Below average — CMS composite of the measures below.
The next survey window likely opens around June 2027
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 Golden Rose Care Center during CMS and state inspections, most recent first.
Failure to Assess and Plan for Elopement Risk: A resident with schizophrenia, anxiety, alcohol abuse disorder, and a history of injury-related trauma eloped from the facility after staff did not have a wandering/elopement risk assessment or an individualized care plan in place. Staff last saw the resident in the evening, but no one observed him for several hours before he was found walking near the facility and returned after being missing overnight. The DON stated the resident should have been assessed on admission and after functional improvement, and that the resident did not have the required elopement care plan.
Two residents with pressure ulcers had LAL mattress settings that did not match their documented body weight, and one resident also lacked weekly skin assessments after the initial assessment. Staff confirmed the mattress settings should have been based on weight, and the DON stated correct settings and weekly documentation were important for pressure ulcer treatment and monitoring.
Two residents who required dialysis did not receive ordered treatments because escort and transportation arrangements broke down, with staff describing miscommunication, missed notifications, and lack of available escorts. One resident also had a fluid restriction order, but a water pitcher was repeatedly observed at the bedside despite staff stating it should have been removed to monitor intake.
Medication administration errors caused the facility’s error rate to exceed the 5% threshold. An LVN preparing meds for a resident with a G-tube crushed bethanechol and a multivitamin, mixed them with unmeasured amounts of water in large cups, and used the remaining water to flush the tube instead of following the ordered measured flushes and the facility’s feeding-tube medication procedure. The DON stated the water amounts should be measured and the meds and flushes should follow the resident’s order and care plan.
MC 1 was left unattended and unlocked while resident medications were visible inside, and an LPN later failed to lock the cart before entering resident rooms. Two medication refrigerators also had significant ice buildup, and staff could not provide evidence of when they were last defrosted. The DON stated the medication storage policy was not followed.
Incorrect Portion Sizes Used for Lunch Meal Servings: Dietary staff did not follow the menu for ranch style beans and brown rice and used the wrong scoops while serving lunch. An employee used a #8 scoop for beans and an unmeasured scoop for rice instead of the #12 scoop listed on the menu, and the DS confirmed the menu-required portion sizes were not followed for residents on CCHO, regular, renal, and low fat/cholesterol diets.
Food was served below the required temperature during lunch when a test meal tray with pork loin, beans, and green beans was observed at 116 degrees F. The DS stated the food was too cold and confirmed that served foods should be above 140 degrees F, consistent with the facility P&P requiring meat, entrees, and vegetables to be served at greater than 140 degrees F.
Improper Food Storage and Unsanitary Tray Line Practices: The Dietary Supervisor observed food stored improperly in dry storage and refrigeration, including cocoa powder kept in a partially closed bag and pumpkin with an expiration label. During tray line preparation, the DS left the cooking area, touched the refrigerator door and personal clothing with gloved hands, and returned to prepare food and handle utensils without changing gloves or performing hand hygiene, contrary to facility policy.
A resident refrigerator in the Activity/Dining Room was observed at 51 degrees F during an observation and interview with the DS. The DS stated the temperature should be 41 degrees F or below to keep food safe, and noted the food in the refrigerator had been brought in by residents' family and visitors. The facility policy required refrigerator temperatures to be 41 degrees F or below.
An LPN failed to perform hand hygiene after removing soiled gloves during medication administration and charting for several residents, including residents with G-tubes, cognitive impairment, and psychiatric or neurologic diagnoses. In addition, catheter drainage bags for three residents were observed touching the floor, and a resident’s oxygen mask, tubing, and storage bag were found on the floor and then placed back into bedside storage. The facility’s policies required hand hygiene after glove removal, catheter bags kept off the floor, and oxygen equipment stored in a sanitary manner.
A resident with quadriplegia, tracheostomy status, and a facial burn, who had severely impaired cognitive skills and was dependent for multiple ADLs, was receiving emergency care for chest pain when the bedside curtain was left open. Another resident and visitors in the room could see the resident during paramedic assessments, including vital signs and an EKG, and the DON stated residents should be treated with respect and dignity and given privacy during care.
Call Light Out of Reach: A resident with right-sided hemiplegia/hemiparesis, dysphagia, and impaired cognition had a care plan directing staff to keep the call light within reach and working. During multiple observations, the call light was found out of reach, including on the bed frame, and the resident stated he could not reach it to request help with turning in bed and getting water; CNA and IPN both confirmed it was out of reach, and the DON stated call lights should be within residents' reach so they can notify staff when assistance is needed.
A resident with encephalopathy, cognitive communication deficit, and dementia was found to have signed a Notice of Medicare Non-Coverage even though the H&P and staff interviews indicated the resident lacked capacity to understand or make decisions. The resident was observed unable to respond to questions, while BOS and the ADM stated the signature was invalid and the resident’s responsible party should have been contacted for the form.
An LPN left an unattended med cart computer open with two residents' electronic records visible while administering medications. One resident had severe cognitive impairment and required extensive assistance with ADLs, and the other had moderate cognitive impairment and required help with multiple ADLs. The LPN stated she forgot to close or sign off the computer, and the DON confirmed the residents' health information was not protected.
A resident with dementia, gastroparesis, type 2 DM, and a gastrostomy tube had dried tan and brown spots on the G-tube pump, floor, floor mat, and nightstand near the bedside feeding setup. The IPN identified the residue as dried enteral feeding that had dripped and spilled, and stated the environment was visibly dirty and should have been clean and sanitary; the DON stated residents’ environments should always be clean and free from dirt.
Improper Use of Left Hand Mitten Restraint: A resident with dementia, anxiety, and ventilator dependence was ordered a left hand mitten for pulling at life-sustaining tubes, but staff treated it as an as-needed restraint. Surveyors observed the mitten in use at one point and later found the resident without it and without nursing staff present. The RN and DON stated the mitten was a restraint, required a prior restraint assessment, and should not be used on a prn basis; there was no documented restraint assessment or 30-minute monitoring record.
MDS assessments were inaccurate for three residents. One resident’s MDS listed a weight of 117 lbs instead of the weights documented in the chart, another resident’s MDS did not reflect anxiety and depression noted in psych records, and a third resident’s MDS failed to show facial BCC lesions that were present on skin assessment. The MDSRN stated the assessments did not reflect resident status at the time of the ARD, and the DON stated accurate MDS documentation is important for resident-centered care planning.
Failure to develop a care plan for a resident’s pressure injuries was identified during record review and staff interview. The resident had multiple pressure injuries, including unstageable wounds to the sacrum and heel, suspected DTI to the hip, and stage 2 wounds to the upper back and vertebrae. The MDSRN and DON stated there was no developed care plan for the right upper/mid back and hip wounds, even though each pressure ulcer should have a specific plan to guide treatment and care.
A resident with UTI, cerebral infarction, and multiple antibiotic resistance had an antibiotic change from Keflex to ceftriaxone after a urine culture was positive for Proteus mirabilis, but the care plan was not revised to reflect the current IV antibiotic or its side effects. The IPN and DON both stated the care plan should have been updated when the medication changed, and the facility’s care planning policy required revisions when a resident’s condition changed.
A resident with COPD and nicotine dependence was observed smoking in the smoking area, but the facility did not complete smoking assessments quarterly as required by policy. Another resident with dementia was seen walking out the front door multiple times and was later placed on a wander guard, yet no elopement or wandering assessment was completed. The DON stated both assessments were required by facility policy and were not followed.
A resident with severe cognitive impairment, dysphagia, and G-tube dependence was found with a white, crusted substance around the mouth on repeated observations. The care plan required maximum assistance with oral care, and staff gave conflicting statements about how often oral care was required, while the DON stated there was no specific oral care policy for dependent residents and the facility relied on Dental Services guidance.
A resident with facial BCC, depression, and dysphagia did not receive required weekly skin assessments for the BCC lesions, and the chart showed no weekly wound documentation after the initial assessment. The resident also had an oncology follow-up order and discharge instruction for outpatient oncology, but the SSD, CM, and assigned LVN were unaware of the need or had not coordinated an appointment or authorization.
Failure to Provide Ordered 1:1 Sitter Supervision: A resident with dementia, a femur fracture, and significant fall risk had an IDT recommendation, care plan intervention, and physician order for 1:1 sitter supervision after an unwitnessed fall and attempts to self-transfer. During observation, the resident was found alone in bed without the assigned sitter, while the RNA stated he was caring for another resident and had left the resident unsupervised.
Incomplete CNA Competency Validation: The facility failed to properly complete competency validation for two CNAs. Review of employee records showed CNA Master Competency Worksheets were incomplete, with skills checked off without documented observation or validation, and one CNA had items marked in the need improvement column with no revalidation documented. The DSD and DSD consultant confirmed the worksheets did not document the method of validation, and the facility assessment and policy required competency checklists after orientation and annually.
Improper G-tube Medication Administration: An LVN failed to follow the resident’s order and facility P&P during med pass for a resident with a G-tube, using water instead of air to check tube placement, mixing crushed meds with too much water in large cups, and not flushing the tube with the ordered amounts between and after medications. The DON and another LPN stated the correct process was to use measured water amounts and follow the resident’s order and care plan.
Incomplete Documentation of Oxygen Therapy: A resident with dementia, DM, and shortness of breath was observed receiving oxygen at 2 L/min via nasal cannula, but the Respiratory MAR did not document oxygen administration on two reviewed dates. RT and an LVN confirmed the resident received oxygen for increased secretions and stated it should have been recorded on the MAR, while the DON said the documentation was needed to verify the ordered therapy and track what treatments the resident was receiving.
Call Light Not Within Reach for a Resident With Quadriplegia and Upper Extremity Weakness. A resident with quadriplegia, impaired cognition, and dependence for multiple ADLs had a care plan directing staff to keep the call light within reach and respond promptly to requests for help. During multiple observations, the resident’s flat, sensitive call light pad was placed on the stomach or chest while the resident lay in bed with both arms under the blanket and stated he could not reach it. A roommate had to call staff for him, and CNA, OTA, and DON interviews confirmed the device was not placed appropriately for the resident to use.
A resident assessed as high risk for pressure ulcer development due to functional quadriplegia, muscle wasting, DM, bedfast status, and very limited mobility did not receive documented weekly skin assessments as required by the facility’s policy. The MDS coordinator, RN, and DON stated weekly skin checks should have been completed and recorded, but the EMR review showed no weekly skin assessment since readmission, with the last documented assessment occurring months earlier.
Missed Labetalol Doses Not Reported to Physician: A resident with HTN and hypertensive heart disease did not receive ordered labetalol 200 mg at the 6 AM dose on two consecutive days because the medication was not available. MAR entries and nursing notes showed the doses were held while waiting for delivery, and the DON confirmed the doses were not given. RN stated the physician should have been notified of the missed doses, but the record did not show that notification occurred.
A resident with COPD, dysphagia, ventilator dependence, and impaired cognition did not have a completed POLST form maintained in the medical record as required by facility policy. When the resident experienced chest pain and required EMS transfer to a GACH, staff, including an LVN, the administrator, and an NP, confirmed that the POLST—completed and dated earlier—was not available in the chart. This resulted in an incomplete medical record and the absence of readily accessible, actionable medical orders reflecting the resident’s end-of-life care preferences during an emergency.
A resident with severe cognitive impairment and a right elbow skin tear had a physician order for daily wound care, but nursing staff failed to consistently provide and document the ordered treatment on multiple days, and there was a lapse in having an active wound care order for a period of time. Review of the TAR and notes showed missing initials and entries for the ordered treatments, and staff confirmed that no treatment order was in place during part of the wound’s course, contrary to the facility’s wound management policy requiring necessary treatment and prompt physician guidance.
A resident with diabetes, protein-calorie malnutrition, and high Braden risk, fully dependent for mobility and enrolled in a turning/repositioning program, was not repositioned every two hours as required by the care plan and facility policy. Surveyors observed the resident lying on the same side for several hours, while the responsible party and roommate reported no repositioning during that time. A CNA stated she typically changed/repositioned the resident only around the start and near the end of the shift, and facility leadership confirmed residents were supposed to be repositioned q2h to prevent skin issues and pressure injuries.
A resident with paraplegia, a Stage 4 sacro-coccygeal pressure ulcer, bacteremia, immunodeficiency, and multidrug-resistant infection required ordered wound care to the sacral area. During an observed dressing change, a treatment nurse removed a soiled dressing and continued the wound care procedure without changing gloves or performing hand hygiene, despite facility PPE policy requiring single-use gloves and handwashing before and after glove removal. In interviews, the nurse and the DON confirmed that gloves should have been removed and hand hygiene performed before applying new gloves and continuing treatment.
A resident with multiple chronic conditions missed a scheduled dental cleaning because the Social Worker did not notify them of the appointment after receiving an email reminder. The resident was out on pass during the visit, and the facility's policy indicated the Social Worker was responsible for coordinating and communicating such appointments.
A resident with a history of G-tube dislodgement and severe cognitive impairment did not have a comprehensive, individualized care plan addressing her repeated behaviors of pulling at her G-tube. Despite multiple incidents and staff awareness of the issue, no specific interventions or interdisciplinary team meetings were documented to address the problem, leading to inconsistent care.
A resident with complex medical needs was transferred to a hospital, and although a 7-day bed hold was requested and confirmed, the facility assigned the resident's bed to another individual after only three days. When the hospital attempted to discharge the resident back, staff reported no available bed, resulting in the resident remaining hospitalized beyond the intended period.
A resident who was fully dependent on staff for personal care due to complex medical conditions was found with long, dirty fingernails and old nail polish, despite a care plan requiring regular nail maintenance. Staff interviews and observations confirmed that nail care was not provided as required by facility policy.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, resulting in a failure to meet individualized care requirements.
The facility did not maintain a working call light system for three nursing stations over several days, as confirmed by maintenance records, staff interviews, and direct observation. Despite policy requirements for immediate repair and hourly safety checks, the system remained non-operational, with incomplete documentation and delayed repairs, leaving multiple rooms without a functional alerting device for resident assistance.
The facility did not ensure timely and appropriate access to call lights for five residents, including delays in answering call lights, placing call lights on the side of a contracted limb, not keeping call lights within reach for residents in bed or wheelchairs, and failing to provide a suitable call device for a resident with hand mittens. These actions did not align with care plans or facility policy, impacting residents with significant cognitive and physical impairments.
Two residents were affected when staff failed to provide bedside fluids for a resident with multiple medical conditions and did not follow the facility's significant weight loss policy for another resident with ESRD on dialysis. Observations confirmed the absence of water at the bedside despite care plan requirements, and staff interviews revealed that required assessments and notifications were not completed after significant weight loss, contrary to facility policy.
Surveyors found that kitchen staff failed to label open food items with required information and did not discard expired foods, as confirmed by the Dietary Supervisor. Multiple items, including beets, cottage cheese, ranch dressing, tortillas, and peanut butter, were either expired or lacked proper labeling, in violation of facility policy and FDA Food Code.
Four outdoor trash dumpsters were observed overfilled with trash bags stacked above the brim, making it impossible to close the lids. The Dietary Supervisor confirmed that the lids should be closed but could not do so due to the excess trash, acknowledging the need for proper disposal to prevent pest infestation. Review of facility policy and FDA guidelines indicated that garbage should be stored in covered containers, but this was not followed.
Staff failed to maintain resident dignity and privacy by feeding a resident while standing above their eye level and by entering two residents' rooms without knocking. The affected residents had severe cognitive impairment and required extensive assistance, and staff acknowledged these actions were not in line with facility policy.
Several residents experienced unsanitary room conditions, including visible trash and soiled areas, and were unable to access hot water for bathing and hygiene. Residents and staff reported that water temperatures in showers and sinks were consistently below policy requirements, resulting in discomfort and missed showers. Facility policies required a clean, homelike environment and suitable water temperatures, but these standards were not met.
Three residents did not receive proper pharmaceutical services, including one who missed multiple doses of Marinol due to pharmacy delivery delays and lack of timely physician notification, another who received several scheduled medications late, and a third who had medications left at the bedside after refusal, contrary to facility policy.
Staff failed to follow infection prevention and control protocols, including not changing gloves or performing hand hygiene between tasks such as incontinence care, tracheostomy care, and medication administration for multiple residents. Staff also exited resident rooms wearing PPE and handled contaminated items without proper doffing or hand hygiene, contrary to facility policy.
A resident with mental health diagnoses and moderate cognitive impairment did not receive a required PASARR Level II evaluation because facility staff did not respond to multiple attempts to schedule the assessment. The case was closed without completion of the evaluation, and the responsible staff member did not submit a new screening as required by facility policy.
Two residents did not have individualized care plans addressing their specific needs: one with severe cognitive impairment and total dependence lacked a care plan for incontinence, while another with end stage renal disease and significant weight loss had no care plan for fluid restriction or weight management. Nursing staff and the DON confirmed these omissions, despite facility policies requiring comprehensive, resident-centered care plans.
A resident with a history of sepsis, tracheostomy, and severe cognitive impairment was weaned off a ventilator and placed on continuous oxygen via tracheostomy, but the care plan was not updated to reflect this change. The DON confirmed the care plan still focused on ventilator dependence, despite physician orders and current therapy indicating oxygen use via tracheostomy.
Failure to Assess and Plan for Elopement Risk
Penalty
Summary
The facility failed to provide adequate supervision, conduct a wandering and elopement risk assessment, and develop and implement an individualized care plan for a resident who later eloped from the facility. The resident was admitted with diagnoses including paranoid schizophrenia, generalized anxiety disorder, alcohol abuse disorder, and a history of an auto vs. pedestrian accident. The MDS dated 6/7/2026 indicated the resident had intact cognitive skills for daily decision making and required varying levels of assistance with dressing, toileting hygiene, bathing, personal hygiene, and bed mobility. The resident’s care plans from 6/2/2026 through 7/17/2026 did not address wandering behavior or elopement risk. The facility’s records also did not show a wandering and elopement risk assessment before the incident. Staff interviews indicated the resident was seen in different areas of the facility during the evening, but no staff observed him from 8 PM to 11 PM. CNA 1 stated she last saw the resident before dinner and later assumed he was in the dining room or walking around the facility. LVN 1 stated she last saw him walking near the west nursing station and was unsure where he went afterward. The resident was found missing during shift rounds, and staff conducted a room-by-room search and drove around neighboring streets to locate him. He was later found walking near the facility and returned after being gone for 12 hours. The resident stated he left because he wanted ice cream and thought he could leave and come back. A wandering and elopement risk assessment completed after his return scored him as moderately at risk. The DON stated the resident should have had a wandering and elopement assessment on admission and after significant functional improvement, and that the resident did not have the required care plan for wandering and elopement.
LAL Mattress Settings and Weekly Skin Assessments Not Completed
Penalty
Summary
The facility failed to ensure that low air loss (LAL) mattress settings were aligned with resident weight for two residents with pressure ulcers and skin breakdown. One resident was admitted and readmitted with diagnoses including type 2 diabetes mellitus with foot ulcer, gastrostomy status, and dysphagia, and was assessed as severely impaired in cognitive skills and dependent for multiple activities of daily living. The resident’s weight was documented as 113 pounds, and the care plan directed that the LAL mattress be set according to resident weight, comfort, and manufacturer setting. During observation, the mattress machine was set in a range of 280 to 320 pounds, and staff confirmed the setting should have matched the resident’s body weight. A second resident was admitted with diagnoses including muscle wasting, atrophy, and multiple pressure ulcers, including unstageable ulcers of the sacrum and left heel, a suspected deep tissue injury of the right hip, and stage 2 wounds on the right upper back and vertebrae. The resident was also documented as having severely impaired cognitive skills and requiring assistance with care activities. The resident’s LAL mattress machine was observed set in a range of 80 pounds to zero pounds, while the resident’s last documented weight was 113 pounds. Staff stated the mattress setting should have been based on the resident’s body weight, and the DON stated it was important to ensure the mattress was set correctly for treatment and prevention of pressure ulcers. The facility also failed to complete and document weekly skin assessments for the second resident after the initial assessment on 6/17/2026. Review of the electronic medical record showed no weekly skin assessments for the weeks after that date through the survey review period. Staff confirmed that no weekly skin assessments had been completed after 6/17/2026, that the wound care nurse was responsible for completing and documenting them, and that the resident should have had weekly skin assessments documented in the chart. The facility’s policies for pressure ulcer prevention and wound management required weekly skin assessments and weekly wound documentation until healing.
Missed Dialysis Treatments and Fluid Restriction Not Followed
Penalty
Summary
Dialysis care was not provided as ordered for two residents who were dependent on renal dialysis. One resident had diagnoses including metabolic encephalopathy, dependence on dialysis, and end stage renal disease, and the MDS indicated severely impaired cognitive skills and extensive assistance needs with multiple activities of daily living. The physician order required dialysis on Tuesday, Thursday, and Saturday with a 6:00 AM chair time and pickup between 5:15 AM and 5:30 AM. Progress notes documented that the resident did not go to dialysis on three occasions because there was no escort available, and staff interviews confirmed that the missed treatments were related to miscommunication and failure to assign or notify escorts in advance. Facility staff stated that the resident’s dialysis transport was by courtesy ride and required an escort, which was to be a CNA or activity staff member. The CM, DSD, ADSD, CNA 4, CNA 5, DBD, and DON all described breakdowns in communication about who was assigned to escort the resident and when the resident was to be picked up. Staff stated that on one occasion the resident missed dialysis because the assigned CNA was not informed, on another because the resident was readmitted and the dialysis pickup time was misunderstood, and on another because the assigned escort was not notified. The DON stated that missing one to two days of dialysis was unacceptable and that the dialysis policy was not followed. A second resident with diagnoses including type 2 diabetes mellitus, ESRD, and dependence on dialysis also missed scheduled dialysis treatments because of no escort and transportation issues. Progress notes documented missed dialysis on two occasions, and the resident stated he had missed dialysis a couple of times because of no transportation or escort staff available. Staff interviews confirmed that there were no staff available to accompany the resident to dialysis and that facility staff, including nursing and the CM, were responsible for arranging transportation. The facility’s dialysis policy stated that the facility would arrange dialysis care and transportation to and from the dialysis provider. The same resident also had a physician order for a 1200 cc per day fluid restriction, but a water pitcher was observed at the bedside during multiple observations. The resident stated the pitcher was used for drinking and that staff refilled it with ice and water, and also stated he was not prescribed fluid restrictions. An LVN stated the resident should not have a water pitcher at the bedside because staff would not be able to measure intake or ensure compliance with the fluid restriction. The DON stated the pitcher should not have been at bedside per facility protocol, and the facility’s fluid restriction policy stated that the licensed nurse would educate the resident or responsible party, initiate intake measurement, and remove the water pitcher.
Medication Administration Error Rate Exceeded Threshold
Penalty
Summary
The facility failed to keep its medication error rate below 5 percent. During observation, interview, and record review, surveyors identified 2 medication errors out of 25 observed medication administration opportunities, resulting in an 8 percent medication error rate for one sampled resident who was observed during medication pass. The deficiency involved Resident 56, who had diagnoses including encephalopathy, gastroparesis, and gastrostomy tube malfunction, and whose MDS indicated severely impaired cognitive skills and dependence for multiple activities of daily living. Resident 56 had physician orders for bethanechol 25 mg via G-tube three times daily, a multivitamin via G-tube daily, and flushing the enteral tubing with at least 5 to 15 ml of water in between each medication. The care plan also directed staff to use 10 ml of water to mix crushed medications. During the observed medication preparation, an LVN crushed the bethanechol and multivitamin, placed them in medication cups, then transferred them into a large clear plastic cup and added approximately 50 ml of water to each medication. The LVN also poured approximately 120 ml of water into another clear plastic cup for flushing. During administration, the LVN gave the medications via G-tube and then used the remaining water in the clear plastic cup, approximately 50 ml, to flush the tube. The LVN stated she did not measure the water added to the medications and did not flush the G-tube with 5 to 15 ml of water in between each medication or with 20 to 30 ml after administration. The LVN later stated she flushed the tube with the remaining water after giving the medications and did not know she had to flush with 10 ml of water in between medications. The DON stated crushed medications should be mixed with approximately 10 ml of water, the G-tube should be flushed with 20 to 30 ml before and after medication administration, and the amount of water should be measured. Facility policy required medications to be administered per physician order and feeding tube medications to be diluted appropriately, given separately, flushed with 5 cc of warm water in between each medication, and flushed with 30 cc after the final medication.
Unsecured Medication Cart and Iced Medication Refrigerators
Penalty
Summary
Medication carts and medication refrigerators were not maintained in accordance with the facility’s medication storage policy. During observation, MC 1 was left unattended and unlocked while resident medications were visible in the first and second drawers. LVN 2 stated he did not lock the cart before stepping away from it. On another observation, LVN 4 was seen failing to lock MC 1 before entering resident rooms, and later stated she forgot to lock the cart before going into the rooms. The DON stated medication carts in the facility should not be left unlocked and unattended, and that the policy for medication storage was not followed. Two medication refrigerators also had built-up ice. During observation and interview, Medication Refrigerator 1 was found with ice buildup, and RNS 1 stated this was not acceptable because it may affect the temperature of the fridge and the efficacy of refrigerated medications. Medication Refrigerator 2 was observed with almost half of the freezer compartment filled with built-up ice, and LVN 1 stated it should have been defrosted because it can impact refrigerator temperature quality. RNS 2 was unable to state or provide documented evidence of when Medication Refrigerators 1 and 2 were last defrosted. The facility policy stated medications and biologicals are to be stored safely, securely, and properly, and medication rooms, carts, and supplies are to be locked or attended by authorized persons.
Incorrect Portion Sizes Used for Lunch Meal Servings
Penalty
Summary
The facility failed to follow the dietary menu and use the correct measuring scooper for lunch servings of ranch style beans and brown rice on 7/9/2026. The Summer Menu directed staff to use a #12 scooper for ranch style beans for residents on controlled carbohydrate and regular diets, and a #12 scooper for brown rice for residents on renal and low fat/cholesterol diets. During observation in the kitchen, [NAME] 1 was seen using a #8 scooper for the ranch style beans and an unmeasured scooper for the brown rice while serving residents' plates. During the concurrent interview and record review, the Dietary Supervisor and [NAME] 1 reviewed the Summer Menu and confirmed the menu required a #12 scooper for both items. [NAME] 1 stated she used the wrong sized scoopers for the ranch style beans and brown rice and should have followed the scooper sizes indicated on the menu. The Dietary Supervisor stated staff are to follow the recipe and provide residents with the exact portion sizes indicated to ensure residents get the right nutrition to maintain and improve their health. The Diet Type Report showed 16 residents on a CCHO diet, 12 on a regular diet, 3 on a renal diet, and 1 on a low fat/cholesterol diet who could have been affected by the portioning error.
Food Served Below Required Temperature
Penalty
Summary
Dietary staff failed to ensure food was served at an appetizing and proper temperature during lunch on 7/9/2026, as observed during a concurrent observation and interview with the Dietary Supervisor. The Dietary Supervisor was seen taking temperatures on a test meal tray that included pork loin, ranch style beans, and southern style green beans, and the recorded temperatures for all three items were 116 degrees Fahrenheit. The Dietary Supervisor stated the food temperatures should be more than 140 degrees Fahrenheit and that the food items were too cold. A later interview with the Dietary Supervisor confirmed that dietary staff should ensure served food is above 140 degrees Fahrenheit to keep it safe for residents to eat. Review of the facility policy titled Food Temperatures, reviewed 1/1/2026, showed that foods prepared and served in the facility are to be served at proper temperatures for food safety and that meat, entrees, and vegetables are required to be served at greater than 140 degrees Fahrenheit.
Improper Food Storage and Unsanitary Tray Line Practices
Penalty
Summary
The facility failed to ensure proper food handling and food storage practices in accordance with its policy and procedure. During a concurrent observation and interview in the kitchen with the Dietary Supervisor, surveyors observed one bag of cocoa powder stored in a partially closed bag inside a cardboard box in dry storage, and a refrigerated container of pumpkin labeled with an expiration date of 7/5/2026. The Dietary Supervisor stated that all foods should be stored according to policy. The facility policy titled, Food Storage, dated 1/1/2026, indicated food items are to be stored, thawed, and prepared in accordance with good sanitary practice, and opened products are to be placed in storage containers with tight fitting lids in dry storage. The facility also failed to maintain sanitary measures during food preparation and serving on tray line. During observation in the kitchen, the Dietary Supervisor intermittently left the cooking area and then used a gloved hand to open the refrigerator door and touch personal clothing before returning to prepare cornbread and handle cooking and serving utensils without changing gloves or performing hand hygiene. During interview, the Dietary Supervisor stated he should have changed his gloves and performed hand hygiene after touching his clothing and the refrigerator door handle, and stated food should be prepared and served in a sanitary manner to prevent residents from getting sick and to reduce the risk of foodborne illness. The facility's policy titled, Dietary Department - General, indicated the dietary department will maintain standards for sanitation and safety and that staff should maintain intact disposable gloves in good condition that are changed appropriately to reduce the spread of infection.
Resident Refrigerator Temperature Above Required Limit
Penalty
Summary
The facility failed to follow its policy and procedure for the use and storage of foods brought to residents by family and other visitors by not maintaining one resident refrigerator at the required temperature. During a concurrent observation and interview in the Activity/Dining Room, the resident refrigerator was observed at 51 degrees F, and the DS stated that refrigerator temperatures should be maintained at 41 degrees F or below to keep food safe for residents to eat. The DS also stated that the food items in the residents' refrigerator were brought in by residents' family and visitors. Review of the facility's policy titled, Refrigerator/Freezer Temperature Records, dated 1/1/2026, showed that refrigerator temperature must be 41 degrees F or below.
Hand Hygiene, Catheter Care, and Oxygen Equipment Storage Failures
Penalty
Summary
The facility failed to provide required infection prevention and control measures during medication administration for four residents when LVN 4 repeatedly removed soiled gloves and did not perform hand hygiene before leaving resident rooms or before charting. Resident 56 had diagnoses including encephalopathy, gastroparesis, and G-tube malfunction, and was on enhanced barrier precautions related to a G-tube and a history of Candida auris. Resident 88 had Parkinsonism, type 2 DM, and major depressive disorder; Resident 32 had metabolic encephalopathy, cerebral infarction, and schizophrenia; and Resident 73 had a head injury, UTI, and paranoid schizophrenia. During observations, LVN 4 checked vital signs, prepared medications, administered medications through a G-tube or directly to residents, removed gloves, and exited rooms without hand hygiene on multiple occasions. The report also documented that indwelling catheter drainage bags for Residents 82, 2, and 95 were touching the floor. Resident 82 had an indwelling catheter ordered for obstructive and reflux uropathy and was observed asleep in bed while the drainage bag touched the floor. Resident 2 had diagnoses including hemiplegia, hemiparesis, dysphagia, carcinoma of the penis, and urine retention, and his catheter drainage bag was observed touching the floor at bedside. Resident 95 had diagnoses including malignant neoplasm of the prostate and obstructive and reflex uropathy, had an indwelling Foley catheter ordered, and his drainage bag was also observed touching the floor. The facility’s catheter care policy stated collection bags should be kept below bladder level and should not touch the floor. Resident 56’s respiratory equipment was also observed in an unclean condition. A plastic bag containing an oxygen mask and tubing was found on the floor under the resident’s bed, and RNA 1 picked up the bag and equipment from the floor, removed the mask and tubing from the bag, and placed the oxygen mask into another plastic bag stored in a nightstand drawer. Resident 56 had dementia, type 2 DM, and shortness of breath, and had an order for oxygen at 2 liters per minute via nasal cannula as needed. The facility’s oxygen administration policy stated oxygen tubing, masks, and cannulas are to be stored in a plastic bag at the bedside and changed when visibly soiled, and the infection prevention and control program required a safe, sanitary, and comfortable environment to help prevent disease and infection.
Failure to Maintain Privacy During Emergency Care
Penalty
Summary
The facility failed to provide privacy for one resident during emergency care when the bedside curtain between Bed B and Bed A was left open while the resident was receiving treatment from paramedics and facility staff for chest pain. During the observation, the resident in Bed A and that resident’s visitor were able to watch the resident receiving care, and the visitor of the resident in Bed C was also seen peeking through the curtain. The Infection Prevention Nurse was present near the foot of Bed A while paramedics performed assessments, including vital signs and an EKG. Resident 1 was admitted with diagnoses including quadriplegia, tracheostomy status, and second degree burn of the face. The MDS dated 6/7/2026 indicated the resident had severely impaired cognitive skills for daily decision making and was dependent in toileting hygiene, bathing, dressing, footwear, and personal hygiene. The DON stated residents should be treated with respect and dignity and that privacy should be provided while care is rendered. The facility policy on Privacy and Dignity stated the facility respects residents’ private space and property and that residents are afforded a right to privacy and confidentiality.
Call Light Out of Resident Reach
Penalty
Summary
The facility failed to ensure the call light was within reach for one sampled resident. Resident 2 was admitted with diagnoses including right-sided hemiplegia and hemiparesis, dysphagia, carcinoma of the penis, and urine retention. The admission MDS dated 6/15/2026 indicated Resident 2 had moderately impaired cognitive skills for daily decision making and was dependent with eating, dressing, shower/bathing, oral, personal, and toileting hygiene. Resident 2's care plan for risk for falls related to confusion and gait/balance problems, dated 6/12/2026, directed staff to ensure the call light was within reach and working and to provide a prompt response to all requests for assistance. During observation and interview on 7/7/2026, Resident 2's call light was observed out of reach, and the resident stated he needed help turning in bed and was unable to reach the call light to call for assistance. CNA 2 also observed the call light out of reach and stated it should not be. On 7/9/2026, the IPN observed the call light positioned on the bed frame and out of reach after Resident 2 stated he needed assistance with water and could not reach the call light. The IPN stated the call light was out of reach and should not be. The DON stated it was important to ensure call lights were within residents' reach so residents can notify staff when they need assistance.
Medicare Non-Coverage Notice Signed by Resident Without Capacity
Penalty
Summary
The facility failed to ensure the Notice of Medicare Non-Coverage for one sampled resident was signed by the responsible party. The resident had diagnoses including encephalopathy, cognitive communication deficit, and dementia, and the admission record showed two individuals listed as responsible parties. The resident’s H&P stated the resident did not have the capacity to understand and make decisions, and the MDS indicated severe cognitive impairment with extensive assistance needed for activities of daily living. The Notice of Medicare Non-Coverage, dated 5/7/26, was signed as if the resident received and understood the notice. However, during observation the resident was awake in bed and did not respond to questions. A CNA stated the resident had dementia and was unable to comprehend or respond to communication attempts. A business office staff member stated the resident did not have the mental capacity to make an informed decision and sign a legal document, and that the facility should contact the responsible party for signature or mark the document unable to complete if no one was available. The administrator also stated the resident did not have the mental capacity to make decisions and the signature was invalid, and the facility should have contacted the responsible party or family member. The facility policy stated the resident’s representative should be contacted when the resident is not competent to sign the form.
Unattended Computer Left Resident Records Exposed During Medication Administration
Penalty
Summary
Facility staff failed to keep resident medical records private and confidential when electronic medical information was left visible on an unattended computer during medication administration. The deficiency involved two sampled residents, Resident 88 and Resident 32, whose records were displayed on the screen while the nurse stepped away from the medication cart and entered their rooms to provide care. Resident 88 was admitted with diagnoses including Parkinsonism, type 2 diabetes mellitus, and major depressive disorder. The MDS dated 6/11/2026 indicated Resident 88 had severely impaired cognitive skills for daily decision making and required varying levels of assistance with eating, bed mobility, toileting/personal hygiene, dressing, bathing, and transfers. On 7/9/2026 at 4:51 PM, LVN 4 removed Resident 88's blood glucose monitor and gabapentin from the medication cart, verified the medication orders on the computer on top of the cart, did not turn off the computer, and left the resident's medical record information exposed on the screen before entering the room to check blood sugar and administer gabapentin. Resident 32 was admitted and later readmitted with diagnoses including metabolic encephalopathy, cerebral infarction, and schizophrenia. The MDS indicated moderately impaired cognitive skills for daily decision making and dependence or partial/moderate assistance with several activities including eating, toileting hygiene, bathing, dressing, bed mobility, and transfers. On 7/9/2026 at 5:01 PM, LVN 4 removed Resident 32's Prostat and risperidone, verified the medication orders on the computer, and entered the room without turning off the computer or signing out, leaving the resident's information exposed. LVN 4 later stated she forgot to close or sign off the computer and acknowledged that leaving the information unprotected was a HIPAA violation. LVN 2 and the DON also stated staff should close or sign out of the computer to protect resident information, and the facility policy stated medical records must be kept secure and confidential.
Dirty Resident Environment Around G-Tube Feeding Area
Penalty
Summary
The facility failed to ensure the environment for Resident 56 was clean and free of dirt in accordance with its policy and procedure titled, Resident Rooms and Environment. Resident 56 was admitted with diagnoses including dementia, gastroparesis, type 2 DM, and gastrostomy, and the annual MDS indicated severely impaired cognitive skills for daily decision making and dependence for oral, personal, toileting, dressing, and shower/bathing care. The resident also had an enteral feeding order for Glucerna 1.5 via gastrostomy tube pump at 40 cc/hour for 20 hours. During an observation at the resident’s bedside, dried tan and brown spots were seen on the G-tube pump, floor, floor mat, and nightstand table. On a later concurrent observation and interview, the same dried spots were still present, and the IPN stated the resident’s environment was visibly dirty and that dried enteral feeding had dripped and spilled on the G-tube pump, floor, floor mat, and nightstand. The IPN stated the environment should have been cleaned up and should be clean and sanitary. The DON stated residents’ environments should always be clean and free from dirt to ensure quality of care and a homelike environment.
Improper Use of Left Hand Mitten Restraint
Penalty
Summary
The facility failed to ensure that Resident 25 was free from the use of a physical restraint in accordance with its Restraints policy. Resident 25 was admitted with diagnoses including dementia, anxiety, and dependence on ventilator status, and the Quarterly MDS indicated severely impaired cognitive skills for daily decision making, substantial/maximal assistance with some activities of daily living, and dependence for others. The resident’s order summary showed an order for a left hand mitten due to attempting to pull out life-sustaining tubes, transcribed by RNS 2. During observation, Resident 25 was seen with the left hand mitten in place, but during a later observation the resident was seen without the mitten and without nursing staff at bedside. MDSRN stated the resident did not and should have a hand mitten on the left hand. During interview, RNS 2 stated the mitten was only applied on an as-needed basis, and MDSRN stated the order could be understood as as-needed because it said the resident may have the left hand mitten. MDSRN also stated there was no restraint assessment prior to use of the mitten and no documented evidence that the resident was observed or checked every 30 minutes while restrained. The DON stated the mitten is a device that limits hand movement and is considered a restraint, that a restraint assessment should be completed before use, and that restraints like the resident’s left hand mitten should not be used on an as-needed basis. The facility policy stated restraints would not be used for convenience or on a prn basis, required an RN assessment before application of any device that restricts movement or access to the body, and required observation at least every 30 minutes.
MDS assessments did not accurately reflect resident weights, psychiatric diagnoses, or skin lesions
Penalty
Summary
The facility failed to ensure the MDS accurately reflected resident status for three sampled residents. For Resident 13, the medical record showed a weight of 103 lbs on 3/5/2026 and 101.0 lbs on 6/5/2026, but the significant change MDS and quarterly MDS both documented the resident’s weight as 117 lbs. Resident 13’s diagnoses included metabolic encephalopathy, protein calorie malnutrition, and dementia, and the MDSRN stated the documented weights did not reflect the resident’s correct weight at the time of assessment. For Resident 25, the admission record listed dementia, anxiety, and ventilator dependence. Psychiatric notes dated 5/2/2026 documented a history of dementia and anxiety and also included depression. The quarterly MDS identified severe cognitive impairment and symptoms including feeling down, depressed, hopeless, sleep disturbance, fatigue, and trouble concentrating, but the MDSRN stated the diagnoses of anxiety and depression were not reflected on the MDS and should have been. The DON stated it was important for the MDS to be accurate to ensure development and implementation of an individualized resident care plan. For Resident 86, the admission record listed BCC of the skin of unspecified parts of the face, major depressive disorder, and dysphagia. A skin weekly assessment dated 6/17/2026 documented facial BCC lesions with granulation and necrotic tissue present. However, the admission MDS indicated no ulcers, wounds, or skin problems were present. The MDSRN stated the resident had facial cancer lesions at the time the assessment was completed and that open lesions should have been reflected on the MDS. The facility policy stated all information recorded within the MDS assessment must reflect the resident’s status at the time of the ARD.
Failure to Develop Pressure Injury Care Plan
Penalty
Summary
Failure to develop a care plan to address Resident 71’s pressure injuries was identified during interview and record review. Resident 71 was admitted with diagnoses that included muscle wasting and atrophy, pressure ulcer of the sacral region, pressure ulcer of other site, pressure ulcer of the left heel, and pressure-induced deep tissue damage of the right hip. The admission Skin Observation Check dated 6/14/2026 documented pressure injuries to the left heel as unstageable, sacrum as unstageable, right hip trochanter as suspected deep tissue injury, right upper back as stage 2, and vertebrae (upper mid right) as stage 2. The admission MDS dated 6/17/2026 indicated severely impaired cognitive skills for daily decision making and need for substantial/maximal assistance with showering/bathing and toileting hygiene, partial/moderate assistance with oral and personal hygiene, and supervision or touching assistance with eating. It also indicated the resident had one or more unhealed pressure ulcers/injuries. During concurrent interview and record review, the medical record from 6/13/2026 through 7/10/2026 did not indicate a developed care plan to address the pressure ulcer on the right upper back, right mid back, and right hip. The MDSRN stated Resident 71 did not have a developed care plan for the right upper and mid back and hip pressure ulcers, and that each pressure ulcer should have a specific care plan addressing the specific treatments and care for that wound. The DON stated Resident 71 should have a developed care plan for each pressure ulcer to ensure proper steps and care were planned and provided, and acknowledged the resident’s pressure ulcer may not receive the proper care without a developed care plan.
Failure to Update Care Plan After Antibiotic Change for UTI
Penalty
Summary
The facility failed to update and revise the care plan for a resident with a urinary tract infection after the resident’s antibiotic therapy changed from Keflex to ceftriaxone. Resident 81 was admitted with diagnoses including cerebral infarction, resistance to multiple antibiotics, and UTI. The resident’s MDS dated 5/14/2026 showed intact memory and cognitive skills for daily decision making, partial/moderate assistance with upper body dressing, personal hygiene, sit to lying, and rolling, and substantial/maximal assistance with toileting hygiene, showering/bathing, and lower body dressing. The resident’s order summary showed ceftriaxone sodium 1 gram IV daily for 5 days starting 7/8/2026 for UTI. The SBAR form dated 7/8/2026 documented a change in condition and a urine culture positive for Proteus mirabilis, with the physician ordering Keflex discontinued and Rocephin started. During interview and record review, the IPN stated the antibiotic therapy care plan had not been revised after the change to ceftriaxone and should have been updated to reflect the current antibiotic and its specific side effects. The DON stated the care plan should have been updated when Keflex was discontinued and ceftriaxone was ordered, and that the policy for care plan revision was not followed.
Missed Smoking and Elopement/Wandering Assessments
Penalty
Summary
The facility failed to complete a quarterly smoking assessment for a resident with chronic respiratory failure, COPD, and nicotine dependence who was observed smoking in the facility smoking area while seated in a wheelchair. The resident was supervised by facility staff and the MDS nurse at the time of observation, and the resident stated he kept his own cigarettes and lighter and did not need protective clothing while smoking. Review of the resident’s smoking assessments showed they were completed only on several scattered dates between 4/20/2022 and 7/1/2026, and the RN supervisor stated the assessments were not completed quarterly as required. The DON stated that smoking assessments should be completed upon admission, quarterly, and as needed for residents who smoke, and that the results are reviewed by the IDT to evaluate the resident’s smoking care plan and interventions. The facility’s Smoking policy, revised 3/24/2023, stated that all smokers are to be assessed for smoking safety at admission and at least quarterly in accordance with OBRA assessment timeframes, and that the licensed nurse provides the smoking assessment for IDT review. The DON stated the facility’s smoking policy was not followed. The facility also failed to conduct an elopement and wandering assessment for a resident with dementia, behavioral metabolic encephalopathy, and anxiety disorder who had a wander guard applied after staff observed her walking out the front door a few times in May 2026. The resident’s MDS indicated severe cognitive impairment and no wandering behavior, but the medical record did not contain an elopement assessment. An LVN stated she reported the resident’s wandering to supervision, and the RN supervisor stated she had not completed any specific elopement or wandering assessment and only called the physician for a wander guard order. The DON stated such assessments are to be completed upon admission, readmission, quarterly, and with significant change in condition, and the facility’s policy required the licensed nurse and IDT to assess wandering/elopement risk and document preventative interventions.
Failure to Provide Oral Care for a Dependent Resident
Penalty
Summary
The facility failed to provide oral care for one sampled resident who was unable to perform self-care. Resident 19 was admitted and readmitted to the facility with diagnoses including type 2 diabetes mellitus with foot ulcer, encounter for attention to gastrostomy, and dysphagia oral pharyngeal phase. The resident’s MDS dated 5/29/2026 indicated severe cognitive impairment and dependence for oral hygiene, toileting hygiene, bathing, dressing, footwear, rolling, and sitting to lying. The care plan for ADL, initiated on 5/31/2025, stated the resident required maximum assistance by one staff member with personal hygiene and oral care, with interventions to help brush the resident’s teeth and provide oral care. During observation, Resident 19 was noted to have a white, crusted substance around the mouth on 7/7/2026 and again on 7/8/2026. CNA 1 stated oral care was very important for dependent residents to keep the mouth clean, prevent white, crusted substance, prevent infection, and maintain dignity. CNA 3 stated CNAs only required providing oral care once a day, but also stated oral care was important for dependent residents for the same reasons. LVN 1 stated CNAs were expected to provide oral care to Resident 19 each shift and that oral care helps prevent serious infections such as aspiration pneumonia, other infections, and oral diseases, while maintaining dignity. The DON stated there was no specific policy for oral care for dependent residents and that the facility used Dental Services as a guide; the facility policy stated that if a resident is unable to perform self-oral care, staff should provide privacy, place an emesis basin in front of the resident, and brush the resident’s teeth.
Failure to complete weekly wound assessments and arrange oncology follow-up
Penalty
Summary
The facility failed to ensure weekly skin assessments were completed for one resident’s facial basal cell carcinoma lesions. The resident was admitted with diagnoses including basal cell carcinoma of the skin, major depressive disorder, and dysphagia. The admission skin weekly assessment documented facial BCC lesions with granulation and necrotic tissue present, and the resident’s MDS indicated intact cognitive skills for daily decision making and varying levels of assistance with activities of daily living. A review of the resident’s electronic medical record showed no completed weekly skin assessments for the facial BCC lesions after the assessment dated 6/17/2026. During interview, the DON stated the resident did not have completed weekly skin assessments documented after that date but should have. The MRD also stated the medical record did not have any weekly skin assessments completed after 6/17/2026. The DON stated weekly skin assessments were important to determine whether the ulcers were improving or declining, whether treatments were effective, or whether new treatment orders were needed. The facility also failed to carry out a follow-up oncology appointment for the resident in accordance with the physician order and discharge instructions. The resident’s GACH discharge instructions called for outpatient oncology follow-up, and the order summary reflected an outpatient oncology follow-up order. The SSD stated no appointment date or time had been documented, no authorization or follow-up actions had been completed, and no oncology appointment had been coordinated. The LVN assigned to the resident stated he was unaware of the need and physician order for the oncology follow-up, and the CM stated she was not aware of the order and had not arranged authorization or requested an oncology appointment prior to the review.
Failure to Provide Ordered 1:1 Sitter Supervision
Penalty
Summary
The facility failed to ensure a 1:1 sitter was provided for a resident with dementia, a femur fracture, muscle wasting, and atrophy, despite the resident’s fall risk assessment showing overestimating or forgetting ambulation limits and a weak gait. After an unwitnessed fall, the interdisciplinary team post-fall review documented that the resident had been attempting to self-transfer and getting in and out of bed before the fall, and the team recommended a 1:1 sitter. The resident’s care plan was revised to include a 1:1 sitter, and the physician’s orders later indicated the resident may have 1:1 sitter. During a concurrent observation and interview, the resident was found lying in bed without a 1:1 sitter or staff at bedside. The Infection Preventionist Nurse stated the resident was alone and unsupervised and should have had a 1:1 sitter because of fall risk. A Restorative Nurse Assistant stated he was supposed to be the resident’s 1:1 sitter but was assisting another resident behind a closed privacy curtain, leaving the resident unsupervised. The DON reviewed the facility’s sitter policy, which described the sitter’s role as providing companionship and notifying staff when taking a break or when away from the resident, and stated the resident should not have been left unattended and without staff at bedside.
Incomplete CNA Competency Validation
Penalty
Summary
The facility failed to ensure that competency and skill sets were completed for two of five sampled nursing staff in accordance with the facility assessment and policy and procedures. During a concurrent review and interview, the Director of Staff Development reviewed Certified Nurse Assistant 4's employee record and stated the CNA Master Competency Worksheet dated 5/1/2026 was incomplete and not conducted correctly. The DSD stated some checklist items were marked without validating the CNA's skills, and that the CNA's skills should have been observed and validated to confirm competency in providing care to residents. During a concurrent review and interview, the DSD consultant reviewed Certified Nurse Assistant 5's employee record and verified that the CNA Master Competency Worksheet dated 6/4/2026 was incomplete and not conducted correctly. The DSD consultant stated some skills were checked off in the need improvement column with no documented evidence of revalidation of skills. The consultant also stated the DSD did not indicate the method of validation for the competency skills checked off for both CNAs 4 and 5, and the Key and Comments column was blank. The facility assessment stated CNAs are required to have a competency checklist after orientation and annually, and the facility's Competency Evaluation policy stated a skills checklist will be completed for each nursing staff to ensure related services provided in the facility are maintained.
Improper G-tube Medication Administration
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of one resident with a G-tube by not following the resident’s physician orders and the facility’s policy during medication administration. Resident 56 had diagnoses including encephalopathy, gastroparesis, dysphagia, and gastrostomy malfunction, and the care plan directed staff to mix crushed medications with 10 ml of water and flush the tube with 20 to 30 ml of water before and after medication administration. The resident’s MDS indicated severely impaired cognitive skills and dependence for multiple activities of daily living, and the resident had a G-tube for feeding and medication administration. During an observed medication pass, an LVN crushed bethanechol and a multivitamin, placed each in large clear plastic cups, and added approximately 50 ml of water to each cup rather than using a measured 10 ml. The LVN then entered the resident’s room, turned off the tube feeding, checked residual with a 60 ml syringe, and used approximately 50 ml of water to check G-tube placement instead of air. The LVN administered bethanechol and the multivitamin with approximately 60 ml of water each, then used the remaining approximately 50 ml of water to flush the tube. The LVN stated she did not measure the water added to the medications, did not flush 5 to 15 ml of water between the two medications, and did not flush 20 to 30 ml after medication administration as ordered. The LVN later stated she checked placement by flushing water into the tube and acknowledged the correct method was to use air and listen for gurgling. The DON and another LVN stated the correct practice was to use measured amounts of water, flush between medications, and follow the physician’s order and care plan. The facility policy required checking tube placement with air, diluting medications appropriately, giving medications separately, flushing with 5 cc between medications, and flushing with 30 cc after the final medication.
Incomplete Documentation of Oxygen Therapy
Penalty
Summary
The facility failed to maintain accurate and complete medical records for a resident receiving oxygen therapy by not documenting oxygen administration in the MAR. The resident was admitted with diagnoses including dementia, type 2 diabetes mellitus, and shortness of breath, and the order summary indicated oxygen at 2 L/min via nasal cannula as needed due to increased respiratory secretions every 24 hours. The resident’s annual MDS showed severely impaired cognitive skills for daily decision making and dependence for oral, personal and toileting hygiene, dressing, and shower/bathing self. During observation, the resident was seen receiving oxygen at 2 L/min via nasal cannula at the bedside. A review of the Respiratory MAR showed no documented oxygen administration on two dates in the month reviewed, even though the respiratory therapist stated the resident had received oxygen therapy on those dates and that the resident received oxygen continuously and daily along with other respiratory care because of respiratory secretions. An LVN also stated the resident had shortness of breath and was given oxygen 2 L for increased secretions, and that the oxygen should have been documented on the MAR. The DON stated oxygen therapy provided to the resident should have been documented on the MAR to ensure the resident was receiving oxygen as ordered and to allow staff to accurately know what treatments the resident was receiving and how often.
Call Light Not Kept Within Reach for Resident With Limited Upper Extremity Movement
Penalty
Summary
The facility failed to ensure that a working call system was available within reach in a resident’s room. Resident 17 was admitted and later readmitted with diagnoses including quadriplegia, abnormal posture, and muscle wasting and atrophy. The resident’s care plan, revised on 5/29/2026, identified fall risk related to right side weakness, confusion, and a left above-the-knee amputation, and directed staff to keep the call light within reach, encourage its use for assistance, and provide prompt response to requests for help. The MDS dated 6/1/2026 showed moderately impaired cognitive skills for daily decision making, substantial/maximal assistance needed for eating, oral/personal hygiene, and upper body dressing, and dependence for toileting hygiene, showering/bathing, lower body dressing, and lying to sitting on the side of the bed. During observation and interview on 7/7/2026, Resident 17 was lying in bed with both arms under the blanket, and the call light pad was placed on top of the resident’s stomach. The resident stated he could not reach the call light pad because he was not able to move his arms and hands, and said he had told different staff members that it should be placed where he could reach it, but staff continued to put it on top of his stomach. The resident stated he usually hollered for staff when he could not reach the call light pad, and that on some occasions his roommates called staff for him when they heard him yell for help. Additional observations on 7/9/2026 showed the call light pad again placed on top of the resident’s stomach and later on top of the resident’s chest while the resident remained in bed with both arms under the blanket. A roommate stated he had called staff for Resident 17 when the resident could not reach the call light pad. CNA 6 stated the resident used a flat, round, sensitive-to-touch call light pad for residents with paralysis or upper extremity weakness and that it should be placed on the side of the resident’s head so he could trigger it when turning his head. OTA 1 stated the call light pad should have been within the resident’s reach and not on the chest because it was too high for the resident. The DON stated staff should know which side or extremity was stronger to place the call light correctly, that it could be placed on the side of the resident’s head if he could not move his upper extremities, and that placing it on the resident’s chest was not appropriate because the resident could not reach it to ask for assistance.
Failure to Complete and Document Weekly Skin Assessments for High-Risk Resident
Penalty
Summary
The facility failed to complete and document weekly skin assessments for one resident who was assessed as high risk for pressure ulcer development from 12/29/2025 to 3/2/2026, in accordance with the facility’s Pressure Ulcer Prevention policy. The resident had been admitted and later readmitted to the facility with diagnoses including functional quadriplegia, muscle wasting and atrophy, and type 2 DM. The resident’s 2/12/2026 MDS showed severe impairment in cognitive skills for daily decision making and dependence or substantial/maximal assistance with multiple ADLs, and the 2/12/2026 Braden Scale identified the resident as high risk due to being bedfast and having very limited mobility. During interviews, the MDS coordinator, RN, and DON stated that a thorough weekly skin assessment should have been completed and documented for the resident because of the resident’s high risk for pressure ulcer development and need for repositioning. A concurrent review of the EMR with the RN showed the resident did not have a weekly skin assessment since readmission, and the last weekly skin assessment was documented on 7/22/2025. The facility policy stated that licensed nurses were to conduct skin assessments upon admission, readmission, weekly, and as needed, and that the results were to be documented in the medical record.
Missed Labetalol Doses Not Reported to Physician
Penalty
Summary
The facility failed to ensure a resident with hypertensive heart disease and hypertension received labetalol 200 mg every eight hours in accordance with the physician’s order and failed to notify the physician of missed doses. The resident’s care plan identified hypertension with a goal to remain free of complications related to HTN and a plan to administer anti-hypertensive medications as ordered. The physician’s order, dated 1/8/2026, directed labetalol 200 mg by mouth every eight hours, with instructions to hold the dose if systolic blood pressure was below 110 mmHg or heart rate was less than 60 per minute. The resident’s MAR for February 2026 showed a code 5 and staff initials for the 6 AM dose on 2/27/2026, and a code 9 and staff initials for the 6 AM dose on 2/28/2026. Nursing progress notes for 2/27/2026 at 5:58 AM and 2/28/2026 at 5:39 AM documented that labetalol was awaiting delivery or waiting for delivery. During review with the DON, the MAR did not show that labetalol was given for the 6 AM doses on those two dates. The pharmacist stated the labetalol had been dispensed on 2/25/2026 for a 14-day supply and was delivered to the facility on 2/27/2026 at 6:59 PM, with all three bubble packs delivered together. RN 2 stated she was waiting for the bubble pack for the resident’s 6 AM doses on 2/27/2026 and 2/28/2026, was unable to administer the medication because it was not available, and stated the physician should have been notified of the missed doses. The facility policy stated that if consecutive doses of a vital medication are not available, the physician is notified and nursing documents the notification and the physician’s response.
Failure to Maintain Completed POLST in Resident Medical Record
Penalty
Summary
The deficiency involves the facility’s failure to maintain a completed Physician Orders for Life-Sustaining Treatment (POLST) form in a resident’s medical record in accordance with its own policy and accepted professional standards. The resident was admitted with COPD, dysphagia, and ventilator dependence, and an MDS assessment showed impaired cognitive skills for daily decision-making and dependence on staff for several ADLs. The facility’s policy required that the current original POLST be placed in the front section of the resident’s medical record, with a copy retained in the advance directive/legal section or scanned into the EHR. Despite this, during an emergency transfer to a GACH for chest pain, the resident’s POLST, dated a few days prior, was not available in the medical record. Staff interviews confirmed that the POLST was missing at the time it was needed. An LVN reported that the POLST was not available in the chart when EMS arrived and stated that having the POLST in the chart was important to know the resident’s wishes. The Administrator acknowledged that the resident had a POLST dated earlier in the month but that it was not in the resident’s medical record, and stated it was important to have the POLST in the chart to provide actionable medical orders and ensure the resident’s care preferences were honored during an emergency. The NP also confirmed that the POLST was not available in the chart on the day of the emergency and stated that it was important for the POLST to be readily available so that all appropriate and desired care could be provided. This failure to maintain the POLST in the medical record resulted in incomplete medical records for the resident.
Failure to Provide and Document Continuous Wound Care for Elbow Skin Tear
Penalty
Summary
The facility failed to obtain and provide continuous wound treatment for a resident’s right elbow skin tear in accordance with physician orders and facility policy. The resident, who had severe cognitive impairment and was dependent for all ADLs, had a physician’s order dated 1/7/2026 for daily wound care to the right elbow skin tear, including cleansing with normal saline, patting dry, applying Xeroform, and covering with a dry dressing for 30 days. Review of the Treatment Administration Record (TAR) and progress notes showed that wound treatments were not documented as provided on 1/19/2026, 1/27/2026, and from 2/6/2026 to 2/14/2026. Treatment Nurse 1 confirmed that there were no initials on the TAR and no progress note documentation indicating that the ordered wound care was performed on those dates. Further review revealed that there was no active treatment order for the right elbow wound between 2/6/2026 and 2/14/2026, despite the ongoing need for care. Registered Nurse 2 confirmed the absence of a treatment order during that period and stated that staff, including LVNs, treatment nurses, and RNs, are responsible for monitoring wound treatment, communicating with the physician, and clarifying continuation of wound care. The facility’s wound management policy, revised 11/1/2017, stated that residents with wounds are to receive necessary treatment and services to promote healing, prevent infection, and prevent new pressure ulcers, and that the attending physician will be notified promptly to advise on appropriate treatment. Staff interviews indicated that continuous treatment and documentation are necessary to assess wound progress and that if wound treatment is not documented, it is considered not to have occurred.
Failure to Reposition High-Risk Resident Every Two Hours
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer prevention care by not turning and repositioning a high‑risk resident every two hours as required by the resident’s care plan and the facility’s positioning policy. The resident had diagnoses including diabetes mellitus and protein‑calorie malnutrition, was assessed as high risk for pressure injuries on a Braden Scale assessment, and the MDS documented dependence for all mobility and ADLs, as well as participation in a turning and repositioning program. The resident’s care plan, revised 7/14/2024, directed staff to turn and reposition the resident every two hours and as needed. The facility’s Positioning and Body Alignment policy, reviewed 1/1/2026, required position changes every two hours. On the survey date, the resident was observed at 10:40 AM lying on her right side. At 11:12 AM and again at 1:20 PM, the resident was still on her right side, and the responsible party and roommate reported that staff had not changed or repositioned the resident since 10:40 AM. The responsible party stated CNAs typically turned the resident only twice during the morning shift, around 8:00 AM and 2:00 PM. CNA 1 later reported she had changed/repositioned the resident at 8:00 AM and 2:00 PM, acknowledging this was not consistent with the every‑two‑hour requirement. The DSD and DON both stated residents should be repositioned every two hours, and the continence management guideline indicated pad/brief changes every 2–4 hours, while the DON noted the policy did not clearly state “every 2 hours and as needed” for changes. This combination of observations, staff statements, and record review showed the resident was not turned every two hours as required, creating the potential for skin tears and pressure injuries.
Failure to Perform Hand Hygiene and Change Gloves During Wound Care
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control practices related to wound care for one resident. The resident had multiple serious medical conditions, including paraplegia, a Stage 4 sacro-coccygeal pressure ulcer, bacteremia, immunodeficiency, and resistance to multiple antimicrobial drugs. The resident’s MDS showed severe cognitive impairment and dependence on staff for activities of daily living, and physician orders directed daily and as-needed wound care to the sacro-coccyx pressure injury, including cleansing with normal saline, patting dry, applying collagen powder and Thera honey, and covering with a foam dressing. During a wound care observation, the treatment nurse removed the resident’s soiled dressing and then continued the wound care procedure without changing gloves or performing hand hygiene, contrary to the facility’s Personal Protective Equipment policy. In interviews, the treatment nurse acknowledged she should have performed hand hygiene and donned a new pair of gloves after removing the dirty dressing and before continuing wound care. The DON also stated that gloves were intended for one-time use during removal of the soiled dressing and that the nurse should have removed the gloves, washed hands, and applied new gloves before proceeding, consistent with the written policy that gloves are single-use and that hands are to be washed before and after glove removal. The report stated these failures had the potential to increase the risk of infection for the resident and spread microorganisms to staff and other residents.
Failure to Notify Resident of Scheduled Dental Appointment
Penalty
Summary
The facility failed to notify a resident of a scheduled routine dental cleaning appointment, resulting in the resident missing the appointment and not receiving the planned oral hygiene care. The resident, who had diagnoses including paraplegia, type 2 diabetes, morbid obesity, and COPD, was assessed to have intact cognition and required partial assistance with oral hygiene. The dental appointment was scheduled and communicated to the facility's Social Worker (SW) via email, but the SW did not check the email until late in the day and did not inform the resident of the upcoming appointment. As a result, the resident was out on pass during the scheduled dental visit and missed the appointment. Interviews confirmed that the SW was responsible for notifying residents of dental appointments and that the facility's policy required the SW to coordinate dental services. The administrator acknowledged that the SW is expected to be aware of and communicate upcoming appointments to residents, and that missing such appointments can affect the quality of care.
Failure to Develop Comprehensive Care Plan for G-Tube Dislodgement
Penalty
Summary
The facility failed to develop and implement a comprehensive, resident-centered care plan for a resident with a history of gastrostomy tube (G-tube) dislodgement. Despite multiple documented incidents of the resident pulling or dislodging her G-tube, there was no care plan addressing this issue from the time of admission through several months of care. The resident had diagnoses including type 2 diabetes mellitus, gastrostomy malfunction, and unspecified dementia, and was assessed as having severely impaired cognitive skills and being dependent on staff for all activities of daily living. Multiple SBAR documents and staff interviews confirmed repeated episodes of G-tube dislodgement and behaviors such as pulling at the tube or linens, especially during care activities like dressing changes. Staff interviews revealed that the resident had a strong grip and would often grab her G-tube, requiring additional staff assistance during care to prevent dislodgement. Despite these ongoing issues, several staff members, including licensed nurses and the MDS nurse, were unaware of any care plan specifically addressing G-tube dislodgement or the resident's behavior of pulling at the tube. The care plan for G-tube dislodgement was not created until months after the initial incidents, and even then, it did not include interventions tailored to the resident's specific behaviors. Record review and interviews with the Registered Nurse Supervisor confirmed that no interdisciplinary team (IDT) meetings had been conducted to address the resident's frequent G-tube dislodgement, and the care plan lacked resident-centered interventions. The facility's own policy required comprehensive, individualized care plans to be developed and updated as needed, but this was not followed in the resident's case, resulting in inconsistent implementation of care.
Failure to Honor Bed Hold Policy for Hospitalized Resident
Penalty
Summary
The facility failed to follow its own bed hold policy for a resident who was transferred to a general acute care hospital (GACH) due to tachycardia and hypertension. The resident, who had significant medical needs including respiratory failure, ventilator dependence, and a persistent vegetative state, had a signed bed hold consent indicating a 7-day bed hold was requested and confirmed. Facility records and staff interviews confirmed that the resident's bed was held for only three days before being assigned to a new resident, despite a physician's order and facility policy requiring a 7-day hold. When the hospital notified the facility that the resident was ready for return within the 7-day period, staff reported that the bed was no longer available, as it had already been given to another resident. This resulted in the resident being unable to return to the facility as planned and remaining in the hospital for additional days. Facility staff, including the administrator, acknowledged that the bed should have been reserved for the full 7 days as per policy and the signed consent.
Failure to Provide Adequate Nail Care and Personal Hygiene
Penalty
Summary
A deficiency was identified when a resident, who was dependent on staff for all activities of daily living due to multiple medical conditions including chronic respiratory failure, tracheostomy, muscle wasting, diabetes, and psychosis, was not provided with adequate nail care. The resident's care plan specifically required staff to check, trim, and clean nails on bath days and as necessary, and to report any changes to the nurse. However, during an observation, the resident was found with long, dirty fingernails, some stained brown, and old, partially removed nail polish. The resident indicated through nonverbal cues that staff had not attempted to provide nail care, and staff interviews confirmed that the resident's nails were not properly maintained. Interviews with facility staff, including a CNA, the Director of Rehabilitation, and the DON, revealed that CNAs were responsible for nail care and that the resident's nails should have been cleaned, trimmed, and old polish removed. Staff acknowledged that the resident's nails were not in compliance with facility policy, which requires nail care to keep nails clean and trimmed. The failure to provide this care was directly observed and confirmed through staff interviews and record review.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The deficiency involves a failure to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. The report indicates that care was not delivered in alignment with established directives or the expressed wishes and objectives of the resident, resulting in noncompliance with required standards for individualized care.
Failure to Maintain Functional Call Light System Across Multiple Nursing Stations
Penalty
Summary
The facility failed to maintain a functional call light system for three nursing stations over a period of seven days. According to maintenance records and staff interviews, the call light system at Stations 1, 2, and 3 became non-operational and remained so despite multiple unsuccessful troubleshooting attempts by the Maintenance Director and external technicians. Observations confirmed that the call light system was not working in all three stations during this period. The maintenance logbook did not show evidence of required testing of the nurse call system during the outage. The transformer for the system was found to be damaged and disconnected, and only partial repairs were made by the end of the period, with several rooms still lacking a functional call light system. Staff interviews, including those with the Maintenance Director, Environmental Health Consultant, Administrator, Director of Staff Development, Registered Nurse Supervisors, and the Director of Nursing, confirmed that the call light system was not operational and emphasized the importance of the system for resident safety and timely care. The facility's policy required immediate reporting and replacement of defective call lights, as well as hourly safety checks and documentation until the system was restored. However, the policy was not followed, as the system remained non-functional for an extended period and the required documentation and immediate repairs were not completed.
Failure to Accommodate Resident Needs for Call Light Accessibility
Penalty
Summary
The facility failed to accommodate the needs and preferences of five residents by not ensuring timely and appropriate access to call lights and specialized call devices. In one instance, a resident with severe cognitive impairment and multiple medical conditions, including a tracheostomy and gastrostomy, had a care plan requiring the call light to be within reach. However, observations showed that the resident's call light was not answered promptly, with a delay of at least seven minutes during an episode of coughing and distress. The facility's policy required call lights to be answered within five minutes, and the DON confirmed that such a delay was unacceptable, especially in emergencies. Another resident with a contracture in the right arm and severe cognitive impairment was found with the call light placed on the contracted side, making it inaccessible. The RN confirmed that the call light should have been placed on the resident's strong side to allow activation if assistance was needed. Additional observations revealed that two other residents did not have their call lights within reach. One of these residents, who was dependent in most activities of daily living and had severe cognitive impairment, was found yelling for help because the call light was on a roommate's bed. The other resident, who required moderate assistance and was cognitively intact, was left in a wheelchair without the call light within reach and was unable to call for help. A fifth resident, who had a tracheostomy, gastrostomy, and was dependent in all activities of daily living, was observed with bilateral hand mittens to prevent removal of medical devices. Despite a care plan indicating the need for an adequate call light, the resident was provided with a push-button call light, which was not appropriate due to the mittens. The respiratory therapist and RN both confirmed that a touch pad call light was needed for this resident. Facility policies required call systems to be accessible and within reach, but these requirements were not met for the residents involved.
Failure to Provide Fluids and Follow Weight Loss Protocols
Penalty
Summary
The facility failed to ensure proper hydration and nutrition for two residents, resulting in deficiencies related to both fluid and nutritional management. For one resident with multiple complex medical conditions, including metabolic encephalopathy, type 2 diabetes, acute kidney failure, hypotension, and a stage 4 pressure injury, staff did not provide a water pitcher or fluids at the bedside as required. Multiple observations over two days confirmed the absence of water at the bedside, despite care plan interventions and signage instructing staff to keep the resident hydrated. Interviews with staff, including CNAs, the Director of Staff Development, and the DON, confirmed that there were no fluid restrictions and that water should have been available at all times. Staff acknowledged that the lack of water could lead to dehydration and related complications, and facility policy required water containers to be provided and maintained daily. For another resident with end stage renal disease and dependence on dialysis, the facility did not follow its significant weight loss policy after the resident experienced a weight loss of nearly 7% in one month. The resident's medical record did not show evidence of a change of condition assessment, notification of the physician or registered dietician, a nutritional assessment, or weekly weights as required by facility policy. Interviews with nursing and dietary staff confirmed that these steps were not taken, and the failure was attributed to a lack of communication and awareness among staff. The facility's policy required prompt notification and assessment in cases of significant weight loss, but these procedures were not followed for this resident. Both deficiencies were substantiated through direct observation, record review, and staff interviews. The failures to provide fluids and to follow weight loss protocols were not isolated incidents but were confirmed by multiple staff members and documented in facility policies. The lack of adherence to established care plans and policies placed the residents at risk for dehydration and continued weight loss, as noted in the findings.
Failure to Label and Discard Expired Food Items in Kitchen
Penalty
Summary
Surveyors observed that the facility failed to follow proper food handling practices in accordance with its own policy and professional standards. During an inspection of the kitchen, multiple food items were found either unlabeled or past their use by dates. Specifically, a clear container of beets and four bags of corn tortillas were found with expired use by dates, while an opened tub of cottage cheese, a gallon container of buttermilk ranch dressing, and a four-pound jar of peanut butter were either expired or lacked required labeling such as the food item name, open date, or use by date. The Dietary Supervisor confirmed that these items were opened and should have been labeled and discarded if expired, as per facility policy. A review of the facility's policy and the 2022 FDA Food Code confirmed that all food items must be labeled and dated, and expired foods must be discarded. The Dietary Supervisor acknowledged that the failure to label and discard expired foods was not in accordance with policy and could result in serving expired food to residents. No information was provided regarding specific residents affected or their medical conditions at the time of the deficiency.
Improper Disposal and Containment of Garbage
Penalty
Summary
During an observation with the Dietary Supervisor, four outdoor trash dumpsters were found overfilled with trash bags stacked above the brim, preventing the lids from being closed. The Dietary Supervisor confirmed that the lids should be closed and was unable to close them due to the excess trash. In a follow-up interview, the Dietary Supervisor acknowledged the need for proper trash disposal to prevent pest infestation and contamination. Review of the FDA Food Code and the facility's own policy confirmed that garbage and refuse should be stored in covered containers to minimize odors and prevent attracting pests, but these procedures were not followed as observed.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to honor residents' rights to dignity, respect, and privacy for three residents. In one instance, a certified nursing assistant (CNA) was observed feeding a resident with severe cognitive impairment and multiple diagnoses, including metabolic encephalopathy, dementia, and Parkinson's disease, while standing above the resident's eye level. The CNA acknowledged that she should have been seated at the resident's eye level during feeding, as per facility policy and the resident's care plan, which required extensive assistance with eating. Additionally, a licensed vocational nurse (LVN) was observed entering the rooms of two different residents, both with severe cognitive impairment and dependent on staff for all activities of daily living, without knocking on their doors. The LVN admitted that staff are required to knock before entering to provide privacy and maintain residents' dignity. Another registered nurse confirmed the importance of this practice, emphasizing that privacy and dignity must be maintained even if the resident is not alert. A review of the facility's policy on resident rights confirmed that each resident must be treated with respect and dignity, and their individuality must be recognized. The observed actions by staff were inconsistent with this policy, resulting in a failure to maintain privacy and dignity for the affected residents.
Failure to Maintain Cleanliness and Adequate Hot Water for Resident Care
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for several residents, as evidenced by direct observations and resident interviews. In one instance, a resident with severe cognitive impairment and high dependence for activities of daily living was found in a room with visible trash, including crushed crackers, a used plastic glove, dried brown smears by the commode, and brown clumps under the bed. Both the DON and an LVN confirmed that such conditions were unsanitary and not conducive to residents' well-being, and that housekeeping should have been notified immediately to address the issue. Additionally, multiple residents reported a lack of hot water in their rooms and shower areas, which persisted for at least a week. Residents described being unable to shower or perform personal hygiene tasks comfortably due to the absence of hot water, with some stating they had to use cold water for bathing and incontinence care. Observations confirmed that water temperatures in various rooms and showers were significantly below the facility's policy requirements, with readings as low as 71.6 to 85 degrees Fahrenheit, far below the expected minimum of 110 degrees Fahrenheit. Facility policies reviewed indicated a requirement to provide a safe, clean, and homelike environment, including maintaining water temperatures suitable for residents' needs. Despite these policies, the facility did not ensure that resident rooms were kept clean or that water temperatures were adequate for daily living activities, directly impacting the comfort and hygiene of several residents with varying degrees of cognitive and physical impairment.
Failure to Provide Timely and Safe Pharmaceutical Services
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for three residents by not ensuring timely administration and proper handling of medications as ordered by physicians. For one resident with severe cognitive impairment and poor appetite, the facility did not administer Marinol as ordered for eight days due to the medication not being available and waiting for pharmacy delivery. Nursing staff did not notify the physician within 24 hours of the medication's unavailability, as required by facility policy, resulting in 15 missed doses. Another resident, also with severe cognitive impairment and dependent on staff for daily activities, did not receive scheduled medications at the prescribed times. The medications, which included apixaban, spironolactone, finasteride, and bethanechol, were administered more than an hour after the scheduled time. The nurse acknowledged that the late administration could affect the resident's health, and the facility's policy allows for a one-hour window before or after the scheduled time, which was not adhered to in this case. A third resident, who had intact cognitive skills but required assistance with daily activities, was found with a medication cup containing two pills left on the bedside table after refusing to take them. The resident had not requested to self-administer medications, and facility policy prohibits leaving medications at the bedside. Staff interviews confirmed that medications should not be left unattended and should be properly documented and disposed of if refused.
Failure to Follow Infection Control Practices During Resident Care
Penalty
Summary
Multiple staff members failed to adhere to standard infection prevention and control practices during direct care of several residents. Certified Nursing Assistant 4 (CNA 4) did not change gloves or perform hand hygiene after providing incontinence care to two residents, subsequently touching their bed sheets, bed remotes, and bodies with contaminated gloves. CNA 4 acknowledged during interview that gloves should have been changed and hand hygiene performed to prevent the spread of infection. The Infection Preventionist Nurse (IPN) confirmed that gloves soiled with urine and feces must be removed and hand hygiene performed before touching other surfaces or the resident. The Respiratory Therapist Director (RTD) was observed providing tracheostomy care to a resident and, without changing gloves or performing hand hygiene, touched the resident's personal items such as a cell phone and television remote. RTD then used the same gloves to prepare a sterile drape and handle a speaking valve, actions which he admitted could spread infection to the resident. The IPN stated that gloves should have been changed and hand hygiene performed after contact with personal items to prevent transmission of microorganisms to the tracheostomy area. Additional deficiencies included CNA 5 exiting a resident's room while still wearing PPE and handling dirty linen in the hallway, which she acknowledged was inappropriate due to the risk of spreading infection. Licensed Vocational Nurse 4 (LVN 4) was observed on two occasions failing to change gloves and perform hand hygiene between tasks during medication administration and gastrostomy tube care for two residents. LVN 4 admitted that gloves should have been changed to reduce the risk of introducing bacteria. The facility's policies and procedures require glove changes and hand hygiene after contact with blood, body fluids, and environmental surfaces, and specify that gloves are single-use only.
Failure to Complete Required PASARR Level II Evaluation
Penalty
Summary
The facility failed to ensure that a required Preadmission Screening and Resident Review (PASARR) Level II evaluation was completed for a resident with diagnoses including anxiety disorder, unspecified psychosis, and end stage renal disease. The resident's admission record and Minimum Data Set (MDS) indicated moderate cognitive impairment and the use of antipsychotic and antianxiety medications. Documentation showed that a PASARR Level I screening determined a Level II Mental Health Evaluation was necessary, and the facility was notified that an evaluator would contact them to schedule the assessment. However, the Level II evaluation was not completed because facility staff were unresponsive to multiple attempts by the evaluator to arrange the assessment within the required timeframe. As a result, the case was closed, and the facility was informed that a new Level I screening would be needed to reopen the case. The staff member responsible for PASARR follow-ups was unaware that the case had been closed and did not submit a new screening, contrary to facility policy, which requires completion of the PASARR Level II prior to admission and incorporation of its recommendations into the resident's care plan.
Failure to Develop Individualized Care Plans for Incontinence, Fluid Restriction, and Weight Loss
Penalty
Summary
The facility failed to develop and implement individualized, resident-centered care plans with measurable objectives, timeframes, and interventions for two of eighteen sampled residents. For one resident with severe cognitive impairment and total dependence on staff for activities of daily living, including toileting, there was no care plan addressing bowel and bladder incontinence, despite direct observation of staff providing incontinence care. Both the registered nurse and the director of nursing confirmed that a care plan for incontinence was missing and acknowledged its importance for ensuring continuity of care. Another resident, diagnosed with end stage renal disease and dependent on dialysis, experienced a significant weight loss of nearly 7% in one month and had a physician order for a strict fluid restriction. Despite these critical needs, there was no care plan in place to address the resident's fluid restriction or significant weight loss. The absence of these care plans was confirmed during interviews and record reviews with nursing staff and the director of nursing, who stated that care plans are essential for communicating interventions and ensuring staff follow prescribed care. Facility policies and procedures reviewed during the survey required the interdisciplinary team to ensure care plans documented renal conditions, necessary precautions, and individualized goals for managing significant weight changes. The policies also mandated that each resident have a comprehensive, person-centered care plan based on assessed needs, but these requirements were not met for the two residents identified.
Failure to Update Care Plan After Change in Respiratory Status
Penalty
Summary
The facility failed to revise the care plan for one resident to reflect a significant change in respiratory status following the discontinuation of ventilator support and the initiation of oxygen therapy via tracheostomy. The resident, who had a history of sepsis, urinary tract infection, ESBL, tracheostomy, and gastrostomy, was originally admitted and later readmitted with these diagnoses. Physician orders indicated the resident was to receive four liters per minute of humidified oxygen via tracheostomy, and the Minimum Data Set documented severe cognitive impairment and high levels of dependence for daily activities. Despite the resident being weaned off the ventilator in the hospital and currently receiving oxygen via tracheostomy, the care plan continued to focus on ventilator dependence and was not updated to reflect the current respiratory needs. This was confirmed during interviews and record reviews, where the DON acknowledged the care plan required revision to ensure appropriate care and staff implementation. The facility's policy required care plans to be updated with changes in resident status, but this was not done in this case.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 7,330 citations issued within 25 miles in the last 12 months — including the 20 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) |
|---|---|---|---|---|
| Camellia Gardens Care Center | 0 mi | ★★★★★ | 18 | 0 |
| Brighton Care Center | 0.1 mi | ★★★★★ | 24 | 0 |
| Saint Vincent Healthcare | 0.1 mi | ★★★★★ | 15 | 0 |
| Cedar Pine Post Acute | 0.3 mi | ★★★★★ | 31 | 0 |
| Pasadena Nursing Center | 0.4 mi | ★★★★★ | 30 | 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.