Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Garden City Healthcare Center during CMS and state inspections, most recent first.
Insulin orders for two residents with DM and hyperglycemia lacked physician parameters for when to hold insulin or notify the physician based on blood glucose results. One resident had a NovoLOG order before meals without hold or notify instructions, and another resident had Glargine and Lispro orders without parameters, leading an LPN to rely on personal judgment to decide whether to administer or hold insulin. The DSD and DON stated that clear parameters were expected for safe insulin administration, and the facility policy required provider-ordered glucose targets and reporting parameters.
A facility failed to ensure reasonable accommodation for several residents when three residents’ call lights were not within reach and a resident with severe hearing impairment was not provided a communication board or other communication device. Staff observed the call lights out of reach in bed-bound residents, and staff and the DON acknowledged the call lights should have been accessible. A resident with dementia and hearing loss stated he could not hear staff and did not have a hearing aid, while staff confirmed he had no communication board despite care plan directions and the facility’s communication policy.
Incomplete POLST and inconsistent Advance Directive documentation: The facility failed to complete Section D of POLST forms for multiple residents and had conflicting records about Advance Directive status. For several residents, the POLST showed no Advance Directive or left the discussion field blank, while Resident Services and AHCD notes showed different information such as interest in completing an AD, refusal, or that a copy already existed. The DON acknowledged the forms were incomplete and that the facility could not verify who made the POLST decisions, and an LPN stated he did not offer assistance with establishing an AD when one was absent.
Medication destruction records lacked a witness signature, an LPN handled hazardous meds without gloves during administration to a resident with prostate disease and a mood disorder, and a resident’s Morphine documentation was inconsistent between the CDR and MAR. The DON confirmed the destruction log was missing witness verification, the nurse forgot PPE when handling hazardous meds, and staff did not complete required controlled-substance documentation.
Medication Storage and Labeling Deficiencies: Surveyors found multiple medication carts, refrigerators, and a medication room with undated, outdated, unlabeled, discontinued, and improperly stored meds and biologicals. Issues included insulin and eye drops without proper open dates, inhalers kept past discard timelines, unlabeled IV bags in an IV cart, and discontinued controlled meds and other drugs stored in active areas. The DON acknowledged that multidose containers should be dated when opened and that discontinued controlled drugs should be removed from active storage.
Infection control failures were observed throughout the facility. Two water dispensers used by residents and staff were dirty with residue, dust, and buildup, and staff confirmed they had not been cleaned recently. Several residents had unlabeled urinals in their rooms, including one with urine visible and another placed on a bedside table next to an uncovered water pitcher; staff stated urinals should be labeled to prevent cross-contamination. A pill cutter on a med cart was found with white dust inside and around the blade, and an LPN cleaned a glucometer with bleach wipes using bare hands after checking a resident’s blood sugar.
Failure to Obtain and Document Informed Consent for Psychotropic Medications: A resident with major depressive disorder and insomnia received bupropion, Rexulti, and trazodone, but the EHR lacked the resident’s signature on the psychotherapeutic drug informed consent forms. The ADON verified that only the MD had signed the forms, and the DON stated licensed nurses were expected to obtain informed consent before treatment began and ensure the resident understood and agreed to the medications.
A resident self-administered an unlabeled oxymetazoline nasal spray kept at the bedside without a MD order or staff awareness while also receiving multiple scheduled meds, including several BP meds. The nurse confirmed there was no order in the EMR, and the DON stated staff should have noticed the bedside medication use; facility policy required self-administered meds to be clinically approved and stored securely.
Homelike Environment Deficiencies: Two residents were found with room conditions that were not maintained in a homelike manner. One resident had a broken bedside cabinet drawer handle that had been reported multiple times but was not documented in the maintenance log, and the resident said he used a small screw to open and close the drawer. Another resident’s room had chipped walls and mismatching paint, which the MTD verified and described as not warm and welcoming.
A resident was sent back to a GACH for insurance purposes despite having no clinical changes or medical complaints. LN stated there was no clinical reason for the return, and the DON reviewed the record and said the resident was stable with no clinical indication for transfer. The resident said being sent back for no clinical reason would upset her, and the ADM verified the discharge did not follow the facility's transfer/discharge policy.
MDS diagnoses were not accurately documented for two residents. One resident had hypothyroidism and osteoporosis documented in the H&P and was receiving medications for both, but those diagnoses were not coded on the MDS. Another resident had DVT documented in hospital admission records and was receiving medication for it, but the DVT diagnosis was also missing from the MDS. The MDSC and DON confirmed the omissions.
PRN Morphine was administered to a resident with chronic low back pain even though the MAR documented a pain score of 0 at the time of administration on multiple occasions. An LPN confirmed staff are expected to assess pain before giving medication and that the order was for severe pain, while the DON also confirmed the medication was given when the resident had no documented pain. The facility policy required pain intensity to be assessed using a standardized pain scale.
A licensed nurse took a photograph of a resident's arm, which was tied to the bed during IV line placement, using her personal phone before the restraint was removed. The resident had dementia, and the use of a personal device to capture the image violated facility policy on privacy and confidentiality.
A resident with impaired mobility was left with an arm positioning device secured to their wrist after a mid-line catheter procedure, restricting arm movement. Multiple staff members noticed the device during shift changes and care, but it was not promptly removed, documented, or reported according to facility policy. This resulted in the resident's arm being unnecessarily restrained and potentially caused discomfort and emotional distress.
A resident with HE, hyponatremia, and severe cognitive impairment became increasingly confused, wandered, and repeatedly tried to leave the facility. Staff documented attempts to place a wander guard, but the resident refused, and the DON later confirmed the initial elopement risk assessment was inaccurate and no elopement care plan was in place before the resident left the building. A physician order to send the resident to the ER for safety concerns was not carried out over multiple shifts, and the resident was later found near a shopping center by a family friend appearing pale, clammy, sweaty, shaking, confused, and disoriented.
A deficiency was cited when an area of the facility was not kept free from accident hazards and lacked adequate supervision to prevent accidents, as required by safety standards.
A resident was allowed to self-administer medications without an assessment of their ability to do so safely. The resident, with multiple diagnoses, was given medications like Norco and gabapentin to take while out on pass, without proper evaluation or training. Nursing staff followed informal practices without consulting administration, and no IDT meeting was held to assess the resident's capability for self-administration, contrary to facility policy.
A facility failed to create a care plan for a resident self-administering medications while out on pass. The resident, with conditions like osteomyelitis and paraplegia, received medications such as Norco and gabapentin without a formal care plan or training. Interviews revealed that medications were given without a guiding policy, and the DON confirmed the need for a care plan to ensure safety.
A resident with a complex medical history experienced an unwitnessed fall and showed signs of delirium. The facility failed to notify the physician promptly and did not conduct necessary assessments, such as neurological, pain, or skin evaluations. This delay in care and communication potentially increased the resident's risk of complications.
A resident with complex medical conditions experienced inadequate pain management when the facility administered acetaminophen for moderate pain instead of the prescribed Hydrocodone-Acetaminophen. Despite reports from family and CNAs about the resident's significant pain, the appropriate medication was not given, leading to unmanaged pain. Facility staff confirmed the resident should have received the stronger medication as per physician orders.
Two residents engaged in sexual activity without the facility assessing their capacity to consent. Despite cognitive impairments and diagnoses such as dementia, the facility did not notify medical professionals or implement protective measures. This led to confusion and distress among residents and staff, as some allowed the activity while others did not, placing residents at risk of abuse.
The facility failed to clean a commercial can opener in the kitchen, leading to potential foodborne illness risks for 98 residents. Observations revealed metal shavings on the blade, and interviews confirmed the can opener was not cleaned per policy, posing a risk of bacteria buildup.
A resident was exposed to her roommate engaging in sexual activity in their shared room, leading to feelings of humiliation and embarrassment. Despite being aware of the situation, the facility did not address the issue. The resident, who required maximum assistance for daily activities, reported the situation to staff, but her complaints were ignored. Facility staff confirmed awareness of the ongoing situation and acknowledged the potential negative psychological impact on the resident.
Two residents were involved in a verbal altercation involving racial slurs and threats, which was not investigated or reported by the facility. Despite policies requiring investigation and reporting of abuse, the facility failed to take appropriate action, leaving the residents at risk for ongoing abuse.
The facility failed to ensure the safe use and storage of Emergency kits (Ekits) for 98 residents. At the North Station, three IV medication Ekits were found open and unsealed, with no documentation on their use. Additionally, two refrigerated Ekits containing controlled drugs were open and missing medications, with no documentation of removal. Staff acknowledged the findings, and the Director of Nursing confirmed that the facility's policy on Ekit management was not followed.
The facility failed to ensure safe medication storage practices, with hazardous drugs stored without proper labeling, outdated and undated medications in carts, and missing emergency drug kits. Staff were unaware of handling precautions, and facility policies were not followed, posing risks of unsafe medication use.
The facility failed to follow infection prevention measures for two residents receiving IV antibiotics through PICC lines, as staff did not wear gowns as required by Enhanced Barrier Precautions. Additionally, aseptic techniques were not used when reconstituting IV antibiotics, as alcohol wipes were not applied to medication vial stoppers. Furthermore, dirty cups were improperly placed with clean cups on a coffee cart, risking cross-contamination. These actions were contrary to the facility's infection control policies.
A resident with epilepsy, osteoporosis, and dementia was unable to reach her call light due to a contracted hand, leaving her unable to communicate with staff for assistance. Despite being dependent on staff for all physical needs and at high risk for falls, the call light was not placed within her reach, contrary to her care plan and facility policies. This deficiency was confirmed by the DON.
The facility failed to report abuse allegations involving four residents to the state agency. Two residents engaged in sexual activity without the capacity to consent, and a verbal altercation with threats and racial remarks occurred between two other residents. The facility did not follow its policies on abuse prevention and reporting, leading to a delay in addressing potential abuse and safeguarding residents.
A facility failed to accurately complete the PASARR Level 1 screening for a resident with schizoaffective disorder and bipolar disorder, resulting in a negative screening outcome. The resident exhibited aggressive behavior and delusions, consistent with her diagnoses, but the necessary referral for a Level II evaluation was not made, as confirmed by the DON. This oversight was due to the facility not following its admission policy and procedure.
A resident with a history of falls and neurological conditions did not receive complete neurological assessments after a fall, as required by their care plan and facility policy. The resident, who had Parkinson's disease and cognitive impairment, fell and hit their head, prompting an order for scheduled neurological checks. However, these assessments were not fully completed, and the resident was later found not breathing and died. Facility staff confirmed the assessments were incomplete, and the policy was not followed.
A resident who preferred to communicate in Greek was not provided with interpreter services, despite the facility's care plan indicating the need for such services. Staff were unaware of the availability of interpreter services, and the facility's policies on effective communication and resident rights were not followed, resulting in a deficiency in the resident's care.
A resident left cigarettes and a lighter unattended on a patio, accessible to other residents, contrary to the facility's smoking policy. The resident, with a history of COPD and other conditions, was assessed as safe to use smoking products, but their care plan required these items to be stored at the nurses' station. Staff interviews confirmed that smoking materials should be kept in medication carts and smoking was only allowed in designated areas, highlighting a failure to follow the facility's policy.
The facility failed to monitor high-risk medications for two residents. One resident received a blood pressure medication against hold parameters, while another had no physician's order for blood sugar monitoring while on insulin. These oversights were confirmed through MAR reviews and staff interviews.
The facility's Antibiotic Stewardship Program failed to track and assess antibiotic use as per policy for 98 residents. The Infection Prevention nurse did not document critical information such as the duration of therapy, culture dates, or outcomes in the tracking log. Empiric antibiotic use was not monitored, and there was no follow-up for de-escalation. The facility's policy requirements for documenting and reviewing antibiotic regimens were not met, leading to the deficiency.
The facility failed to maintain infection control standards as air filters in AC units across several hallways were found caked with dust and debris. Observations confirmed that filters had not been changed as required, with no documentation of maintenance for several months. The Maintenance Director and Administrator acknowledged the oversight, which contradicted facility policy and CDC guidelines.
The facility failed to document post-fall assessments for three residents who experienced falls, despite having a policy requiring monitoring for late injuries. Interviews confirmed the absence of necessary documentation, which should have been conducted to monitor for late injuries or changes in neurological status.
A facility failed to document essential details for a resident's transfer to an acute care hospital, including the date, time, destination, mode of transportation, and disposition of personal effects and medications. The DON confirmed the lack of necessary documentation and acknowledged that the facility's emergency transfer policy was not followed.
A resident with COPD did not receive her prescribed Trelegy Ellipta inhaler for several days, and the physician was not informed of the unavailability. The medication was mistakenly placed in the destruction pile, contrary to the facility's pharmacy policy.
A resident with COPD and morbid obesity fell from bed while a CNA was changing her fitted sheet, resulting in multiple injuries. The resident's care plan required two-person assistance for bed mobility, but the CNA performed the task alone, contrary to facility policies.
Insulin Orders Lacked Physician Parameters
Penalty
Summary
The facility failed to ensure insulin services met professional standards of practice for 2 residents with diabetes and hyperglycemia because their insulin orders did not include physician parameters for when to notify the physician or when to hold insulin based on blood glucose levels. Resident 1 was admitted with type 2 DM with hyperglycemia and had an order for NovoLOG 6 units subcutaneously before meals. During record review and interview, the LN confirmed the order was being followed as written, but also confirmed the order did not contain parameters for holding insulin or notifying the physician, and there were no progress notes showing the physician had been contacted about adding such parameters. Resident 2 was admitted with type 2 DM with hyperglycemia and diabetic neuropathy and had orders for Insulin Glargine 36 units at bedtime and Insulin Lispro 10 units before breakfast, lunch, and dinner. During review of the MAR and insulin orders, the LN confirmed there were no physician-ordered parameters for either insulin medication. The LN stated she would use her own critical thinking to decide whether to hold or administer insulin. The record showed that on one occasion the resident received Lispro when the blood sugar was 110, on another occasion the insulin was held when the blood sugar was 93, and on another occasion the resident refused the insulin when the blood sugar was 112. Interviews with the DSD and DON confirmed that all insulin orders should include clear physician-ordered parameters to guide when insulin should be administered, held, and when the physician should be notified. The facility policy titled Diabetes - Clinical Protocol stated that the provider will order glucose targets, monitoring regimens, and parameters for reporting blood sugar management information, and that staff will incorporate those orders and reporting parameters into the MAR and care plan.
Call Lights Out of Reach and Missing Communication Support
Penalty
Summary
The facility failed to ensure reasonable accommodation of resident needs and preferences when three residents did not have their call lights within reach. Resident 12, who had diagnoses including Alzheimer’s disease, seizures, gait and mobility abnormalities, and a right shoulder blade fracture, was observed lying in bed with the call light hanging from the left side bed rail, out of reach. Resident 54, who had diagnoses including epilepsy, nontraumatic intracranial hemorrhage, and dysphagia, was observed in bed with the call light hanging from the bedside top drawer and out of reach. Resident 79, who had diagnoses including traumatic subdural hemorrhage, dementia, and abnormal posture, was observed in bed with the call light on the floor next to the bed and not within reach. During the observations, staff confirmed the call lights were not within reach. A CNA stated Resident 54’s call light should have been within reach for safety and that, because the resident was nonverbal and did not have a call light within reach, something bad could have happened in an emergency. Another CNA picked up Resident 79’s call light from the floor and placed it within reach. A nurse stated Resident 12’s call light was not within reach and said that if the resident could not reach or use it to ask for help, the resident would be at risk for falls, injury by hitting his head, and unmet needs. The nurse also stated Resident 12 had a fall in the past. Record review showed each of these residents had care plan interventions directing staff to keep the call light within reach and to use it for assistance. The DON stated that residents’ call lights should be within reach to anticipate needs and avoid delayed care or falls. The facility policy titled "Answering the Call Light" stated that when a resident is in bed or confined to a chair, the call light should be within easy reach of the resident. The facility also failed to provide Resident 71 with a communication board or other communication device. Resident 71 had diagnoses including unspecified dementia and a history of falls, and stated he could not hear and did not have a hearing aid. He said he had told staff that his old hearing aid did not work and that the facility did not provide a communication board or other device. Staff confirmed Resident 71 was deaf, did not have a functioning hearing aid, and did not have a communication board or other communication device in the room. Staff also stated communication with him was difficult and that he should have a communication board to communicate properly with staff. The DON stated Resident 71 should have a communication board per his care plan, and the facility policy for hearing-impaired residents stated to evaluate and address obstacles to effective communication and provide pencil and paper or a tablet to communicate in writing if the resident is able.
Incomplete POLST and inconsistent Advance Directive documentation
Penalty
Summary
The facility failed to ensure consistent implementation of its Advance Directive process for nine sampled residents when Section D of the POLST forms was incomplete and/or the documentation of Advance Directive status did not match other facility records. For Residents 142, 138, 78, 137, 139, 103, 105, 117, and 3, the POLST forms had missing entries in the section identifying who discussed the form, and several forms also had Advance Directive status left blank or marked as having no Advance Directive despite other records showing different information. For Resident 142, the POLST dated 1/29/26 had Section D left blank and indicated no Advance Directive, while the Resident Services document dated 2/1/26 stated the resident was interested in executing an Advance Directive and a case management note stated AHCD declined. For Resident 137, the POLST indicated no Advance Directive, but Resident Services stated the resident had executed an Advance Directive and would bring in a copy, while a progress note stated AHCD declined. For Resident 139, the POLST indicated no Advance Directive, while Resident Services and progress notes stated the resident had executed an Advance Directive and would provide a copy. For Resident 105, the POLST indicated no Advance Directive, Resident Services stated refused, and a progress note stated the daughter already had a copy. For Resident 117, the POLST indicated no Advance Directive, Resident Services stated the resident was interested in executing an Advance Directive, and a progress note stated AHCD no, declined. During interview and record review, the DON stated the POLST forms should have been completed in their entirety and acknowledged that Section D was incomplete for Resident 142 and that the facility could not verify who made the decision reflected on the POLST. The DON also stated the facility should have ensured Advance Directive discussions were conducted with the resident or responsible party and documented upon admission. LN 16 stated the POLST needed to be completed from Sections A through D before physician signature, that it should be completed with the resident if the resident had capacity or with family if not, and that if a resident had no Advance Directive he did not offer assistance with establishing one but encouraged discussion with family. LN 16 further stated he was not aware whether a blank Advance Directive form was available in the facility, and later stated the DON instructed that residents without an Advance Directive should be directed to social work for assistance. The facility team acknowledged inconsistency between the POLST, Resident Services document, and AHCD documentation, and acknowledged the process for offering assistance with Advance Directives required improvement.
Medication destruction, hazardous drug handling, and controlled substance documentation failures
Penalty
Summary
Medication destruction and disposal of non-controlled prescription medications were documented without a witness signature in the facility’s Medication Disposition Log for July 2025 through January 2026. During interview and record review with the DON, the log was reviewed and the DON confirmed she signed the section indicating the medications were destroyed, but no witness signature was documented to verify the destruction process. The DON agreed that medication destruction should be witnessed to ensure accountability and reduce the risk of drug diversion. The facility policy titled Discarding and Destroying Medications, revised October 2014, stated that the medication disposition record will contain the signature of witnesses. Resident 146 was admitted with diagnoses including benign prostatic hyperplasia without lower urinary tract symptoms and mood disorder. During observation, an LN was seen administering Finasteride and Divalproex, both labeled as hazardous medications, and handled them without wearing gloves while dispensing them into a small container. The LN acknowledged that gloves were required when handling hazardous medications and stated she forgot to wear them. The DON stated staff are expected to wear gloves when handling hazardous medications to protect themselves and ensure safe handling practices, and the facility policy on Hazardous Drugs stated hazardous pharmaceutical drugs are handled according to practice standards to minimize staff and resident exposure and that staff are trained on and required to wear PPE specific to the risk of exposure and activities performed. Resident 86 was admitted with muscle weakness, chronic low back pain, depression, and anxiety. Review of the resident’s Controlled Drug Record for Morphine and the MAR for January 2026 through February 2026 showed discrepancies, including one date with CDR removal documentation present but no MAR documentation, and other dates with MAR documentation present but no corresponding CDR removal documentation. During interview and record review, the DON confirmed nursing staff did not complete the required documentation when removing and administering the resident’s controlled medication. The DON stated accurate documentation was necessary to ensure medication accountability and reconciliation of controlled substances, and the facility policy on Controlled Substances stated the facility complies with laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure safe medication storage practices in medication carts, medication refrigerators, and medication rooms. Surveyors observed multiple instances of undated, outdated, unlabeled, discontinued, and improperly stored medications and biologicals across the south hall and north hall medication areas, including refrigerated items, inhalers, IV solutions, eye drops, insulin, testosterone, and controlled medications. The findings were made during observations, interviews with nursing staff and the DON, and record review in a facility with a census of 101. In the south hall medication refrigerator, surveyors observed excessive frost buildup in the freezer section and temperature logs showing repeated readings below the posted acceptable refrigerated range of 36 to 46 degrees Fahrenheit. The refrigerator stored insulin aspart with no open date, insulin glargine vials with open dates of 12/31/25 and 1/1/26, and latanoprost eye drops with an open date of 10/7/25. The labels on these products indicated specific storage requirements and discard timelines, including refrigeration before first use, avoidance of freezing, and limited use periods after opening. LN 5 stated that open dates and expiration dates were to be marked when drugs were first opened. Surveyors also found medication cart 3 in the south hall storing multiple open and undated inhalation medications, including DuoNeb vials removed from the protective foil pouch, open Breo Ellipta and Incruse Ellipta inhalers without dates, and three outdated Advair inhalers with open dates of 10/30/25, 11/25/25, and 12/16/25. In the north hall, the IV medication cart contained two unlabeled IV bags, one sodium chloride solution and one dextrose and sodium chloride solution, which the ADON identified as emergency supply items that should not have been in the IV cart without a resident name. The north hall medication refrigerator also contained discontinued, unlabeled, and outdated medications, including testosterone vials, insulin degludec without a resident label, insulin glargine past its expiration date, multiple eye drops stored together in crowded conditions, and six vials of multi-dose lorazepam that the record showed had been discontinued on 12/9/25. Medication cart 4 in the south hall likewise contained outdated and undated Breo Ellipta and DuoNeb medications. The DON stated that multidose containers should be dated when opened, discontinued controlled drugs should be removed from active storage, and nurses needed education on handling out-of-range temperatures.
Infection Control Failures With Dirty Water Dispensers, Unlabeled Urinals, and Contaminated Equipment
Penalty
Summary
The facility failed to maintain safe infection prevention practices and a clean, sanitary environment in multiple areas of the building. During observations at the North and South Nurses Stations, two water dispensers used by residents and staff were found dirty, with brown, yellow, and white residue around the dispensing nozzles, brown residue in the drip trays, dust on the dispensers, and calcium buildup. Staff members, including LNs, the MTD, and the DON, stated that residents and staff drank water from these dispensers and confirmed that the dispensers were dirty and had not been cleaned recently; the MTD also stated there was no cleaning log to show when they were last cleaned. The facility also failed to maintain proper handling of resident urinals. Resident 9, who had diagnoses including difficulty walking, abnormal posture, urinary retention, and generalized muscle weakness, had an unlabeled urinal hanging on the grab bar in the room. Resident 98, who had diagnoses including diabetes mellitus, generalized muscle weakness, gait and mobility abnormalities, and falls, had an unlabeled urinal with urine visible and the lid uncovered. Resident 116, who had diagnoses including generalized muscle weakness, gait and mobility abnormalities, right below-knee absence, left leg prosthesis, and diabetes mellitus, had two urinals in the room, including one on the mattress and another on the bedside table next to an uncovered water pitcher; staff confirmed the urinals were not placed appropriately and should have been labeled. Multiple staff members stated that urinals should be labeled to identify the resident and prevent cross-contamination. Additional infection control concerns were identified with equipment used for medication administration and blood glucose monitoring. A pill cutter stored on medication cart 4 was observed with white dust inside and around the blade, and an LPN stated it should be cleaned after each use to prevent cross-contamination. During a blood sugar check on Resident 66, an LPN used a glucometer with gloved hands, then removed the gloves and cleaned the glucometer with bleach wipes using bare hands. The LPN stated she forgot to put gloves on, and the IP stated that nursing staff were expected to use gloves when cleaning a contaminated glucometer because bare hands can spread germs to the nurse and among residents.
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain and document informed consent for psychotropic medications for one sampled resident with diagnoses including major depressive disorder and insomnia. The resident’s record showed orders for bupropion for depression, Rexulti for depression, and trazodone for insomnia, and the medication administration record showed the resident received these medications during the reviewed period. During a concurrent interview and record review, the ADON reviewed the psychotherapeutic drug informed consent forms and verified that the MD had signed forms for Rexulti, trazodone, and bupropion, but the resident had not signed any of the forms. The ADON stated the psychotropic informed consent should have been signed immediately by the MD and the resident and verified by the admitting nurse or whoever entered the psychotropic medication orders in the EHR. The DON stated licensed nurses were expected to obtain informed consent before treatment was started and that the resident needed to be informed about the medications, acknowledge understanding, and agree to treatment.
Unordered Nasal Spray Kept at Bedside Without Staff Awareness
Penalty
Summary
The facility failed to ensure safe bedside medication storage and use for one resident who was self-administering a nasal spray without a physician’s order or staff awareness. During a medication administration observation, a nurse administered 16 morning medications to the resident, including five blood pressure medications. At the same time, two unlabeled bottles of oxymetazoline nasal spray were observed on the resident’s bedside table. The resident stated she ordered the nasal spray from an online retailer, did not wait for the facility to call the doctor and order it, did not notify the facility, and had been using it for about 4 or 5 days. During interview, the nurse stated she did not realize the nasal spray was at the bedside and confirmed there was no doctor’s order for it in the electronic medical record. The DON stated the nursing staff should have noticed the bedside use of medications and that the resident needed to notify the facility if she used her own medication. The facility policy stated residents may self-administer medications only if the interdisciplinary team determines it is clinically appropriate and safe, and that self-administered medications must be stored in a safe and secure place not accessible by other residents. The report also noted that oxymetazoline is a decongestant with a warning for use in the setting of high blood pressure.
Homelike Environment Deficiencies
Penalty
Summary
The facility failed to ensure a home-like environment for two residents when Resident 116’s bedside cabinet drawer handle was broken and remained unrepaired after the resident reported it several times. Resident 116’s record showed diagnoses including generalized muscle weakness, gait and mobility abnormalities, right above-knee amputation, artificial left leg, and diabetes mellitus. During observation, the bedside cabinet on the left upper side of the bed was seen with a broken handle. Resident 116 stated he had reported the issue multiple times, that staff had taken no action, and that he used a small screw to open and close the drawer because it had not been fixed. LN 2 confirmed the handle was broken and needed repair, and later stated she forgot to enter the issue in the maintenance log and only reported it verbally. The DON stated staff were expected to follow the proper process and document such issues in the maintenance log so they would be addressed promptly. The facility also failed to maintain Resident 127’s room in a homelike condition when the walls were observed with a 1 inch by 1 inch paint chip and a mismatching white paint area measuring 17 inches by 5 inches. Resident 127’s record showed diagnoses including insomnia and abnormalities of gait and mobility. During observation, Resident 127 pointed out that the walls were chipped and the paint did not match. The MTD verified the wall condition and stated the room should have been warm and welcoming, clean, maintained, and ready for the resident, who had just changed rooms the day before. The facility policy stated residents are to be provided with a safe, clean, comfortable, and homelike environment with clean, sanitary, orderly surroundings and inviting colors and décor.
Inappropriate discharge to hospital for insurance reasons
Penalty
Summary
The facility failed to ensure that one resident was appropriately discharged when the resident was sent back to a GACH for insurance purposes rather than for a clinical reason. Resident 7 was admitted with diagnoses including type 2 diabetes, shortness of breath, and muscle weakness. A progress note documented that the administrator notified the nurse that the resident needed to be sent back to the GACH due to insurance purposes, with no clinical changes noted and the family and MD aware. The GACH document stated the patient presented from rehab without medical complaints and was sent back due to what appeared to be a medical billing problem after being discharged from the hospital the day before. During interviews, LN 1 stated the resident was sent back to the GACH for insurance purposes and that there was no clinical reason for the return. The DON reviewed the record and stated the resident was stable and had no clinical indication to be sent back to the GACH. The resident stated that being sent back to the GACH for no clinical reason would upset her. The administrator reviewed the facility policy on transfer or discharge and verified that the resident's discharge did not follow the policy, which allows transfer or discharge only under specified clinical or operational circumstances.
MDS Diagnoses Not Accurately Documented
Penalty
Summary
The facility failed to ensure accurate MDS diagnostic assessments for 2 of 5 residents reviewed for unnecessary medications. Resident 2 was admitted with multiple diagnoses, including dementia and atrial fibrillation, and the H&P dated 6/9/25 documented hypothyroidism and osteoporosis for which medications were prescribed. However, the diagnosis section of the MDS dated [DATE] did not include the thyroid and bone disease diagnoses even though the resident was receiving medication to treat both conditions. Resident 105 was admitted with multiple diagnoses including dementia and heart disease, and Hospital A admission records dated 10/20/25 documented deep vein thrombosis with medication prescribed for that condition. The diagnosis section of the MDS dated [DATE] did not reflect the DVT diagnosis while the resident was receiving medication for it. During interviews and record review, the MDS Nurse Coordinator and the DON confirmed the diagnoses were missing from the MDS assessments and stated that MDS assessments must be completed accurately.
PRN Morphine Given Despite Zero Pain Scores
Penalty
Summary
The facility failed to ensure safe, appropriate pain management for Resident 86 by administering PRN Morphine despite documented pain assessments showing a pain level of 0 on multiple occasions. Resident 86 was admitted with multiple diagnoses, including muscle weakness, chronic low back pain, and major depressive disorder. The resident had a physician order for Morphine PRN for severe pain, and the MAR documented Morphine administration on several dates when the resident’s pain level was recorded as 0. During a concurrent interview and record review, LN 6 confirmed that staff administered PRN Morphine when the documented pain level was 0 and stated staff are expected to assess pain levels prior to administering medication. LN 6 also stated the order was for severe pain, which she described as a pain level of 7 to 10, and that accurate pain assessment was important because opioid medication may place the resident at risk for oversedation. The DON also confirmed Morphine was administered when the documented pain level was 0 and stated staff received training on accurate MAR documentation to prevent documentation discrepancies. The facility policy titled Pain Assessment and Management stated that pain assessment includes gathering the intensity of pain using a standardized pain scale.
Resident Privacy Breach Due to Staff Use of Personal Phone
Penalty
Summary
A licensed nurse (LN) used her personal phone to take a photograph of a resident's right arm while it was tied to the bed during an intravenous (IV) line placement. The nurse was informed by a night shift nurse that the resident's arm had been tied, and before instructing the nurse to untie the arm, she took a picture with her personal device. The resident involved had been admitted with diagnoses including dementia, which affects memory, thinking, and social abilities. The facility administrator confirmed that the photograph was taken on the nurse's personal phone, which may not have been encrypted and could potentially be accessed by unauthorized individuals. Facility policy requires employees to treat residents with kindness, respect, and dignity, and to maintain privacy and confidentiality of resident information. The act of taking a photograph with a personal phone constituted a failure to maintain the resident's privacy and confidentiality.
Failure to Remove Arm Positioning Device After Procedure
Penalty
Summary
A deficiency occurred when a resident's right wrist remained secured in an arm positioning device following a mid-line catheter insertion. The device, intended to stabilize the arm during the procedure, was not removed after completion, leaving the resident unable to move their arm freely. Multiple staff members, including CNAs and LNs, became aware of the device during shift changes and routine care, but the device remained in place for an extended period. The use of the device was not documented, nor was its continued presence reported to the licensed nurse on duty by the nurse who performed the procedure. The resident involved had a medical history that included a recent fall, abnormal gait, and impaired mobility, making them particularly vulnerable to hazards. Staff interviews revealed that the arm positioning device was noticed by several caregivers during their shifts, but there was confusion and lack of clear communication regarding its removal. One CNA removed the device temporarily to provide care but replaced it afterward, while a licensed nurse was informed about the device but did not remove it, instead passing the information to the next shift. Another nurse instructed that the device should be removed, but it remained in place until further inquiry. Facility policy required that hazardous equipment and devices be identified and addressed to ensure resident safety. The failure to remove the arm positioning device, document its use, and communicate its status to the appropriate staff resulted in the resident's arm being unnecessarily restrained and secured to the bedframe. This situation had the potential to cause discomfort and emotional distress to the resident, as confirmed by the administrator and clinical nurse officer during interviews.
Failure to Assess Elopement Risk and Follow Hospital Transfer Order
Penalty
Summary
The facility failed to implement appropriate safety interventions and supervision for a resident with hepatic encephalopathy, hyponatremia, and severe cognitive impairment. The resident’s BIMS score was 5, and records showed increasing confusion, wandering, pacing, and repeated statements that he wanted to leave the facility. Although an elopement risk evaluation was completed on admission, the DON later confirmed it was inaccurate because the resident’s cognitive diagnosis was not marked correctly, which prevented the resident from being identified as at risk for wandering or elopement at that time. As the resident’s condition changed, staff documented that he became more confused, resisted care, wandered in the building, and attempted to elope multiple times. Nursing notes and interviews showed staff tried to place a wander guard, but the resident refused it. Staff also documented that he was not redirectable, was walking around unassisted, and was considered a high fall risk. The DON and other nurses stated the resident should have been reassessed for elopement risk and should have had an elopement care plan, but the care plan was not initiated until after the elopement occurred. A physician order was entered to send the resident to the hospital for safety concerns and change in condition, but staff did not carry out that order over multiple shifts. The record also showed ordered labs related to confusion and encephalopathy were not drawn as expected. On the morning of the elopement, the resident was redirected back to his room around 7:30 a.m., but by about 8:30 to 8:45 a.m. staff were searching for him and notified the DON after he was not found in the facility. He was later located about one mile away near a shopping center by a family friend, appearing pale, clammy, sweaty, shaking, confused, and disoriented.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to the risk of accidents occurring. There is no mention of specific residents, staff, or detailed events, but the deficiency centers on the lack of appropriate hazard control and supervision in the area.
Failure to Assess Resident for Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure the safe and clinically appropriate self-administration of medications for Resident 1, who was not assessed for self-administration before being provided medications to take while out on pass. Resident 1, diagnosed with osteomyelitis, paraplegia, and chronic pain, was given medications such as Norco, gabapentin, and Sivextro to self-administer without a proper assessment or training. The resident reported taking medications to school since the summer of 2024, with nurses placing the medications in envelopes for him. Interviews with nursing staff revealed that they routinely provided Resident 1 with medications to take on pass without consulting administration or following a specific policy. LN 1 and LN 2 admitted to giving medications in baggies based on observed practices from other nurses, without receiving formal training or guidance. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) were unaware of the practice and confirmed that no Inter-Disciplinary Team (IDT) meeting was held to evaluate the safety and appropriateness of Resident 1's self-administration of medications. The facility's policy on self-administration of medications requires an IDT assessment to determine a resident's cognitive and physical abilities to safely self-administer medications. This includes understanding medication labels, following directions, and comprehending the purpose and dosage of medications. The DON confirmed that there was no documentation in Resident 1's medical record regarding training on safe handling or self-administration of medications, which is crucial to prevent potential harm from improper medication use.
Failure to Develop Care Plan for Self-Administration of Medications
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident who was self-administering medications while out on pass from the facility. The resident, who had diagnoses including osteomyelitis, paraplegia, and chronic pain, was given medications such as Norco, gabapentin, and Sivextro by facility staff to take with him to school. However, there was no care plan in place to address the self-administration of these medications, and the resident had not received training on how to properly take them while away from the facility. Interviews with the resident and facility staff revealed that the medications were provided in envelopes or baggies without a formal policy or care plan guiding this practice. The Director of Nursing confirmed that a care plan should have been developed to ensure the resident's safety and proper medication administration. The facility's policy indicated that self-administration of medications should be determined by the interdisciplinary team as clinically appropriate and safe, but this process was not followed for the resident in question.
Failure to Provide Timely Care After Resident Fall
Penalty
Summary
The facility failed to provide adequate care and services following an unwitnessed fall involving a resident. The resident was found on the floor next to his bed in the early hours of the morning, exhibiting signs of delirium. Despite this, the Licensed Nurse (LN) delayed notifying the physician until several hours later. The nurse also failed to document a neurological, pain, or skin evaluation, which are critical assessments following a fall, especially when the resident shows signs of confusion and delirium. The resident had a complex medical history, including liver cirrhosis, muscle weakness, and a recent amputation, which increased his risk for falls and complications. His care plans specifically required monitoring and reporting signs of delirium to the medical doctor. However, the nurse did not adhere to these protocols, as evidenced by the incomplete SBAR Communication Form and the lack of immediate physician notification. The Assistant Director of Nursing confirmed these lapses during a review of the incident. Interviews with family members and staff further highlighted the resident's condition and the facility's response. The family member noted the resident's increased confusion and pain prior to the fall, and staff reported the resident's distress and physical injuries after the fall. Despite these observations, the necessary assessments and timely communication with the physician were not conducted, potentially delaying treatment and increasing the risk of further complications for the resident.
Inadequate Pain Management for Resident with Moderate Pain
Penalty
Summary
The facility failed to provide comprehensive and effective pain management for a resident, identified as Resident 1, who was experiencing moderate pain. Despite having a pain assessment scale indicating moderate pain, Resident 1 was administered acetaminophen, a medication intended for mild pain, instead of the prescribed Hydrocodone-Acetaminophen for moderate to severe pain. This discrepancy in medication administration occurred on multiple occasions, including when Resident 1 reported a pain level of 5 and 6, which were categorized as moderate pain. Resident 1 was admitted to the facility with several complex medical conditions, including dehiscence of an amputation stump, cirrhosis of the liver, end-stage renal disease, and ascites. The resident's pain was not effectively managed, as evidenced by the administration of acetaminophen for moderate pain levels, contrary to the physician's orders. The resident's family member and certified nursing assistants (CNAs) reported that Resident 1 was in significant pain, and the CNAs repeatedly informed the licensed nurse (LN 1) of the resident's condition. However, the appropriate pain medication was not administered in a timely manner. Interviews with facility staff, including the Assistant Director of Nursing (ADON) and the Medical Doctor (MD), confirmed that the resident should have received Hydrocodone-Acetaminophen for moderate pain. The facility's policy and procedure for administering medications emphasized the importance of following prescriber orders and administering medications based on resident needs. The failure to adhere to these guidelines resulted in Resident 1 experiencing unmanaged pain, which was further complicated by the resident's complex medical history.
Failure to Assess Consent Capacity for Sexual Activity
Penalty
Summary
The facility failed to protect the rights of two residents, Resident 32 and Resident 38, to be free from abuse and neglect. The facility was aware that these residents were engaging in sexual activity but did not assess their capacity to consent to such activities. Despite the ongoing relationship, the facility did not notify the medical doctor or psychiatrist to assist in determining if both residents were capable of consenting to the sexual relationship. This lack of assessment and communication led to a situation where the residents were allowed to engage in sexual activity without a clear understanding of their ability to consent. Resident 32 was admitted with diagnoses including cerebral infarction, hypertension, and myocardial infarction, and had a history of cognitive impairment with a BIMS score indicating moderately impaired cognition. Despite this, the facility did not involve Resident 32's psychologist or notify the responsible party about the sexual relationship. Similarly, Resident 38, who had diagnoses including dementia and bipolar disorder, was also not assessed for her capacity to consent, and her medical records indicated she did not have the capacity to make her own decisions. The facility's failure to implement protective measures or involve relevant healthcare professionals left both residents vulnerable to potential abuse. The facility's inaction resulted in confusion and distress for the residents, as some staff allowed the sexual activity while others prevented it. This inconsistency, coupled with the lack of a formal process to evaluate residents' capacity for consent, placed not only Resident 32 and Resident 38 at risk but also other vulnerable residents in the facility. The facility's failure to address these issues promptly and effectively created a likelihood of serious physical and psychosocial harm to occur.
Improper Cleaning of Kitchen Equipment
Penalty
Summary
The facility failed to maintain cleanliness standards for a commercial can opener in the kitchen, which could have led to foodborne illnesses for 98 residents. During an observation and interview with the Dietary Director, it was noted that the can opener had old metal shavings on its blade, indicating it was not cleaned properly after use. The Dietary Director acknowledged the oversight and confirmed that the can opener should be cleaned after each use and deep cleaned weekly, although there was no log to track these cleanings. This lack of proper cleaning posed a risk of infection and potential foodborne illnesses. Further interviews with the cook and the Registered Dietitian revealed that the facility's policy required the can opener to be cleaned after each work shift and more frequently if necessary. The Registered Dietitian confirmed that the policy was not followed, as the can opener was not cleaned after each use or run through the dishwasher after each shift. The presence of metal shavings on the blade could have led to bacteria buildup, increasing the risk of residents becoming ill. The failure to adhere to the established cleaning procedures directly contributed to the deficiency.
Failure to Ensure Resident's Right to Dignity
Penalty
Summary
The facility failed to ensure a resident's right to a dignified existence when a resident, identified as Resident 49, was exposed to her roommate and another resident engaging in sexual activity in their shared room. Despite being aware of the situation, the facility did not address the issue, leading to Resident 49 feeling humiliated and embarrassed. Resident 49, who was admitted in 2023, had diagnoses including arthritis and depression, and required maximum assistance with transfers, bathing, dressing, and personal hygiene. She reported the situation to the staff, but her complaints were not heeded. Interviews with facility staff, including the Activity Assistant and the Director of Nursing, confirmed that the facility was aware of the sexual activity occurring in Resident 49's room. The Activity Assistant acknowledged that the situation had been ongoing since January 2024 and that there was no known policy regarding residents engaging in sexual activity. The Director of Nursing confirmed that Resident 49 could not leave the room without assistance and acknowledged the potential negative psychological impact on residents unable to leave the room during such activities. The facility's policies on dignity and resident rights emphasize treating residents with respect and ensuring their well-being, which were not upheld in this situation.
Failure to Investigate and Report Resident Altercation
Penalty
Summary
The facility failed to investigate and implement safeguards following allegations of verbal abuse and threats of physical violence between two residents, Resident 311 and Resident 25. Resident 311, who was admitted with conditions including cellulitis, anxiety, and depression, reported to the Ombudsman that her roommate had used a racial slur against her. The Ombudsman noted that the incident was a verbal altercation and that Resident 311 was asked to move rooms, which she felt was unfair. The facility's Case Manager 1 reportedly told Resident 311 that if she did not move, the police would be called, and suggested she could leave the facility if unhappy with her care. Certified Nursing Assistant 4 witnessed an altercation between the two residents, where they exchanged derogatory names and threats, and involved Licensed Nurse 7 for assistance. Despite the altercation, the facility's Administrator acknowledged that there was no follow-up or investigation into the incident, nor was it reported to the state agency. The Administrator stated that typically such incidents would involve an interdisciplinary team meeting and monitoring of the residents, which did not occur in this case. The facility's policies on abuse prevention and reporting require that all allegations of abuse be investigated and reported to the appropriate agencies. However, the review of Resident 311's clinical record confirmed that no investigation or reporting took place. This lack of action placed both residents at risk for ongoing abuse, as the facility did not adhere to its own policies or federal requirements to protect residents from abuse and ensure their safety.
Deficiency in Emergency Kit Management
Penalty
Summary
The facility failed to ensure the safe use and storage of Emergency kits (Ekits) for a census of 98 residents. At the North Station, three Ekits for IV medications were found open and unsealed, with no documentation on when they were opened, what was removed, or which residents the medications were used for. The Ekits contained disorganized IV medications, premixed antibiotics, and IV solutions, some without a beyond-use date. Licensed Nurse (LN) 3 was unable to provide information on why the Ekits were left open and unsealed or when they were last used. The facility's records showed sparse documentation of IV medication and supply use, with only a few entries in recent months. Additionally, two refrigerated Ekits containing controlled drugs, such as lorazepam, were found open and unsealed in a locked room. These kits were missing medications, including Ativan and insulin, with no documentation of their removal. LN 2 and LN 3 acknowledged the findings and indicated that staff should have documented the removal of medications and faxed the usage slip to the pharmacy for kit replacement. The Director of Nursing (DON) confirmed that the staff should have documented any medication or supplies removed from the Ekits and re-sealed them with a yellow color sealer. The facility's policy, dated 2019, requires that only authorized individuals trained in the appropriate use of emergency kits may obtain medications from them. The policy mandates that Ekits be stored in a secured area and that any drug removal be documented with specific details. However, the policy did not address how Ekit replacement and medication removal, including controlled drugs, should be handled by nursing staff. The DON acknowledged that the staff might not have followed the facility's policy regarding Ekit medication removal.
Unsafe Medication Storage Practices
Penalty
Summary
The facility failed to ensure safe medication storage practices, as observed in multiple instances across different medication carts and stations. At the North station, hazardous medications like Megestrol were stored without proper warning labels or protective bags, and the nursing staff was unaware of the necessary precautions for handling such drugs. Additionally, an extra IV medication cart contained a large supply of prescription IV medication bags without patient-specific labels or a tracking system, leading to potential misuse or misadministration. Further inspection revealed that the IV medication cart at the North station stored outdated and undated medications, including those for residents no longer in the facility. The cart was cluttered, with discontinued and active medications co-mingled, and lacked proper labeling for beyond-use dates. At the South station, the medication cart and refrigerator contained undated, unlabeled, and outdated medications, including missing emergency drug kits. This included expired insulin pens, improperly stored probiotics, and unaccounted controlled medications like Lorazepam. The facility's policies on medication storage and handling were not followed, as evidenced by the lack of proper labeling, dating, and storage of medications. The Director of Nursing acknowledged these deficiencies, noting that the facility's procedures for handling controlled substances and emergency kits were not adhered to. These lapses in medication management could lead to unsafe medication use and pose risks to residents receiving spoiled or unusable medications.
Infection Control Deficiencies in Resident Care and Facility Practices
Penalty
Summary
The facility failed to implement appropriate infection prevention and control measures for two residents, Resident 300 and Resident 60, who were receiving intravenous antibiotics through Peripherally Inserted Central Catheter (PICC) lines. During observations, a Licensed Nurse (LN) entered the rooms of these residents wearing only a facemask and gloves, despite Enhanced Barrier Precautions (EBP) signs indicating the need for gown and glove use during high-contact activities such as device care. The LN admitted to not wearing a gown, acknowledging the risk of spreading infection. The Infection Preventionist and Director of Nursing confirmed that the EBP policy was not followed, which was intended to prevent the transmission of multi-drug resistant organisms. Additionally, the facility did not adhere to aseptic techniques when reconstituting intravenous antibiotics for the same residents. The LN was observed not using an alcohol wipe on the rubber stopper of a medication vial before connecting it to a bag of normal saline. The LN believed the stopper was sterile and did not require wiping, contrary to the standard practice of using alcohol wipes to disinfect small surfaces. The Director of Nursing confirmed that the expectation was to use alcohol wipes, aligning with CDC guidelines for disinfection and sterilization in healthcare facilities. Furthermore, the facility failed to maintain proper infection control practices with the coffee cart used in resident areas. Dirty cups were found stacked alongside clean cups on the cart, posing a risk of cross-contamination. Both a Certified Nursing Assistant and a Licensed Nurse acknowledged that dirty cups should not be placed on the coffee cart, and the Director of Nursing confirmed that the procedure was not followed. The facility's Infection Prevention and Control Program policy emphasized the importance of standard precautions, including the separation of clean and dirty items to prevent the spread of infection.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 37, had her call light within reach, which is crucial for her to communicate with the nursing staff for assistance. Resident 37, who has a diagnosis of epilepsy, osteoporosis, and dementia, was observed in her bed with a contracted right hand, unable to reach the call light that was hanging off the right side of the bed rail. This situation was verified by a Licensed Nurse, who acknowledged that the resident was dependent on staff for all physical needs and was at high risk for falls. The nurse stated that the call light should have been placed near the resident's left hand or an adaptive call light should have been used. The resident's care plan indicated that she had severe cognitive impairment and was at high risk for falls, with interventions including keeping the call bell within reach. However, during the observation, it was noted that these interventions were not followed. The Director of Nursing confirmed that the facility's policies and procedures, which require the call light to be within easy reach of residents, were not adhered to. The failure to accommodate the resident's needs and preferences, as outlined in the facility's policies, resulted in the deficiency noted in the report.
Failure to Report Abuse and Ensure Resident Safety
Penalty
Summary
The facility failed to report allegations of abuse to the state survey agency after incidents involving four residents. Two residents, who lacked decision-making capacity, engaged in sexual activity without the ability to consent. Despite staff awareness and documentation of their relationship, the facility did not implement safeguards to prevent sexual contact or report the situation to the state agency. The residents' medical records indicated cognitive impairments, and their responsible parties were not adequately informed about the sexual activities, leading to a lack of proper consent assessment. Another incident involved a verbal altercation between two residents, which included threats of physical violence and racial derogatory remarks. The altercation was not documented in the clinical records, and there was no investigation or report to the state agency. The facility's staff failed to hold an interdisciplinary team meeting to address the altercation and ensure resident safety. The lack of documentation and follow-up actions contributed to the deficiency in handling the situation. The facility's policies on abuse prevention and reporting were not followed, as the incidents were not reported to the appropriate authorities within the required timeframes. The administrator and other staff members were aware of the incidents but did not take the necessary steps to protect the residents or investigate the allegations. This failure to act in accordance with the facility's policies and federal requirements resulted in a delay in addressing the potential abuse and safeguarding the residents' well-being.
Inaccurate PASARR Screening for Resident with Mental Health Disorders
Penalty
Summary
The facility failed to accurately complete the Preadmission Screening and Resident Review (PASARR) for a resident, identified as Resident 20, who was diagnosed with schizoaffective disorder and bipolar disorder. The PASARR Level 1 screening, conducted prior to the resident's admission, incorrectly indicated that the resident did not meet the criteria for a serious mental illness, resulting in a negative screening outcome. This error was identified during a review of the resident's clinical records, which showed multiple instances of aggressive and combative behavior, as well as delusions, all of which are consistent with her diagnosed mental health conditions. The facility's policy and procedure for admissions, which requires a Level 1 PASARR screening for all potential admissions, was not followed in this case. The Director of Nursing confirmed that the PASARR Level 1 was not completed correctly, and the necessary referral to the state PASARR representative for a Level II evaluation was not made. This oversight could have prevented the resident from receiving the appropriate mental health services needed to address her conditions.
Failure to Complete Neurological Assessments Post-Fall
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 96, received the necessary neurological assessments following a fall, as outlined in the resident's care plan and facility policy. Resident 96 had a history of muscle wasting, cognitive impairment, and Parkinson's disease, which increased their risk for falls. After being admitted to the facility from an acute care hospital, Resident 96 experienced a fall in their room, during which they hit their head and sustained discoloration to their buttocks and left knee. The primary care provider ordered scheduled neurological assessments to monitor for potential changes in the resident's condition. However, the neurological assessments were not fully completed as required. Specifically, assessments were missed at two critical times, which could have led to a delay in identifying any neurological changes. The resident was later found not breathing and subsequently died. Interviews with facility staff, including a Licensed Nurse and the Director of Nursing, confirmed that the neurological assessments were incomplete, and the facility's policy and procedure for neurological assessments were not followed. This oversight could have resulted in missing significant changes in the resident's neurological status.
Failure to Provide Language Interpreter Services
Penalty
Summary
The facility failed to ensure effective communication for a resident whose preferred language is Greek, which could have impacted her ability to maintain or improve her communication skills. During observations and interviews, it was noted that the resident was unable to respond to questions in English and communicated primarily by pointing at objects and using a few English words. The care plan for the resident indicated the need for interpreter services due to impaired communication, but staff members, including licensed nurses and certified nursing assistants, were unaware of the availability of such services and did not utilize them. The Director of Nursing (DON) and other staff members confirmed that there were no Greek-speaking staff available and that interpreter services had not been used for the resident. The facility's policies and procedures on effective communication and resident rights, which require assistance for residents with language barriers, were not followed. The DON acknowledged that the staff could have been using interpreter services to communicate effectively with the resident, but this was not done, leading to a deficiency in the resident's care.
Resident Smoking Materials Left Unattended
Penalty
Summary
The facility failed to maintain an environment free of accident hazards for one of the residents, identified as Resident 84, who left cigarettes and a cigarette lighter accessible to other residents on a patio. Resident 84 was admitted to the facility with several diagnoses, including a wedge compression fracture, neuropathy, and COPD. Despite being assessed as safe to maintain and use smoking products, Resident 84's care plan indicated that their cigarettes and lighter should be stored at the nurses' station. However, during an observation, Resident 84 was seen smoking on a patio outside their room, leaving the smoking materials unattended and accessible to other residents. Interviews with facility staff, including a Licensed Nurse, the Assistant Director of Nursing, and the Director of Nursing, revealed that the facility's policy required residents' smoking materials to be kept in medication carts and that smoking was only allowed in designated areas. The Director of Nursing confirmed that the facility's policy was not followed, as residents were not permitted to smoke on patios outside their rooms due to safety risks, especially for those on oxygen. The facility's smoking policy, revised in October 2023, stated that residents with independent smoking privileges could keep smoking items in their possession, but the policy was not adhered to in this instance.
Failure to Monitor High-Risk Medications
Penalty
Summary
The facility failed to monitor the use of high-risk medications for two residents, leading to potential adverse drug effects. For one resident, the nursing staff did not adhere to the hold parameters for a blood pressure medication, Florinef, which was administered seven times despite a physician's order to withhold it when the resident's systolic blood pressure exceeded 130. This oversight was confirmed during a review of the resident's Medication Administration Record (MAR) and an interview with a licensed nurse, who acknowledged the failure to follow the prescribed parameters. For another resident, the facility did not have a physician's order or parameters for monitoring blood sugar levels while the resident was on two insulin products. The nursing staff measured the resident's blood sugar without guidance on managing high or low levels, which could lead to inconsistency in treatment. This lack of parameters was confirmed during a review of the resident's MAR and an interview with a licensed nurse, who noted the absence of orders for blood sugar testing upon the resident's readmission from the hospital. The Director of Nursing acknowledged that the monitoring and parameters should have been addressed upon readmission.
Deficiency in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to ensure that its Antibiotic Stewardship Program (ASP) effectively tracked and assessed antibiotic use according to its policy for a resident census of 98. During an interview, the Infection Prevention nurse (IP) revealed that when a new antibiotic was ordered or a resident was admitted with an antibiotic order, he was notified and would enter the information into a spreadsheet for tracking. However, the spreadsheet lacked critical information such as the duration of antibiotic therapy, date of culture, and outcome or stop date for the drug. The IP also admitted that empiric antibiotic use was not tracked, and there was no follow-up to de-escalate antibiotic use once test results were available. Additionally, the criteria to assess the development of an infection by nursing staff before contacting a doctor were not utilized. Further review revealed that the facility's policy required antibiotic usage and outcome data to be collected and documented using a facility-approved tracking form, which was not adhered to. The IP stated that culture results were not documented in the antibiotic use tracking record, and individual physician prescribing patterns were not tracked or shared with other healthcare providers. The Director of Nursing acknowledged the importance of monitoring in-house antibiotic use and working with doctors to optimize appropriate use, especially for residents with long-term IV antibiotic use. The facility's policy outlined specific requirements for documenting and reviewing antibiotic regimens, which were not met, leading to the deficiency.
Inadequate Maintenance of AC Units Leads to Infection Control Deficiency
Penalty
Summary
The facility failed to maintain proper infection prevention and control standards due to the condition of air filters in freestanding air conditioning units located in various hallways. Observations made on September 27, 2024, revealed that the air filters in units at the ends of the North long hall, North short hall, South long hall, and South short hall were caked with dust and debris. This condition was confirmed during interviews with the Maintenance Director and the Administrator, who acknowledged that the filters appeared not to have been changed and were overdue for replacement. The Maintenance Director admitted that the air conditioning units were installed at the beginning of summer and that the filters should be changed monthly and as needed. However, there was no documentation in the maintenance logs indicating that the filters had been changed in July, August, or September 2024. The facility's policy, dated June 2011, required weekly inspections and monthly changes of air filters during use. Additionally, the CDC guidelines and the operation manual for the AC units emphasized the importance of regular maintenance to prevent the spread of airborne infections, highlighting the facility's failure to adhere to these standards.
Failure to Document Post-Fall Assessments for Residents
Penalty
Summary
The facility failed to meet professional standards of care for three residents who experienced falls, as post-fall documentation was not completed. Resident 1, admitted with dementia, was found on the floor with injuries to the head and wrist, but lacked 72-hour post-fall monitoring documentation. Similarly, Resident 2, with muscle weakness and a left below-knee amputation, was found on the bathroom floor after a fall, yet there was no follow-up documentation for three days post-fall. Resident 3, with a history of falls and Alzheimer's disease, experienced a fall from a wheelchair resulting in a laceration, but also lacked the required post-fall documentation. Interviews with the Director of Nurses and licensed staff confirmed the absence of necessary post-fall documentation for all three residents, which should have been conducted to monitor for late injuries or changes in neurological status. The facility's policy, dated 2001, mandates monitoring and documentation following falls to rule out delayed complications, but this protocol was not followed for the residents in question.
Incomplete Documentation for Resident Transfer
Penalty
Summary
The facility failed to ensure accurate and complete documentation for a resident when she was transferred to an acute care hospital. The resident, who had diagnoses including chronic obstructive pulmonary disease (COPD) and a urinary tract infection, was transferred without documentation of the date and time of transfer, the destination hospital, the mode of transportation, or the disposition of her personal effects and medications. The progress notes indicated that the resident was receiving acute care outside the facility, but there was no physician's order for the transfer or a completed transfer form. During an interview and record review, the Director of Nurses (DON) confirmed that the resident's health record lacked necessary documentation for the transfer. The facility's policy and procedure for emergency transfers, which requires notifying the attending physician, the receiving facility, and preparing a transfer form, was not followed. The DON acknowledged that the documentation should have been completed as per the facility's policy.
Failure to Administer Prescribed Medication and Notify Physician
Penalty
Summary
The facility failed to ensure professional standards of practice were followed for a resident when the resident did not receive her prescribed medication, Trelegy Ellipta, and the physician was not informed that the medication was unavailable. The resident, who was admitted with chronic obstructive respiratory disease (COPD), did not receive her medication from 3/16/24 to 3/20/24, which she stated sometimes worsened her breathing. The licensed nurse (LN) and the Director of Nurses (DON) confirmed the medication was missing and that the physician had not been notified of the missed doses. The DON discovered that the medication had been delivered on 3/14/24 but was mistakenly placed in the medication destruction pile and documented as destroyed on 3/17/24. The facility's pharmacy policy requires that the physician be notified if a vital medication is unavailable, but there was no documentation indicating that the physician was informed about the missed doses. This oversight had the potential to negatively impact the resident's health and well-being.
Resident Falls from Bed During Sheet Change
Penalty
Summary
The facility failed to provide a safe environment for a resident when the resident fell from bed while her fitted sheet was being replaced. The resident, who had chronic obstructive pulmonary disease (COPD) and morbid obesity, was admitted to the facility in 2007. During the incident, the resident was being given a bed bath and was turned on her side to change the fitted sheet. The resident was holding onto the side rail but let go, resulting in a fall that caused lacerations to her left great toe and right knee, a nosebleed, and a hematoma on her forehead. The CNA involved stated that the resident was on an air mattress, which may have been too soft, and he was unable to prevent the fall when she let go of the rail. A review of the resident's care plan indicated that she required two-person assistance for bed mobility due to her weakness and obesity. The CNA, however, was performing the task alone. The facility's policy and procedure for repositioning residents in bed required staff to check the care plan for specific positioning needs and the number of staff required. Additionally, the facility's fall risk assessment policy emphasized the need to identify and document resident risk factors for falls and establish a resident-centered falls prevention plan. The Director of Nurses confirmed that the CNA should have reviewed the resident's care information, which was accessible through the electronic charting system, to ensure proper assistance was provided.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 254 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 Modesto
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Almond Vista Healthcare | 1.1 mi | ★★★★★ | 2 | 0 |
| Modesto Post Acute Center | 1.1 mi | ★★★★★ | 17 | 0 |
| Valley Skilled Nursing Center | 1.1 mi | ★★★★★ | 3 | 0 |
| Golden Modesto Care Center | 1.7 mi | ★★★★★ | 5 | 0 |
| English Oaks Convalescent & Rehabilitation Hospita | 1.9 mi | ★★★★★ | 12 | 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.