30 minutes before a meal. The MAR did not indicate that Linzess needed to be given on an empty stomach. For a third resident, a nurse administered scheduled oral medications and also gave vitamin D in a dose that did not match the order. The MAR ordered cholecalciferol 5,000 units daily, but the nurse stated she gave 2,000-unit tablets and later clarified she gave two and a half tablets of the 2,000-unit product. During interview, the DON confirmed the doxycycline was given with calcium, iron, and vitamins with minerals, and stated the nurses were expected to use drug information and communicate warnings or timing issues. The facility policy stated medications must be administered in accordance with orders and state and federal guidelines.
Unsafe Storage of Expired and Single-Use Medications and Supplies
Penalty
Summary
The facility failed to ensure safe medication storage practices in the [NAME] Station treatment cart and medication cart for a resident census of 103. During a concurrent observation and interview, the treatment cart was found to contain sterile normal saline wound care solution that had been opened even though the product label indicated it was for one-time use, and perineal spray lotion that had expired on 2/28/26. LN 1 initially stated the normal saline was good for 24 hours after opening, then after reading the label stated it was for one-time use and discarded it. LN 1 also stated expired products should not have been stored in active storage areas in the cart. During a separate observation and interview, the medication cart bottom drawer stored a fleet enema in the same bin as oral medications. LN 2 confirmed the finding and stated the enema should have been stored separately from oral medications. The DON later stated one-time use drugs should have been discarded after use, expired medications and treatment care supplies should have been removed and discarded from the cart, and the enema should have been separated from oral medications with a divider in the medication cart. The facility policy titled, LABELING OF BIOLOGICALS AND STORAGE OF BIOLOGICALS, and the policy titled, ADMINISTERING MEDICATIONS, both addressed accurate labeling, safe storage, and single-dose or single-use vials being used only for one resident in a single procedure.
Failure to Monitor and Care Plan Long-Term Antibiotic Use
Penalty
Summary
The facility failed to ensure long-term antibiotic use was clinically justified, monitored, and included in the nursing plan of care for one sampled resident who was prescribed doxycycline for more than one year. Resident 56 had diagnoses including diabetes, kidney disease, obesity, and a history of knee surgery with infection. The resident’s MAR showed doxycycline 100 mg by mouth twice daily for streptococcal infection starting 3/21/25, and the order history showed repeated doxycycline courses throughout 2024. Resident 56’s records showed a chronic right knee periprosthetic joint infection and mechanical complication of the right knee. An orthopedic note from 2/2/24 documented chronic PJI of the right knee and a recommendation for another surgical procedure. A later orthopedic note from 3/15/24 documented surgery on the right knee for chronic PJI on 2/14/24 and stated wound healing was the most critical part of recovery, with concerns about eschar around the incision site and a plan to continue local wound care with a dry dressing at the facility. During interview and record review, the facility IP showed a letter sent to the orthopedic doctor asking for reassessment of the indefinite doxycycline order and referencing McGeer criteria, but there was no response or clinical justification from the orthopedic provider. The IP stated she did not escalate the issue to the medical director. A consultant pharmacist note stated that when a resident is on prophylactic antibiotic therapy, risk versus benefit and medical justification statements are required, and the record contained a handwritten clarification that the order was indefinite due to streptococci sensitivity to tetracycline. The nursing plan of care, last reviewed on 4/10/26, did not address the long-term antibiotic use or the chronic surgical wound infection and wound care. The DON and administrator both confirmed there was no care plan for the resident’s antibiotics, and the medical director stated the facility did not contact her to address the long-term antibiotic use and did not order lab work or consult with an infection control specialist to reassess it.
Failure to Maintain a Homelike Environment Due to Constant Yelling and Non-Person-Centered Behavior Care
Penalty
Summary
The facility failed to provide a homelike environment when one resident with severe cognitive impairment, blindness, schizophrenia, vascular dementia, anxiety, and a history of aggression repeatedly screamed and yelled throughout the day and night, and the resident’s behavior care plan was not person centered or specific enough for staff to use effectively. The resident’s BIMS score was 5, indicating severe cognitive impairment. The behavior care plan identified screaming and yelling as related to increased agitation and combative behavior, but the plan contained blank “Specify” sections for disruptive behaviors and diversion tasks. The ADON acknowledged the plan was not filled out with specific interventions and stated it should have been revised after a later altercation. Staff interviews and record review showed the resident was often confused, blind, and needed reassurance and close presence from staff to remain calm. Multiple staff members stated the resident yelled constantly, often at night and in the early morning, and that music, soft voices, or someone staying close to him could calm him. The ADON stated the resident did not currently have a one-on-one staff member assigned, although one had previously been used after an altercation with a staff member. The ADON also stated she was not sure whether an interdisciplinary team meeting occurred before the one-on-one support was discontinued and could not locate a progress note documenting it. Other residents reported being directly affected by the resident’s yelling. One resident stated the noise disrupted sleep and mental health and required headphones. Another resident stated he could not sleep and that the yelling affected his attitude and phone conversations with family. A third resident reported an altercation after telling the resident to shut up because of the constant yelling, and another resident stated the yelling occurred for hours at a time and left him exhausted and unable to sleep. Staff also stated the resident’s yelling bothered nearby residents, caused complaints, and led to other residents yelling back. The ADON stated residents in nearby rooms could hear the yelling and that the expectation was that residents should be able to rest at night and have a relaxing day without constant yelling.
Failure to Protect a Vulnerable Resident from Roommate Assault
Penalty
Summary
The facility failed to protect a resident with paraplegia, cervical spine fusion, and contractures of both hands from physical abuse and neglect when he was placed in a room with another resident who had a documented history of aggressive and combative behavior. The abused resident was bedbound, had limited use of his hands from a prior stroke, and relied on staff assistance for movement and care. The other resident had diagnoses including cerebrovascular disease, vascular dementia, schizophrenia, psychotic disorder, generalized anxiety disorder, legal blindness, and difficulty walking, and his record reflected ongoing yelling, screaming, and aggression toward staff and others. On the night of the incident, the abused resident repeatedly called for staff because the roommate kept coming over to his side of the room. According to the resident and staff documentation, the roommate walked to his side of the bed, pulled the curtain, grabbed the resident’s call light and tossed it away, and then grabbed his throat and choked him. The resident stated he could not get away because of his physical limitations, felt trapped, was scared for his life, and yelled for help. Staff entered the room during the event, separated the residents, and assessed the abused resident, with documentation noting no visible injury except a watery left eye and later a scratch on the neck reported by the resident. The record also showed the roommate had a long history of disruptive and aggressive behavior, including screaming, yelling, wandering to roommates’ sides of the room, and prior aggression toward staff. The behavior care plan contained incomplete and nonspecific interventions, and the ADON acknowledged the plan was not person-centered, was not clear on what staff should do, and had not been revised after the altercation. The ADON also stated the resident did not have constant one-on-one supervision at the time, despite acknowledging that the resident was unpredictable, had delusions, and that roommates who could not protect themselves were at risk when placed with him.
Unsafe Environment and Inadequate Supervision for Residents With Substance Use Histories
Penalty
Summary
The facility failed to ensure a safe environment free of accident hazards and adequate supervision for two residents with substance use histories and homelessness. One resident was admitted with osteomyelitis, diabetes with foot ulcer, toe amputations, methamphetamine abuse, and homelessness, and was receiving IV vancomycin through a PICC line. Although a wandering/elopement risk evaluation and psychosocial assessment were completed, the record incorrectly indicated no history of substance use and no smoking history, and the elopement risk form marked the resident as not able to self-propel off the premises. Staff interviews showed multiple employees were unaware of the resident’s homelessness and recent methamphetamine use, and no care plan was in place to address exit-seeking behavior, drug use, or related psychosocial needs. The resident left the facility in the early morning hours while still requiring IV antibiotic treatment scheduled to continue through the end of July. Staff documented that he was last seen near the patio and later could not be located, prompting a facility-wide search, code green, and police notification. Interviews confirmed he left in his wheelchair with the PICC line intact and did not complete the prescribed IV antibiotic course. The Administrator, Social Services Director, Assistant Director of Nursing, and nursing staff all acknowledged that the resident’s homelessness and methamphetamine use should have been identified and care planned, and that the inaccurate assessments prevented staff from recognizing his elopement risk and related needs. A second resident was admitted with diagnoses including psychoactive substance abuse, depression, and homelessness, and the hospital record documented current alcohol use and marijuana use. The facility’s psychosocial assessment incorrectly reflected no history of alcohol or substance use and did not reflect the resident’s homelessness in a way that led to a substance-use care plan. After admission, the resident’s boyfriend visited while reportedly under the influence of drugs, became agitated, grabbed her face, pushed her onto the bed, and threatened her. Staff observed discoloration on her cheeks, the police were called, and an abuse report was filed. Interviews with staff and the resident showed that no care plan had been developed to address her substance use history, possible need for drug counseling or psychiatric support, or monitoring of visitors who might be under the influence of illicit drugs.
Medication Mismanagement and Delayed Diagnostic Testing
Penalty
Summary
The facility failed to maintain professional standards of quality care for a resident when prescribed medications were left unattended at her bedside, and a diagnostic test ordered to determine the cause of her illness was not completed in a timely manner. The resident, who was admitted with diagnoses including type 2 diabetes mellitus and hypertension, was observed with her medications left in a plastic cup on her tray table. The resident stated she could not take her morning medications due to excessive coughing. The Licensed Nurse (LN) left the medications with the resident, assuming it was permissible since the resident was alert, despite the absence of an order allowing the resident to self-administer these medications. The Minimum Data Set Coordinator confirmed that the resident's assessment only permitted self-administration of Bengay, not other medications. The Director of Staff Development highlighted the risks associated with leaving medications unattended, such as potential access by other residents and the risk of choking. The LN acknowledged that the medications should not have been left at the bedside and should have been administered within the prescribed time frame. The facility's policy on administering medications emphasized the need for safe and timely administration per physician orders and compliance with state and federal guidelines. Additionally, there was a delay in completing a diagnostic chest X-ray ordered to rule out pneumonia. The order was placed on January 17, but the X-ray was not performed until January 19, with the report dated January 20. The delay was attributed to the X-ray provider's limited operating hours and a lack of follow-up by the facility staff. The facility's policy on laboratory services required timely completion of diagnostic services and prompt reporting of abnormal results to ensure quick action. The Licensed Vocational Nurse's job description also emphasized the responsibility to manage care plans and report any undelivered care to the Director of Nursing.
Failure to Follow Menu and Recipes During Meal Preparation
Penalty
Summary
The facility failed to adhere to the planned menu and recipes during lunch meal preparation, affecting 94 residents. The Dietary Service Supervisor (DSS) substituted ingredients without approval from the Registered Dietician (RD), which included using only eight cucumbers instead of the required three gallons for the Asian Cucumber Salad. The DSS also added unapproved ingredients like three-bean salad and Italian dressing, deviating from the standard recipe that required rice vinegar, honey, sesame oil, red crushed pepper, and salt. The RD confirmed that these substitutions were not approved and could lead to poor intake and weight loss among residents. Additionally, the facility did not follow the recipe for Asian [NAME] Rice, as it was served without the necessary ingredients such as low sodium chicken stock, soy sauce, sesame oil, and sliced green onions. Furthermore, the Asian Smooth Sauce, which was required for residents needing soft, bite-sized, minced, moist, and ground consistency, was not prepared. This oversight meant that no alternative was provided for these residents, potentially impacting their dining experience and nutritional intake.
Failure to Meet Dietary Needs During Meal Service
Penalty
Summary
The facility failed to ensure that meals were prepared and served according to the dietary needs of 94 residents during a lunch meal. Residents on regular portion diets received less than the required amount of food, as the kitchen staff used a #10 scoop instead of the #8 scoop specified in the facility's serving directions. Additionally, residents with orders for chopped, easy to chew, soft bite-sized, and minced and moist textured diets did not receive the correct portion sizes of Beef and Broccoli. Residents on pureed diets received incorrect portions of Asian Beef and Broccoli and did not receive Potstickers as required. Furthermore, three residents on large portion diets did not receive the correct amount of Asian Beef and Broccoli and Asian Rice. Residents on Consistent Carbohydrate Diets (CCHO) received incorrect portion sizes of Asian Rice, and 14 residents requiring fortified diets did not receive the additional items needed to increase their caloric intake. These deficiencies were observed during a lunch tray line observation and confirmed through interviews with dietary staff and a review of facility documents, indicating a failure to follow the established dietary guidelines and serving sizes.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain proper food storage and preparation standards, as evidenced by multiple observations of unsanitary conditions and improper handling of food. The stove and oven were found to have significant grease and food particle buildup, and the cleaning schedule was not adhered to due to staffing issues. Over-ripe and spoiled produce was found in the walk-in refrigerator, and food items were stored beyond their use-by dates or not kept at the required temperatures. Additionally, food labeled to be kept frozen was improperly stored in the refrigerator. The walk-in refrigerator and freezer were not maintaining the correct temperatures, posing a risk of food spoilage. The external and internal thermometers showed temperatures outside the safe range, and the facility's maintenance team had to adjust the equipment settings. Unit refrigerators and freezers at various nurse stations were also found to be unclean, with missing temperature logs and improperly labeled resident food. These conditions were confirmed by the Dietary Service Supervisor and other staff members, who acknowledged the risks of foodborne illness to residents. A visibly ill employee was observed preparing food without following proper hand hygiene protocols, such as washing hands after coughing. This employee was allowed to work despite showing symptoms of illness, and there was no clear policy for excluding sick staff from food preparation duties. Additionally, unwashed mushrooms with visible dirt were prepared and served, contrary to the facility's policy and FDA guidelines. These deficiencies in food safety practices placed residents at risk for foodborne illnesses.
Infection Control Deficiencies in PPE Usage and EBP Implementation
Penalty
Summary
The facility failed to adhere to appropriate infection prevention and control measures for several residents, leading to potential health risks. In one instance, a Licensed Nurse (LN) did not wear the required personal protective equipment (PPE) while providing gastrostomy tube care to a resident on Enhanced Barrier Precautions (EBP). Despite the presence of a sign indicating EBP isolation, the nurse only wore gloves and failed to don a gown, which is necessary to prevent cross-contamination and the spread of multi-drug resistant organisms. Another deficiency was observed when a sterile wound dressing was improperly stored in an open state within a treatment cart. A nurse admitted to opening the dressing package in preparation for a procedure that was postponed, and acknowledged that the dressing should have been discarded to prevent infection risks. The facility's policy mandates the disposal of unused opened dressings to avoid cross-contamination, which was not followed in this case. Additionally, a resident's room lacked the necessary EBP signage and PPE supplies outside the door, despite the resident having a permacath that required such precautions. Staff members, including a Certified Nurse Assistant (CNA), were unaware of the EBP requirements and did not use PPE when assisting the resident, increasing the risk of infection. Furthermore, another LN failed to wear a gown while accessing a PICC line for a resident, contrary to the EBP guidelines, which require gown and glove use during high-contact care activities involving indwelling devices.
Failure to Adhere to Antibiotic Stewardship Program
Penalty
Summary
The facility failed to adhere to its Antibiotic Stewardship Program (ASP) and national standards, resulting in deficiencies in monitoring and optimizing antibiotic use. Specifically, the facility did not follow the McGeer Criteria for prescribing antibiotics to Resident 31, as no laboratory specimen was sent out for testing despite the criteria indicating that two infection criteria were met. Additionally, the facility did not consistently document the duration of antibiotic therapy or monitor the outcomes of antibiotic use, which are essential components of the ASP. During the review of the facility's ASP spreadsheet, it was found that the documentation was incomplete and inconsistent. The spreadsheet did not include the duration of antibiotic therapy, the date of diagnostic tests ordered, or the outcomes of antibiotic use. The Infection Preventionist (IP) confirmed that the spreadsheet used to include this information but no longer did. Furthermore, the IP acknowledged that outcome monitoring was not being conducted, and the McGeer Criteria marked as met for Resident 31 was done in error. The Pharmacist Consultant emphasized the importance of conducting diagnostic tests when prescribing antibiotics to prevent antibiotic resistance. The facility's failure to order culture and sensitivity tests when prescribing antibiotics could lead to prescribing incorrect medications, contributing to the development of Multiple Drug Resistant Organisms (MDRO). The facility's policy on the Antibiotic Stewardship Program, which aims to limit antibiotic resistance and improve treatment efficacy, was not being followed, as evidenced by the lack of infection surveillance data analysis and outcome measurement.
Violation of Resident's Right to Dignity Due to Language Barrier
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect when two CNAs spoke a foreign language over the resident while providing care. During an observation, the CNAs were seen on opposite sides of the resident's bed, engaging in a conversation in a foreign language that was audible from outside the room. The conversation was personal and unrelated to the resident's care, which was confirmed by the CNAs during a joint interview. The resident expressed discomfort and dissatisfaction with the situation, stating that the CNAs should not have spoken in a foreign language over her. Interviews with the Director of Staff Development and the Director of Nursing revealed that the facility's policy required staff to speak English to avoid making residents feel emotionally uncomfortable. The facility's policy on dignity and respect emphasized the importance of treating residents with kindness, respect, and dignity at all times. The incident was identified as a violation of the resident's right to dignity, as it made the resident feel excluded and uncomfortable during care.
Failure to Secure Medications for Self-Administering Residents
Penalty
Summary
The facility failed to ensure that two residents, who were permitted to self-administer medications, had their medications stored safely. For Resident 16, a variety of both prescribed and over-the-counter medications were found unlocked and accessible at the bedside, some of which were expired. Despite having a physician's order to self-administer only Vitamin D3 and Centrum Silver, Resident 16 had numerous other medications, including Tylenol, Aspirin, and Metformin, which were not secured. The facility did not have a system to track the self-administration of these medications, and the medications were not stored in a locked container as required by the facility's policy. Resident 16's roommates were noted to have cognitive impairments, increasing the risk of accidental ingestion of the unsecured medications. The facility's Licensed Nurse confirmed that the medications should have been locked and acknowledged the risk of overdose and reduced efficacy due to expired medications. The facility's policies on medication storage and self-administration were not followed, as evidenced by the presence of expired medications and the lack of secure storage. Similarly, Resident 60 was found carrying medications in a tote bag on her walker, which was accessible to other residents. Although Resident 60 had a locked box for medications in her room, the medications were not stored securely when outside the room. The facility's Regional Nurse Consultant and Assistant Director of Nursing confirmed that the facility's policy was not followed, as medications should have been stored in a locked container to prevent access by other residents.
Failure to Implement PASRR Recommendations in Care Plan
Penalty
Summary
The facility failed to implement an individualized care plan intervention for a resident who had recommendations from a PASRR Level II screening. This screening is designed to identify additional resources needed for residents with mental illness, intellectual, or developmental disabilities. The resident, who was admitted in 2023, had diagnoses including dementia and schizophrenia. Although the PASRR Level I screening results were present in the resident's electronic medical record (EMR), the PASRR Level II report was not attached. The Minimum Data Set Coordinator confirmed that the PASRR Level II screening was completed but not uploaded to the EMR, and the recommendations were not incorporated into the resident's care plan. The Director of Nursing acknowledged that the facility's policy was not followed, as the PASRR Level II recommendations should have been added to the resident's care plan. The facility's policy and procedure for developing comprehensive care plans emphasize the need to incorporate PASRR recommendations to address the resident's medical, physical, mental, and psychosocial needs. The failure to include these recommendations in the care plan posed a risk that the resident would not receive the necessary specialized services or rehabilitative services as identified by the PASRR Level II evaluation.
Failure to Provide Consistent ROM Services
Penalty
Summary
The facility failed to provide appropriate range of motion (ROM) services to Resident 12, who had a history of stroke and aphasia, resulting in limited mobility and a contracted right hand. The resident's care plan included Assisted Active ROM (AAROM) exercises for both upper and lower extremities during daily activities, but these were not consistently documented or performed. Observations and interviews revealed that the resident's right hand was contracted, and AAROM exercises were not regularly conducted or recorded, as evidenced by multiple instances where documentation was marked as 'Not Applicable' or missing. Interviews with staff, including a Certified Nursing Assistant (CNA) and a Licensed Nurse (LN), confirmed that AAROM exercises were not consistently performed or documented. The CNA admitted to not performing AAROM on a specific date, and the LN acknowledged the importance of these exercises in maintaining the resident's hand function. The lack of documentation for refusals of AAROM further indicated a failure to adhere to the facility's policy and procedures, which required reasons for not providing ROM services to be documented in the medical record. The Therapy Director assessed the resident and noted the stiffness in the resident's right thumb, suggesting the need for a splint, which had not been provided. The facility's Administrator and Director of Nursing reviewed the records and acknowledged the failure to ensure that AAROM was performed as required. This deficiency in care could have impacted the resident's ability to use his right hand effectively, potentially affecting his quality of life.
Unattended Razors Pose Risk in Shared Bathroom
Penalty
Summary
The facility failed to ensure the safety of residents by leaving three shaving razors unattended on the counter in a shared bathroom used by four residents. This oversight was observed during a survey on January 7, 2025, at 10:20 AM. The razors were accessible to residents, which posed a risk of injury and infection, particularly for those who might be confused or disoriented. Licensed Nurse 8 confirmed the presence of the razors and acknowledged the potential danger they posed to residents. Further interviews with the Director of Staff Development and the Director of Nursing reinforced the concern that leaving razors unattended in a shared bathroom was against facility policy and posed a risk of injury and infection. The facility's policy, dated March 2023, emphasized the importance of maintaining a resident environment free from accident hazards and ensuring adequate supervision. The policy specifically mentioned the need to contain hazards to protect residents from harm, highlighting the facility's failure to adhere to its own guidelines.
Deficiencies in Pharmaceutical Services and Documentation
Penalty
Summary
The facility failed to ensure safe pharmaceutical services for its residents, as evidenced by two main deficiencies. Firstly, the emergency kit (E-kit) for oral medications was opened and resealed on January 2, 2025, but had not been replaced by January 7, 2025. During an observation and interview, a licensed nurse (LN) confirmed that medications were removed from the E-kit, and the required confirmation fax receipt from the pharmacy was not found. The Director of Nursing (DON) confirmed that the facility policy, which required the form to be faxed to the pharmacy within 24 hours and followed up to ensure receipt, was not followed. Secondly, the facility failed to accurately document the use of narcotic medication for a resident. The Controlled Drug Record (CDR) indicated that Hydrocodone-Acetaminophen was signed out for the resident on two occasions, but the Medication Administration Record (MAR) did not reflect these dosages. The DON acknowledged this discrepancy and confirmed that the facility policy was not followed, which required accurate documentation of medication administration. The resident involved had a medical history of intervertebral disc degeneration, which can cause significant pain. The failure to document narcotic medication use accurately could lead to unsafe medication practices and potential drug diversion. The facility's policies and procedures for administering medications and handling controlled substances were not adhered to, as confirmed by the DON.
Failure to Adhere to Antibiotic Stewardship for a Resident
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary medications, specifically antibiotics, as part of their drug regimen. Resident 31 was prescribed Ciprofloxacin for a urinary tract infection (UTI) without meeting the established McGeer Criteria for continued use of the antibiotic. The Infection Preventionist (IP) confirmed that the resident was started on the antibiotic based on an SBAR assessment tool, but a urine specimen was not collected to confirm the infection, which was a requirement for meeting the McGeer Criteria. The review of Resident 31's records revealed that there were no urinalysis results for December, and no physician progress notes addressed the assessment of a new infection or the review of antibiotic effectiveness. The Director of Medical Records confirmed the absence of urinalysis results, and the Pharmacist Consultant emphasized the importance of diagnostic tests to prevent antibiotic resistance. The facility's policy required a review of antibiotics 48 hours after initiation, but this was not documented in the resident's records. The facility's Infection Prevention and Control Program policy, as well as the Antibiotic Stewardship Interventions policy, were not adhered to in this case. The policies required maintaining records of infections and corrective actions, as well as performing a review of antibiotics to ensure appropriate use. The failure to collect a urine specimen and review the antibiotic regimen led to the unnecessary continuation of antibiotic therapy for Resident 31, which could contribute to the development of multi-drug resistant organisms.
Failure to Secure Controlled Medications in Locked Storage
Penalty
Summary
The facility failed to ensure the safe storage of medications, specifically liquid controlled substances, for a census of 104 residents. During an observation and interview, it was found that the refrigerator in the Medication Storage Room, which contained liquid narcotic medications and an emergency kit, was unlocked. A Licensed Nurse acknowledged that the refrigerator should have been locked and immediately secured it. The risk identified was that unauthorized individuals could access the medications if the refrigerator remained unlocked. Further interviews and record reviews with the Director of Nursing confirmed that the facility's policy was not followed. The facility's policy and procedure documents indicated that controlled medications should be stored separately and securely, with access limited to authorized personnel. The policy also specified that controlled medications requiring refrigeration must be stored within a locked, permanently affixed box inside the refrigerator. The failure to adhere to these policies increased the risk of drug diversion.
Failure to Maintain Closed Garbage Bins
Penalty
Summary
The facility failed to maintain a closed garbage (dumpster) bin, which had the potential to lead to insect and rodent infestation. During an observation and interview with the Dietary Service Supervisor (DSS), it was noted that the lids of the garbage bins were not in place, and the dumpsters were open. The DSS acknowledged that the garbage dumpsters should be kept closed to avoid pests. A review of the facility's policy titled 'Adequate Sewage Disposal and Plumbing,' dated 2019, indicated that improperly disposed of garbage is a source of unsanitary practices and unpleasant odors, and it can harbor vermin, flies, rodents, and cockroaches. The policy outlined practices to prevent this, including providing garbage containers in adequate supply to hold all garbage between collections and ensuring lids are tight-fitting and secure.
Confidentiality Breach in Resident Medical Records
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's medical records, specifically for one resident whose records were mistakenly placed in another resident's electronic health record (EHR). This error was identified during an interview and record review with the Director of Medical Records (DMR), who confirmed that the Preadmission Screening and Resident Review (PASSR) forms for the affected resident were found in another resident's EHR. The DMR acknowledged that this was a Health Insurance Portability and Accountability Act (HIPAA) issue and noted that this type of error had been an ongoing problem, which she had been addressing as they were discovered. The Administrator (ADM) also confirmed the error, acknowledging that the facility had been using a specific software program to scan medical records into the EHR for a year, but despite this, records were still being uploaded incorrectly. The ADM confirmed that the affected resident's records were removed from the incorrect chart and uploaded to the correct one. The facility's Privacy and Confidentiality Policy, which aligns with HIPAA standards, was not followed in this instance, leading to the potential exposure of private and confidential information to unauthorized individuals.
Failure to Coordinate Hospice Care for Resident
Penalty
Summary
The facility failed to ensure proper coordination of care between the facility and the hospice agency for a resident receiving end-of-life care. The resident, who was admitted with diagnoses including palliative care and Alzheimer's disease, was involved in an incident where they scratched another resident. Following this, the interdisciplinary team (IDT) recommended a medication review by the hospice agency on a specific date. However, the facility did not follow up on the outcome of this review, resulting in the medication review not being available in the resident's clinical record. During interviews and record reviews, it was confirmed that the hospice agency had conducted the medication review and faxed the report to the facility. However, the facility staff, particularly during shift changes, did not receive the faxed report. The Director of Nursing (DON) acknowledged that the facility's service agreement with the hospice agency and the facility's policy and procedure for hospice services, which required documentation of communication between the facility and hospice provider, were not followed. This oversight had the potential to impact the quality of care provided to the terminally ill resident.
Delayed Administration of Pain Medication
Penalty
Summary
The facility failed to provide care and services according to professional standards of practice and the comprehensive care plan for a resident when a physician-ordered pain medication, Tramadol, did not arrive from the pharmacy until three days after the resident's admission. Despite the availability of Tramadol in the E-kit, the medication was not administered, leaving the resident at risk for increased, uncontrolled pain. The resident's medication administration record indicated a start date for Tramadol on the day of admission, with instructions to monitor and document pain levels. However, the resident experienced moderate pain levels of 5 on a 0-10 scale on the days following admission. The nursing staff attempted to address the issue by contacting the pharmacy and the physician, but the Tramadol prescription was delayed due to the need for a triplicate prescription. The resident was instead given Tylenol, which was deemed inadequate for the reported pain level. Interviews with nursing staff revealed that the resident repeatedly requested Tramadol, and there was an acknowledgment that uncontrolled pain could lead to other health concerns. The Tramadol prescription was eventually signed by the facility physician, and the medication was delivered to the facility, but not until after the resident had endured days of moderate pain.
Failure to Provide Scheduled Showers for Residents
Penalty
Summary
The facility failed to provide necessary services for two residents, resulting in missed showers over a period of several days. Resident 1, admitted with generalized weakness and difficulty walking, did not receive a shower for a week, from June 19 to June 26, 2024. Despite needing partial to moderate assistance with bathing, Resident 1 reported that showers were sometimes only offered once a week, and bed baths were given without the option of a shower. The resident expressed a preference for showers and had never refused one. Family Member 1 had to intervene multiple times to ensure Resident 1 was scheduled for showers. Resident 2, admitted for generalized weakness and rehabilitation, also experienced missed showers, going six days without one. CNA 1 confirmed that showers were supposed to be given twice a week but acknowledged that new admissions might not be scheduled correctly, leading to missed showers. Resident 2's family member had to provide a shower after complaints to the staff went unaddressed. Both the Licensed Nurse and the Director of Staff Development confirmed the missed showers and acknowledged the lack of documentation for refusals or reasons for the missed showers. The facility's policy on dignity and respect, which emphasizes grooming according to residents' preferences, was not adhered to in these cases.
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What surveyors actually found near you
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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
A prioritized, do-first checklist
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Illustrative
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Nursing homes near Stockton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Noble Care Center | 0.5 mi | ★★★★★ | 5 | 0 |
| Hampton Post Acute | 0.6 mi | ★★★★★ | 17 | 0 |
| Oak Grove Post Acute | 0.8 mi | ★★★★★ | 61 | 0 |
| Good Samaritan Rehab And Care Center | 1.4 mi | ★★★★★ | 1 | 0 |
| Riverwood Health Care | 1.4 mi | ★★★★★ | 60 | 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.