Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at George L Mee Memorial Hospital D/p Snf during CMS and state inspections, most recent first.
The facility failed to complete required elopement risk assessments on nearly all residents, including two residents with alcoholism and significant medical and cognitive conditions, and did not develop or implement individualized care plans for a resident who frequently went to the garden independently. Staff did not use any elopement assessment tool, did not consistently monitor residents’ whereabouts when they were in the garden or off the unit, and relied on residents signing LOA forms as if this released the facility from responsibility. LOA documentation for both residents showed repeated missing time-in entries, incomplete destinations, absent nurse initials, and no documented mental, physical, or functional assessments before leaving or upon return, despite facility policy. One cognitively intact, ambulatory resident with a history of leaving and returning intoxicated eloped from the building without signing out, was later struck by a vehicle as a pedestrian, was found to have an elevated ETOH level, and subsequently died from multiple traumatic injuries, while another severely cognitively impaired, wheelchair-bound resident routinely left the facility alone in the early morning hours without appropriate assessment or supervision.
Food was served at an inappropriate temperature. A resident stated breakfast was always cold, and the resident council president reported most food served was cold. During a resident council meeting, residents agreed the food was brought cold. A test tray of regular and pureed lunch items showed temperatures below the facility's stated standard, and the DM confirmed the food was not served hot.
Food storage, sanitation, and hand hygiene practices were not maintained in the kitchen. The dry storage temperature log was incomplete and did not show the required checks, a box of lemons in the walk-in refrigerator contained a moldy lemon, a staff purse was stored in the clean plate rack, the rack had dust-like substance and food crumbs, and an FSW touched her eyeglasses while mixing batter without changing gloves or performing hand hygiene.
A facility failed to ensure three residents were free from unnecessary psychotropic use and chemical restraint concerns. One resident received quetiapine without documented behaviors supporting its use or AIMS monitoring, another received quetiapine and trazodone without documented non-pharmacological interventions, sleep monitoring, or AIMS, and a third received aripiprazole, olanzapine, and trazodone without documented target behaviors, side effect monitoring, sleep monitoring, or AIMS.
Two residents had inaccurate MDS coding for pressure injuries. One resident’s quarterly MDS failed to reflect that two unstageable PIs present on admission later became Stage 4 PIs on both hips, and an MDS nurse acknowledged the coding error. Another resident’s admission MDS did not accurately capture the pressure injuries present on admission, including a sacral ulcer, resulting in inaccurate assessment data submitted to CMS.
Multiple residents had missing, incomplete, or not-updated care plans. A resident on Eliquis had no anticoagulant care plan, another resident on quetiapine and trazodone had no medication care plans, and a resident with aspiration risk and poor intake had no nutrition care plan despite RD notes and a family conference. Other records lacked initials, signatures, or quarterly updates for antipsychotic, fall, and pain care plans, and one resident received potassium chloride ER without being timed with meals as ordered.
Failure to complete and document LOA assessments: Two residents repeatedly signed out of the facility for LOA, including trips to the garden, outside, downstairs, stores, and other destinations, but LNs did not complete and document the required mental, physical, and functional assessments before departure and upon return. One resident had alcoholic cirrhosis, alcohol dependence, ascites, and hepatic encephalopathy; the other had alcoholism, DM, hemiplegia from an old stroke, HTN, hypercholesteremia, and was wheelchair bound. The SNF NM confirmed the missing assessments, and LOA records often lacked time in, nurse initials, destination, or other required details.
Surveyors found multiple medication storage and labeling problems, including an expired tuberculin vial, an expired Admelog vial, an open but undated latanoprost bottle, and another latanoprost bottle left sealed in a box despite a label instructing refrigeration until opened. Staff confirmed the labeling and storage issues, and the DON stated opened medications should have a date-opened label. Surveyors also observed a med cart left unlocked with medication on top during administration, and controlled drugs, including discontinued narcotics, were kept in the med cart instead of a double-locked area as required by policy.
Improper Storage of Food Brought From Home: A facility failed to ensure food brought from home was stored safely and sanitarily in a resident refrigerator/freezer. During observation, homemade tamales and other items were found unlabeled or missing dates, and some foods had exceeded the facility's 72-hour storage expectation. Staff confirmed the items should have been discarded, and the facility policy required resident food to be labeled with the resident name and date brought in and discarded after 3 days.
The facility failed to follow infection control practices during resident care and dining activities. An LPN touched her face with gloved hands and placed glucometer and insulin syringe items on an overbed table without cleaning it or using a barrier, another LPN placed medication on an unclean overbed table without a barrier, resident toothbrushes and used basins were left unlabeled and uncleaned in a shared bathroom, and a CNA and a volunteer did not perform HH when moving between residents or after handling soiled items.
Failure to Offer and Document Pneumococcal and Flu Vaccines: The facility did not offer or document recommended pneumococcal vaccines for three residents, including residents with prior PPSV23 history and one resident with no pneumococcal vaccine history. One resident also had no record of a current seasonal flu vaccine being offered. The QNC confirmed the missing vaccine offers during record review, and the IP stated staff were responsible for updating and documenting refusals.
An LVN left an open laptop on a med cart unattended in the hallway during med pass, with resident info and MARs visible while checking blood sugar and administering insulin to two residents. The LVN confirmed the screen was left open, and the SNF NM stated resident information should be safeguarded and not visible to unauthorized persons.
A resident receiving dialysis had incomplete NF/DUCR forms, including the dialysis unit portion, on two occasions. The SNF NM confirmed the forms were incomplete and stated they should be completed before the resident goes to the dialysis center because they serve as transfer-of-care communication.
Controlled Medication Not Fully Documented: A resident receiving PRN acetaminophen-codeine had one tablet not accounted for in the CDR, and the nurse did not sign the medication out of the CDR or document the administration there. The eMAR showed the dose was signed in, but the CDR did not reflect the removal or administration, contrary to the facility's controlled medication storage policy.
The facility failed to ensure competent food safety practices among kitchen staff, leading to deficiencies in dish machine sanitizer testing, cool down processes, and produce handling. Staff were unable to correctly test sanitizer concentrations, verbalize proper cool down procedures, and wash melons before cutting, contrary to FDA guidelines and facility policies. The lack of training was acknowledged by the Dietary Manager and emphasized by the Registered Dietitian.
The facility failed to maintain food safety and sanitation standards, with issues including an unclean ice machine, improper plumbing of drainage pipes, and expired food items in refrigerators. The Dietary Manager and Stationary Engineer acknowledged these deficiencies, which also included rust on shelves, dirty equipment, and worn-out cutting boards.
The facility failed to follow its policies for advance directives and POLST forms for several residents. Critical sections of the POLST forms were left incomplete, and there was no documentation of discussions or assistance with advance directives for multiple residents. The chief nursing officer confirmed these deficiencies, highlighting a lack of adherence to established procedures.
The facility failed to develop comprehensive, resident-centered care plans for six residents, including those with chronic kidney disease, dementia, and paraplegia. The care plans did not include specific activities provided to the residents, such as music, television, and social events, as verified by the activity coordinator. This lack of documentation and implementation could impact the residents' well-being.
The facility failed to follow approved menus and lacked a written emergency menu plan. The Dietary Manager admitted to not using a therapeutic menu spreadsheet, and a cook used the wrong ladle size for serving, violating portion control policies. Additionally, the facility did not have a detailed emergency food plan, which could affect residents' nutritional needs during emergencies.
The facility failed to maintain appropriate food preparation and serving temperatures, leading to cold meals and improper textures for pureed diets. Observations revealed that meals were prepared hours in advance, affecting their quality. A resident reported receiving cold meals, and test trays showed non-compliance with temperature standards and recipe adherence.
Two residents with foley catheters had their drain bags left uncovered, compromising their dignity. One resident, with neurogenic bladder and renal cell carcinoma, confirmed the lack of a privacy cover since admission. Another resident, with Parkinson's disease and other conditions, also had an uncovered drain bag. A nurse and the CNO acknowledged the oversight, which violated the facility's policy on patient privacy.
A resident with severe anemia and metastatic cancer was administered oxygen without a physician's order, contrary to the facility's policy. The resident was observed receiving oxygen at 2 liters per minute, despite the order being discontinued over a month prior. Interviews with staff confirmed the lack of an active order, highlighting a failure to verify physician orders before administering oxygen.
A resident was served a meal that did not align with their documented food dislikes and preferences, as observed during a lunch service. The resident's tray card indicated a dislike for carrots and a preference for soup, but they were served carrots and not provided soup. This was confirmed by both a CNA and the dietary manager, who acknowledged the dietary staff's failure to follow the resident's documented preferences.
A registered nurse failed to perform hand hygiene after removing gloves and before preparing medications for a resident, breaching infection control protocols. The resident had diagnoses including alcoholic liver disease and hypertension. The nurse acknowledged the oversight, and the infection preventionist confirmed the breach of facility policy.
Failure to Assess and Supervise Residents at Risk for Elopement and Misuse of LOA Process
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe environment and adequate supervision for residents at risk of elopement, particularly two residents with known risk factors, and the failure to complete required elopement risk assessments for nearly all residents. One resident with alcoholic cirrhosis, alcohol dependence, ascites, and hepatic encephalopathy was cognitively intact per BIMS and independent in transfers and walking, and he frequently went to the facility’s garden. Staff reported that he had previously left the facility in the morning and returned intoxicated in the evening, and that this incident should have been reported to management. Despite a physician’s order for an Elopement Evaluation and an order that he could only leave the SNF/hospital property with a responsible party, no Elopement Evaluation Assessment was completed upon admission, and staff confirmed there was no tool in use to assess elopement risk. The nurse manager stated the assessment was not done because the resident was alert, oriented, and independent. The same resident’s preference for frequent independent garden time was documented in his activity preferences, but the activity staff did not develop a comprehensive activity care plan that included objectives, interventions, supervision requirements, or monitoring of his whereabouts during garden time. The activities coordinator and nursing staff acknowledged that the existing documentation did not constitute a true care plan and that there was no constant monitoring of the resident while he was in the garden. In addition, the facility did not follow its Leave of Absence (LOA) policy requiring a complete mental, physical, and functional assessment within 30 minutes before leaving and upon return, documented in the nursing progress notes. Multiple LOA forms for this resident showed times out with no times in, missing nurse initials, and incomplete destination information, and the nurse manager confirmed that nurses did not complete or document required assessments on numerous dates. Staff interviews revealed that nurses and CNAs did not routinely check on residents in the garden, did not sign the resident back in when he returned for medications, and believed that the resident’s signature on the LOA form released the facility from responsibility. On the day of the fatal incident, the resident signed out in the morning to go to the garden, was seen on surveillance video leaving and re-entering the building, and later left again in the early afternoon without signing out. He took his medication early that afternoon, but staff did not verify his whereabouts afterward. Surveillance footage reviewed by the director of quality showed the resident exiting through the lobby doors and heading toward a nearby street, after which he was no longer visible until a truck stopped in front of the hospital later that evening, coinciding with the time of a motor vehicle accident in which he was struck as a pedestrian. He was subsequently admitted to the acute hospital as a trauma patient with extensive injuries and an elevated blood alcohol level and later died; the hospital death summary listed multiple traumatic injuries and alcohol intoxication among the diagnoses and contributing conditions. A second resident, with diagnoses including alcoholism, diabetes mellitus, hemiplegia due to prior stroke, hypercholesterolemia, hypertension, and wheelchair dependence, had a BIMS score indicating severe cognitive impairment. No Elopement Evaluation Assessment was completed upon his admission. The nurse manager stated that such assessments were only done when residents were “triggered” by an elopement incident or a change in condition, rather than upon admission. This resident routinely signed LOA forms and left the facility or went to the garden unassisted, propelling his wheelchair using his left arm and leg, often in the early morning hours. CNA staff reported that he preferred to go out alone to stores to purchase lottery scratcher tickets and that staff did not take his vital signs each time he returned from LOA. Review of his LOA forms showed numerous entries with times out but no times in, missing nurse initials, missing destinations, and lack of documentation of assessments before leaving or upon return, contrary to facility policy. Beyond these two residents, the facility failed to complete Elopement Evaluation Assessments upon admission for 39 of 40 residents reviewed. The report states that this failure could result in not identifying residents’ elopement risk levels and not implementing resident-centered plans of care, with the potential to result in harm, injury, or death for residents at high risk of elopement. The cumulative failures to assess elopement risk, to develop and implement individualized care plans for residents with known preferences for independent outdoor time, and to follow the LOA policy for assessment and documentation led to an immediate jeopardy situation, as the noncompliance caused or was likely to cause serious injury, harm, impairment, or death to residents, exemplified by the elopement and subsequent fatal motor vehicle accident involving the first resident.
Food Served at Inappropriate Temperature
Penalty
Summary
The facility failed to provide and serve food at an appropriate temperature. During interviews, a resident stated he always received his morning breakfast cold, and the resident council president stated that 97% of the food served to residents was cold. During a resident council meeting observed by surveyors, residents were asked whether their food was served hot, and the resident council president stated no, with the other residents agreeing that the food was brought cold. Facility records from the resident council meeting minutes documented residents' concerns that the food was cold and questioned whether there was a better way to keep food warm. A test tray was then observed for regular and pureed lunch items, including Shepherd's pie and citrus basil roasted vegetables. The dietary manager checked temperatures and found the regular Shepherd's pie at 135 F, the regular vegetables at 113.5 F, the pureed Shepherd's pie at 121.7 F, and the pureed vegetables at 117.9 F. The dietary manager and two nurse surveyors tasted the food and agreed it was not served hot. The dietary manager stated the steam table should maintain food temperature and serve food at 135 F, and the facility policy stated hot foods should be held at 135 F or higher.
Food Storage, Sanitation, and Hand Hygiene Deficiencies
Penalty
Summary
Food was not stored, prepared, and served in accordance with professional standards in the kitchen. During observation and document review, the dry storage room temperature log showed blank spaces from 1/16/2026 through 1/20/2026, and the log also showed that kitchen staff checked the dry storage room temperature only once daily from 1/1/2026 through 1/15/2026 instead of twice daily as required. The dietary manager confirmed the log was incomplete and stated that checking and entering the dry storage room temperature is important to prevent food spoilage. In the walk-in refrigerator, a box of lemons was observed with one lemon covered in a white substance mixed in with the other lemons. The dietary manager identified the substance as mold and stated the lemons should have been checked twice a week. The facility policy on receiving and storage stated that food is inspected upon arrival, especially perishables, and prior to use, and that ventilation, humidity, and moisture are controlled in storage areas to prevent condensation and mold growth. In the kitchen, a staff personal purse was stored in the clean plate storage rack, and the same rack had dust-like substance and food crumbs where clean plates, disposable plastic cups, and clean metal containers were stored. The dietary manager and registered dietitian confirmed both observations and stated the purse should not be stored there and the racks should be cleaned. During meal preparation, a food service worker mixed batter for an apple sauce bar while wearing gloves, touched and adjusted her eyeglasses twice, and continued mixing without changing gloves or performing hand hygiene; she touched her eyeglasses again later. The dietary manager stopped her and had her remove her gloves and wash her hands, and stated staff should not touch eyeglasses, hair, or face during food preparation without changing gloves and washing hands.
Unnecessary psychotropic use and missing monitoring for antipsychotics and sleep medications
Penalty
Summary
The facility failed to ensure three residents were free from unnecessary psychotropic medication use and from medication use as a chemical restraint. Resident 25, who had diagnoses including dementia, diabetes mellitus, and atrial fibrillation, continued to receive quetiapine 100 mg nightly for dementia even though the nurse manager stated there was no identified behavior documented to support its use. The nurse manager and MDS nurse also confirmed that the diagnosis or indication of dementia was not appropriate for the resident’s use of quetiapine, and there was no scheduled AIMS monitoring completed for this resident. Resident 9, who had diagnoses including failure to thrive, mild dementia, and generalized osteoarthrosis, continued to receive quetiapine 100 mg at bedtime for psychosis and dementia without documentation that non-pharmacological interventions were implemented for observed behaviors. The nurse manager confirmed that the resident had documented combativeness, yelling, and agitation on multiple occasions, but the record did not show non-pharmacological interventions for those behaviors. Resident 9 also received trazodone 50 mg at bedtime for insomnia without documentation of non-pharmacological interventions or monitoring of hours of sleep, and there was no AIMS monitoring completed for the antipsychotic use. Resident 1, who had diagnoses including hyponatremia, peripheral vascular disease, and schizoaffective disorder, depressive type, continued to receive aripiprazole 5 mg daily and olanzapine 2.5 mg at bedtime for psychosis and agitation without documentation of specific behaviors supporting the use of both antipsychotics. The nurse manager confirmed that nurses did not monitor the resident for possible effects of the antipsychotics during multiple periods in December 2025 and January 2026, and there was no AIMS monitoring completed. Resident 1 also received trazodone 300 mg at bedtime for insomnia without documented monitoring of hours of sleep, non-pharmacological interventions, or side effects of trazodone use.
Inaccurate MDS Coding for Pressure Injuries
Penalty
Summary
Resident 9’s quarterly MDS assessment was not coded to reflect her actual pressure injuries at the time of assessment. She was admitted to the facility with diagnoses including failure to thrive, mild dementia, and generalized osteoarthrosis, and her admission MDS documented two unstageable pressure injuries. During interview and record review, the MDS nurse confirmed the quarterly assessment incorrectly showed only one unstageable pressure injury that was not present on admission, even though the resident had been admitted with two unstageable pressure injuries that later opened and became Stage 4 pressure injuries on both hips. The MDS nurse stated the quarterly coding should have shown two Stage 4 pressure injuries present on admission and acknowledged, “it was my mistake.” Resident 5’s admission MDS assessment also did not reflect the actual pressure injuries present on admission. He was admitted for wound care with diagnoses including a sacral decubitus ulcer and history of spina bifida. The admission MDS indicated one Stage 4 pressure injury and coded the number of Stage 3 pressure injuries as zero. During concurrent interview and record review, the DON and skin assessment documentation were reviewed, but the report ends before the full findings for Resident 5 are completed. The deficiency cited that the admission MDS did not accurately capture the pressure injuries he was admitted with, resulting in inaccurate resident assessment data submitted to CMS.
Care Plans Missing, Incomplete, or Not Updated for Multiple Residents
Penalty
Summary
The facility failed to ensure resident-centered care plans were developed, updated, or documented in accordance with professional standards and its own policies for multiple residents. Resident 22, who was admitted with atrial fibrillation, HTN, and coronary artery disease, had an order for apixaban (Eliquis) 5 mg twice daily starting 11/3/2025, but the SNF NM confirmed there was no care plan developed for the use of Eliquis. RN G stated the resident was taking Eliquis for stroke prophylaxis and that its use should be care planned. Resident 9, admitted with failure to thrive, mild dementia, and generalized osteoarthrosis, had physician orders for quetiapine 100 mg at bedtime for psychosis and dementia starting 10/1/2025, and trazodone 50 mg at bedtime for insomnia starting 12/11/2025. During record review and interview, the SNF NM confirmed there were no care plans developed for either medication. The SNF NM stated long-term care plans were developed by nurses and that initial care plans should have been developed by the admitting nurse, with comprehensive care plans developed by floor nurses. Resident 34, readmitted with aspiration pneumonia, HTN, history of stroke, and aphasia, had been aspirating even with a pureed diet and honey-thickened liquids. The SNF NM stated a care conference was held with the family on 1/9/2026 and that the family wanted oral gratification only and no artificial nutrition. LVN B stated the family wanted comfort measures only and was aware the resident could decline if not getting enough nutrition and was at risk for aspiration. Despite RD assessment notes in 9/2025, 10/2025, 12/2025, and 1/22/2026, the SNF NM confirmed there was no care plan developed for alteration in nutrition. The facility also had documentation deficiencies in care plan review and revision for other residents. Resident 2 had an antipsychotic care plan dated 7/25/2025 for quetiapine 50 mg at bedtime, but the SNF NM confirmed there was no initial of who reviewed or resolved the care plan. Resident 3, who had functional gait abnormality, muscle weakness, frequent falls, and a history of traumatic brain injury, had an unsteady gait, impaired sensory, poor judgment, and motor and sensory deficits; the SNF AM/MDSN confirmed there was no care plan for refusal to use the call light, and the SNF NM stated no IDT meeting or notes for the resident’s falls were done. Resident 4’s chronic pain care plan for polymyalgia rheumatica had multiple review dates, but the SNF NM confirmed there was no initial or signature of the staff who reviewed or resolved the care plan. Resident 21’s chronic pain care plan also had blank outcome date/signature fields, and the SNF NM confirmed there were no names or signatures for quarterly revisions and that three quarters were missed for the care plan updates.
Failure to complete and document LOA assessments
Penalty
Summary
The facility failed to implement its Leave of Absence (LOA) policy and procedures for two residents when licensed nurses did not complete and document mental, physical, and functional assessments before the residents left the facility and when they returned. The report states that the facility policy required a licensed nurse to complete a full assessment immediately prior to leaving, within 30 minutes, and again upon return, with documentation entered in the nursing progress notes in the EHR. One resident had diagnoses including alcoholic cirrhosis, alcohol dependence, ascites of the liver, and hepatic encephalopathy. The resident repeatedly signed himself out to go to the garden, outside, downstairs, or other destinations, and the LOA forms frequently lacked documented time in, nurse initials, destination details, or other required entries. During a concurrent interview and record review, the SNF NM confirmed that nurses did not complete and document the resident’s assessment before leaving and upon returning to the facility on multiple dates in December 2025. The second resident had diagnoses including alcoholism, diabetes mellitus, hemiplegia due to an old stroke, history of completed stroke, hypercholesteremia, hypertension, and was wheelchair bound. The resident repeatedly signed out to go outside, downstairs, to the bakery, store, street market, downtown, plaza, and other locations, with many LOA entries lacking documented time in, nurse initials, destination, relationship, or complete time out/time in information. The SNF NM confirmed the resident had signed out and signed in on the listed dates, and a CNA stated the resident left the facility by propelling his wheelchair and that staff did not take vital signs every time he returned from LOA.
Medication Labeling, Storage, and Controlled Substance Security Deficiencies
Penalty
Summary
Drugs and biologicals were not consistently labeled and stored according to facility policy and manufacturer instructions. During inspection of the medication refrigerator, surveyors found one open vial of Tuberculin Purified Derivatives with an open date and an expired date, and LVN H confirmed it was outdated. In medication cart BB, surveyors found one vial of Admelog with an open date and an expired date, and LVN D confirmed it was expired. In medication cart AA, surveyors found a bottle of latanoprost 0.005% eye drops that was open and undated, and RN J confirmed it was undated. Surveyors also found a second bottle of latanoprost 0.005% eye drops inside a box that was unopened and still sealed, with the pharmacy label stating to refrigerate until open. RN J verified the medication had not been used and should be kept refrigerated. The SNF NM stated that once a vial or bottle is opened, the anticipated date should be placed on the label, and that some expirations are 28 or 30 days depending on the manufacturer. Facility policy required expired medication to be removed from stock and required nurses to place a date-opened sticker on medication if one was not provided by the pharmacy. Medication security and controlled substance handling were also not followed. During medication administration, cart CC was left unlocked with medication on top of the cart in the hallway outside resident rooms, and LVN F confirmed the cart should always be locked. Surveyors also found controlled drugs kept in the medication cart, including discontinued controlled drugs left there until pharmacy destruction. The SNF NM stated the facility had no double-lock cabinet and acknowledged the possibility of diversion of controlled drugs. Facility policy required controlled medications remaining after discontinuation to be retained in a securely double-locked area with restricted access until destroyed.
Improper Storage of Food Brought From Home
Penalty
Summary
The facility failed to ensure resident foods brought from home were stored in a safe and sanitary manner in the residents' refrigerator with built-in freezer. During observation with an LVN, homemade tamales were found in the freezer, including 10 tamales stored in zip lock bags on a plastic container labeled with a resident's room number and dated 1/4/2026, and one homemade tamale in a zip lock bag with a resident's room number but no date. In the refrigerator, a sauce in a small plastic container was not labeled, and one plastic box container with pinto beans was labeled with a resident's room number and dated 1/22/2026. The LVN confirmed the observations and stated the foods should be discarded. During interviews, the LVN stated resident food brought from home should be labeled with the resident's name and the date it was brought in, and opened food should be discarded after 72 hours. The dietary manager stated dietary staff were responsible for checking the temperature of the residents' refrigerator and freezer, while skilled nursing staff were responsible for making sure foods brought from home were stored only for 72 hours. The facility policy titled Food From Outside Source Policy stated food not eaten right away should be stored in a sealed container, labeled with the resident name and date brought to the facility, and leftover food should be discarded after 3 days, with the nursing department responsible for monitoring the pantry refrigerator and discarding outdated foods daily.
Infection Control Lapses in PPE Use, Resident Item Handling, and Hand Hygiene
Penalty
Summary
The facility failed to implement infection prevention and control practices in a resident room with Enhanced Barrier Precautions. Resident 39’s door had EBP signage, but during observation the Skilled Nursing Facility Nurse Manager confirmed there was no isolation cart at the room. The nurse manager stated EBP residents include those with chronic wounds, Foley catheters, and no active infection, and that an isolation cart should be available with gowns, gloves, face shields, and signage. The nurse manager also stated the facility had run out of yellow gowns and that the isolation cart was important because of the potential spread of infection. During observation of care for Resident 2, LVN D was seen wearing gown, mask, and gloves, then touching her nose with clean gloves before handling the glucometer, gauze, and alcohol swab. She placed those items on the overbed table without cleaning the table and without placing a barrier first. After doffing and sanitizing her hands, she again prepared an insulin syringe and repeated the same sequence, placing the syringe and alcohol swab on the overbed table without cleaning it or using a barrier. LVN D later confirmed she did not place a barrier on the table before setting down the glucometer and insulin syringe and acknowledged touching her face area with clean gloves. The nurse manager stated the overbed table should have been cleaned before and after placing the items and that a liner should have been used. Medication preparation in an isolation room also showed the overbed table was not cleaned and no barrier was placed before medication was set down. LVN A placed a cup of medication on the overbed table without cleaning it or using a barrier. In the shared bathroom for Residents 38 and 9, two toothbrushes were stored together in one cup without labels, and three used basins were stored on the bathroom floor, two with white substance buildup, with no labels; another basin was also on the floor beside the toilet. LVN D confirmed the items were unlabeled and stated resident items should be labeled, while the infection preventionist stated used basins should be cleansed and labeled and toothbrushes should be labeled and stored separately. During dining observations, CNA L assisted Resident 17 with lunch, then went to another table to assist Resident 41 without performing hand hygiene, and then returned to continue assisting Resident 17 without hand hygiene. A volunteer handled Resident 22’s used napkin and empty coffee creamer cup, discarded them, then handled more creamer cups and gave them to CNA M without performing hand hygiene. The volunteer confirmed she forgot to use hand sanitizer and stated she had not attended hand hygiene in-services, and CNA L confirmed she did not realize she had not performed hand hygiene. The infection preventionist stated staff should perform hand hygiene when assisting two different residents and after handling dirty or soiled napkins.
Failure to Offer and Document Pneumococcal and Flu Vaccinations
Penalty
Summary
The facility failed to offer and administer pneumococcal vaccination and, for one resident, the current seasonal flu vaccine, in accordance with CDC recommendations. During a concurrent interview and record review with the Quality Nurse Coordinator, Resident 3 was confirmed to have been admitted with a history of PPSV23 received on 11/22/2013, but there was no record that PCV20, PCV15, or PCV21 had been offered after the prior PPSV23 dose. Resident 5 was confirmed to have been admitted with a history of PPSV23 received on 4/23/22, but there was no record that PCV15, PCV20, or PCV21 had been offered at least 1 year later as recommended by CDC. Further review showed Resident 5 had received a flu vaccine on 10/11/24, but there was no record of a current 2025 flu vaccine being offered. Resident 20 was confirmed to have been admitted with no history of receiving any pneumococcal polysaccharide vaccine, and the Quality Nurse Coordinator stated there was no pneumococcal vaccine on the record and no education on the importance of the vaccine; she also stated it was not offered. During interview, the Infection Preventionist stated it was staff responsibility to update and document if the resident refused the vaccine.
Unattended Open Laptop Exposed Resident PHI During Medication Pass
Penalty
Summary
The facility failed to protect resident confidentiality when an LVN left an open laptop computer on the medication cart unattended in the hallway outside of two residents’ rooms during medication administration. During observation, the laptop screen displayed resident information and medication records while the LVN stepped away to check a resident’s blood sugar, then prepared insulin with verification from another nurse and entered the room to administer the medication while the computer remained open. The same pattern occurred outside another resident’s room, where the medication cart with the open laptop was left unattended in the hallway while the LVN checked blood sugar, then returned to prepare and administer insulin with the laptop still open. During interview, the LVN confirmed the computer had been left open and unattended while administering medication and stated it should be closed at all times, especially when away from it. The SNF NM stated computers should not be left open because resident information must be safeguarded and the med cart should be blocked in the door, and that leaving the computer open exposed resident information. Facility policy stated resident health information must remain private and that computer screens should not be visible to unauthorized persons, and the HIPAA Security Rule requires safeguards against impermissible uses or disclosures of e-PHI.
Incomplete Dialysis Transfer Communication
Penalty
Summary
The facility failed to ensure safe, appropriate dialysis care/services for a resident receiving dialysis when the nursing facility/dialysis unit communication reports were incomplete. Resident 7 was admitted with diagnoses including end stage renal disease, hypertension, anemia in chronic kidney disease, aortic stenosis, and COPD. Review of the resident’s NF/DUCR forms dated 1/19/26 and 1/21/26 showed that the dialysis unit portion of the forms was incomplete. During a concurrent interview and record review, the Skilled Nursing Facility Nurse Manager confirmed the forms were incomplete and stated they should be filled out completely before the resident goes to the dialysis center. The Nurse Manager also stated the NF/DUCR is a form of communication of transfer of care to the receiving transfer facility.
Controlled Medication Not Fully Documented
Penalty
Summary
The facility failed to ensure controlled substance medications were fully accounted for on the eMAR for one resident receiving PRN medication. Resident 29 had an order for Acetaminophen-Codeine 300 mg/30 mg by mouth three times daily as needed for severe pain, with a start date of 10/1/25. During interview and record review, LVN D verified that one tablet of Acetaminophen-Codeine was not accounted for in the CDR and that there was no nurse signature on the CDR for the medication. A concurrent review with the SNF AM/MDSN showed that the eMAR for Resident 29 reflected nursing staff signed the medication in on 1/20/26 at 22:43, but the medication was not signed out in the CDR and the administration was not documented there. The SNF AM/MDSN stated staff should follow the policy and sign out the medication in the CDR when it is taken out for administration, and that both the eMAR and CDR should reflect the medication that was given. The facility policy on Controlled Medication Storage stated that at each shift change or when keys are surrendered, a physical inventory of all Schedule II controlled medications is conducted by two licensed nurses or per state regulation and documented on the controlled substances accountability record or verification of controlled substance count report.
Deficiencies in Food Safety Practices
Penalty
Summary
The facility failed to ensure that food and nutrition services staff carried out their duties competently, as evidenced by several deficiencies observed during a survey. Two kitchen staff members were unable to properly test the dish machine sanitizer solution concentration. One staff member, identified as DSW E, incorrectly described the normal sanitizer range for the dish machine solution, while another, CK I, demonstrated a misunderstanding of the testing process. The facility's policy required a minimum concentration of 50-100 ppm of chlorine, which was not correctly identified by the staff. Additionally, the Dietary Manager acknowledged the lack of proper training for the staff in this area. Further deficiencies were noted in the cool down process for cooked foods and the handling of produce. CK B incorrectly verbalized the cool down process, stating incorrect temperature ranges and timeframes, which did not align with the 2022 Federal FDA Food Code requirements. Moreover, DA D was observed chopping melons without washing them, contrary to FDA recommendations and the facility's policy. The Dietary Manager confirmed that no in-service training on these critical food safety practices had been provided to the kitchen staff from June 2023 through June 2024. The Registered Dietitian emphasized the importance of proper training to prevent exposure to contaminated foods.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to food safety and sanitation standards, as evidenced by multiple deficiencies observed during a survey. The ice machine was found to have visible pink slime and tan residue on its ice-making parts, which were not cleaned according to the manufacturer's guidelines. The Stationary Engineer admitted to using an inappropriate cleaning solution and not following the recommended cleaning schedule. Additionally, the ice machine's silver mesh filter was clogged with gray lint, indicating a lack of regular maintenance. Further inspection revealed that two drainage pipes were directly plumbed into floor sinks without air gaps, posing a risk of backflow contamination. The Dietary Manager was unaware of this issue, and the Stationary Engineer confirmed that air gaps should have been present. The kitchen also had three floor sink drains that were visibly dirty with dark stains and food debris, which the Dietary Manager acknowledged should have been cleaned by the evening staff. The survey also uncovered expired food items, including sliced cheese, pears, and cranberry juice, in various refrigerators. The Dietary Manager and a registered nurse confirmed that these items should have been discarded according to the facility's policy. Additionally, moldy bell peppers were found in the walk-in refrigerator, and the Dietary Manager admitted they should have been checked upon delivery. Other issues included rust on metal shelves, a dirty freezer door gasket, unclean serving scoops, and worn-out cutting boards, all of which were acknowledged by the Dietary Manager as needing attention.
Failure to Complete Advance Directives and POLST Forms
Penalty
Summary
The facility failed to adhere to its policies and procedures regarding advance directives (AD) and physician orders for life-sustaining treatment (POLST) forms for seven out of eight sampled residents. Specifically, the facility did not complete the necessary sections of the POLST forms for Residents 9, 22, 24, 26, 31, and 184, leaving critical sections such as those for advance directives and artificially administered nutrition blank. Additionally, there was no documentation indicating that the facility discussed or assisted in executing advance directives for Residents 22, 24, 26, 31, 32, and 184, nor was there evidence of requests for copies of executed advance directives. During an interview, the facility's chief nursing officer confirmed these findings, acknowledging that case management or social service staff should have been involved in discussing and assisting with advance directives, and that nursing staff should have completed all sections of the POLST forms. The facility's policies, revised in 2022 and 2021, respectively, outline the responsibilities of registration/admitting staff and healthcare providers in ensuring that advance directives are documented and that POLST forms are completed based on the patient's expressed treatment preferences. The failure to follow these procedures has the potential to result in the delivery of medical services against the residents' wishes.
Deficiency in Resident-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, resident-centered care plans for six out of thirteen sampled residents. These residents included individuals with various medical conditions such as chronic kidney disease, dementia, hypertension, alcoholic liver disease, depression, paraplegia, congestive heart failure, diabetes, and anxiety. The care plans for these residents were not comprehensive and did not include specific activities that were provided to them, as observed and verified by the activity coordinator. For instance, Resident 15, who has chronic kidney disease and dementia, was observed to enjoy activities like listening to music, doodling, and receiving manicures. However, these activities were not documented in her care plan. Similarly, Resident 8, who has alcoholic liver disease and paraplegia, enjoyed watching television and participating in candlelight dinners, but these preferences were not reflected in his care plan. The activity coordinator confirmed that the care plans lacked measurable objectives and timetables to meet the residents' needs. The chief nursing officer verified that the facility's policy required comprehensive, resident-centered care plans that include measurable objectives and timelines. However, the care plans for Residents 3, 5, 1, and 29 also lacked specific activities that were provided to them, such as haircuts, nail care, and social activities. This failure to document and implement comprehensive care plans had the potential to result in the residents not receiving the necessary interventions to maintain their highest level of well-being.
Deficiency in Menu Compliance and Emergency Planning
Penalty
Summary
The facility failed to ensure that approved menus were followed and that emergency menus were developed to properly feed residents in an emergency. During an interview with the Dietary Manager (DM), it was revealed that the facility did not use a therapeutic menu spreadsheet, and instead, cooks used a daily production tally sheet. An observation during a tray line showed that the cook used a 2-ounce ladle instead of the required 4-ounce ladle to serve orzo, which was acknowledged by the DM as incorrect. This failure to use the correct serving utensils was against the facility's policy on portion control, which mandates standardized portions to ensure nutritional content and food cost standards are met. Additionally, the facility did not have a written emergency menu plan. The DM stated that in an emergency, the facility would use existing food supplies, including rehydrated meals stored in an outdoor connex. However, there was no detailed emergency menu or food plan to describe how these foods would be used to meet the nutritional needs of residents on regular and therapeutic diets during emergencies. The Registered Dietitian (RD) emphasized the importance of following approved menus and having a well-defined emergency food and water plan. The facility's policy on disaster planning requires a documented Food & Nutrition Services Department Disaster Plan, which should include guidelines for meal planning during emergencies. The plan should ensure the facility is self-sustaining for a minimum of six days and outline menu plans for various emergency scenarios. However, the facility did not have such a plan in place, which could potentially impact their ability to meet residents' nutritional needs during an emergency.
Deficiency in Food Preparation and Serving Temperatures
Penalty
Summary
The facility failed to ensure that food was prepared and served at appropriate temperatures, which compromised the flavor and nutritive value of meals. During a kitchen tour, it was observed that cooked green peas were left uncovered on warm water, and chili was stored in a food warmer hours before mealtime. The facility's meal preparation schedule indicated that meals were prepared well in advance of serving times, which could affect the quality of the food. Additionally, a resident had previously reported receiving cold meals during a Resident Council Meeting. The facility also did not adhere to approved recipes for pureed meals, resulting in lumpy textures that were not suitable for residents requiring pureed diets. During a test tray observation, the pureed macaroni and cheese was found to be lumpy instead of smooth, and the regular macaroni and cheese was served at a temperature below the required standard. The facility's policies required specific temperature controls and adherence to standardized recipes, which were not followed, potentially impacting the residents' nutritional intake.
Failure to Cover Foley Catheter Drain Bags
Penalty
Summary
The facility failed to ensure that residents were treated with dignity by not covering the foley catheter (F/C) drain bags for two residents. Resident 31, who was admitted with diagnoses including neurogenic bladder and renal cell carcinoma, had an uncovered F/C drain bag secured to their bed frame. This was observed during a survey, and Resident 31 confirmed that the drain bag had been without a privacy cover since their admission. The resident's minimum data set indicated intact cognition, suggesting awareness of the situation. Similarly, Resident 32, admitted with conditions such as Parkinson's disease, frontoparietal cerebral atrophy, and a sacral decubitus ulcer, also had an uncovered F/C drain bag. This was confirmed by a registered nurse, who acknowledged that the nursing staff should have used privacy bags to cover the F/C drain bags to maintain the residents' privacy and dignity. The facility's chief nursing officer also confirmed that the staff should have adhered to the facility's policy on patient confidentiality, which emphasizes the importance of privacy and dignity.
Oxygen Therapy Administered Without Physician's Order
Penalty
Summary
The facility failed to adhere to its policy and procedure for oxygen therapy by administering oxygen to a resident without a physician's order. Resident 31, who was admitted to the facility with diagnoses including renal cell carcinoma, metastatic cancer of the spine, severe anemia, and was under palliative care, was observed receiving oxygen via nasal cannula at a rate of 2 liters per minute. However, a review of the resident's records indicated that the order for oxygen had been discontinued over a month prior, and no new order had been issued. Interviews with the registered nurse and the chief nursing officer confirmed that there was no active physician's order for the oxygen therapy being administered to Resident 31. The facility's policy, which requires verification of a physician's order before administering oxygen, was not followed. The chief nursing officer acknowledged the oversight and confirmed that the licensed nurse should have verified the presence of an active order before administering oxygen to the resident.
Failure to Accommodate Resident's Food Preferences
Penalty
Summary
The facility failed to accommodate the food dislikes and preferences of Resident 30, which was observed during a lunch meal service. On the specified date, Resident 30 was served cut carrot pieces mixed with Italian vegetables, and soup was not provided, despite the resident's lunch tray card indicating a dislike for carrots and a preference for soup at lunch and dinner. This oversight was confirmed during an interview with a certified nursing assistant (CNA H) and the dietary manager (DM), both of whom acknowledged that the dietary staff should have adhered to the resident's documented food dislikes and preferences. The facility's policy and procedure on food preferences, revised in May 2023, outlines the importance of communicating with residents about their food and beverage preferences within 72 hours of admission. This includes documenting food dislikes, preferences, intolerances, and allergies. The dietary manager confirmed that the dietary staff did not follow the policy, as they failed to serve the meal according to Resident 30's documented preferences, which could potentially lead to decreased food intake and negative health effects for the resident.
Infection Control Breach During Medication Administration
Penalty
Summary
The facility failed to implement proper infection prevention and control practices during medication administration for a resident. Specifically, a registered nurse did not perform hand hygiene after removing used gloves and before preparing medications for a resident. This was observed on two separate occasions during a medication pass, where the nurse disposed of gloves in a trash bin attached to the medication cart and proceeded to handle medications without sanitizing her hands. The resident involved was admitted with diagnoses including alcoholic liver disease, left hip arthritis, and hypertension. The registered nurse acknowledged the failure to perform hand hygiene during an interview, confirming that she should have sanitized her hands after glove removal. The infection preventionist also verified that hand hygiene should have been performed according to the facility's policy, which emphasizes the importance of hand hygiene after contact with inanimate objects and glove removal.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near King City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Eden Valley Care Center | 18.9 mi | ★★★★★ | 0 | 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 October 2026) and official state health department websites.