Below average — CMS composite of the measures below.
The next survey window likely opens around October 2026
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 Gem Tcu during CMS and state inspections, most recent first.
Nonfunctional Call System and Delayed Response to Resident Call Lights: Two residents with impaired cognition and significant assistance needs had care plans directing staff to keep call lights within reach and answer them promptly. During observation, the Room A call light indicator was lit but produced no audible alert at the nursing station. Both residents stated staff often took an hour or more to answer the call light, and the DON, LVNs, and CNA confirmed the system lacked sound and was not functioning as intended. Staff also stated the facility’s Call System policy and the residents’ care plans were not followed.
A resident with hemiplegia, hemiparesis, hydrocephalus, and Guillain-Barre syndrome was dependent for many ADLs and severely impaired in daily decision making. Although the MDS identified a mechanical lift as a device and aid used for the resident, CNAs stated they transferred the resident with a two-person assist and had never used a mechanical lift. The care plan still referenced assistive devices including a mechanical lift, and the MDS nurse stated the care plan should have been reviewed and revised after each MDS assessment to keep it current.
Failure to Address Resident’s Bed-Sliding Fall Risk: A resident with hemiplegia, hemiparesis, hydrocephalus, and Guillain-Barre syndrome had severely impaired cognition and was dependent for multiple ADLs. After being returned to bed, the resident slid off the bed onto a floor mat while the CNA briefly left the room. The CNA stated the resident kicks a lot in bed, and the DON confirmed the care plan did not include resident-centered fall precautions or address this behavior, despite a prior fall from the same cause.
A resident with a feeding tube, who was totally dependent on staff and at risk for weight loss and dehydration, did not have their enteral feeding administration set changed every shift as ordered by the physician. Evidence from a family member and confirmation by the DON showed the set was not changed for three days, contrary to both physician orders and facility policy.
PASARR screening was not completed or followed through for two residents. One resident with dementia and paranoid schizophrenia had no PASARR Level I screening completed for a later admission, despite severe cognitive impairment and extensive dependence in ADLs. Another resident with psychosis and bipolar disorder had a PASARR Level I indicating a Level II evaluation was required, but staff did not follow up with the PASARR representative. Facility policy required screening of new admissions and readmissions and referral for Level II when indicated.
Unlabeled Frozen Food Items: An open bag of eight chicken patties and a cheesecake were found in the kitchen walk-in freezer without required dates, including open, received, expiration, or best by dates. The DS stated the items should have been labeled per P&P, and another DS stated the foods were not safe to use or serve because no one knew how long they had been stored.
Food brought in by family and visitors was not handled per policy for several residents. Unlabeled or undated items were found in resident refrigerators, food remained in a discharged resident’s refrigerator, a dated pizza box was still stored, and visitor-brought food was left uncovered at a resident’s bedside for more than 2 hours. The DON and DS confirmed the items were not managed according to the facility’s food storage rules.
Staff failed to follow infection control precautions for residents on contact isolation. For several residents with C. diff orders, the supply carts outside their rooms contained Super Sani-Cloth wipes that were not labeled effective against C. diff, while the IP stated bleach wipes were needed. In another instance, a CNA carried a resident’s disposable tray, bowl, utensil, napkin, and food container out of the isolation room and said it would be thrown in the dumpster, even though the resident’s care plan called for isolation precautions and proper handling of waste and supplies.
Failure to maintain dignity during feeding assistance: A resident with dementia and dysphagia, who was dependent for eating and other ADLs, was observed sitting up in bed while a CNA stood above eye level and attempted to feed her. The CNA acknowledged that she should have been seated next to the resident, and the DON reviewed facility policies stating residents must be fed with attention to safety, comfort, and dignity and treated with respect, kindness, and dignity.
Call Lights Left Out of Reach for Three Residents. Three residents with documented ADL and mobility limitations were observed with call lights positioned out of reach despite care plan directions to keep them accessible. One resident with a fracture and osteoarthritis was waving for help while her call light was curled up on the bed, another resident with C. difficile enterocolitis and pneumonia was calling out while his call light hung off the bed, and a third resident with reduced mobility and lack of coordination could not reach her call light while lying in bed.
A resident with ESRD, dialysis dependence, and paraplegia was found in a room with a dusty electric fan and a pool of water beside the bed after a shower. The resident said a CNA left the room without cleaning and drying the floor, and CNA 5, the HS, and an RNS all verified the dusty fan and wet floor, stating the room was not clean or dry.
LAL Mattress Set Incorrectly for a Resident at Risk for Pressure Injury: A resident with a pressure ulcer history, diabetes, and impaired mobility had a LAL mattress ordered for skin integrity and wound management, but the mattress was found set at 300 lbs despite the resident weighing 139 lbs. Staff stated the setting should have matched the resident’s weight and that the incorrect setting defeated the mattress’s purpose.
Wet Floor Left as an Accident Hazard: A resident with ESRD, dementia, and GAD was observed approaching his bed where a pool of water was on the floor. The resident required setup or clean up assistance with transfers, and staff stated the floor needed to be clean and dry because a wet floor could cause a slip or fall. Facility policy identified wet floors as a fall risk factor.
Incomplete Post-Dialysis AV Fistula Assessment: A resident with ESRD and an AV fistula had incomplete dialysis communication records after returning from dialysis, with blank documentation for bruit, thrill, access site, skin, cognitive status, and respiratory assessment. RN and MDS staff confirmed the post-dialysis assessment was not completed as required by the physician order and facility policy.
Meal trays contained egg for a resident with a documented egg allergy. The resident was cognitively intact and needed setup or clean-up assistance with eating. Photos reviewed by the DS showed egg on the resident’s tray on two occasions, and the resident said she notified staff and asked for a fresh tray. The DS and DON both confirmed the trays should not have contained egg.
A kitchen dumpster was observed overflowing at the back of the facility with the lid only halfway open. A dietary aide stated the dumpster was full and could not be closed, and the DS later stated that trash must be fully inside the dumpster with the lid closed. Record review showed the facility policy directed that outside dumpster lids be kept closed.
Ice machine drainage lacked an air gap, with the drain connected into a closed system of hoses, a water storage bin, and pipes with no unobstructed separation from the building drainage. The DS and MS both confirmed the setup, and the MS stated the machine had been moved to the utility room about a month earlier. The facility’s policy stated ice must have no contact with outside contaminated sources, and the Administrator acknowledged the air gap requirement.
Improper Charge to Resident Personal Funds: A resident with severe cognitive impairment and dependence for multiple ADLs was admitted under Medicare with supplemental coverage, and billing records showed an overpayment of $8,170.50 tied to coinsurance. Staff interviews confirmed the resident had no share of cost and that the copay was covered by supplemental insurance, yet the refund was not received and follow-up stopped after an email to the prior biller.
Daily Staffing Information Not Posted: The facility failed to post current staffing information in a visible and prominent area, and the hallway posting remained dated with an older staffing sheet while the weekend and current-day postings were not displayed. An RNS confirmed the missing postings, and the DSD stated the printed staffing sheets were left in a binder instead of being posted. The facility policy required daily posting of nurse staffing data, including the census and the number of RN, LVN, and CNA staff on each shift.
Rooms 12, 14, 15, 16, 17, 21, 22, 23, 24, 25, and 26 did not meet the required square footage for multiple-occupancy rooms. The facility's Room Waiver listed each room at 228 sq. ft. with 3 beds, below the 240 sq. ft. minimum for a 3-bed room. Residents were observed moving freely, staff stated there was enough room to provide safe care, and residents did not voice concerns about room size.
The facility did not obtain food from approved or satisfactory sources and failed to ensure that food was stored, prepared, distributed, and served according to professional standards.
A resident with multiple mental health and physical diagnoses was not readmitted to the facility after discharge from a GACH, despite being medically stable and beds being available. The facility's Administrator refused readmission, citing the resident's need for a private room due to a dog and prior behavioral issues, even though facility policy required residents to be allowed to return within the bed hold period.
A resident with depression, anxiety, and borderline personality disorder was identified as a danger to self and others after expressing intentions to cause harm. Despite physician orders for hospital transfer and psychiatric consultation, the resident refused these interventions, and the facility did not implement 1:1 observation, monitor or document behaviors, or develop a care plan to address the refusals. The lack of monitoring and intervention led to the resident being found unresponsive from an intentional medication overdose, requiring emergency hospitalization and intensive care.
A resident with a history of depression, anxiety, and borderline personality disorder was found unresponsive with opened prescription medications and alcohol in their possession, which were brought in from an outside pharmacy despite facility policy prohibiting such items. Staff interviews and records confirmed that required checks for contraband were not performed, resulting in the resident's hospitalization for an apparent overdose.
Two residents were administered antibiotics for UTIs without meeting the required McGeer criteria, as the facility failed to complete antibiotic stewardship assessments and did not document necessary clinical symptoms. Nursing staff confirmed that antibiotics were given based solely on positive urine cultures, without following established protocols for appropriate antibiotic use.
The facility did not have a designated Infection Preventionist (IP) with specialized training for nearly a month, with IP duties being performed by a registered nurse and other licensed nurses who lacked IP certification. The previous IP had left several months earlier, and current staff covering the role did not have the required training, contrary to facility policy.
A resident reported being physically abused by another resident, but staff failed to notify the State Survey Agency, ombudsman, and law enforcement within the required two-hour window. Although internal incident reports were completed and residents were separated and assessed, the event was not reported externally as required by facility policy. Staff interviews revealed misunderstandings about reporting obligations, and a review of policy confirmed that immediate reporting was necessary but not followed.
A resident with multiple mental health diagnoses and no cognitive impairment reported to staff that a male visitor had attempted to forcefully kiss her. Although the allegation was communicated up the chain of command, the Administrator did not report the incident to the State Survey Agency and ombudsman within the required 2-hour window, instead delaying notification for several days, contrary to facility policy.
A resident with a physician-ordered vegetarian diet and no cognitive impairment was served pizza containing chicken, despite clear documentation of her dietary preference and facility policy requiring adherence to such preferences. The incident was confirmed by both kitchen and nursing staff after the resident reported the issue.
A resident with significant mobility impairments and a history of heart disease and traumatic brain injury was transferred from a wheelchair to bed by a CNA without the required second staff member, despite clear assessments indicating a two-person assist was necessary. The resident slid to the floor during the transfer and was subsequently sent to the hospital. Staff interviews confirmed knowledge of the two-person assist requirement, but it was not followed at the time of the incident.
A resident with a documented vegetarian diet and food intolerances was repeatedly served meals containing meat, despite clear physician orders and care plan instructions. The resident experienced distress and physical symptoms after consuming or discovering meat in her food. Staff interviews confirmed that the dietary preferences were known and documented, but existing tray-checking procedures failed to prevent these incidents.
A resident with severe cognitive impairment and a history of anxiety-related leg kicking was not monitored or documented for this behavior, despite being at risk for fractures. The care plan did not include interventions to address the repetitive kicking, and staff confirmed that no monitoring or documentation occurred. The resident subsequently sustained multiple left foot fractures, likely due to repeated kicking of the bed's footboard, in violation of facility policy on resident safety and supervision.
A resident with severe cognitive impairment and multiple diagnoses was prescribed lorazepam and quetiapine at doses and for indications not aligned with federal guidelines. The consultant pharmacist’s recommendations to adjust these medications were not communicated to the physician for nearly two months, due to the facility’s lack of a defined timeframe in its policies and failure to follow procedures for timely action.
Two residents with unstageable pressure ulcers were not provided appropriate care as their Low Air Loss (LAL) mattresses were set to incorrect weight settings. Despite care plans indicating the use of LAL mattresses, staff were unaware of the residents' actual weights, leading to settings that were too high. This resulted in inadequate therapy from the mattresses, potentially worsening the residents' conditions.
A resident with dementia, Parkinson's disease, and ataxia was found with unexplained swelling on the right hand, which was not reported by the RN to the Administrator or DON as required. The facility's policy mandates reporting such incidents within two hours and to the state agency within 24 hours, but this was not followed, delaying medical evaluation and intervention.
A resident with dementia, Parkinson's disease, and ataxia experienced a fall, but the facility failed to update the Care Plan to include new fall prevention measures. Despite being at high risk for falls, the Care Plan had not been revised since a previous fall, contrary to facility policy. Staff interviews confirmed the oversight, highlighting a deficiency in care plan management.
A facility failed to coordinate with a resident's primary physician regarding medication orders, resulting in a 66-day lapse in seizure medication and unadministered supplements. The resident, with conditions including epilepsy and malnutrition, did not receive lacosamide due to a lack of communication between the facility and the neurologist. Additionally, new orders for N-Acetyl-L-Carnitine, Vitamin D3, and Zinc were not communicated to the primary physician, leading to deficiencies in care.
The facility did not adhere to menu and recipe guidelines, affecting the nutritional needs of 63 residents. The Cajun Country Rice lacked key ingredients, and the tarragon sauce was too salty due to the use of regular chicken broth instead of low sodium. The Dietary Supervisor confirmed these issues, noting potential impacts on residents' food intake and weight. The facility's policy on standardized recipes was not followed, leading to inconsistencies in food quality.
The facility failed to prepare food by methods that conserved flavor and appearance, affecting the quality of meals served to residents. Two residents expressed dissatisfaction with the food, leading them to order from outside. The dietary supervisor confirmed that recipes for tarragon sauce and Cajun rice were not followed, resulting in salty and altered flavors. The facility's policies emphasized the importance of following standardized recipes and tasting food before serving, which was not adhered to.
The facility failed to ensure safe food storage and preparation practices, with chipped refrigerator racks, expired dairy products, and dented cans improperly stored. A staff member did not wash hands after cleaning, risking cross-contamination. These deficiencies could lead to foodborne illnesses among residents.
Two residents in a facility were inadequately supervised, leading to harm. One resident, with a history of dementia, was not monitored as per their care plan and developed an infection from a ring they picked up. Another resident, with mental health conditions, was not checked on after a dental appointment and was later found hospitalized. The facility's failure to follow care plans and policies on supervision and wandering contributed to these incidents.
The facility failed to ensure call lights were within reach for four residents, violating its policy. Residents with various medical conditions, including hyperlipidemia, anemia, and chronic kidney disease, were observed with call lights either on the floor or not within reach. Staff confirmed these observations, acknowledging the risk of delayed care and potential injury. The facility's policy requires call lights to be accessible, which was not followed, resulting in this deficiency.
The facility failed to post No Smoking/Oxygen in Use signs for two residents receiving oxygen therapy, contrary to its policy. One resident with severe cognitive impairment and another with intact cognitive skills but requiring assistance were observed without the necessary signage. Both a Registered Nurse Supervisor and the Director of Nursing confirmed the oversight, acknowledging the importance of such signs due to the flammable nature of oxygen.
The facility failed to follow proper food handling practices, including improperly sealed food containers, an unclean and rusted can opener, and the use of a dirty potholder. Additionally, a resident's breakfast tray was not replaced with a clean one, and the kitchen had an overflowing trashcan in contact with clean items. These deficiencies were observed during a survey, indicating non-compliance with the facility's policies on food safety and infection control.
The facility failed to follow infection control protocols, including improper use of PPE by CNAs and LVNs, inadequate water management to prevent Legionnaire's disease, and improper handling of contaminated materials. Staff did not wear gloves when handling dirty linen and trash, and a resident's nasal cannula was found on the floor, increasing the risk of infection spread.
A facility failed to maintain a resident's dignity during meal assistance when a CNA stood over a resident while feeding them, contrary to the care plan and facility policy. The resident, who required full assistance with eating, was admitted with conditions including lack of coordination and chronic kidney disease. Staff interviews confirmed the requirement to maintain eye level with residents during feeding to ensure respect and dignity.
A facility failed to ensure a resident's Advance Health Care Directive was readily retrievable by staff. Despite the resident having an advance directive, a copy was not available in the medical chart, contrary to the facility's policy. This was confirmed by a nurse supervisor and acknowledged by an LVN, highlighting the importance of having the directive accessible to honor the resident's wishes in emergencies.
A resident with mild protein calorie malnutrition and adult failure to thrive was not provided with the necessary assistance during meals, as required by their care plan. Observations revealed the resident ate without staff help, with their bed not elevated to the recommended angle, consuming only 10-15% of their meal. Interviews with staff confirmed the need for assistance to prevent aspiration and ensure adequate nutrition, highlighting a deficiency in following the facility's policy on Activities of Daily Living.
A facility failed to follow its infection control policy by not labeling a resident's nebulizer tubing with the date of change and the resident's name. The resident, who had moderate cognitive impairment and required assistance for daily activities, was prescribed albuterol sulfate for wheezing. The oversight was confirmed by the IP and DON, who noted the tubing should have been labeled as per the facility's policy.
A facility failed to provide proper dialysis care for a resident by not having a dialysis emergency kit at the bedside and lacking warning signage to prevent the use of the resident's left arm for medical procedures. The resident, with end-stage renal disease, required hemodialysis, and the absence of these safety measures was confirmed by facility staff, highlighting a deviation from standard practice.
Nonfunctional Call System and Delayed Response to Resident Call Lights
Penalty
Summary
The facility failed to provide a functional call system in the bathroom and bathing area for two residents, Resident 2 and Resident 3, in accordance with its Call System policy. Resident 2 was admitted with diagnoses including type 2 diabetes mellitus, muscle weakness, UTI, and urinary retention. The MDS dated 4/19/2026 indicated moderately impaired cognitive skills for daily decision making, supervision or touching assistance for personal hygiene, and substantial maximal assistance for sit-to-stand. The care plan initiated on 4/19/2026 stated that Resident 2 required bilateral 1/4 side rails as an enabler and that the call light and frequently used items were to be placed within reach and answered promptly. Resident 3 was admitted with diagnoses including muscle weakness, cirrhosis, and dysphagia. The MDS indicated moderately impaired cognitive skills for daily decision making, supervision or touching assistance for personal hygiene, and dependence for chair-to-bed transfer and tub/shower transfer. The care plan initiated on 12/24/2026 stated that Resident 3 required bilateral 1/2 side rails, was at risk for entrapment or injury, and that the call light and frequently used items were to be placed within reach and answered promptly. During observation on 5/6/2026 at Nursing Station A, the call light indicator for Room A was lit, but no sound was heard. CNA 1 and LVN 1 were observed at the nursing station, and the Room A indicator by the door was also lit. Resident 3 stated staff do not answer the call light and that it took one hour or more for the call light to be answered, and sometimes he had to bang the grabber on the table for staff to come. Resident 2 stated it took one hour or more for staff to answer the call light and that this happened all the time. The DON pressed the call light in Room A and stated the indicator was lit but did not make an alert sound. LVN 1 stated the call light in Room A does not have sound when pressed, and LVN 2 stated the call light board at the nursing station does not have sound, only light, and that the call light was broken. LVN 2 also stated the facility's Call System policy was not followed, and LVN 3 stated the care plan for Resident 2 and Resident 3 was not implemented because their call lights were not answered promptly.
Care Plan Not Revised for Mechanical Lift Use
Penalty
Summary
Facility staff failed to revise Resident 1’s care plan to reflect the resident’s actual transfer method for use of a mechanical lift. Resident 1 was admitted and later readmitted to the facility with diagnoses including hemiplegia and hemiparesis following cerebral infarction, hydrocephalus, and Guillain-Barre syndrome. The MDS indicated the resident was severely impaired in daily decision making and dependent for multiple activities of daily living, including toileting hygiene, bathing, dressing, personal hygiene, and sit-to-lying. The comprehensive admission MDS also indicated that a mechanical lift was one of the devices and aids used for the resident. During observation, Resident 1 was transferred from the shower chair back to bed by two CNAs, and both CNAs stated they had always used a two-person assist and had never used a mechanical lift for the resident. However, the care plan dated 8/9/2025 included an intervention for fall and injury precautions that referenced assistive devices such as a wheelchair and mechanical lift. The MDS nurse stated she was not aware staff were not using the mechanical lift and acknowledged she should have reviewed and revised the care plan after each MDS assessment to keep it current. The facility policy stated care plans are revised when information changes, when the desired outcome is not met, when a resident is readmitted from a hospital stay, and at least quarterly.
Failure to Address Resident’s Bed-Sliding Fall Risk
Penalty
Summary
Facility staff failed to develop and implement a care plan with proper safety precautions for one resident who had significant neurologic and functional impairments. The resident was admitted and readmitted to the facility with diagnoses including hemiplegia, hemiparesis following cerebral infarction, hydrocephalus, and Guillain-Barre syndrome. The MDS dated 1/23/2026 indicated the resident had severely impaired cognitive skills for daily decision making and was dependent for multiple ADLs, including eating, oral hygiene, toileting hygiene, bathing, dressing, footwear, personal hygiene, and sit-to-lying. On 3/24/2026, the resident slid off the bed and down to the floor mat, as documented on the SBAR communication form. During interview and record review, the RNS stated she was not aware how the resident slid off the bed. During a later interview, CNA 3 stated she had placed the resident back in bed after showering, raised the bilateral side rails, and then left the room to get linen from the cart outside the room. When she returned, the resident was sitting on the floormat with his back against the bed frame. CNA 3 stated the resident tends to kick a lot when in bed and that he was kicking a lot during ADL care on 3/24/26. The DON reviewed the resident's care plan and stated it did not include resident-centered safety protocols to prevent falls and did not address the resident's behavior of kicking his legs, which could result in sliding off the bed. The DON also stated the resident had another fall in 11/2025 from the same behavior. Facility policy required staff to identify interventions related to the resident's specific risks and causes and to implement a resident-centered fall prevention plan for residents at risk or with a history of falls.
Failure to Change Enteral Feeding Set per Physician Order
Penalty
Summary
The facility failed to follow physician orders and facility policy regarding the changing of enteral feeding administration sets for a resident with a feeding tube. Specifically, the order required that the enteral administration set be changed with every bottle of formula, every shift. However, evidence from a family member's screenshot and interview confirmed that the resident's enteral feeding set was not changed for three consecutive days. The Director of Nursing acknowledged that the licensed nurse did not change the enteral feeding bottle and hydration water bag every shift as ordered. The resident involved had a history of dysphagia, a gastrostomy, and adult failure to thrive, and was totally dependent on staff for care, including tube feeding. The resident's care plan identified risks for significant weight loss and dehydration, with interventions requiring staff assistance for tube feeding and water flushes. Facility policy also required formula and administration set changes within specified timeframes. The failure to adhere to these protocols resulted in the resident not receiving the prescribed nutrition and hydration support.
PASARR Screening Not Completed or Followed Through
Penalty
Summary
The facility failed to complete and follow through with PASARR screening requirements for two residents. For Resident 3, the admission record showed the resident was admitted and later readmitted with diagnoses of dementia and paranoid schizophrenia. The resident’s MDS dated 9/1/2025 showed severe impairment in cognitive skills for daily decision making, dependence for chair/bed-to-chair transfers, lying to sitting, upper and lower body dressing, footwear, and personal hygiene, and substantial/maximal assistance needed with eating. During interview and record review, the SSD stated Resident 3’s last PASARR Level I screening was dated 9/16/2019 and verified there was no PASARR Level I screening completed for the resident’s later admission. For Resident 4, the admission record showed the resident was admitted and later readmitted with diagnoses of psychosis and bipolar disorder. A PASARR completed on 7/2/2024 indicated that a Level II evaluation was required. The resident’s MDS showed independent cognitive skills for daily decision making, set up or clean up assistance with eating, substantial/maximal assistance with oral hygiene, upper body dressing, and personal hygiene, and dependence with toileting hygiene, showering, lower body dressing, and putting on/taking off footwear. The MDS also indicated the resident was receiving an antipsychotic medication. During interview, the MDS nurse stated she was responsible for overseeing PASARR and had not checked all PASARRs yet. She verified that Resident 4’s Level I evaluation required a Level II evaluation and stated no follow-up had been made with a PASARR representative regarding the Level II evaluation. The facility policy stated that all new admissions and readmissions are screened for MD, ID, or related disorders, and if the Level I screen indicates possible criteria, the resident is referred to the state PASARR representative for Level II screening.
Unlabeled Frozen Food Items
Penalty
Summary
The facility failed to ensure proper food handling practices were followed in the kitchen by leaving an open bag containing eight chicken patties in the walk-in freezer without an open date, expiration date, or best by date. A cheesecake was also observed in the walk-in freezer without a received date, expiration date, or best by date. During the observation, the Dietary Supervisor 1 stated she did not know why the items were not labeled with the required dates and stated that items opened in the kitchen should have a label showing the date opened or first use and a use by or expiration date. During a later interview, Dietary Supervisor 3 stated that food items in the kitchen without an open date, received date, or best by date are not safe to use or serve because there is uncertainty about whether they are still good to use. DS 3 stated the eight chicken patties and the cheesecake observed in the walk-in freezer should be discarded because no one knows how long they had been there and they might cause residents to get sick or experience stomach issues such as diarrhea. Facility policy titled Food Receiving and Storage stated that all foods stored in the refrigerator or freezer are to be covered, labeled, and dated, and the Refrigerators and Freezers policy stated that all food is to be appropriately dated for proper rotation by expiration dates.
Food brought by visitors was not labeled, stored, or discarded per policy
Penalty
Summary
The facility failed to follow its policy and procedure for food brought in by family and visitors for five sampled residents. During observations and interviews, a container of rice and a container of noodles in Resident 4’s refrigerator were identified as having the resident’s name but no use-by date. Resident 4 had diagnoses including psychosis and bipolar disorder and was on a renal/CCHO mechanical soft diet. For Resident 9, who had been discharged from the facility, the refrigerator still contained sour cream, yogurt, pickles, and prune juice labeled with the resident’s name; the Dietary Supervisor stated these items should have been discarded after discharge. For Resident 25, the refrigerator contained a container of pozole and a bag of cabbage with the resident’s name, but neither item had the date received or a use-by date. Resident 25 had diagnoses including ESRD and paraplegia and was on a double protein renal/CCHO diet. For Resident 37, a box of pizza labeled with the resident’s name and dated 9/6/2025 remained in the refrigerator with two slices still inside; the Dietary Supervisor stated it should have been discarded and not left in the refrigerator for a long time. Resident 37 had diagnoses including hypertension, anemia, and muscle weakness and was on a regular diet. Resident 32 had diagnoses including paroxysmal atrial fibrillation and type 2 diabetes mellitus and was cognitively intact per the MDS. During observation, food brought by visitors was found uncovered and unlabeled at the bedside, including a bowl of fish soup with a half-eaten piece of chicken and later two Tupperware containers of rice and soup without use-by date or time. The resident stated the food had been brought by a visitor or friend and intended to eat it later. The DON verified that food brought in from outside at noon was still at the bedside more than two hours later. The facility policy stated that food left with the resident to consume later must be labeled with the resident’s name, item, and use-by date, perishable foods must be stored in resealable containers in a refrigerator, partially eaten food should not be kept in the resident’s refrigerator, and potentially hazardous foods left out longer than two hours must be discarded.
Infection control lapses with C. diff isolation supplies and disposal of disposable meal items
Penalty
Summary
The facility failed to follow its infection control policies and procedures for residents on contact isolation for C. diff by not ensuring that EPA-registered sanitizing wipes or bleach wipes effective against C. diff were available for use outside the rooms of four residents. Residents 10, 18, 61, and 77 all had orders for contact isolation related to stool C. diff, and their care plans directed staff to place them on contact isolation and disinfect all equipment used before it left the room. During observations, a purple container of Super Sani-Cloth Germicidal Disposable Wipes was kept on supply carts outside the rooms of Residents 10 and 61 and outside the room of Residents 18 and 77. The label on the wipes did not indicate that they were effective against C. diff, and the Infection Preventionist stated that bleach wipes should be used for C. diff isolation. Resident 10 had diagnoses including enterocolitis due to clostridium difficile and pneumonia, and the MDS indicated severe impairment in cognitive skills for daily decision making, dependence for dressing, footwear, and personal hygiene, and substantial to maximal assistance for bed mobility. Resident 18 had diagnoses including enterocolitis due to clostridium difficile and multiple sclerosis, with the MDS showing moderate cognitive impairment and dependence for transfers, bed mobility, dressing, footwear, and personal hygiene. Resident 61 had diagnoses including polyarthritis and dysphagia, with the MDS showing severe cognitive impairment and dependence for bed mobility, dressing, footwear, personal hygiene, and eating. Resident 77 had diagnoses including SIRS and GERD, and the H&P stated the resident had the capacity to understand and make decisions; the resident also had an order for contact isolation until stool C. diff was confirmed negative. The facility also failed to properly dispose of disposable meal items used by a resident on contact isolation. Resident 40 had diagnoses including enterocolitis due to clostridium difficile, dysphagia, and attention to gastrostomy, and the MDS showed severe cognitive impairment and dependence for eating, oral hygiene, toileting hygiene, showering, dressing, footwear, personal hygiene, and bed mobility. The care plan identified contact isolation precautions related to Candida auris at the gastrostomy tube site and directed staff to handle and transport linen and waste to avoid transfer of microorganisms, maintain isolation supplies near the room, and place necessary equipment and supplies in the room. During observation, a CNA was seen carrying Resident 40's disposable tray, disposable bowl, used spoon, used napkin, and disposable food container in the hallway and stated she would throw it outside the facility in the dumpster. The Infection Preventionist stated the disposable items should have been thrown inside the resident's room, or placed in an enclosed trash bag if transported outside the room, and the CNA later stated the tray should have been discarded inside the room.
Failure to Maintain Dignity During Feeding Assistance
Penalty
Summary
The facility failed to promote dignity and respect for one sampled resident when CNA 3 was observed standing above the resident's eye level while assisting with mealtime. Resident 49 was admitted and later readmitted to the facility with diagnoses of dementia and dysphagia oropharyngeal phase. The resident's MDS dated 11/5/2025 indicated severe impairment in cognitive skills for daily decision making, and the resident was dependent for transfers, dressing, footwear, personal hygiene, and eating. During an observation on 9/29/2025 at 2:47 PM, Resident 49 was sitting up in bed with the bed in the lowest position while CNA 3 stood next to the resident and attempted to feed her a spoonful of food. During an interview the next day, CNA 3 stated she had been standing while attempting to feed the resident and acknowledged she should not stand over a resident during feeding, explaining that the correct way is to sit down next to the resident. CNA 3 also stated that standing over a resident while assisting with feeding could potentially scare the resident. The DON reviewed the facility's policies on Assistance with Meals, Dignity, and Resident Rights, which stated residents should be fed with attention to safety, comfort, and dignity and should be treated with respect, kindness, and dignity.
Call Lights Left Out of Reach for Three Residents
Penalty
Summary
The facility failed to ensure that the call light was within reach for three sampled residents, identified in the report as Residents 6, 10, and 43. Each resident had care plan interventions directing staff to place the call light within reach, and each had documented ADL and mobility limitations that affected their ability to independently access the device. The report states that the call light is used by residents to request assistance from staff. Resident 6 had diagnoses including a Colles' fracture of the right radius and osteoarthritis, and the MDS indicated moderate cognitive impairment with substantial to maximal assistance needed for transfers, personal hygiene, footwear, and lower body dressing. During observation, Resident 6 was sitting in a wheelchair to the left of the bed and was waving for help, while the call light was curled up on the right side of the bed and out of reach. Resident 6 stated she needed help being changed and could not reach the call light, and the MDS nurse confirmed the call light was wrapped around itself on top of the bed and out of reach. Resident 10 had diagnoses including enterocolitis due to C. difficile and pneumonia, and the MDS indicated severe cognitive impairment with dependence for dressing, footwear, and personal hygiene, as well as substantial to maximal assistance needed for bed mobility. During observation, Resident 10 was calling out for help while lying diagonally on the bed, and the call light was hanging off the right side of the bed and out of reach. Resident 43 had diagnoses of reduced mobility and lack of coordination, and the MDS indicated cognitive intactness but dependence for transfers and substantial to maximal assistance for standing, footwear, and lower body dressing. During observation, Resident 43 was lying in bed with the call light hanging off the left side of the bed and out of reach, and both the resident and the RN supervisor stated the resident could not reach it.
Dusty Fan and Pool of Water in Resident Room
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment for one resident by leaving a pool of water beside the resident’s bed and allowing a dusty electric fan to remain in the room. The resident had been admitted and readmitted to the facility with diagnoses including ESRD, dependence on renal dialysis, and paraplegia. The resident’s MDS dated 9/1/2025 indicated modified independence for cognitive skills in daily decision making, setup or clean up assistance with eating and oral hygiene, partial/moderate assistance with upper body dressing, substantial/maximal assistance with showering, lower body dressing, footwear, and personal hygiene, and dependence with toileting hygiene. The resident’s care plan for allergic rhinitis, initiated on 8/24/2025, included an intervention to keep the room cool and free of irritants such as smoke, dust, and cleaning agents. During observation, a dusty electric fan was seen in front of the resident’s bed, and later the fan was again observed to be dusty while a pool of water was seen next to the bed after the resident had returned from a shower. The resident stated a CNA left the room after placing the resident in bed without cleaning and drying the floor. CNA 5 confirmed the water on the floor and stated the CNA should not have left it there. The HS and RNS both verified that the fan was dusty and stated it should have been cleaned because dust could affect the resident. RNS also stated the floor should remain dry and that CNAs should ensure the room is clean and clutter free before leaving.
LAL Mattress Set Incorrectly for Resident at Risk for Pressure Injury
Penalty
Summary
The facility failed to ensure that a Low Air Loss mattress for one resident with pressure ulcer care was set at the correct weight-based setting. The resident was admitted with diagnoses including pressure ulcer of unspecified site, lack of coordination, and type 2 diabetes mellitus. The resident’s MDS indicated dependence for toileting, need for substantial to maximal assistance with personal hygiene, and risk for pressure ulcer/injury development, with treatment including a pressure-reducing device for bed and ointments/medications. The care plan identified impaired mobility and fragile skin and included use of a LAL mattress for skin management, and the physician ordered the LAL mattress to maintain skin integrity. Record review and observation showed the resident weighed 139 lbs, but the LAL mattress was set at 300 lbs. During interview, the RNS stated the mattress should have been set between 140 and 150 lbs based on the resident’s weight and that an incorrect setting defeats the mattress’s purpose and can cause more harm than prevent pressure ulcer. An LVN also stated the setting should have been between 140 and 150 lbs and that the resident was at high risk for pressure injury, with the mattress ordered for wound management to prevent development or reopening of the sacrococcyx pressure injury. Facility policy and the manufacturer’s manual both indicated the mattress should be set according to the resident’s weight.
Wet Floor Left as an Accident Hazard
Penalty
Summary
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents was not met when the facility failed to identify a wet floor as a potential hazard for Resident 12. During observation, Resident 12 was seen sitting in a wheelchair and approaching the side of the bed where there was a pool of water on the floor. Resident 12 stated that he was going to his bed. Resident 12's record showed diagnoses of ESRD, dementia, and GAD, and the MDS dated 8/15/2025 indicated that his cognitive skills for daily decision making were independent. The MDS also showed that Resident 12 required setup or clean up assistance with multiple activities, including transfers from chair/bed to chair. During interview, the RNS stated it was important to keep Resident 12's floor clean, dry, and free of clutter because he could transfer independently from wheelchair to bed and vice versa, and that he could slip and fall if the floor was wet or had a pool of water. The MDSN stated staff should provide a safe environment such as a clean and dry floor to allow Resident 12 to transfer safely, and that a wet floor could place him at risk for an accident such as a fall. Facility policy identified wet floors as an environmental factor contributing to fall risk and stated staff would identify interventions to prevent falls.
Incomplete Post-Dialysis AV Fistula Assessment
Penalty
Summary
The facility failed to provide safe, appropriate dialysis care and services for a resident with ESRD, dependence on renal dialysis, and paraplegia by not completing the required post-dialysis assessment of the resident’s left upper arm AV fistula access site on 11/11/2025, 11/12/2025, and 11/18/2025. Resident 25’s record showed an order to monitor bruit and thrill on the left arm AV shunt every shift, and the dialysis communication records for those dates had blank boxes for the presence of bruit and thrill and were not filled out completely when the resident returned from dialysis. During record review and interviews, the RN supervisor stated the blank boxes indicated an incomplete dialysis access site assessment and that this could cause confusion when delivering care. The MDS nurse stated the post-dialysis assessment, including cognitive status, AV shunt, access site, skin assessment, and breathing patterns/breath sounds, was not completed on those dates and that the dialysis communication record should be completed by the charge nurse upon the resident’s return from dialysis. The facility’s policy required assessment of the AV fistula for infection, patency, thrill/bruit, and documentation of post-dialysis observations, but the records reviewed did not show those assessments were completed.
Meal Trays Contained Egg Despite Documented Allergy
Penalty
Summary
The facility failed to ensure that Resident 17, who had a documented egg allergy, received a meal tray free of eggs. Resident 17’s admission record identified an allergy to eggs, and the MDS dated 7/18/2025 showed the resident was cognitively intact and required varying levels of assistance with daily activities, including eating with setup or clean-up assistance. The care plan dated 10/4/2025 included interventions to document the allergy throughout the chart and dietary records, alert staff, and offer food alternatives. During record review and interviews, photographs from the resident’s phone showed a meal tray with a piece of egg on the plate on 8/22/2025 and another tray with a salad and a hard-boiled egg cut in half on 9/20/2025. Resident 17 stated she notified staff both times and requested a fresh tray without egg. The Dietary Supervisor verified the egg was present in both photos and stated trays for residents with allergies are checked using an allergy spreadsheet and tray card, but it was not acceptable for Resident 17 to receive egg on her tray. The DON also stated the resident should not have received any tray containing food she was allergic to.
Overflowing Kitchen Dumpster Left Lid Open
Penalty
Summary
The facility failed to dispose of garbage and refuse properly when the designated green kitchen dumpster was observed overflowing at the back of the facility with the lid only halfway open. During the observation, a dietary aide stated the dumpster was full and overflowing, which was why the lid could not be closed. In a later interview, the Dietary Supervisor stated that an overflowing dumpster was not acceptable, that trash needed to be entirely inside the dumpster with the lid properly closed, and that open or overflowing trash could attract rats, insects such as ants, or flies. Record review of the facility’s Sanitation and Infection Control policy, dated 2011, indicated that lids of outside trash dumpsters were to be kept closed.
Ice Machine Drain Lacked Required Air Gap
Penalty
Summary
The facility failed to ensure the ice machine drainage had an air gap to prevent contact with an outside contaminated source, as required by the facility’s policy and procedures. During an observation on 11/19/2025 at 8:00 AM, the ice machine was seen inside the utility room across from nursing station 2. During a concurrent observation and interview at 8:31 AM, the Dietary Supervisor observed that there was no air gap in the ice machine drainage and stated the drainage was connected to other pipes for drain. The Dietary Supervisor also stated the usual setup is for the ice machine drainage hose to have an air gap to the floor drain to prevent water from backing up from the machine, and noted water dripping from the pipe. During a concurrent observation and interview at 8:40 AM, the Maintenance Supervisor stated the ice machine had been moved to the utility room about a month earlier and that the drain was a closed system with the drainage hose connected to a water storage bin and pump, with all hoses, the water storage bin, and pipes connected with no air gap. The Maintenance Supervisor stated the water dripping from the black pipe was condensation from water inside the pipe. During the exit conference, the Administrator stated it is the regulation for the ice machine to have an air gap. The facility’s Ice Handling policy stated ice will be dispensed through an ice machine with no contact with outside contaminated source, and the Food Receiving and Storage policy stated food may not be stored under leaking water lines or under lines on which water has condensed.
Improper Charge to Resident Personal Funds
Penalty
Summary
The facility failed to ensure that a charge was not imposed against one resident’s personal funds for items or services covered under Medicare or Medicaid. Resident 79 was admitted with diagnoses of metabolic encephalopathy and sepsis and, on the 4/9/2025 MDS, was documented as severely cognitively impaired and dependent for multiple activities of daily living, including transfers, personal hygiene, footwear, and dressing, with substantial/maximal assistance needed for eating. A review of the resident’s account detail for the stay from 4/3/2025 through 6/13/2025 showed an ending balance of $8,170.50. During interviews and record review, the BOM and BOC stated the resident was under Medicare with supplemental insurance, had no share of cost, and that the copayment was covered by supplemental insurance. The billing records were reviewed with staff, and the amount reflected an overpayment of $8,170.50. Staff interviews also showed that the resident’s family and the previous biller had discussed the refund, and emails were sent to the prior biller regarding the resident’s request for reimbursement. The BOM stated there was no follow-up after the last email and that the refund was assumed to have been handled. The record review and interviews established that the resident had not received the reimbursement for the overpayment during the stay.
Daily Staffing Information Not Posted
Penalty
Summary
The facility failed to ensure that its staffing information was posted and placed in a visible and prominent area on 9/27/2025, 9/28/2025, and 9/29/2025 in accordance with its policies and procedures. During an observation on 9/29/2025 at 8:24 AM, staffing information dated 9/26/2025 was posted in the hallway near the nursing station. During a concurrent observation and interview at 9:35 AM, the Registered Nurse Supervisor verified that the posted staffing information was still dated 9/26/2025 and stated that the staffing information for the weekend and for 9/29/2025 had not been posted. During an interview on 10/1/2025, the Director of Staff Development stated she did not know why the staffing information printed for 9/27/2025, 9/28/2025, and 9/29/2025 was not posted in the hallway and said it had been left in the binder instead. She stated that the posting should include the census and the total number of RN, LVN, and CNA staff working each shift and should be easily seen and read by residents, visitors, and staff. The facility's policy titled Posting Direct Care Daily Staffing Numbers, revised in August 2022, required daily posting of nurse staffing data, including the number of nursing personnel responsible for providing direct care to residents.
Insufficient Room Square Footage in Multiple Resident Rooms
Penalty
Summary
Rooms 12, 14, 15, 16, 17, 21, 22, 23, 24, 25, and 26 did not meet the minimum square footage requirement of 80 sq. ft. per resident in multiple resident rooms. During the initial observation, these rooms were identified as not meeting the required space standard, and the facility's Room Waiver listed each of the rooms as 228 sq. ft. with 3 beds. The minimum square footage for a 3-bedroom room was 240 sq. ft. The residents in these rooms were observed to be able to ambulate and/or move around in their wheelchairs freely. Nursing staff were observed to have enough space to provide safe quality care, and there was enough space for beds, side tables, dressers, and other medical equipment. During interviews, CNA 1 and CNA 2 each stated there was enough room to provide care safely in the residents' rooms, and residents interviewed individually and collectively did not express concerns about the size of their rooms.
Noncompliance with Food Procurement and Handling Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating noncompliance with established food safety and handling requirements. No additional details regarding specific residents, staff, or observed events are provided in the report.
Failure to Readmit Resident After Hospitalization in Accordance with Bed Hold Policy
Penalty
Summary
The facility failed to readmit a resident following discharge from a General Acute Care Hospital (GACH), despite the resident being medically stable and the facility having available beds. The resident, who had diagnoses including spondylosis, anxiety disorder, depression, and borderline personality disorder, was originally transferred to the hospital due to being a danger to herself. Upon discharge from the hospital, the GACH contacted the facility to arrange for the resident's return, but the facility refused readmission by order of the Administrator, even though the facility's policy and procedure on Bed Holds and Returns required that residents be permitted to return following hospitalization within the bed hold period. Record review and staff interviews confirmed that the facility's Director of Admissions and Administrator were aware of the policy but chose not to readmit the resident. The Administrator cited the resident's need for a private room due to having a dog and previous behavioral issues as reasons for the refusal. The facility's own policy, however, indicated that all residents, regardless of payer source, should be allowed to return to their previous room if available within the bed hold period. This action resulted in the resident being unable to return to the facility after hospital discharge.
Failure to Provide Treatment and Monitoring for Resident with Mental Health Crisis
Penalty
Summary
A resident with diagnoses of depression, anxiety, and borderline personality disorder was identified as being a danger to self and others (DTSO) after verbalizing intentions to harm self and others. Despite a physician's order for transfer to a general acute care hospital (GACH) and recommendations for psychiatric and psychological consultations, the resident refused these interventions. The facility failed to implement 1:1 sitter observation, did not monitor or document the resident's behavior after being identified as DTSO, and did not develop or implement a care plan to address the resident's refusal of transfer or psychiatric consultation. There was no evidence in the medical record that the facility monitored the resident's behavior or provided additional interventions after the resident refused psychiatric consultation. Staff interviews confirmed that no hourly monitoring, documentation, or care planning was initiated following the resident's refusal of transfer and ongoing verbalizations of self-harm or harm to others. The interdisciplinary care team did not meet to address the situation, and there was no documentation of behavioral observations or safety interventions in the resident's chart during the period of risk. As a result of these failures, the resident was later found unresponsive in their room with opened prescription medication containers not dispensed by the facility. The resident was transferred to the hospital via emergency services, where toxicology confirmed an intentional overdose of tricyclic antidepressants. The resident required intubation and admission to the intensive care unit. The facility's lack of assessment, supervision, monitoring, and care planning for a resident identified as DTSO directly preceded this critical incident.
Removal Plan
- The charge nurse will immediately notify the physician if the resident refused to go to the hospital, refusal of care and treatment for psychiatry and psychologist.
- If a resident has an order to be transferred to the hospital for further evaluation who exhibits any behavior, and refused to be transferred to the hospital licensed nurse will immediately notify MD.
- The Director of Social Services completed a Psychosocial Assessment of identified residents who has a diagnosis of depression, reviewed and updated Care Plan as necessary.
- Licensed staff were instructed to document behavioral observations in the monitoring log such as DTSO every hour and notify the nurse or RN supervisor and/or designee.
- The Medical records Director generated an audit of all residents with diagnoses including anxiety disorder, borderline personality disorder, and Depression; and provided the list to the Assistant Director of Nursing (DON) and the Administrator for further review and analysis.
- The Director of Social Services completed a psychosocial assessment of all residents with a diagnosis of depression to identify residents who may be DTSO and no other residents were identified at risk of harming themselves or others.
- Situation, Background, Assessment, and Recommendation (SBAR) / Change in Condition (COC) was implemented, and in-service was conducted by Assistant DON and Clinical Consultant to licensed nurses that the facility promptly notifies the resident, the resident's physician and the resident's representative of any changes in the resident's medical/mental condition and/or status.
- 72-hour monitoring including mood/behavioral changes, interactions with staff and peers, response to redirection, and safety observations will be implemented for the resident/s. The Assistant DON and clinical consultant conducted an in-service to licensed nurses to include mood/behavioral changes, interactions with staff and peers, response to redirection, and safety observations.
- The care plan was reviewed and updated for identified residents who has a diagnosis of depression. Assistant DON and clinical consultant provided in-service to license nurses regarding Care plan documentation for residents that addressed a psychiatric crisis and refusal to comply with the physician's recommendation for hospital transfer for resident's safety.
- The Administrator conducted 1:1 in-service to SSD regarding Care plan documentation for residents that addressed a psychiatric crisis and refusal to comply with the physician's recommendation for hospital transfer to ensure resident's safety.
- Crisis Intervention Plan included: Provide safe and clean environment; Visual check and document monitoring of resident behavior every hour for resident safety; Administer medication as ordered; Diet as ordered; Encourage to verbalize feelings; Always approach in calm and friendly manner and unhurriedly; To ensure all needs are met; Provide emotional support; Maintain comfort and dignity; To call doctor of medicine (M.D) for any noted change of condition.
- Social Services will re-evaluate and update initial psychosocial assessment of the resident when a resident refused for psychiatric consult and licensed nurse will inform MD.
- Social services will make daily visits to re-engage the resident and residents who are identified with diagnosis of depression, anxiety and borderline personality disorder and documented in the progress notes and provide resident's education on the importance of psychiatric evaluation.
- Behavioral and Crisis intervention care plan will be implemented to reflect ongoing risk for harm to self and others. Interventions included: PRN and scheduled psychiatric medication management; Behavior tracking and psychiatric consultation follow-up; Staff re-education on management of residents with psychosocial adjustment difficulties; Development of a crisis intervention care plan to Resident 1's behavior that triggers and de-escalation techniques.
- The ADON and Clinical consultant conducted in-service licensed nurses regarding policy and procedure SBAR/COC with emphasis on immediately reporting resident for any change in the resident medical/mental condition.
- Licensed staff in-services will continue until compliance is met.
- All licensed nurses and social services staff were in-serviced by Administrator, ADON and Clinical consultant regarding the existing policies and procedures: Charting and Documentation Policy for management of residents with psychiatric/psychologist who has a diagnosis of depression, anxiety, borderline personality disorder and danger to self and others; Requesting, Refusing and/or Discontinuing Care or Treatment; Initial Psychosocial Assessment, Intervention and Monitoring Policy and Implementation of Crisis Intervention Policy.
- The Director of Nursing (DON) and/or ADON will audit all residents with behavioral risks for residents who have diagnosis of depression, anxiety, borderline personality disorder and danger to self and others weekly x 4 weeks, then monthly x 3 months.
- All refusals of psychiatric care or hospital transfers will be reviewed by the IDT within 24 hours of occurrence and to notify primary care physician.
- Results of audits and compliance monitoring will be reported by the DON and/or ADON monthly to the Quality Assurance and Performance Improvement (QAPI) committee.
Failure to Prevent Resident Possession of Contraband Medications and Alcohol
Penalty
Summary
The facility failed to provide a safe environment for a resident by not preventing the possession of a bottle of alcoholic beverage and multiple prescription medication bottles from an outside pharmacy, despite having a policy prohibiting such items. The resident, who had diagnoses including depression, anxiety, and borderline personality disorder, was admitted with cognitive intactness and required some assistance with daily activities. The facility's policy clearly stated that restricted items, including non-facility prescribed medications and alcohol, were not allowed, and staff were responsible for monitoring for such items. On the day of the incident, the resident was found unresponsive in their room by an LVN, with opened containers of doxepin and ondansetron at the bedside, both labeled from an outside pharmacy. Further investigation by local police and facility staff revealed additional bottles of prescription medications and a bottle of wine among the resident's belongings. Interviews with staff confirmed that medications from outside pharmacies were not permitted and that the facility's procedures for checking residents' belongings for contraband were not followed. Staff acknowledged that the resident was able to bring in alcohol and medications without detection, which was against facility policy. Medical records from the hospital indicated that the resident was admitted with altered mental status, a Glasgow Coma Scale of 3, and was intubated for a suspected intentional overdose of tricyclic antidepressants and possibly clonazepam. The resident remained in intensive care before being discharged home. The presence of unauthorized medications and alcohol in the resident's possession, and the lack of adequate supervision and enforcement of the facility's contraband policy, directly led to the resident's medical emergency.
Failure to Implement Antibiotic Stewardship Protocol for UTI Treatment
Penalty
Summary
The facility failed to implement its protocol for Antibiotic Stewardship by not ensuring that antibiotics were only administered when the established criteria, specifically the McGeer criteria, were met. For two sampled residents, antibiotics were given for urinary tract infections (UTIs) without documented evidence that both required clinical and microbiological criteria were satisfied. In both cases, the residents received antibiotics based on positive urine cultures, but there was no documentation of the necessary clinical symptoms as outlined in the McGeer criteria. One resident, with a history of cerebral infarction, epilepsy, and paraplegia, was prescribed and administered Keflex via gastrostomy tube for a UTI. The medical record showed a positive urine culture for Escherichia coli, but there was no evidence that the resident exhibited the required clinical signs or symptoms for UTI treatment per the McGeer criteria. Nursing staff confirmed that the antibiotic stewardship process was not completed and acknowledged that the resident did not meet the criteria for antibiotic therapy. Another resident, diagnosed with atherosclerotic heart disease, hyperlipidemia, and dementia, was prescribed Bactrim DS for a UTI following a positive urine culture for Klebsiella pneumoniae. The resident's care plan included monitoring for UTI symptoms, but there was no documentation that the resident met both the clinical and microbiological criteria for antibiotic use. Nursing staff confirmed that the antibiotic stewardship protocol was not followed, and the required Nurse to Physician Report was not completed prior to administering the antibiotic.
Lack of Designated, Trained Infection Preventionist
Penalty
Summary
The facility failed to employ a designated Infection Preventionist (IP) with specialized training, as required for the infection prevention and control program. According to interviews, the facility had been without a designated IP for almost a month, and the responsibilities were being covered by a registered nurse and other licensed nurses, none of whom had IP certification. Record review confirmed that the previous IP's last day was several months prior, and staff currently performing IP duties lacked the required specialized training. The facility's policy indicated that the IP is responsible for coordinating infection prevention and control policies and practices.
Failure to Timely Report and Investigate Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report an allegation of physical abuse involving two residents to the State Survey Agency, ombudsman, and local law enforcement within the required two-hour timeframe, as mandated by facility policy. The incident occurred when one resident reported being kicked by another resident at the nursing station. The resident who experienced the incident immediately informed the Assistant Director of Nurses (ADON), who assessed both residents and separated them but did not escalate the report to the appropriate authorities. Interviews with facility staff, including the ADON, Medical Record Nurse, and social worker, revealed that although incident reports were filed internally, the event was not reported externally as required. Staff members indicated a lack of understanding or misinterpretation of the reporting requirements, with the ADON stating she did not consider the kick to be an allegation of physical abuse and the Medical Record Nurse expressing unawareness of the need to report to external agencies. A review of the facility's policy confirmed that all allegations of abuse must be reported immediately, defined as within two hours for abuse or serious bodily injury. The policy also specifies that such reports must be made to the administrator, state agency, ombudsman, law enforcement, and other relevant parties. Despite this, the required notifications were not made, and the incident was not thoroughly investigated in accordance with policy.
Failure to Timely Report Alleged Sexual Abuse
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving a resident within the required 2-hour timeframe to the State Survey Agency and the state ombudsman, as mandated by the facility's abuse policy. The incident involved a resident with a history of spondylosis, anxiety disorder, depression, and borderline personality disorder, who was cognitively intact and required some assistance with daily activities. The resident reported that a male visitor had tried to forcefully kiss her, and this was communicated to a CNA and then to an RN, who subsequently informed the Administrator. Despite the facility's policy requiring immediate reporting of abuse allegations, defined as within 2 hours, the Administrator acknowledged that the incident was not reported to the appropriate authorities until several days after the initial allegation was made. The delay in reporting was confirmed through interviews and record reviews, and the facility's own policy and procedure documentation was reviewed during the investigation. The failure to promptly report the allegation had the potential to compromise the resident's protection from further abuse.
Failure to Honor Resident's Vegetarian Diet Preference
Penalty
Summary
A deficiency occurred when the facility failed to honor the food preferences of a resident who had a physician's order for a vegetarian diet. The resident, who had diagnoses including spondylosis, anxiety disorder, depression, and borderline personality disorder, was cognitively intact and able to make daily decisions. Despite documentation in the care plan and physician's orders specifying a vegetarian diet, the resident was served pizza containing a small piece of chicken. This incident was confirmed by both the cook and a registered nurse after the resident reported the issue. The facility's policy required that individual food preferences be assessed upon admission, communicated to the interdisciplinary team, and documented in the care plan. The policy also stated that if a resident is unhappy with their diet, a care plan should be created to address their satisfaction. In this case, the resident's food preference was not honored, as evidenced by the presence of meat on her meal tray, contrary to her dietary restrictions and documented preferences.
Failure to Provide Required Two-Person Assistance During Resident Transfer
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) attempted to transfer a resident from a wheelchair to bed without the required assistance of a second staff member. The resident had a history of atherosclerotic heart disease and traumatic brain injury, and was assessed as non-ambulatory and dependent for transfers, requiring two-person assistance according to the Minimum Data Set (MDS) and physical therapy evaluation. Despite this, the CNA proceeded alone after the resident requested to return to bed, resulting in the resident sliding to the floor in an assisted fall. The resident's care plan and physical therapy assessment both indicated a need for two-person assistance for all transfers due to decreased strength, impaired lower extremity function, and high risk for falls. On the day of the incident, the CNA was aware of the two-person assist requirement, having been informed by a licensed nurse at the start of the shift. However, when the resident requested to go back to bed, the CNA attempted the transfer alone, leading to the resident's gradual slide to the floor and subsequent contact of the resident's head with the floor. Following the fall, the resident was transferred to a general acute care hospital for further evaluation. Interviews with facility staff, including the CNA, registered nurse, and director of nursing, confirmed that the resident required two-person assistance and that the CNA did not follow this protocol at the time of the incident. The facility's fall risk assessment policy also emphasized the need for individualized prevention plans based on resident assessments, which in this case were not adhered to during the transfer.
Failure to Accommodate Resident's Vegetarian Diet Preferences
Penalty
Summary
A deficiency occurred when the facility failed to provide food that accommodated a resident's documented vegetarian preference and food intolerances. The resident, who was cognitively intact and independent in daily activities, had a physician's order and care plan specifying a vegetarian diet, with additional notes indicating a dislike for milk, eggs, and meat. Despite these clear dietary instructions, the resident was served meals containing meat on at least two separate occasions. On one occasion, the resident received a lunch tray with beef mixed into her rice, which led to her becoming upset and vomiting twice. The incident was documented in the nursing notes, and it was confirmed that the kitchen staff was aware of her vegetarian status. On another occasion, the resident found two pieces of chicken in her soup during dinner, which was witnessed by both a CNA and an LVN. The resident retained the chicken pieces as evidence and reported that this was not the first time such an incident had occurred. Interviews with facility staff, including the Administrator, DON, kitchen staff, and direct care staff, confirmed that the resident's vegetarian preference was known and documented on her meal tickets. The kitchen had a process for double-checking trays, and CNAs performed additional checks before distribution, but these measures failed to prevent the errors. Facility policies required that individual food preferences be assessed and accommodated, but these were not effectively implemented in this case.
Failure to Monitor and Address Repetitive Leg Kicking Resulting in Foot Fractures
Penalty
Summary
Facility staff failed to monitor and document a resident's behavior of constant leg kicking during episodes of severe anxiety or agitation, despite the resident's known history of this behavior and associated risk for pathologic fractures. The resident, who had diagnoses including Alzheimer's disease, anxiety disorder, and a prior left foot fracture, was dependent on staff for most activities of daily living and had a care plan identifying risk for spontaneous fractures related to severe anxiety and agitation. However, the care plan did not include specific interventions to monitor or address the resident's repetitive leg kicking behavior. Over a period from January to March, there was no documented evidence that staff monitored or recorded the resident's leg kicking, even though the behavior was known to occur when the resident was agitated, particularly in relation to discomfort with a gastrostomy tube. Staff interviews confirmed that monitoring and documentation of this behavior were not performed, and this omission was not reflected in the Treatment Administration Record or other documentation systems. The Director of Nursing acknowledged that monitoring and documentation should have been implemented as part of a resident-centered approach to prevent injury, in accordance with facility policy. The resident was eventually found to have multiple fractures in the left foot, which were determined to be most likely caused by repetitive kicking of the bed's footboard, despite a protective barrier being in place. The lack of monitoring and documentation of the resident's behavior, as well as the absence of targeted interventions in the care plan, directly contributed to the failure to prevent this accident, contrary to the facility's policy on safety and supervision of residents.
Failure to Timely Communicate Pharmacist Recommendations for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that the consultant pharmacist’s recommendations regarding the use of lorazepam (Ativan) and quetiapine (Seroquel) for a resident were communicated to the attending physician in a timely manner. The pharmacist’s drug regimen review, dated 2/4/2025, identified that the resident was prescribed Ativan at a dosage exceeding the maximum daily allowable dose for individuals over a certain age, and recommended a dose reduction or a risk-benefit assessment. The review also noted that Seroquel was being used for anxiety disorder, which is not an approved indication for elderly patients, and recommended discontinuation or substitution with an appropriate medication. Despite these recommendations, there was no documentation that the physician was informed or had reviewed the pharmacist’s suggestions until nearly two months later, on 3/30/2025. The resident involved had a history of Alzheimer’s disease, anxiety disorder, and a fracture of the left foot, and was assessed as having severely impaired cognitive skills and requiring significant assistance with daily activities. The resident was receiving antipsychotic and antianxiety medications, including quetiapine and lorazepam, through a gastrostomy tube. The orders for these medications did not specify a discontinuation date and were carried over from previous months, with the lorazepam order being changed to allow administration every four hours as needed. The facility’s policies and procedures required that findings and recommendations from the drug regimen review be reported to the appropriate staff and acted upon, but did not specify a timeframe for action. The Director of Nursing acknowledged that the policy was not followed, and that the lack of a defined timeframe contributed to the delay in communicating the pharmacist’s recommendations to the physician. This failure to promptly address the consultant pharmacist’s recommendations constituted the deficiency identified in the report.
Inadequate Pressure Ulcer Management Due to Incorrect LAL Mattress Settings
Penalty
Summary
The facility failed to provide appropriate pressure ulcer management for two residents by not ensuring that their Low Air Loss (LAL) mattresses were set to the correct weight settings. Resident 2 was admitted with diagnoses including an unstageable pressure ulcer in the sacral region and was at risk for pressure ulcer development due to constant skin moisture and limited mobility. Despite having a care plan that included the use of a LAL mattress, the mattress was observed to be set at a weight range significantly higher than Resident 2's actual weight of 101 lbs. Similarly, Resident 3, who was admitted with a cerebral infarction and had severely impaired cognitive skills, also had an unstageable pressure ulcer. The care plan for Resident 3 included the use of a LAL mattress, but the mattress was set at a weight range much higher than Resident 3's actual weight of 114 lbs. Observations and interviews revealed that the staff, including the Certified Nurse Assistant and Treatment Nurse, were unaware of the residents' current weights and had not adjusted the LAL mattress settings accordingly. The Director of Nursing confirmed that the LAL mattresses should be set according to the residents' current weights to prevent pressure ulcers effectively. The facility's policy indicated that pressure-reducing devices should be set to the resident's weight to optimize effectiveness. The failure to adjust the LAL mattress settings to the residents' actual weights resulted in inadequate therapy from the mattresses, potentially worsening the residents' pressure ulcers.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for a resident who was observed with unexplained swelling on the right hand. The resident, who had been admitted with diagnoses of dementia, Parkinson's disease, and ataxia, was noted to have severely impaired cognition and required varying levels of assistance for daily activities. On the date of the incident, the resident's wife informed a Registered Nurse (RN) about the swelling and pain in the resident's hand, which was visibly larger than the other hand. Despite this, the RN did not report the unusual occurrence to the Administrator or the Director of Nursing (DON) as required by the facility's policy. The facility's policy mandates that any injury with an unknown cause should be reported within two hours to the Administrator and DON, and within 24 hours to the state agency. However, the Administrator confirmed that she was not informed about the incident, and no investigation was conducted to determine the cause of the injury. The facility's policy also requires a written report detailing the incident and actions taken to be sent to the state agency within 48 hours, which was not done in this case. This failure compromised the resident's safety and well-being by delaying appropriate medical evaluation and intervention.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to revise and update the Care Plan for a resident who experienced a fall on February 11, 2025. The resident, who was admitted with diagnoses of dementia, Parkinson's disease, and ataxia, had severely impaired cognition and required varying levels of assistance for daily activities. Despite being identified as high risk for falls, the Care Plan was not updated following the fall incident, which was necessary to implement new fall prevention interventions. Interviews with facility staff revealed that the Care Plan had not been revised since September 4, 2024, after a previous fall. The Licensed Vocational Nurse confirmed the absence of an updated Care Plan post-fall, and the Assistant Director of Nursing emphasized the importance of revising Care Plans following any change in a resident's condition. The facility's policies require Care Plans to reflect current standards and be revised with any change in the resident's condition, yet this was not adhered to, resulting in a deficiency.
Failure to Coordinate Medication Orders with Primary Physician
Penalty
Summary
The facility failed to provide necessary care and services in accordance with professional standards of practice for a resident by not notifying and coordinating with the resident's primary physician regarding the continuation of lacosamide medication. The resident, who was admitted with diagnoses including cerebral infarction, epilepsy, and moderate protein-calorie malnutrition, had a neurologist's order to continue lacosamide to manage seizures. However, the medication was stopped on November 2, 2024, without notifying the neurologist or the primary physician, leading to a 66-day period without the medication until it was restarted on January 8, 2025. Additionally, the facility failed to communicate new medication orders from the resident's Doctor of Osteopathic Medicine to the primary physician. These orders included starting N-Acetyl-L-Carnitine and increasing Vitamin D3 and Zinc, which were not reflected in the resident's Physician Order Sheet. The licensed staff did not inform the primary physician of these new orders, resulting in the resident not receiving the prescribed medications. The facility's policy and procedure on medication therapy emphasize the importance of consistent medication use with an individual's condition and the need for staff and practitioners to review medication regimens periodically. However, the lack of communication and coordination with the primary physician regarding the resident's medication orders led to deficiencies in the delivery of necessary care and services, potentially causing adverse health outcomes for the resident.
Failure to Follow Menu and Recipe Guidelines
Penalty
Summary
The facility failed to adhere to its menu and recipe guidelines, impacting the nutritional needs of 63 out of 67 sampled residents on both regular and therapeutic diets. During a review, it was found that the recipe for Cajun Country Rice was not followed, as it lacked celery, diced red and green peppers, and thyme. Additionally, the tarragon sauce prepared for the fish was too salty because the cook used regular chicken broth instead of the specified low sodium chicken broth and omitted cornstarch in water. This deviation from the recipe resulted in a sauce that was not suitable for serving to residents. The Dietary Supervisor confirmed these discrepancies during an observation and interview, noting that the failure to follow recipes could lead to residents not eating the food due to its taste, potentially resulting in decreased calorie intake and weight loss. The facility's policy on food preparation emphasizes the use of standardized recipes to ensure consistency and quality, which was not adhered to in this instance. The failure to follow these guidelines was observed during a test tray evaluation, where the tarragon sauce was deemed too salty and unacceptable for resident consumption.
Failure to Follow Recipes Leads to Poor Food Quality
Penalty
Summary
The facility failed to prepare food by methods that conserved flavor and appearance, specifically during breakfast service. Cook 1 did not follow the recipes for tarragon sauce and Cajun rice, resulting in a salty food product and altered flavors, respectively. These failures had the potential to result in unplanned weight loss for 63 of 67 residents, including two residents who expressed dissatisfaction with the food quality and presentation. Resident 2, admitted with diagnoses including spinal stenosis, muscle wasting, atrophy, and chronic kidney disease, reported ordering food from outside due to the poor quality of meals served at the facility. Resident 2 stated that the chicken with sauce tasted bad and bitter, and no food substitute was offered. Similarly, Resident 1, with diagnoses including spinal stenosis, muscle wasting, atrophy, and gastro-esophageal reflux disease, also expressed dissatisfaction with the facility's food, preferring to buy food from outside. Resident 1 reported being served raw fish, which was then overcooked upon request. The facility's dietary supervisor confirmed that the Cajun rice lacked essential ingredients like celery, diced red and green peppers, and thyme, and the tarragon sauce was too salty. Cook 1 admitted to not using low sodium chicken broth and cornstarch in water as per the recipe, leading to the excessive saltiness. The facility's policies and procedures emphasized the importance of following standardized recipes and tasting food before serving to ensure quality, which was not adhered to in this instance.
Deficiencies in Food Storage and Preparation Practices
Penalty
Summary
The facility failed to maintain safe and sanitary food storage and preparation practices, as observed during a survey. The walk-in refrigerator contained racks with chips, which the Dietary Supervisor acknowledged could lead to bacterial growth and food contamination. Additionally, several dairy products, including Greek yogurts and cottage cheeses, were found to be past their expiration dates, posing a risk of foodborne illness to residents. The facility's policy and procedure for refrigerated storage and labeling were not adhered to, as expired items were not discarded as required. In the dry storage area, dented cans were stored alongside non-dented cans, contrary to the facility's policy that requires dented cans to be separated and returned to the vendor. The Dietary Supervisor confirmed that dented cans could be hazardous due to the risk of botulism, which could cause gastrointestinal issues in residents. The facility's failure to properly manage canned goods storage was a significant oversight in maintaining food safety standards. Furthermore, a staff member was observed not washing hands after wiping the food preparation sink and then touching scoops used for the lunch trayline. This action violated the facility's handwashing policy and increased the risk of cross-contamination. The Dietary Supervisor acknowledged the importance of hand hygiene in preventing food contamination and the potential for residents to suffer from foodborne illnesses as a result of such lapses in protocol.
Inadequate Supervision Leads to Resident Harm
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents for two residents. Resident 1, who has a history of dementia, osteoporosis, and anxiety disorder, was not monitored every two hours as required by their care plan. This resident, known for picking up and hiding items, was found with a ring on their left middle finger, which was not theirs. The ring caused swelling and pus formation, leading to an infection that required hospital intervention, including IV antibiotics and ring removal via an electric saw. Resident 4, diagnosed with bipolar disorder, major depressive disorder, and anxiety disorder, was not adequately monitored during a dental appointment. Despite being independent in activities of daily living, Resident 4 was at risk for elopement or wandering. After leaving for a dental appointment, the resident did not return within the expected timeframe. The facility failed to check on the resident's whereabouts until nine hours later, by which time the resident had been admitted to a hospital with nausea, vomiting, and low oxygen saturation. The facility's policies on safety and supervision, as well as wandering and elopement, were not effectively implemented. The care plans for both residents indicated the need for specific interventions to prevent accidents, but these were not followed. The lack of timely monitoring and follow-up on the residents' whereabouts contributed to the deficiencies observed, placing both residents at risk of harm.
Failure to Ensure Call Lights Within Reach
Penalty
Summary
The facility failed to ensure that the call lights were within reach for four residents, which is a violation of the facility's policy. Resident 6, who was admitted with conditions such as hyperlipidemia, anemia, and muscle atrophy, required substantial assistance with daily activities. Observations revealed that Resident 6's call light was wrapped around the side rails and later found on the floor, both times verified by staff members who acknowledged it should have been within reach. Resident 20, diagnosed with lack of coordination, hyperlipidemia, and chronic kidney disease, was dependent on staff for daily activities. During an observation, Resident 20's call light was found on the floor, confirmed by the Director of Nursing, who stated it should have been accessible. Similarly, Resident 171, with diagnoses including type 2 diabetes and hypertension, required assistance with daily activities. Observations on multiple occasions showed Resident 171's call light on the floor, which was verified by staff who acknowledged the risk of delayed care and potential injury. Resident 34, who had aphasia, generalized muscle weakness, and an ataxic gait, was at high risk for falls and required assistance with daily activities. Observations indicated that Resident 34's call pad was not within reach, confirmed by family and staff members who noted the resident's inability to call for help. The facility's policy mandates that call lights be accessible to residents, but this was not adhered to, leading to the deficiency.
Failure to Post Oxygen Precautionary Signs
Penalty
Summary
The facility failed to post precautionary and safety signs indicating the use of oxygen for two residents, as required by the facility's oxygen administration policy. Resident 120, who has severe cognitive impairment and is dependent on assistance for daily activities, was observed receiving oxygen therapy without a No Smoking/Oxygen in Use sign posted outside their room. This oversight was confirmed by a Registered Nurse Supervisor, who acknowledged the importance of such signage for safety reasons, as oxygen is flammable and poses a fire risk if smoking occurs nearby. Similarly, Resident 121, who has intact cognitive skills but requires assistance with daily activities, was also observed receiving oxygen therapy without the necessary precautionary signage. The Director of Nursing confirmed that the absence of a No Smoking/Oxygen in Use sign was against the facility's policy, which aims to ensure safe oxygen administration. The facility's policy, revised in October 2010, explicitly requires the posting of such signs to alert everyone of the potential fire hazard associated with oxygen use.
Deficiencies in Food Handling and Kitchen Sanitation
Penalty
Summary
The facility failed to adhere to proper food handling practices, as observed during a survey. Several issues were identified, including improperly sealed food containers in the refrigerator, such as a cracked lid on a jelly container and a loose lid on a ham container. Additionally, a can opener was found to be unclean and rusted, which the dietary supervisor acknowledged as a potential source of foodborne illness. These observations indicate a lack of compliance with the facility's policies and procedures regarding food storage and equipment sanitation. Further deficiencies were noted in the handling of meal trays and kitchen cleanliness. A dietary aid was observed using a dirty potholder, which had fallen on the floor, to handle food trays. This action was confirmed by the dietary aid, who admitted the potholder was contaminated. Additionally, a breakfast tray returned by a resident was not replaced with a clean tray and plate before being redelivered, and the staff used the clean entrance instead of the dirty entrance, violating infection control protocols. The kitchen environment also presented issues, with an overflowing trashcan in contact with clean plate covers, as observed by a dietary aid. This situation was acknowledged as a risk for food contamination. The facility's policies emphasize the importance of maintaining cleanliness and proper food handling to prevent foodborne illnesses, yet these practices were not consistently followed, as evidenced by the observations and interviews conducted during the survey.
Infection Control and Water Management Deficiencies
Penalty
Summary
The facility failed to adhere to its infection prevention and control policies, resulting in multiple deficiencies. Certified Nursing Assistants (CNAs) and Licensed Vocational Nurses (LVNs) did not don personal protective equipment (PPE) before entering the room of a resident under enhanced barrier precautions (EBP) due to a gastrostomy tube site, which increased the risk of multidrug-resistant organism (MDRO) transmission. Observations revealed that staff entered the resident's room without wearing gowns and gloves, despite the presence of signage indicating the need for PPE. Interviews with staff confirmed the lack of compliance with EBP protocols, and the Infection Preventionist acknowledged the expectation for all staff to follow these precautions. The facility also failed to maintain an effective water management program to prevent Legionnaire's disease. After receiving a positive test result for legionella in the water, the Maintenance Supervisor did not retest the water as advised by the testing company, citing being too busy. This oversight placed all residents at risk for severe respiratory infections. The facility's policies and procedures, as well as external guidelines, emphasize the importance of retesting and maintaining control measures to prevent the spread of waterborne microorganisms. Additional deficiencies included improper handling of dirty linen and trash, with staff observed not wearing gloves while handling potentially contaminated materials. Housekeeping staff were seen transporting trash without gloves, contrary to infection control policies. Furthermore, a resident's nasal cannula was found on the floor, not stored in a clean plastic bag, posing a risk of contamination. These actions and inactions by the facility staff contributed to the potential spread of bacteria and viruses within the facility.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to provide care that maintained or enhanced a resident's dignity and respect. This deficiency was observed when a Certified Nursing Assistant (CNA) was seen standing over a resident while assisting them during a meal. The resident, identified as Resident 20, was dependent on assistance for eating, as indicated in their Minimum Data Set (MDS). The CNA stated that there were no chairs in the room, which led to the CNA standing over the resident during the feeding process. Resident 20 was admitted to the facility with diagnoses including lack of coordination, hyperlipidemia, and chronic kidney disease. The resident's care plan specified that staff should sit at eye level when feeding the resident to ensure respect and dignity. Interviews with facility staff, including a Registered Nurse Supervisor and another CNA, confirmed that the facility's policy required staff to maintain eye level with residents during feeding to avoid making residents feel scared or intimidated. The facility's policies on dignity and assistance with meals emphasized the importance of treating residents with respect and ensuring their comfort and dignity during meals.
Failure to Maintain Readily Retrievable Advance Directive
Penalty
Summary
The facility failed to ensure that the Advance Health Care Directive for one of the sampled residents was readily retrievable by any facility staff. This deficiency was identified during a review of the resident's admission record and medical chart. The resident, who was admitted with diagnoses including hypertension, Parkinson's disease, and dyskinesia, had an Advance Directive Acknowledgement Form indicating the presence of an advance directive. However, a copy of this directive was not available in the resident's medical chart, as confirmed by a Registered Nurse Supervisor during a concurrent interview and record review. The facility's Policies and Procedures on Advanced Directives, revised in September 2022, state that if a resident has an advance directive, copies should be maintained in the same section of the resident's medical record and be readily retrievable by any facility staff. Despite this policy, the advance directive for the resident was not accessible, which was acknowledged by a Licensed Vocational Nurse who emphasized the importance of having the directive available to honor the resident's wishes in case of an emergency.
Failure to Assist Resident with Eating as per Care Plan
Penalty
Summary
The facility failed to provide necessary assistance to Resident 12 during meal times, as outlined in the resident's care plan and the facility's policy. Resident 12, who was admitted with diagnoses including mild protein calorie malnutrition and adult failure to thrive, was observed eating without assistance from facility staff. The care plan indicated that Resident 12 was at risk for weight loss due to poor intake and required assistance with meal consumption to prevent aspiration. However, during an observation, it was noted that the resident's head of bed was not elevated to the recommended 30 degrees while eating, and the resident consumed only 10 to 15 percent of the food provided. Interviews with facility staff, including a CNA, RN Supervisor, and LVN, confirmed that Resident 12 should have been assisted while eating to ensure adequate calorie intake and to prevent aspiration. The facility's policy on Activities of Daily Living emphasized the importance of providing care to maintain or improve residents' ability to perform ADLs. Despite this, the facility did not adhere to the care plan's directives, resulting in a deficiency that could potentially impact Resident 12's nutritional status and overall wellbeing.
Failure to Label Nebulizer Tubing for Infection Control
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding respiratory infection control for a resident, identified as Resident 220. The deficiency was observed when Resident 220's nebulizer tubing was found stored in a plastic bag on the nightstand without a label indicating the date the tubing was changed or the resident's name. This oversight was confirmed during an observation and interview with the Infection Preventionist and the Director of Nursing, who acknowledged that the tubing should have been labeled to ensure proper infection control measures were followed. Resident 220 was admitted to the facility with diagnoses of atrial fibrillation and pleural effusion and was noted to have moderate cognitive impairment, requiring various levels of assistance for daily activities. The resident had an order for albuterol sulfate nebulization as needed for wheezing. The facility's policy, revised in November 2011, clearly stated that nebulizer circuits should be stored in a plastic bag marked with the date and resident's name between uses, a protocol that was not followed in this instance, potentially putting the resident at risk for infection.
Failure to Provide Dialysis Care and Safety Measures
Penalty
Summary
The facility failed to provide appropriate dialysis care and services to a resident on hemodialysis by not ensuring the availability of a dialysis emergency kit at the resident's bedside. The resident, who was admitted with diagnoses including type 2 diabetes, end-stage renal disease, and hypertension, required hemodialysis three times a week. During an observation, it was noted that there was no dialysis e-kit in the resident's room, which was confirmed by the Director of Nursing and a Registered Nurse Supervisor. The absence of the e-kit, which is essential for managing potential bleeding from the dialysis access site, was against the facility's normal process for residents on dialysis. Additionally, the facility did not have visible warning signage at the resident's bedside to prevent the use of the resident's left arm for blood pressure checks, blood draws, or finger sticks, which could damage the arteriovenous shunt. The lack of signage was confirmed during interviews with the Registered Nurse Supervisor and the Treatment Nurse, who emphasized the importance of such signage for safety. The Director of Nursing acknowledged the absence of specific policies and procedures regarding the placement of dialysis e-kits and warning signage, although it was considered standard practice for safety.
What surveyors are citing around you — mapped
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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 7,019 citations issued within 25 miles in the last 12 months — including the 35 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Pasadena
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Californian Pasadena Healthcare | 0.2 mi | ★★★★★ | 21 | 0 |
| The Bellefontaine Healthcare Center | 0.2 mi | ★★★★★ | 3 | 0 |
| South Pasadena Care Center | 1.4 mi | ★★★★★ | 9 | 0 |
| Villa Gardens Health Care Unit | 1.8 mi | ★★★★★ | 16 | 0 |
| York Healthcare & Wellness Centre | 2.5 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.