Above 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 View Post Acute Rehabilitation during CMS and state inspections, most recent first.
A resident with dementia, severely impaired cognition, and dependence for ADLs was hospitalized with pneumonia, respiratory failure, COPD, sepsis, candida auris, and CRE. When the hospital CM contacted the facility about readmission, the facility said no isolation bed was available and staff reported difficulty finding a room because the resident needed contact isolation and a private restroom. Survey review showed available beds in the facility, and the resident remained in the hospital instead of being readmitted to the first available bed.
A resident with morbid obesity, an above-knee amputation, and muscle weakness was involved in an altercation with a roommate who threw items, grabbed the resident’s leg, and struck the resident with a container. Multiple nurses and a CNA responded, but the resident was not asked what happened and was not physically assessed or body-checked after the incident. Staff documented the roommate’s behavior, while the resident later reported no one checked for injury and noticed a discoloration on the back of a hand later that day.
Call Light Not Within Reach for Two Residents: Two residents with hx of falls, hemiplegia/hemiparesis, and impaired cognition were observed with their call lights out of reach. One resident was in bed with the call light stuck on the side of the bed and rails, and the other was in a wheelchair with the call light placed on the opposite side of the bed. Staff, including the TN, DSD, and DON, stated the call light needed to be accessible for resident use.
Inaccurate MDS coding affected two residents. One resident was receiving Rivaroxaban for PVD, but the MDS did not code the anticoagulant despite the order, care plan, and staff acknowledgment that it should have been included. Another resident was discharged home with home health for RN, PT/OT, and wound care, but the MDS coded the discharge only as home/community. The MDSN and DON stated the assessments were not coded accurately.
A facility failed to ensure low air loss mattresses were set correctly for three residents with pressure injuries or high skin breakdown risk. One resident with a Stage 3 PI was found on static mode with the mattress set below the ordered weight, while two other residents were observed with mattress settings higher than their documented weights. Staff interviews confirmed the mattresses should have been set to each resident’s actual weight and, for one resident, should not have been on static mode.
Failure to Follow Fall Precautions and Supervision Orders: Two residents with significant fall risk factors were not managed according to orders and care plans. One resident with impaired cognition, hemiplegia, and a history of getting up unassisted was observed without the ordered cushion alarm in bed or in the wheelchair, and staff confirmed the device was not in place. Another resident with prior falls, fractures, weakness, and dependence for transfers was found with the bed not in a low position and no landing pad present; staff also reported the resident needed supervision and was later found on the floor after being left alone in the room.
Missing Nursing Staff Competency Documentation: The facility failed to complete required competency documentation for a CNA and an LVN. The DSD stated the CNA did not have an annual skills competency on file and the LVN’s skills checklist was not signed and dated upon hire. The DON confirmed the CNA’s competency should have been completed upon hire and annually, and the facility policy required nursing staff to complete orientation competency assessment within 30 days of hire.
Failure to Provide Routine Dental Care: Two residents with significant care needs, including dependence or partial dependence for oral hygiene, were not seen by the facility dentist for routine dental care since admission. Both residents reported that no dentist had checked their teeth for a long time, CNA staff were unaware of any dental visits, and the SSD and DON confirmed that routine dental care had not been provided or coordinated as required by the facility’s policy.
A resident with parkinsonism, asthma, dysphagia, intellectual disability, and severely impaired cognition was fed in the dining room by an TN while the TN sat higher than the resident, side to side, and looking down rather than facing the resident at eye level. The TN stated the resident was a feeder and that a lower chair could have been used, while the DON stated residents should be fed at eye level and facing the resident and that labeling residents as feeders and feeding while looking down on them was a dignity issue.
Dusty Shower Room Exhaust Fan: A shower room near the north nurses' station had an exhaust fan protective grill visibly covered with dust. A CNA said nursing assistants and housekeeping staff are responsible for cleaning shower rooms, and Maintenance stated the fan removes excess moisture and cleaning it helps prevent bacterial growth. The IP stated care areas must be kept clean to protect residents from infection, and the facility P&P includes cleaning and disinfecting bathing areas.
Unordered Use of Cushion Pad Alarms: A resident with muscle weakness, osteoporosis, anxiety, and moderately impaired cognition had cushion pad alarms attached to the bed and wheelchair. Staff stated there was no physician order or documented consent for the alarms, and the DON confirmed that restraint use required both an order and consent per facility policy.
A resident with depression and polyneuropathy was ordered PRN Remeron for inability to sleep and stay asleep related to insomnia, but the indication was not tied to a specific diagnosed condition and the resident’s hours of sleep were not monitored. RN and DON stated the order lacked a specific diagnosis and that sleep monitoring should have been done to assess effectiveness, consistent with the facility’s psychotropic medication policy.
Failure to update fall risk care plan after a resident fall. A resident with COPD, malnutrition, HTN, prior fracture, and a history of falls was found on the floor, and an SBAR documented the incident with a hip x-ray ordered. Although the ED note showed no new fracture, the fall risk care plan was not revised, and the DON stated it was not updated to reflect the bed in low position or the use of a landing pad.
Failure to provide required 2-person ADL assistance for a resident with quadriplegia, left hand contracture, and cerebral palsy. The resident was dependent for toileting, bathing, dressing, and personal hygiene, and the care plan stated the resident was totally dependent for turning and repositioning. A CNA was observed alone cleaning and turning the resident, while the CNA, an LVN, and the DON stated the resident needed 2-person assistance for safety and to complete care properly.
Inadequate Foley catheter care and infection monitoring. A resident with a Foley catheter, urinary retention, acute kidney failure, and a history of MDRO infection was observed with about two inches of white sediment in the catheter tubing. The DSD stated the sediment should not have been present and could be a sign of UTI, while the DON stated nurses should monitor residents with Foley catheters every 8 hours for signs of infection. The facility policy required daily and PRN catheter care to promote hygiene, comfort, and reduce infection risk.
Inadequate GT site care was identified for a resident with quadriplegia, dysphagia, and a GT. The physician ordered the GT site to be cleaned with NS, patted dry, covered with split gauze daily, and secured with paper tape every shift, but the dressing was observed loose and dated earlier than the observation, and the TAR showed the dressing change was not current. The TN and DON both stated the GT site should be kept clean and in place per the order and facility policy.
Medication Error With Early MS Contin Administration An LPN administered MS Contin ER 15 mg to a resident for severe pain before the ordered interval had elapsed, after an earlier dose had been given and not documented in the eMAR. The resident had left arm abscess pain and an open wound to the left shoulder, and the RN later confirmed the earlier dose had been given but not charted. The DON identified the event as a medication error, and staff stated the CDR and eMAR should be checked before giving controlled meds.
Medication Room Storage and Cleanliness Deficiencies: The facility failed to keep the medication room clean and appropriately maintained when crackers were found stored in a medication cabinet, insect repellent spray was observed near medications, and five unidentified loose pills were found on the floor by the medication destruction container. The RNS and DON stated food should not be in the med room and that discontinued or expired meds should be placed in the destruction container; the facility policy required medication storage areas to be kept clean and free of clutter.
Oxygen tubing left on the floor. A resident with dysphagia, GT status, and severe cognitive impairment was ordered continuous O2 at 2 L via NC, but observations showed the NC tubing touching the floor in the resident’s room on two occasions. The IPN, RNS, and DON all stated the tubing should not touch the floor, and the facility’s oxygen policy stated tubing should be kept off the floor.
Two residents experienced a breach of privacy and dignity when staff failed to close privacy curtains during care. One resident was exposed during a bed bath, and another during a surgical site check. The facility's policy requires privacy measures to be in place during such procedures.
The facility failed to ensure that call lights were within reach and properly explained to residents, affecting four residents. A resident with severe cognitive impairment had their call light on the floor, while another could not reach theirs due to its placement on an oxygen concentrator. A third resident's call light was tangled on a bed rail, and a fourth resident was not instructed on its use, leaving them to shout for help. Staff interviews confirmed the need for call lights to be accessible and explained, as per facility policy.
The facility failed to provide necessary care for residents with indwelling catheters, leading to potential infection risks. A resident's Foley catheter was not secured and had white sediments, while another's suprapubic catheter was not properly maintained. Nephrostomy tubes for a third resident were positioned incorrectly, and a fourth resident's catheter showed signs of potential infection. Facility policies on catheter care were not followed.
The facility failed to follow its policy on bedrails and grab bars for two residents, leading to deficiencies. For one resident with impaired cognition, grab bars were installed without attempting alternatives or obtaining informed consent. Another resident with intact cognition had bedrails installed without consent or alternative attempts. The facility's policy required assessment and consent, which were not followed.
The facility failed to ensure staff wore required PPE while providing care to residents on Enhanced Barrier Precautions (EBP). A CNA provided care to a resident with a Foley catheter without a gown, an LVN entered a resident's room without PPE to check a G-tube, and another CNA entered a room to provide a bed bath without a gown. These actions were against the facility's infection control policies, risking the spread of infection.
A facility failed to provide a communication board for a non-English speaking resident, impacting their ability to communicate effectively with staff. The resident, who preferred speaking Spanish, had no communication board in their room, contrary to facility policy. This oversight had the potential to affect the resident's care and quality of life.
A resident with a history of falls and multiple medical conditions was at risk due to the facility's failure to maintain their bed in the lowest position, as required by their care plan. Observations confirmed the bed was not adjusted properly, despite the resident's medium fall risk and the facility's fall management policy.
A facility failed to label the nasal cannula (NC) tubing for a resident, which could lead to infection. The resident, with acute respiratory failure and dysphagia, was on continuous oxygen via NC. The NC was not dated or labeled, contrary to the facility's policy requiring weekly changes. The Infection Preventionist Nurse confirmed the labeling requirement to prevent bacterial accumulation.
A facility failed to act on a pharmacist's medication regimen review (MRR) recommendation for a resident prescribed PRN Ondansetron. The MRR suggested specifying the therapy length, but no action was taken until the medication was discontinued months later. Interviews revealed the facility did not notify the prescribing physician or update the order, missing the opportunity to prevent unnecessary medication use.
A facility failed to document a specific indication for the use of Mirtazapine for a resident with major depressive disorder, as required by its policy on psychotropic medications. The resident's physician order cited mood, sleep, and appetite stimulant as reasons for the medication, but these were not considered specific manifestations by the DON. This lack of documentation could lead to unnecessary psychotropic drug use.
A facility failed to keep an electric fan in a safe and sanitary condition for a resident with severe cognitive impairment and health issues like CHF and asthma. The fan was dusty and covered with lint, which was noted by a CNA as potentially harmful. The DON stated that housekeeping should ensure personal equipment is clean, as per the facility's housekeeping policy.
The facility failed to accurately post the actual number of nursing staff on duty, leading to discrepancies in staffing information available to residents and family members. The Director of Staff Development acknowledged the inaccuracies, which could mislead residents and family members about staffing levels.
A resident with multiple health conditions, including edentulous status, did not have a timely care plan developed for their dental needs. The facility failed to adhere to its policy requiring a baseline care plan within 48 hours of admission and a comprehensive care plan within seven days of MDS completion. This delay in care planning was acknowledged by staff and had the potential to impact the resident's health.
A resident with diabetes and dementia experienced a delay in podiatric care due to the facility's failure to arrange a timely consult with a podiatrist. Despite a care plan indicating the need for foot care, the consult was delayed by three months, leading to untreated foot issues. Staff interviews confirmed the oversight, acknowledging the risk of complications due to the resident's condition.
Failure to Readmit Resident to First Available Bed
Penalty
Summary
The facility failed to readmit a resident to the first available bed in a private room after the hospital contacted the facility about readmission. The resident had a history of altered level of consciousness, dementia, severely impaired cognition, and dependence on staff for ADLs, and had been hospitalized with diagnoses including pneumonia, respiratory failure, COPD, and sepsis. The hospital case manager documented that the resident had candida auris and CRE and that the facility was contacted for readmission, but the facility stated no isolation bed was available. Facility staff stated the resident needed contact isolation and a private restroom because of the two isolations, and admissions staff reported it was difficult to find a room. The DON stated that readmissions are given the first available bed and that the resident, as a long-term resident, would have to come back to the facility. Survey review showed seven available beds in the facility and 34 beds available on the admission/discharge reports, with eight rooms having a private bathroom, yet the resident remained in the hospital from the initial readmission inquiry through the later discharge planning review.
Failure to Assess Resident After Roommate Incident
Penalty
Summary
The facility failed to assess and monitor a resident involved in an incident with a roommate after staff discovered the event on the morning of 5/4/2026. Resident 6 had diagnoses including morbid obesity, acquired absence of the right leg above the knee, and muscle weakness, and was documented as dependent on staff for toileting hygiene and lower body dressing. Resident 6 also had the capacity to understand and make decisions. During observation and interviews, Resident 6 stated that the roommate, Resident 7, entered the room wearing only a soiled diaper, threw a water pitcher and a container of potato chips, grabbed Resident 6’s left leg, and struck Resident 6 with the chip container. Resident 6 stated staff separated the residents and cleaned the chips from Resident 6’s body and bed. Staff interviews showed that multiple licensed nurses and a CNA responded to the room, but Resident 6 was not specifically assessed after the incident. CNA 1 stated the room was in disarray, Resident 7 was standing at the foot of Resident 6’s bed, and Resident 6 appeared agitated and reported that Resident 7 had thrown belongings. RN 1 stated RN 1 saw Resident 6’s belongings on the floor, including scissors, but did not ask Resident 6 what had happened and did not assess Resident 6 because the morning shift took over. LVN 1 stated LVN 1 focused on Resident 7 and did not assess Resident 6, and RN 2 stated RN 2 did not complete a change of condition for Resident 6 and did not physically assess Resident 6 after the incident. Resident 6 later told staff that no one had asked for details of the incident or checked Resident 6’s body afterward, and Resident 6 noticed a discoloration on the back of the right hand later that day. The DON stated that when a resident’s condition changes, the licensed nurse should assess the resident, identify needed interventions, and communicate with the provider as needed. The facility’s Change in Condition policy stated that when a resident’s condition or care needs change, the licensed nurse or nurse supervisor should be notified and must perform and document an assessment of the resident and identify any additional interventions.
Call Light Not Within Reach for Two Residents
Penalty
Summary
The facility failed to ensure the call light was within reach for two residents who had significant mobility and cognitive impairments and were identified as being at risk for falls. Resident 1 had diagnoses including difficulty walking, a history of falling, a displaced intertrochanteric fracture of the right femur, hemiplegia, and hemiparesis. The resident’s fall risk evaluation noted prior falls, bedbound status, a recent change in condition, and recent hospitalization. The care plan directed staff to ensure the call light was within reach, and the MDS indicated moderately impaired cognition and maximum assistance needs for multiple activities of daily living. During observation, Resident 1 was lying in bed with the call light stuck on the right side of the bed and rails, and the resident’s responsible party and the treatment nurse stated the resident could not reach it. Resident 50 had diagnoses including difficulty walking, a history of falling, hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side. The resident’s fall risk evaluation noted prior falls, intermittent confusion, bedbound status, a recent change in condition, and recent hospitalization. The care plan directed staff to ensure the call light was within reach, and the MDS indicated moderately impaired cognition and maximum assistance needs for eating, oral hygiene, toileting, bathing, dressing, and footwear. During observation, Resident 50 was sitting in a wheelchair on the bottom right side of the bed with the call light placed on the left upper side of the bed. The DSD stated the resident was unable to reach the call light and that residents’ needs would not be met if the call light was not within reach. The facility policy stated to ensure the call device is within the resident’s reach before leaving the room.
Inaccurate MDS Coding for Anticoagulant Use and Discharge Status
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) accurately reflected Resident 5’s anticoagulant use. Resident 5 was admitted and re-admitted with diagnoses including essential hypertension and peripheral vascular disease, and the order summary showed Rivaroxaban 2.5 mg by mouth twice daily for PVD. The history and physical stated the resident did not have the capacity to understand and make decisions, and the care plan identified anticoagulant therapy related to a history of PVD. The MDS for Resident 5 documented the resident’s functional assistance needs, but it did not indicate that the resident was receiving an anticoagulant medication. During interview, the RN supervisor stated that residents on anticoagulants should be documented in the MDS to monitor for adverse reactions or risks associated with high-alert medications. The MDS Coordinator stated the MDS was not properly documented and no modification was submitted regarding Rivaroxaban, and confirmed that the anticoagulant should have been coded. The DON also stated Rivaroxaban should have been coded correctly in the MDS so staff could formulate a care plan and monitor for side effects. The facility also failed to accurately code Resident 106’s discharge status on the MDS. Resident 106 was admitted with muscle wasting and atrophy, need for assistance with personal care, and a chronic ulcer of the right foot. The discharge summary and physician order indicated the resident was discharged to home with home health services, including nursing, therapy, medication management, and wound care. However, the MDS coded the discharge as home/community rather than discharged to home with organized home health services. The MDS Nurse and DON both stated the assessment was not coded accurately and should have reflected discharge to home with home health services.
Low Air Loss Mattress Settings Not Matched to Resident Weight
Penalty
Summary
The facility failed to provide necessary treatment to prevent pressure ulcer development and promote healing for three residents by not ensuring low air loss mattresses were set correctly. Resident 7 was admitted and readmitted with diagnoses including sepsis, DM, and difficulty walking, and had intact cognition and the ability to understand and make decisions. Resident 7 had an active order for a low air loss mattress based on weight, with the resident’s weight documented as 139 lbs., and also had a Stage 3 pressure injury at the intergluteal cleft extending to the left buttock. During observation, Resident 7 was found in bed with the low air loss mattress on static mode and set at 125 lbs., while a sticker on the device indicated 139 lbs. The resident stated the mattress felt firm and soft. The AD confirmed the mattress was on static mode and set at about 120 lbs. Staff interviews confirmed the mattress should have been in alternating mode and set to the resident’s weight, and the DON stated the mattress should not have been on static mode because airflow not alternating could delay wound healing. Resident 9 had diagnoses including dysphagia, paraplegia, contractures, and muscle weakness, and was dependent for multiple activities of daily living with severely impaired decision-making. Resident 9 had an order for a low air loss mattress for wound management based on weight, with a documented weight of 103 lbs. During observation, Resident 9 was resting on a low air loss mattress set to approximately 125 lbs. Staff stated the mattress settings needed to match the resident’s weight and that inaccurate settings could create complications and increase the risk of skin breakdown. Resident 46 had diagnoses including a stage 4 sacral pressure ulcer, right heel pressure ulcer, urinary retention, and acute kidney failure, and had intact cognition with the capacity to understand and make decisions. Resident 46 had a care plan and physician order for a low air loss mattress set based on actual weight, and the resident’s weight was documented as 107 lbs. During observation, Resident 46 was lying on a low air mattress set at 125 lbs. The DSD, treatment nurse, and DON all stated the mattress should have been set according to the resident’s actual weight, and the treatment nurse stated the physician’s order was not followed.
Failure to Follow Fall Precautions and Supervision Orders
Penalty
Summary
The facility failed to provide necessary care and services in accordance with physician orders and its fall management policy for two residents. One resident had diagnoses including hemiplegia, hemiparesis, and anxiety disorder, was assessed as having severely impaired cognition, and was identified as high risk for falls with intermittent confusion and poor vision. The care plan and order summary both directed that a cushion alarm be used in bed and in the wheelchair to remind the resident not to get up unassisted, with monitoring of placement and function every shift. During observation, the resident was found in bed without a cushion alarm connected in bed or in the wheelchair. The LVN stated the resident did not have a cushion alarm in either location and had a history of getting out of bed unassisted. Record review showed no documentation that the active order for the cushion alarm had been discontinued. The DON stated the cushion alarm should be applied as ordered to alert staff that the resident needed immediate assistance and for safety while in bed or in a wheelchair. A second resident had diagnoses including COPD, protein-calorie malnutrition, hypertension, a right pubis fracture, a history of falling, and need for assistance with personal care. Assessments showed the resident was dependent for lying-to-sitting, had weakness in both legs and feet, and was high risk for falls. The care plan stated the bed should be in a low position, but during observation the bed was not in a low position and no landing pad was present. Staff interviews stated the resident needed supervision when sitting, lying in bed, and transferring, and the resident was later found on the floor after being left in the room by evening shift staff.
Missing Nursing Staff Competency Documentation
Penalty
Summary
The facility failed to conduct required competencies for two sampled staff members, CNA 4 and LVN 2. During a concurrent record review and interview with the DSD on 2/26/2026 at 10:20 am, CNA 4’s employee file was reviewed and the DSD stated CNA 4 had been employed full-time since 11/11/2024 but did not have a skills competency on file for 11/2025. The DSD stated that skills competency should be completed yearly to ensure staff understand assigned tasks and remain competent in providing care and treatment for residents, and that competency should be completed by the DSD for CNAs upon hire and annually thereafter. During the same review, LVN 2’s employee file was examined and the DSD stated LVN 2 had been employed full-time since 5/22/2025, but the DON did not sign and date LVN 2’s skills checklist upon hire. The DSD stated that if it was not signed, it was not done. During an interview on 2/26/2026 at 1:30 pm, the DON stated CNA 4’s skills competency should have been completed by the DSD upon hire and annually to ensure employees were competent in providing care and services to residents. The facility policy titled Nursing Staff Competency, reviewed in 2/2026, stated that within 30 days of hire, the nursing staff member shall complete the orientation competency assessment for the appropriate job category.
Failure to Provide Routine Dental Care
Penalty
Summary
The facility failed to provide routine dental care and services for two residents, Resident 3 and Resident 72, in accordance with its Quality of Care policy. Resident 3 was admitted with diagnoses including hemiplegia, hemiparesis, muscle weakness, and COPD. The MDS dated 12/30/2025 indicated Resident 3 required substantial/maximal assistance with oral hygiene and personal hygiene. The clinical admission assessment dated 11/20/2025 documented that Resident 3 had his own teeth, but the oral/dental status section was not checked. Resident 72 was admitted with diagnoses including COPD, protein-calorie malnutrition, essential hypertension, fracture of the right pubis, history of falling, and need for assistance with personal care. The MDS dated 12/29/2025 indicated Resident 72 required partial/moderate assistance with oral hygiene and personal hygiene. The clinical admission assessment dated 12/26/2025 documented that Resident 72 had his own teeth and difficulty chewing, but the oral/dental status section was not checked. Both residents stated that no dentist had seen or checked their teeth for a long time, CNA staff were not aware of any dental visits, the SSD stated neither resident had been seen by the facility dentist for routine dental care since admission, and the DON stated routine dental care had not been provided and should have been coordinated through Social Services.
Failure to Feed a Resident at Eye Level and Use Proper Name
Penalty
Summary
The facility failed to ensure that one sampled resident was assisted with eating at eye level and was called by the resident's legal, proper, and preferred name. Resident 66 was admitted and re-admitted with diagnoses including parkinsonism, asthma, dysphagia, and intellectual disability. The resident's order summary showed an active order for a no-added-salt fortified diet with pureed texture meals and thin liquids. The history and physical indicated intellectual disability, and the care plan identified an ADL self-care performance deficit related to limited mobility, impaired balance, and confusion, with a goal to maintain the resident's current level of function, including eating. The MDS assessment indicated severely impaired cognition and that the resident required partial/moderate assistance for eating. During observation in the dining room, Treatment Nurse 2 was feeding Resident 66 while seated on a black stool about one-half foot above the resident, positioned on the resident's right side, side to side with the resident, and looking down during feeding. In interview, TN 2 stated the resident was a feeder and needed assistance with feeding, that the stool was higher because the resident's wheelchair was low, and that a lower chair could have been used to assist at eye level. TN 2 also stated the feeding was not at eye level and was not facing the resident because attention was being given to other residents in the dining room. The DON stated residents should be fed at eye level and facing the resident for safety and engagement, and that labeling residents as feeders and feeding while looking down on them was a dignity issue. The facility's Dignity and Privacy policy stated residents are to be treated with kindness, dignity, and respect, and staff shall display respect when speaking with, caring for, or talking about them as affirmation of their individuality and dignity.
Dusty Shower Room Exhaust Fan
Penalty
Summary
The facility failed to maintain a safe and clean area in a shower room near the north nurses' station. During observation, the shower room's exhaust fan protective grill was visibly covered with dust. A CNA stated that most residents follow a shower schedule and that nursing assistants and housekeeping staff are responsible for cleaning the shower rooms. Maintenance explained that the exhaust fan removes excess moisture inside the shower room and that cleaning it helps prevent bacterial growth. The Infection Preventionist stated that it is important to keep all care areas clean to protect residents from any source of infection. The facility's Infection Prevention and Control Program policy states that the program addresses detection, prevention, and control of infections among residents and personnel, including effective cleaning and disinfecting equipment such as bathing areas.
Unordered Use of Cushion Pad Alarms
Penalty
Summary
The facility failed to implement its policy and procedures on the use of cushion pad alarms for one sampled resident. Resident 12 was admitted and later readmitted with diagnoses including muscle weakness, osteoporosis, and anxiety. The resident’s MDS dated 1/23/2026 indicated moderately impaired cognition and the need for assistance with eating, oral hygiene, personal hygiene, toileting, showering, and dressing. During an observation in the resident’s room, Treatment Nurse 2 stated that Resident 12 had a cushion alarm connected to both the bed and wheelchair. During record review, Licensed Vocational Nurse 4 stated that Resident 12 did not have an order for cushion pad alarms for the bed and wheelchair and that there was no documented consent for their use. LVN 4 stated cushion pad alarms were considered restraints because they restricted mobility in bed and in the chair, and that a physician’s order and consent were needed before use. The DON also stated that cushion pad alarms should have a physician’s order and consent from the resident and/or responsible party before use. The facility’s restraint policy stated that restraints include lab cushions and lap trays the resident cannot remove easily, and that any resident using a restraint must have a current order and signed consent in the clinical chart.
PRN Remeron Ordered Without Specific Diagnosis or Sleep Monitoring
Penalty
Summary
The facility failed to ensure that one sampled resident’s order for Remeron included a specific indication for a specific diagnosed condition and that the resident’s hours of sleep were monitored, as required by the facility’s policy on Chemical Restraints and Psychotropic Medication Management. Resident 108 was admitted with diagnoses including depression and polyneuropathy, and the history and physical noted the resident had the capacity to understand and make decisions. The order summary report showed Remeron oral tablet was to be administered as needed for inability to sleep and stay asleep related to insomnia for 14 days. During interview, RN 1 stated the indication was not a specific diagnosis and that the resident’s hours of sleep were not monitored. The DON stated psychotropic medications should be administered with a specific diagnosis, that insomnia is not a diagnosis for Remeron use, and that the resident’s target behavior for inability to sleep should have been monitored to determine whether the medication was effective. The facility policy stated PRN psychotropic drugs require a documented specific diagnosed condition and monitoring for adverse consequences and effectiveness.
Failure to Update Fall Risk Care Plan After Resident Fall
Penalty
Summary
The facility failed to update Resident 72’s care plan after a fall on 2/24/2026. Resident 72 had diagnoses including COPD, protein-calorie malnutrition, essential hypertension, a fracture of the right pubis, a history of falling, and need for assistance with personal care. The resident’s MDS dated 12/29/2025 indicated dependence on lying-to-sitting and a history of fall on admission with a fracture related to a fall prior to admission. The clinical admission assessment dated 12/26/2025 noted weakness in both legs and feet, the PT evaluation dated 12/29/2025 noted decreased stride length, decreased velocity, and uneven step length associated with knee instability, and the nursing fall risk evaluation dated 12/29/2025 identified the resident as bedbound/incontinent with balance problems and high risk for falls. After the resident was found on the floor at 7:15 p.m. on 2/24/2026, an SBAR form documented the fall and a right hip x-ray was ordered. The ED note dated 2/25/2026 indicated there was no new fracture from the fall. However, the care plans reviewed on 2/25/2026 at 8:45 a.m. showed the fall risk care plan had not been updated after the incident. During interview, LVN 1 stated the care plan was not revised after the fall and that Resident 72 had no landing pad. The DON stated the nurses did not update the care plan to include the bed being in a low position and placing a landing pad, and stated the care plan should have been revised so staff would know how to care for the resident.
Failure to Provide Required 2-Person ADL Assistance
Penalty
Summary
The facility failed to provide required assistance during ADLs for one resident with quadriplegia, left hand contracture, and cerebral palsy. The resident’s MDS dated 2/2/2026 indicated severely impaired cognition and dependence with eating, oral hygiene, toileting, showering, upper and lower body dressing, and personal hygiene. The resident’s care plan stated the resident was totally dependent on staff for repositioning and turning in bed and required total assistance with personal hygiene. During a concurrent observation and interview on 2/24/2026, a CNA was observed alone cleaning and turning the resident onto the resident’s left side. The CNA stated the resident required 2-person assistance for showering, toileting, upper and lower body dressing, and personal hygiene, and that two staff were needed for safety and to prevent injury to the resident and staff. An LVN later stated the resident could not turn and hold position during toileting and personal hygiene and needed 2-person assistance, and that one person should not provide this care. The DON stated dependent residents required assistance of 2 or more persons during ADLs. The facility policy stated residents unable to carry out ADLs would receive necessary services to maintain personal hygiene.
Inadequate Foley Catheter Care and Infection Monitoring
Penalty
Summary
The facility failed to provide necessary care and services for a resident with an indwelling Foley catheter in accordance with its urinary catheter care policy. The resident was admitted and readmitted with diagnoses including stage 4 sacral pressure ulcer, right heel pressure ulcer, urinary retention, and acute kidney failure. The MDS indicated the resident had intact cognition for daily decision making and required maximum assistance with toileting hygiene, showering, lower body dressing, and putting on/off footwear. The care plan identified the resident as at risk for infection related to the indwelling catheter and history of MDRO infection, with interventions for staff to use Enhanced Barrier Precautions during close contact care and to monitor for signs and symptoms of active infection and notify the physician. During a concurrent observation and interview, the resident was in bed with a Foley catheter hanging on the right side of the bed, and approximately two inches of white sediment was observed inside the catheter tubing. The DSD stated the tubing should not have white sediment and that it could be a sign of UTI. The DON stated licensed nurses should monitor residents with Foley catheters every eight hours for signs and symptoms of infection, including burning upon urination, sediment in the tubing, blood in the urine, fever, and alteration in level of consciousness, to prevent UTI. The facility policy stated each resident with an indwelling catheter will receive catheter care daily and as needed to promote hygiene, comfort, and decrease the risk of infection.
Inadequate GT Site Care
Penalty
Summary
The facility failed to provide necessary care and services for a resident’s gastrostomy tube site in accordance with the physician’s order. Resident 51 was admitted with diagnoses including quadriplegia, left hand contracture, and gastrostomy, and the care plan identified tube feeding related to dysphagia with a goal of remaining free of side effects or complications related to tube feeding. The physician’s order required licensed staff to clean the GT site with normal saline, pat dry, apply split gauze dressing daily, and secure it with paper tape every shift. On observation, Resident 51 was lying in bed with the gastrostomy tube in place, and the CNA stated the GT dressing was loose and dated 2/22/2026. The TAR showed the tube feeding site dressing was changed on 2/23/2026. The TN stated GT sites needed to be cleaned, patted dry, covered with split gauze daily and as needed, and secured with tape to prevent infection and accidental pulling. The DON stated the GT site should be cleaned daily as ordered and the dressing should be kept clean and in place to prevent infection and tugging during bed mobility. The facility policy stated that proper care and maintenance of gastrostomy tubes was required and that all stoma sites were to be cleaned daily per MD orders.
Medication Error With Early Administration of MS Contin
Penalty
Summary
Resident 109 was admitted with diagnoses including a cutaneous abscess of the left upper arm and pain in the left shoulder. The resident’s H&P indicated the resident had the capacity to understand and make decisions. The resident had an active order for MS Contin ER 15 mg by mouth every 12 hours as needed for severe pain rated 7-10, and the care plan addressed acute pain related to an open wound to the left shoulder with interventions for MS Contin and administration of medications and treatments as ordered. During a medication pass observation, LVN 1 administered MS Contin ER 15 mg to Resident 109 for 9/10 left arm abscess pain at 8:51 am. The medication was documented in the eMAR and CDR, and the eMAR also showed the medication as given the prior day at 4:20 pm. The CDR indicated the morphine sulfate ER tablet 15 mg had been administered at 4:20 am before the 8:50 am dose. LVN 1 stated the dose given at 4:20 am was not charted in the eMAR, and RN 3 later stated RN 3 had given the MS Contin ER 15 mg at 4:20 am and forgot to document it in the eMAR. In interviews, LVN 1 stated the medication was given before it was due and could cause lethargy, low blood pressure, and a change in condition. RN 3 stated the CDR and eMAR should be checked before giving the medication and that giving the dose too early could cause adverse side effects, decreased respirations, and cardiac issues. The DON stated the administration of MS Contin ER 15 mg at 8:50 am was a medication error, and that nurses should document controlled drugs on both the CDR and eMAR so the next nurse would know when the medication was available to prevent medication errors.
Medication Room Storage and Cleanliness Deficiencies
Penalty
Summary
The facility failed to maintain medication-related equipment and storage areas in a clean and appropriate manner. During observation in the center station medication room, crackers were found stored inside a medication room cabinet, a can of insect repellent spray was observed on top of the cupboard near medications, and five unidentified loose medication pills were found on the floor next to the medication destruction container. The Registered Nurse Supervisor stated that food items should not be inside the medication room because they can attract pests, and that discontinued and expired medications should be placed inside the destruction container. During interview, the DON stated there should be no food items inside the medication room because they can attract pest infestation, and that nurses are responsible for keeping medication rooms clean to avoid possible infection. The DON also stated that if nurses do not manage discontinued and expired medications by placing them in the destruction container, this compromises resident safety. The facility policy on Medication Storage stated that outdated, contaminated, or deteriorated medications are to be immediately removed from stock, disposed of according to medication disposal procedures, and that medication storage areas are to be kept clean and free of clutter.
Oxygen tubing left on the floor
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when the facility failed to follow infection prevention procedures for one sampled resident. Resident 80 was admitted and readmitted with diagnoses including dysphagia and gastrostomy status, and the MDS indicated the resident had severely impaired cognitive skills for daily decision making and was dependent for eating, oral hygiene, toileting hygiene, bathing, dressing, footwear, and personal hygiene. The resident’s OSR dated 1/12/26 indicated continuous oxygen at 2 liters per nasal cannula to keep oxygen at 92% every shift. During observations inside the resident’s room on 2/24/26 at 9:43 AM and again at 1:57 PM, the resident’s nasal cannula tubing was touching the floor. During interviews, the IPN stated that if the nasal cannula was touching the floor it could result in an infection and that it should not touch the floor; when not in use, it should be placed inside a bag and safely stored. The RNS stated the tubing touching the floor was an infection control issue and not sanitary, and the DON stated the resident’s nasal cannula should not be touching the floor for infection control. The facility’s P&P titled Use of Oxygen, revised 5/2007, stated that tubing should be kept off the floor.
Failure to Maintain Resident Privacy and Dignity
Penalty
Summary
The facility failed to maintain the dignity and privacy of two residents, resulting in a deficiency. Resident 138, who was admitted with diabetes mellitus and generalized muscle weakness, was found exposed from above the knee to the chest area while lying in bed. The privacy curtain was not closed, allowing the resident's body to be visible from the hallway. This occurred after a Certified Nursing Assistant (CNA) prepared the resident for a bed bath and forgot to close the privacy curtain, which is a necessary step to ensure the resident's privacy and dignity. Similarly, Resident 238, admitted with a fracture of the right femur, experienced a breach of privacy when a Minimum Data Set Nurse (MDSN) checked the resident's surgical site without closing the privacy curtain. This action exposed the resident's thigh, compromising their privacy. The Director of Nursing (DON) confirmed that the privacy curtain should have been closed to maintain the resident's dignity. The facility's policy and procedure on resident rights emphasize the importance of maintaining privacy during examinations and treatments by using closed doors or drawn curtains.
Failure to Ensure Call Light Accessibility and Understanding
Penalty
Summary
The facility failed to provide reasonable accommodation for the needs of four residents, specifically regarding the accessibility and understanding of the call light system. For Residents 13, 20, and 57, the call light was not within reach, which is crucial for residents to request assistance from the nursing staff. Resident 13, who had severe cognitive impairment and was at risk for falls, had their call light on the floor, making it inaccessible. Similarly, Resident 20, who was assessed as high risk for falls, could not reach their call light as it was hanging on an oxygen concentrator three feet away. Resident 57, with severely impaired cognition, had their call light tangled on the bed rail, rendering it unusable. Resident 39, who had moderately impaired cognition and was at high risk for falls, did not know how to use the call light, and its purpose was not explained to them. This lack of instruction left Resident 39 without a reliable means to communicate with staff, as they resorted to shouting for help. The facility's policy requires that the call light be within reach and that its use be explained to residents, but this was not adhered to in Resident 39's case. Interviews with staff, including the Director of Nursing and the Director of Staff and Development, confirmed that the call lights should be within reach and that residents should be instructed on their use. The facility's policy and procedure on call lights emphasize the importance of providing residents with a means of communication with the nursing staff, which was not consistently implemented, leading to the deficiencies observed.
Deficiencies in Catheter Care and Management
Penalty
Summary
The facility failed to provide necessary care and services for residents with indwelling catheters, as observed in four residents. Resident 19's Foley catheter tubing was not secured and had visible white sediments, which were not monitored as required. The resident's care plan indicated the need for a catheter stabilizer and monitoring of urine characteristics every shift, but these interventions were not followed, placing the resident at risk for urinary tract infections. Resident 26 had a suprapubic catheter that was not secured, and the site dressing was wet and unclean. The care plan required securing the catheter to prevent kinking and accidental removal, and the dressing was to be changed daily. However, during observation, the catheter tubing was found under the resident's leg, and the dressing was not maintained as per the facility's policy, increasing the risk of infection and skin irritation. Resident 32's nephrostomy tubes were not covered with a privacy bag and were positioned higher than the bladder, contrary to the care plan's instructions to position the bags lower to prevent backflow and infection. Resident 78's Foley catheter tubing had white sediments, which were not reported to the medical doctor as required. The facility's policies on catheter care and management were not adhered to, leading to potential risks of infection for the residents involved.
Failure to Implement Bedrail and Grab Bar Policies
Penalty
Summary
The facility failed to adhere to its Policy and Procedure regarding the use of bedrails and grab bars for two residents, leading to deficiencies in care. For Resident 51, who was admitted with a displaced fracture and dislocation, the facility did not document any attempts to use appropriate alternatives before installing grab bars. The resident, who had moderately impaired cognition, was unaware of the reason for the grab bars, indicating a lack of informed consent and understanding of the risks and benefits associated with their use. Similarly, for Resident 33, who had diagnoses including hemiplegia and neuropathy, the facility installed bedrails without attempting alternative interventions or obtaining informed consent. The resident, who had intact cognition, was not informed about the bedrails and did not request them. The facility's Director of Nursing acknowledged that alternatives should have been attempted and consent obtained before installation. The facility's policy required an interdisciplinary team assessment and informed consent prior to the use of bedrails, which was not followed in these cases.
Failure to Implement Infection Control Measures
Penalty
Summary
The facility failed to implement its infection prevention and control program by not ensuring that staff wore the required personal protective equipment (PPE) while providing care to residents on Enhanced Barrier Precautions (EBP). In one instance, a Certified Nurse Assistant (CNA 2) provided care to a resident with an indwelling catheter without wearing a gown, only using gloves. This resident was on EBP due to the presence of a Foley catheter, which required the use of gown and gloves during high-contact care activities to prevent the spread of multidrug-resistant organisms (MDROs). Another incident involved a Licensed Vocational Nurse (LVN 4) who entered a resident's room without donning the required PPE before checking the resident's gastrostomy tube (G-tube) placement for medication administration. The resident was on EBP due to the presence of a G-tube, and the facility's policy required staff to wear gown and gloves during such care activities to prevent the transmission of infections. Additionally, a Certified Nurse Assistant (CNA 6) entered a resident's room to provide a bed bath without wearing a gown, despite signage indicating the need for PPE due to the resident being on EBP for an open wound. The facility's policy mandated the use of gown and gloves during high-contact care activities, such as bathing and providing hygiene, to protect both residents and staff from infection. These failures in adhering to the facility's infection control policies had the potential to result in the spread of infection and cross-contamination.
Failure to Provide Communication Board for Non-English Speaking Resident
Penalty
Summary
The facility failed to provide an effective communication method for a non-English speaking resident, identified as Resident 138, which had the potential to impact the resident's ability to receive necessary care and services. Resident 138 was admitted with diagnoses including diabetes mellitus and generalized muscle weakness. The resident's Minimum Data Set (MDS) indicated that they had clear speech, intact cognition, and a preference for speaking Spanish. However, during an observation and interview, it was noted that Resident 138 was unable to communicate in English, and there was no communication board present in the resident's room to facilitate communication with non-Spanish speaking staff. The Minimum Data Set Coordinator (MDSC) and the Social Service Director (SSD) both acknowledged the absence of a communication board, which was against the facility's policy for non-English speaking residents. The facility's policy required that a communication board with universally known drawings be provided to residents who do not speak English to ensure effective communication and meet the resident's needs. The lack of a communication board in Resident 138's room was a failure to adhere to this policy, potentially affecting the resident's quality of life and care.
Failure to Maintain Bed in Lowest Position for Fall Risk Resident
Penalty
Summary
The facility failed to maintain an environment free of accident hazards for a resident, identified as Resident 40, by not ensuring that the resident's bed was in the lowest position. This oversight was observed during multiple visits to the resident's room, where the bed was found to be 25 to 26 inches from the top of the mattress to the floor, contrary to the care plan's directive for fall reduction measures. The resident, who has a history of falls and multiple medical conditions including Parkinson's disease and arthritis, was assessed as being at medium risk for falls. The resident's care plan, initiated on July 29, 2024, specifically indicated that the bed should be adjusted to the lowest position to mitigate fall risks. Despite this, observations on January 7 and January 8, 2025, confirmed that the bed was not in compliance with the care plan. Interviews with the resident and a Certified Nursing Assistant (CNA) further highlighted the resident's need for assistance with transfers and the importance of maintaining the bed in the lowest position to prevent falls. The facility's policy on fall management, revised in June 2020, mandates an environment as free of accident hazards as possible, which was not adhered to in this instance.
Failure to Label Nasal Cannula Tubing
Penalty
Summary
The facility failed to label the nasal cannula (NC) tubing for a resident, identified as Resident 64, which had the potential to result in infection. Resident 64 was admitted with acute respiratory failure and dysphagia and was dependent on others for certain activities. The resident's Minimum Data Set (MDS) indicated clear speech and the ability to understand and communicate. The Order Summary Report (OSR) for January 2025 showed an order for continuous oxygen via NC at 2 liters per minute every shift. During an observation, it was noted that the NC was not dated or labeled with the application date. The Infection Preventionist Nurse (IPN) confirmed that the NC should be labeled with the date of application and changed weekly to prevent bacterial accumulation. The facility's policy on Oxygen Therapy, dated January 2024, required oxygen tubing to be replaced every 7 days.
Failure to Act on Pharmacist's Medication Review Recommendation
Penalty
Summary
The facility failed to act upon the consultant pharmacist's medication regimen review (MRR) recommendation for a resident, identified as Resident 40. The MRR, conducted between August 1, 2024, and August 26, 2024, suggested specifying the length of therapy for the resident's PRN Ondansetron prescription, which is typically used for short-term nausea and vomiting. However, there was no documentation or change in the physician's order regarding this recommendation until the medication was discontinued on December 3, 2024. Interviews with the registered nurse and the Director of Nursing revealed that the facility did not notify the prescribing physician or update the order based on the pharmacist's recommendation, which was acknowledged as a missed action. Resident 40 was readmitted to the facility with diagnoses including depression disorder and hypertension. The resident's Minimum Data Set indicated they had clear speech, could understand others, and required assistance with personal hygiene and dressing. Despite the pharmacist's recommendation, the facility did not act within the stipulated time frame of seven days as per their policy and procedure, potentially exposing the resident to unnecessary medication and adverse health consequences. The Director of Nursing confirmed that the MRR should have been addressed promptly to prevent such risks.
Failure to Document Specific Indication for Psychotropic Medication Use
Penalty
Summary
The facility failed to identify and document a specific indication for the use of Mirtazapine, an antidepressant, for Resident 20, as required by the facility's policy on psychotropic medications. Resident 20 was admitted with diagnoses including spondylolisthesis and major depressive disorder. The Minimum Data Set (MDS) indicated that Resident 20 had intact cognition for daily decision-making and required supervision during showers. The physician's order for Mirtazapine was related to major depressive disorder, manifested by mood, sleep, and appetite stimulant, but these were not considered specific manifestations or behaviors by the Director of Nurses (DON). During an interview and record review, the DON acknowledged that the medication needed to be administered with a specific diagnosis and symptoms, which were not adequately documented. The facility's policy stated that psychotropic medications should not be used for discipline or convenience and should only be administered to treat the resident's medical symptoms. The lack of specific documentation for the use of Mirtazapine had the potential to result in unnecessary psychotropic drug use, which could lead to significant adverse consequences for Resident 20.
Failure to Maintain Sanitary Conditions for Resident's Equipment
Penalty
Summary
The facility failed to maintain an electric fan in a safe, operating, and sanitary condition for a resident with severe cognitive impairment and multiple health conditions, including congestive heart failure and asthma. The fan, located at the resident's bedside, was observed to be dusty and covered with lint, which was acknowledged by a Certified Nurse Assistant as potentially harmful to the resident's health. This observation was made during a room inspection and interview with the CNA. The Director of Nursing confirmed that housekeeping staff are responsible for ensuring that residents' personal equipment is kept clean and in good working condition. The facility's policy and procedure for the housekeeping department, revised in 2007, mandates effective environmental sanitation to reduce exposure to contaminated air, dust, and equipment. The policy emphasizes frequent cleaning to remove microorganisms that could pose health hazards, with the housekeeping supervisor collaborating with the infection control team to maintain high cleanliness standards.
Inaccurate Posting of Nursing Staff Numbers
Penalty
Summary
The facility failed to accurately post the actual number of nursing staff who worked on specific dates, leading to discrepancies in the staffing information available to residents and family members. On January 1, 2025, during the night shift, five CNAs worked instead of the six that were posted. On January 2, 2025, during the morning shift, 16 CNAs worked instead of the 14 that were posted. On January 3, 2025, during the morning shift, 13 CNAs worked instead of the 14 that were posted. On January 5, 2025, during the night shift, seven CNAs worked instead of the six that were posted. The Director of Staff Development acknowledged that the staffing information was not accurate, which could mislead residents and family members about the actual staffing levels. The facility's policy and procedure required the posting of accurate staffing numbers for those directly responsible for resident care.
Failure to Develop Timely Dental Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident's oral/dental status, which was necessary due to the resident's edentulous condition. The resident, who was admitted with diagnoses including a cerebral vascular accident, type 2 diabetes, and dementia, required assistance with eating and oral hygiene. Despite these needs, the facility did not create a care plan for the resident's dental condition until several months after admission, which was not in compliance with the facility's policy. Interviews with the Assistant Director of Nursing/MDS Nurse and a Registered Nurse revealed that the care plan for the resident's dental condition was not initiated until months after admission, and a dental consult was delayed. The facility's policy required a baseline care plan within 48 hours of admission and a comprehensive care plan within seven days of the MDS completion, which was not adhered to in this case. This oversight had the potential to impact the resident's health, as noted by the staff, who acknowledged the risk of weight loss due to the lack of a timely care plan.
Delay in Podiatric Care for Diabetic Resident
Penalty
Summary
The facility failed to ensure timely podiatric care for a resident, leading to a delay in necessary foot treatment. The resident, who was admitted with a history of a cerebral vascular accident, type 2 diabetes, and dementia, had a care plan dated 8/11/24 that included a referral to a podiatrist for foot care. However, the consult was not arranged until 11/14/2024, three months later. This delay in implementing the care plan resulted in the resident not receiving timely foot care, which could lead to podiatric complications due to their diabetes. Interviews with the Assistant Director of Nursing and a Registered Nurse confirmed that the care plan for podiatric consultation was not followed through in a timely manner. The facility's policy indicated that residents should receive podiatry services every 60 days or as needed, especially for those with diabetes and circulatory disorders. The resident's podiatry visit note from 11/14/2024 indicated significant foot issues, including dystrophic toenails and fungal infection, which were addressed during the visit. The delay in care was acknowledged by the staff, who recognized the risk of further injury due to the resident's diabetic condition.
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 6,232 citations issued within 25 miles in the last 12 months — including the 22 immediate-jeopardy cases — 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Baldwin Park
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| West Covina Healthcare Center | 0.6 mi | ★★★★★ | 17 | 0 |
| Victoria Care Center | 0.8 mi | ★★★★★ | 13 | 0 |
| Beacon Healthcare Center | 1.1 mi | ★★★★★ | 11 | 0 |
| West Haven Healthcare | 1.1 mi | ★★★★★ | 17 | 0 |
| West Covina Medical Center D/p Snf | 1.2 mi | ★★★★★ | 15 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.