Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Good Samaritan Rehab And Care Center during CMS and state inspections, most recent first.
A resident with chronic pain syndrome, ESRD, PVD, multiple wounds, gangrene, and bilateral lower extremity amputations repeatedly reported severe pain, including 10/10 pain, yet staff administered PRN acetaminophen ordered only for mild pain and did not consistently notify the physician when pain remained uncontrolled. The ordered oxycodone-acetaminophen for severe pain was not available due to a delayed C-II prescription and pharmacy delivery issues, and staff were unable to obtain authorization to use the narcotic E-kit despite the resident’s ongoing severe pain. Nursing staff acknowledged administering pain medication inconsistent with the pain scale parameters, failing to obtain clear PRN orders for mild, moderate, and severe pain, and not promptly addressing the resident’s pain, while the DON confirmed there was no order for moderate pain medication and that pain management for this resident was a concern.
A resident who was fully dependent on staff for ADLs due to significant neurological impairment did not receive weekly showers for two months, as required by facility policy. Despite daily bed baths, staff interviews and record reviews confirmed the absence of weekly showers, and the DON acknowledged the policy was not followed.
The facility did not maintain confidentiality or proper organization of medical records when documents belonging to two residents, including intake/output forms and a physician's order for time of death, were found in another resident's file. This mix-up was confirmed by medical records staff, who stated that facility policy was not followed, potentially exposing private information and leading to inappropriate care actions.
Dietary aides were observed discarding meal tray tickets containing residents' personal and medical information into regular trash bins, rather than shredding them as required by facility policy. Both the Registered Dietician and DON acknowledged this as a breach of confidentiality, and the facility's policy specifies that such information must be destroyed to prevent unauthorized access.
Surveyors identified multiple deficiencies in food storage, preparation, and kitchen sanitation, including improper thawing of raw meat, storage of spoiled produce, incorrect dating and handling of leftovers, staff food stored with resident food, food and supplies placed on the floor, non-food and personal items in storage areas, dented cans ready for use, wet food service items stored without drying, and dirty kitchen equipment. These actions and inactions were confirmed by interviews with the CDM, RD, and kitchen staff, and were found to be inconsistent with facility policy and FDA Food Code requirements.
Surveyors found that a can opener was not properly cleaned, with visible food debris and metal shavings, and the dishwashing machine failed to reach the required sanitizing temperature, as confirmed by dietary staff and the RD. These deficiencies were not in line with FDA Food Code requirements for safe and sanitary food service equipment.
Roaches were found in and around a microwave used to reheat residents' food, with visible old food splatters and inadequate cleaning by housekeeping. Despite regular monthly pest control, staff confirmed the presence of roaches and acknowledged the infection control risk, and records showed prior reports of pest sightings and treatment.
A resident with a urinary catheter for urinary retention was observed with an uncovered catheter bag in their room. Both a CNA and an LN confirmed the lack of a privacy cover, acknowledging it should have been in place to maintain dignity. The DON and facility policy require catheter bags to be covered to protect resident privacy and dignity.
A resident with dementia, under the care of a court-appointed conservator, was prescribed and administered Risperidone and Valproic Acid without documented informed consent from the responsible party. Facility staff confirmed that consent forms were incomplete and lacked evidence of discussion with the conservator, despite facility policy requiring informed consent prior to psychotropic medication use.
Two residents were not properly supervised while smoking and had access to smoking materials against facility policy. One resident with cognitive impairment was left alone in the courtyard to smoke after staff lit his cigarette, despite his care plan requiring supervision. Another resident with respiratory conditions kept a lighter in his room and on his person, with staff providing inconsistent guidance about storage and supervision of smoking paraphernalia. These actions were not in accordance with the facility's smoking policies and placed residents at risk for accidental burns and injuries.
A nurse administered Amlodipine to a resident with a blood pressure below the physician-ordered hold parameter, despite documentation in the MAR and order summary indicating the medication should be withheld if systolic blood pressure was under 110. The DON confirmed that facility policy was not followed, and the nurse acknowledged the error.
Surveyors identified multiple deficiencies in medication and supply storage, including staff beverages and personal items in medication rooms, an unlocked medication refrigerator containing narcotics, expired and unlabeled medications in medication and treatment carts, and opened but undated multi-use wound care solutions. Nursing staff and the DON confirmed these practices did not follow facility policy.
A resident admitted with muscle weakness and repeated falls had physician orders for PT and OT evaluations and treatments, but did not receive these services as required. Both therapists confirmed they did not receive referrals, and the DON acknowledged that therapy services were unavailable during a transition period. The resident's care plans referenced the need for therapy, but no evaluations or treatments were provided.
A resident receiving care from an outside primary care provider did not have the provider's progress notes included in their medical record. Staff interviews revealed that the facility had not received or requested these notes, and the DON confirmed their absence, resulting in incomplete documentation of the resident's care and communication among the care team.
The facility did not provide evidence of an ongoing QAPI program, as required, and only produced QAPI documents that were created during the survey week after deficiencies were identified. Despite having written policies describing QAPI processes, there was no documentation showing active implementation or a current QAPI plan prior to the survey.
A Medical Records Assistant refilled a personal soda bottle from a resident water dispenser, allowing the bottle's mouth to touch the dispenser spout, contrary to facility policy. The DON confirmed that staff were instructed to avoid such contact to prevent contamination and infection, but this protocol was not followed.
A resident who developed a UTI and was prescribed antibiotics was not tracked according to the facility's Antibiotic Stewardship Program. The required stewardship guideline form was not initiated, the resident was not added to antibiotic tracking logs, and an antibiotic time-out was not performed or documented. The Infection Preventionist was unaware of the antibiotic prescription, and the facility's policy for monitoring and reassessment of antibiotic use was not followed.
Four rooms were found to be below the required minimum square footage per resident, with three triple-occupancy rooms and one double-occupancy room not meeting the 80 square feet per resident standard. Despite this, residents and staff reported no issues with care delivery or mobility within these rooms, and the Administrator confirmed no complaints had been received.
A resident with end-stage renal disease missed a scheduled dialysis session due to unavailable transportation, resulting in a four-day gap without treatment. The facility did not attempt alternative transportation options or notify the resident's family. Additionally, the facility failed to maintain up-to-date lab results from the dialysis center in the resident's medical record, as required by policy.
The facility failed to ensure safe handling of hazardous medications during storage and administration. LNs administered hazardous drugs like valproic acid and finasteride without using gloves or PPE, and MARs lacked handling instructions. Interviews revealed staff were unaware of special handling requirements, and the DON acknowledged the issue.
A resident with a history of left-side paralysis and a crushed left leg experienced unmanaged severe pain due to the facility's failure to notify the physician and obtain appropriate pain medication. Despite repeated complaints of severe pain, the resident was given ibuprofen, which was insufficient, instead of the prescribed Morphine Sulfate for severe pain, which was only administered at bedtime. The facility did not follow its policy for physician notification, resulting in prolonged unmanaged pain for the resident.
The facility failed to ensure prescribed medications were available and communicated unavailability to the medical doctor for two residents. Additionally, the facility did not follow safe pharmaceutical practices, including proper medication disposal and accountability of delivered medications.
The facility failed to ensure safe infection control practices with shared medical devices and did not have a water management program, putting residents at risk for infections. Additionally, a resident's room was found to be cluttered and unsanitary, further increasing the risk of infection.
The facility failed to ensure a resident's POLST form was fully completed and uploaded to their EHR. The form lacked essential identifying information, which could lead to incorrect life-sustaining measures being administered. Staff interviews confirmed the omission and the potential for a full code to be performed contrary to the resident's wishes.
The facility failed to ensure that two residents received care and services safely when they were unable to open a heavy and sticky bathroom door. Both residents reported difficulty and feelings of entrapment, with observations confirming the door's inaccessibility. The facility's policy on resident accommodation was not followed, impacting the residents' independence and dignity.
The facility failed to develop and implement care plans for psychotropic and high-risk medications for three residents, leading to inadequate monitoring of medication use and potential adverse effects. The deficiencies were confirmed by the DON and LNs during a review of the residents' medical records.
The facility failed to ensure a safe environment and adequate supervision for a resident with epilepsy and muscle weakness. The fall risk assessment was inaccurate, and interventions were not updated after multiple falls. Additionally, the resident eloped from the facility, and staff were unaware until contacted by the police. The care plan did not address the elopement risk, and facility policies were not followed.
The facility failed to follow the physician's orders for supplemental oxygen administration for a resident with COPD and asthma. The resident was observed receiving higher levels of oxygen than prescribed, and clinical records showed multiple instances of incorrect oxygen administration. Interviews with staff and the Director of Nursing confirmed that the facility's policy on oxygen therapy was not followed.
The facility failed to apply appropriate siderails for a resident who was ordered half siderails but was found with two full bed siderails in use. The resident's medical records indicated a high risk for falls and specified the use of half siderails for bed mobility and transfers. Both a licensed nurse and the DON confirmed the presence of full siderails and acknowledged the order for half siderails, with no proper assessment, care plan, or consent for full siderails.
The facility failed to monitor the adverse effects of high-risk medications in two residents. One resident was prescribed multiple blood thinners and a pain medication, while another was on aspirin and clopidogrel for stroke prevention. In both cases, there was no documented monitoring for adverse effects, which was acknowledged by the DON.
The facility failed to monitor psychotropic medication side effects and behaviors for a resident prescribed duloxetine and cariprazine for anxiety. The oversight was confirmed during a review of the resident's medical records, which showed no documented daily monitoring as required by the facility's policy.
The facility failed to review and update the Facility Assessment annually, with the last update occurring in January 2018. This was confirmed by the Administrator and DON during an interview and record review. The facility policy requires annual reviews and updates of the Facility Assessment.
Four rooms in the facility did not meet the required square footage per resident. Despite this, residents reported no concerns, and staff indicated they could perform their duties effectively. The Administrator confirmed the measurements and acknowledged the shortfall.
Failure to Provide Ordered and Appropriate Pain Management for a Resident With Severe Chronic Pain
Penalty
Summary
The facility failed to provide pain management consistent with professional standards of practice for a resident with extensive medical conditions and chronic pain. The resident was admitted with chronic pain syndrome, acquired absence of limb, peripheral vascular disease, pressure ulcers, chronic cholecystitis, and end stage renal disease, and had multiple open sores, gangrene, and bilateral lower extremity amputations. Physician orders included acetaminophen 325 mg, two tablets every six hours as needed for mild pain, and oxycodone-acetaminophen 10-325 mg, one tablet twice daily for severe pain. The resident’s care plan indicated the resident was on pain medication therapy related to ESRD, PVD, and multiple wounds, with a goal that the resident would be free of discomfort, and interventions directing staff to administer analgesics as ordered, assess pain intensity, and request changes in the regimen if pain control was not adequate. From admission and during subsequent stays, the resident repeatedly reported severe pain that was not managed according to the physician’s orders or the resident’s reported pain levels. Nursing progress notes documented that on admission the resident expressed 10/10 pain, refused PRN acetaminophen stating it would not help, and was informed that oxycodone would arrive with the pharmacy delivery, but the ordered oxycodone was not available. On another date, the resident again expressed 10/10 pain, and the charge nurse administered PRN Tylenol despite the order specifying it for mild pain only. Later that same day, the resident was observed yelling and screaming in extreme pain rated 10/10; PRN Tylenol was given at 2100 with no relief, and the scheduled oxycodone dose due at that time was not available because the pharmacy had not delivered it. The on-call pharmacy contact declined to authorize use of the narcotic emergency kit, and the resident continued to report severe pain. Further documentation and interviews showed that the resident’s severe and moderate pain continued to be treated with a medication ordered only for mild pain, without appropriate physician notification or adjustment of orders. A nursing note indicated the pharmacy had mistakenly faxed the required C-II prescription form to the wrong physician, delaying oxycodone dispensing, and that the resident had been screaming in pain since admission. The pharmacist stated she could have authorized emergency kit use if a physician verbal order had been obtained. Review of the MAR with LN 3 showed that acetaminophen for mild pain was administered on multiple dates when the resident reported severe pain scores of 8–10, and LN 3 acknowledged this did not match the physician’s order and that the physician should have been contacted. Review with LN 2 showed acetaminophen for mild pain was given when the resident reported moderate pain scores of 5–6, and LN 2 acknowledged she should have reviewed the orders, reassessed pain, and contacted the physician for clear PRN orders for mild, moderate, and severe pain. The DON confirmed that there was no order for moderate pain medication, that nurses were expected to contact the physician when pain was not adequately controlled, and stated that pain management for this resident was a concern. Pharmacist interviews confirmed that a delay in receiving the completed C-II prescription and lack of communication from the facility contributed to the unavailability of the ordered narcotic, leaving the resident’s severe pain untreated. Facility policies required assessment for pain, review of physician orders, calling the physician if there was no pain medication order or if medication was ineffective, and monitoring and documenting effectiveness, which were not consistently followed in this case.
Failure to Provide Weekly Showers for Dependent Resident
Penalty
Summary
A facility failed to provide a dependent resident with weekly showers for a period of two months, despite the resident's need for assistance with all activities of daily living (ADLs) due to conditions including cerebral infarction, hemiplegia, and hemiparesis. The resident was admitted in 2018 and was documented as being dependent on staff for completion of ADLs. Interviews with the responsible party and staff, as well as review of clinical records and electronic medical records (EMR), confirmed that the resident did not receive a shower in May or June 2025, although daily bed baths were provided. The facility's policy required that bedridden residents receive daily bed baths and weekly showers, but this was not followed for the resident in question. Multiple staff members, including the Director of Staff Development, Licensed Nurse, Medical Records staff, and the DON, confirmed through interviews and record reviews that there was no documentation of showers being provided during the specified period. The DON acknowledged that the facility's policy was not followed and confirmed the absence of weekly showers for the resident. The deficiency was identified through interviews, record reviews, and confirmation that the facility's own bathing policy was not adhered to for this resident.
Failure to Maintain Confidentiality and Proper Organization of Medical Records
Penalty
Summary
The facility failed to maintain the confidentiality and proper organization of resident medical records, resulting in portions of two residents' medical records being found in another resident's file. Specifically, intake and output forms for one resident and a physician's order regarding the time of death and release of body for another resident were discovered in a third resident's medical record. This was confirmed during a concurrent interview and record review with the Medical Records staff, who acknowledged that the documents were mixed up and that facility policy was not followed. The affected residents had significant medical histories, including conditions such as cerebral infarction, hemiplegia, hemiparesis, respiratory failure, and diabetes mellitus. The facility's policy required that all medical records be complete, accurately documented, and stored to protect against unauthorized use, with each patient assigned a unique medical record number. The improper filing and mixing of documents created the potential for exposure of private and confidential information to unauthorized individuals and could have led to inappropriate care actions if orders were followed for the wrong resident.
Improper Disposal of Meal Tray Tickets Containing PHI
Penalty
Summary
The facility failed to protect residents' personal and medical information by improperly disposing of meal tray tickets that contained sensitive data. During observations in the kitchen, dietary aides were seen discarding meal tray tickets, which included residents' names, unit, room and bed numbers, diet orders, allergies, food notes, and other identifying information, into regular trash bins along with food scraps. This practice was confirmed by dietary staff as the standard method of disposal for these documents. Interviews with the Registered Dietician and the Director of Nursing revealed that both recognized the confidentiality issue associated with this practice. The Director of Nursing specifically stated that all meal tray tickets should be shredded after use to maintain privacy, and acknowledged that the current practice violated residents' privacy expectations. A review of the facility's policy confirmed that patient health information should be destroyed in a manner that renders it unreadable before disposal, which was not being followed in this case.
Widespread Food Safety and Sanitation Deficiencies in Kitchen Operations
Penalty
Summary
Surveyors observed multiple failures in food storage, preparation, and kitchen maintenance that did not meet professional standards for food safety. Raw chicken was found thawing in a sink without running water, contrary to facility policy and FDA Food Code requirements, which specify that thawing under water must be done with running water at 70°F or lower. Over-ripe and spoiled produce, including eggplants with discoloration, bell peppers with mold, and tomatoes with black fuzzy substances, were found in the walk-in refrigerator and available for use. Additionally, containers of food were incorrectly dated or lacked use-by dates, and leftover food was kept beyond safe time frames without following the required cool down process or proper documentation. Staff food was stored in the same refrigerator as resident food, with raw tilapia intended for staff placed on top of cooked food and vegetables, increasing the risk of cross-contamination. Boxes of food, drinks, and supplies were found stored directly on the floor in the dry storage room, and non-food items such as chairs, a space heater, a fan, and personal lunch pails were also stored in this area. Dented cans were found in the dry storage area, ready to serve, despite facility policy requiring such items to be separated and returned to the vendor. Clean food service items, such as trays and steam table pans, were put away while still wet, and the oven was found dirty with layers of grease and food debris. Interviews with the Certified Dietary Manager (CDM), Registered Dietician (RD), and kitchen staff confirmed that these practices did not align with facility policies or food safety standards. The RD and CDM acknowledged that the observed conditions, such as improper thawing, storage of spoiled produce, lack of proper labeling and dating, and failure to follow cleaning schedules, were unacceptable and posed risks for foodborne illness. The facility's own documentation and the FDA Food Code were referenced throughout the findings, highlighting the discrepancies between expected and actual practices.
Failure to Maintain Safe and Sanitary Kitchen Equipment
Penalty
Summary
Surveyors observed that essential kitchen equipment was not maintained in safe operating condition. During a kitchen tour, a can opener was found with chipped paint, food debris, and a layer of metal shavings behind the blade. The condition of the can opener was confirmed by kitchen staff and the Registered Dietician (RD), who stated that the can opener should be cleaned regularly according to a cleaning schedule. The RD also noted that staff had been instructed to use a wire brush for cleaning, but the can opener was not maintained as expected, creating a risk of harboring pathogens. Additionally, the dishwashing machine was observed over three complete cycles and failed to reach the manufacturer-required minimum temperature of 120 degrees Fahrenheit, with the highest recorded temperature being 117 degrees. The Certified Dietary Manager (CDM) and RD confirmed that the machine was not operating at the required temperature, and the Maintenance Supervisor stated that the machine needed calibration. The FDA Food Code was referenced, indicating that both the can opener and dishwashing machine were not in compliance with standards for cleanliness and safe operation.
Failure to Prevent Roach Infestation in Food Preparation Area
Penalty
Summary
The facility failed to maintain an environment free of pests, as evidenced by the presence of roaches in the area where residents' food was reheated. During an observation with the Certified Dietary Manager, the microwave used for reheating outside food for residents was found to have layers of old food splatters, and the manager indicated that housekeeping was responsible for cleaning it. A subsequent observation revealed a roach walking in front of the microwave, and when the microwave was moved, multiple roaches were seen running away. The Housekeeping Supervisor confirmed that the microwave had not been cleaned as required and acknowledged the presence of roaches. The Maintenance Supervisor stated that the facility had regular monthly pest control services but confirmed the presence of roaches and recognized the infection control issue they posed. Record review showed that there had been previous reports of roaches in a resident's room, and treatment was provided. The Physical Plant Supervisor emphasized the importance of daily cleaning and pest control to prevent the spread of disease. These findings demonstrate a failure to ensure proper cleaning and pest control measures, resulting in a pest infestation in a food preparation area.
Failure to Maintain Privacy for Resident with Urinary Catheter
Penalty
Summary
A deficiency was identified when a resident's urinary catheter bag was observed without a privacy cover in the resident's room. During the observation, both a CNA and a licensed nurse confirmed that the catheter bag was not covered, and acknowledged that it should have been covered to maintain the resident's privacy and dignity. The licensed nurse further explained that the privacy cover is important because not all residents are comfortable with the catheter bag being visible, both inside and outside the room. The resident had a physician's order for a catheter to drainage bag due to urinary retention. The Director of Nursing confirmed that the facility's policy requires urinary catheter bags to be covered to preserve resident dignity. Facility policy also states that residents are to be treated with respect, kindness, and dignity, and that staff are to be educated and monitored for compliance with resident rights.
Failure to Obtain Informed Consent for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a resident was fully informed and provided with informed consent regarding the use of psychotropic medications, specifically Risperidone and Valproic Acid. The resident, who had a diagnosis of dementia and a court-appointed conservator as the responsible party, was prescribed and administered these medications without documented evidence that the risks, benefits, and alternatives were explained to the conservator. Review of the resident's records showed that the required informed consent forms were incomplete, undated, and only signed by the physician, with no indication of discussion or consent from the conservator. Interviews with facility staff, including a licensed nurse and the DON, confirmed that the forms lacked necessary details such as dates and documentation of with whom the consent was discussed. The facility's own policies require that residents or their surrogate decision makers be fully informed and provide consent prior to the use of psychotropic medications. Despite this, the medications were administered as ordered, as evidenced by the Medication Administration Record, without proper informed consent procedures being followed.
Failure to Supervise Smoking and Control Smoking Paraphernalia
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for residents who smoked, specifically for two residents. One resident, who had a diagnosis of metabolic encephalopathy resulting in confusion and memory loss, was observed smoking a cigarette in the facility courtyard without required supervision. The nursing assistant lit the cigarette for the resident and then left the resident alone in the courtyard, despite the resident's care plan and smoking assessment indicating that supervision was necessary due to cognitive and physical limitations. The nursing assistant confirmed that she was not permitted to supervise the resident and acknowledged the risk of harm from leaving the resident unsupervised. Another resident, with a history of acute respiratory failure and COPD, reported keeping a cigarette lighter in his room and in his pocket, making it accessible to other residents. This resident stated he received conflicting information about whether he needed to lock up his smoking materials and believed he could smoke outside whenever he wanted. Interviews with facility staff revealed inconsistencies in the enforcement of the smoking policy, with some staff stating that only residents assessed as independent smokers could keep lighters and cigarettes in their rooms, while others stated that lighters should not be kept in resident rooms for safety reasons. Facility policy required that residents who were physically or cognitively incapacitated be closely supervised while smoking and that smoking paraphernalia only be made available under safe conditions as determined by the interdisciplinary team. Despite these policies, both residents were allowed access to smoking materials and opportunities to smoke without the required supervision, contrary to their care plans and facility procedures. These failures placed the residents and others at risk for accidental burns and injuries.
Blood Pressure Medication Administered Outside Prescribed Parameters
Penalty
Summary
A licensed nurse administered an oral tablet of Amlodipine, a medication prescribed for hypertension, to a resident whose blood pressure reading was 102/57. The resident's physician order specified that the medication should be held if the systolic blood pressure was less than 110. Despite this hold parameter being documented in both the order summary and the medication administration record (MAR), the nurse proceeded with the administration. The nurse later confirmed awareness of the hold parameter and acknowledged that the medication should not have been given under these circumstances. The resident had a medical history including cerebral infarction and hypertension. The Director of Nursing confirmed that facility policy requires nurses to check blood pressure and hold parameters before administering such medications, and that the policy was not followed in this instance. The facility's policy and procedure on medication administration also requires medications to be given as prescribed and in accordance with written orders, which was not adhered to during this event.
Medication and Supply Storage Deficiencies Identified
Penalty
Summary
Surveyors observed multiple failures in the facility's medication and medical supply storage practices. Staff beverages and personal belongings were found stored in medication storage rooms at multiple nursing stations, which staff acknowledged posed an infection risk. Additionally, the medication refrigerator containing narcotics was not locked, and a narcotic locked box inside the refrigerator contained lorazepam, a controlled substance. Staff confirmed that the refrigerator should have been locked when narcotics were present to prevent unauthorized access. Further observations revealed expired medications and opened, unlabeled medications stored in the medication cart, including expired eye drops, oral calcium, docusate sodium capsules, an Albuterol Sulfate inhaler, and an opened, unlabeled bottle of Milk of Magnesia. In the treatment cart, surveyors found expired single-use wound care irrigation solutions that were opened but not dated, as well as expired wound care ointments, creams, and dressing materials. An opened sterile dressing was also found in the treatment cart and had not been discarded. Multi-use wound care solutions, such as povidone iodine ointment and Dakin's solution, were opened but not dated. Interviews with nursing staff and the Director of Nursing confirmed that these practices were not in accordance with facility policy, which requires medications and biologicals to be stored safely, securely, and properly, with expired or contaminated items immediately removed from inventory. The facility's policies also require that controlled substances be stored in locked compartments and that multi-dose containers be dated when opened. The observed deficiencies were acknowledged by staff and leadership as not meeting these standards.
Failure to Provide Ordered PT/OT Services Upon Admission
Penalty
Summary
A resident was admitted to the facility with diagnoses including generalized muscle weakness, repeated falls, and cognitive symptoms. Upon admission, there were physician orders for both physical therapy (PT) and occupational therapy (OT) evaluations and treatments. However, a review of the resident's medical record showed that neither PT nor OT evaluations or treatments were provided as ordered. The resident reported not receiving therapy services for balance problems, which were a primary reason for admission. Both the occupational therapist and physical therapist confirmed that they did not receive referrals for the resident, despite the presence of orders in the medical record. The facility's protocol required that rehabilitation services be initiated within 72 hours of the order, but this did not occur. Further interviews revealed that the facility did not have rehabilitation services available from early December through mid-January due to a transition period while negotiating a new contract for in-house rehabilitation services. The Director of Nursing confirmed that therapy orders were present upon admission and acknowledged that evaluations should have been completed within 24 hours. The resident's care plans and baseline care plan also referenced the need for PT and OT services, but these were not implemented. Facility policy stated that residents requiring rehabilitation services would be identified and evaluated, but this process was not followed for the resident in question.
Incomplete Medical Records for Resident Under Outside Provider Care
Penalty
Summary
The facility failed to maintain and obtain complete medical records for a resident who was under the care of an outside primary care provider. During observation, the resident was seen scratching her chest and upper extremities. Interviews with staff revealed that the resident's care and medications were managed by an external provider, but a review of the resident's medical record showed that progress notes from this provider were missing. The Director of Nursing confirmed that the outside provider had been managing the resident's care since August 2024, but their notes were not present in the facility's records. Further investigation found that the medical records staff had not received or requested the necessary documentation from the outside provider. The outside primary care provider stated that their progress notes served as communication for new orders, updates, and continuity of care. The Director of Nursing acknowledged that the absence of these notes in the resident's medical record would result in a lack of information regarding required measures or interventions for the resident.
Failure to Provide Evidence of Ongoing QAPI Program
Penalty
Summary
The facility failed to provide evidence of an ongoing Quality Assurance and Performance Improvement (QAPI) program or plan for its resident population. During the survey, the Administrator (ADM) was repeatedly asked to provide QAPI documents, including the plan and the names of committee members, as required by federal regulations. Despite these requests, the only QAPI-related documents produced were created during the week of the survey, after the survey team had already identified a deficiency related to expired medications. The ADM acknowledged that the QAPI plan presented was newly created in response to the survey findings, rather than being an established, ongoing program. Further review of facility policies and undated documents indicated that the facility had written policies describing the QAPI process and requirements, but there was no evidence that these policies were being actively implemented or that a QAPI plan was in place prior to the survey. The lack of a current, ongoing QAPI program meant the facility could not demonstrate systematic efforts to identify, report, investigate, analyze, and prioritize quality concerns as required.
Staff Failed to Prevent Contamination of Resident Water Dispenser
Penalty
Summary
A deficiency occurred when a Medical Records Assistant was observed refilling an empty plastic soda bottle from a resident water dispenser at a nurses' station, allowing the mouth of the bottle to touch the dispenser spout. The staff member confirmed this action and acknowledged that it was not acceptable, recognizing the risk of contaminating the dispenser and potentially spreading illness to residents who use the dispenser. Disposable cups were available for use, and staff were instructed to avoid contact between personal containers and the dispenser spout, but this protocol was not followed. The Director of Nursing confirmed that the facility's policy required water dispensers to be cleaned every 24 hours and that disposable cups were provided for drinking water. The DON also stated that staff should not allow personal containers to touch the dispenser spout when refilling. The facility's infection control policy aimed to provide a safe and sanitary environment to prevent the development and transmission of disease and infection, but this policy was not adhered to in this instance.
Failure to Follow Antibiotic Stewardship Program for Resident on Antibiotics
Penalty
Summary
The facility failed to follow its Antibiotic Stewardship Program (ASP) for a resident who developed signs and symptoms of a urinary tract infection (UTI). When the resident complained of a burning sensation during urination, a urine analysis was ordered and later, an antibiotic (Ciprofloxacin) was prescribed for five days. However, the facility's required ANTIBIOTIC STEWARDSHIP GUIDELINE form was not initiated for this resident at the time of the initial complaint or diagnosis. The Infection Preventionist (IP) was not aware that the resident had been prescribed antibiotics and did not add the resident to the ANTIBIOTIC STARTS TRACKING log, the MONTHLY SURVEILLANCE REPORT FORM, or the ANTIBIOTIC LOG. Review of these tracking documents for the relevant month confirmed that the resident was not listed, despite being on antibiotic therapy. The IP stated that the nurse should have completed the required form and placed it in the designated binder for tracking, but this did not occur. Additionally, the facility did not conduct an antibiotic time-out for the resident, which is a reassessment of the antibiotic prescription 48-72 hours after initiation, as required by facility policy. The IP acknowledged that antibiotic time-outs were not being performed for any residents on antibiotics, and this process was not documented in the resident's record as required. The facility's policy specifies that antibiotic starts, days of therapy, antibiotic use, stewardship actions, and outcomes must be tracked, and a monthly ASP Tracking Report compiled, but these steps were not followed for the resident in question.
Resident Rooms Below Required Square Footage
Penalty
Summary
Four resident rooms (rooms 5, 18, 22, and 45) did not meet the required minimum square footage per resident, as observed and measured by the Maintenance Supervisor. Specifically, three of the rooms, each housing three residents, measured between 233.21 and 237.37 square feet, which is less than the required 240 square feet (80 square feet per resident). The fourth room, a two-bed room, measured 142.85 square feet, which is below the required 160 square feet (80 square feet per resident). These measurements were confirmed during direct observation and interviews with the Maintenance Supervisor. Residents occupying these rooms, as well as staff providing care, were interviewed and consistently reported no issues with space, care delivery, or mobility within the rooms. Residents stated they had enough room for their needs, including the use of wheelchairs and movement around the room. Staff, including licensed nurses and certified nursing assistants, also confirmed that the room sizes did not hinder their ability to provide care or perform daily tasks. The Administrator acknowledged the room sizes and stated there had been no complaints from residents or staff regarding space limitations.
Failure to Provide Timely Dialysis and Maintain Lab Records
Penalty
Summary
The facility failed to provide appropriate dialysis care and services for a resident with end-stage renal disease, who was dependent on dialysis. The resident missed a scheduled dialysis session due to unavailable transportation, and a make-up session was not arranged promptly. Interviews with facility staff revealed that the resident missed a dialysis session on a Friday and did not receive treatment until the following Monday, resulting in a four-day gap without dialysis. The Nursing Secretary admitted to not attempting alternative transportation options or notifying the resident's family for assistance. The facility's contract and policy indicated responsibility for arranging transportation, which was not fulfilled. Additionally, the facility did not maintain up-to-date lab results from the dialysis center in the resident's medical record. The resident's monthly lab results were not available in the facility's records since May, despite being conducted at the dialysis center. The Director of Nursing confirmed that charge nurses were responsible for reviewing these labs, but the Primary Doctor only reviewed critical values. The facility's policy required documentation of laboratory tests in the resident's medical record, which was not adhered to, leading to a potential lapse in care coordination between the facility and the dialysis center.
Failure to Ensure Safe Handling of Hazardous Medications
Penalty
Summary
The facility failed to ensure safe practices in handling hazardous medications during storage and medication administration. During observations, Licensed Nurses (LNs) administered hazardous medications such as valproic acid and finasteride without using gloves or other personal protective equipment (PPE). The Medication Administration Records (MARs) for the residents did not contain any instructions on how to handle these hazardous drugs safely. This was observed with multiple residents, including Resident 33, Resident 55, Resident 8, and Resident 10, across different hallways and stations in the facility. Interviews with the LNs revealed a lack of awareness regarding the special handling requirements for hazardous medications. LN 4 and LN 5 both stated they were not aware of the need for gloves or other protective measures when handling these drugs. The pharmacy labels only indicated that the drugs should not be taken if pregnant, without providing specific handling instructions. The Director of Nursing (DON) acknowledged the shortcomings and mentioned that the facility was in the process of revising their policy to ensure safe handling of hazardous drugs. Review of drug information from Lexicomp and guidelines from the National Institute for Occupational Safety and Health (NIOSH) confirmed that valproic acid and finasteride should be handled with appropriate precautions, including the use of gloves. The lack of proper handling instructions and PPE use during medication administration poses a health risk to both staff and residents. The facility's failure to adhere to these guidelines led to the identified deficiencies in medication handling practices.
Failure to Manage Severe Pain for Resident
Penalty
Summary
The facility failed to manage the severe pain of a resident, identified as Resident 28, who had a history of left-side paralysis following a stroke and a crushed left leg from the Vietnam War. Despite repeated complaints of severe pain in the left leg and knee, the facility administered ibuprofen, which was only ordered for mild to moderate pain, instead of notifying the physician to obtain an appropriate medication for severe pain. This resulted in Resident 28 experiencing unmanaged severe pain for extended periods. Resident 28's clinical records showed consistent complaints of severe pain, with pain levels frequently recorded as 8 or 9 out of 10. The records indicated that the resident had an order for Morphine Sulfate for severe pain, but it was only to be administered at bedtime. During the daytime, the resident was given ibuprofen, which was insufficient for managing the severe pain. The licensed nurse acknowledged that the physician should have been contacted for a new medication order to address the severe pain during the day. Interviews with the physician and the Director of Nursing (DON) confirmed that the facility's policy and procedures for physician notification were not followed. The physician stated that Resident 28 could have benefited from around-the-clock pain medication, and the DON acknowledged that the licensed nurses should have called the physician for an additional pain medication order to cover severe pain during the day. The failure to notify the physician and manage the resident's severe pain appropriately was a significant deficiency in the care provided by the facility.
Medication Unavailability and Unsafe Pharmaceutical Practices
Penalty
Summary
The facility failed to ensure prescribed medication unavailability was communicated to the medical doctor and failed to ensure vital medications were available for administration for two residents. Resident 43, who has PTSD and Parkinson's Disease, did not receive her anxiety medication, Alprazolam, on multiple days in February 2024. Additionally, her pain medication, Tramadol, was not available for administration on several days in March 2024. The facility did not follow up adequately with the pharmacy or the medical director to ensure these medications were available, leading to gaps in her treatment. The pharmacist and physician both acknowledged issues in the process, but no alternative medications were provided during the unavailability period. The DON confirmed the lapses in medication administration and the lack of documented follow-up actions to resolve the issue promptly. The facility's policy on medication ordering and receiving was not adhered to, resulting in these deficiencies. Resident 80, who has a diabetic diagnosis, did not receive her insulin glargine on the mornings of March 1 and March 2, 2024, due to unavailability from the pharmacy. Despite the high blood sugar levels recorded, there was no documentation indicating that the medical doctor was contacted to address the issue. The DON acknowledged that the nursing staff could have used the emergency supply of insulin but did not do so. The facility's policy on medication administration and documentation was not followed, leading to this deficiency. The facility also failed to ensure safe pharmaceutical services with medication disposal, waste, and the accountability of delivered medications. The pharmaceutical waste bin was accessible by hand, and medications were not rendered unusable, posing a risk of drug diversion. Additionally, prescription drug disposition records were not co-signed and witnessed by licensed staff during destruction and disposal. Medication delivery receipts and manifests by the pharmacy provider were not consistently signed by licensed staff, compromising accountability and accuracy. The DON confirmed these lapses and acknowledged the missing witness signatures and the improper handling of the pharmaceutical waste bin. The facility's policies on medication disposal and controlled substance handling were not followed, leading to these deficiencies.
Infection Control Deficiencies and Lack of Water Management Program
Penalty
Summary
The facility failed to ensure safe infection control practices with the use of shared blood pressure devices and glucometers between residents. During multiple observations, Licensed Nurses (LNs) were seen using the same blood pressure device and glucometer on different residents without proper cleaning and sanitization. The LNs used alcohol wipes instead of the facility's approved disinfectant wipes, which were not effective against serious pathogens. Interviews with the LNs, Infection Preventionist (IP), and Director of Nursing (DON) confirmed that the staff did not follow the correct procedures for cleaning these devices, and the facility's policies were inconsistent and outdated. The facility also failed to develop and implement a water management program to reduce the risk of bacterial growth in the water system. The Administrator and IP admitted that there was no such program in place, which put residents at risk for waterborne illnesses. This was in direct violation of guidelines issued by the Centers for Medicare and Medicaid Services (CMS), which require healthcare facilities to have policies and procedures to prevent the growth and spread of Legionella and other pathogens in water systems. Additionally, the facility did not maintain a clean and infection-free environment in Resident 19's room. The room was cluttered with personal belongings, plastic bags, and trash, creating a strong sour smell and posing a hazard. The resident had a history of chronic urinary tract infections and sepsis, and the cluttered environment increased the risk of infection. Interviews with the CNA, LN, IP, and DON confirmed that the room's condition was a significant infection control issue, and the facility's housekeeping policy was not followed.
Incomplete POLST Form for Resident
Penalty
Summary
The facility failed to ensure the Physician's Orders for Life Sustaining Treatment (POLST) for Resident 64 was fully completed and uploaded to the resident's Electronic Health Record (EHR) per facility policy. Resident 64's POLST form, which is crucial for documenting the types of medical treatment the resident wants to receive during serious illness, was missing essential identifying information. Specifically, Section A, which indicates the resident's preference for Cardiopulmonary Resuscitation (CPR), was marked for Do Not Attempt Resuscitation (DNR), but Section D, which requires the resident's name and signature, was left blank. This omission was confirmed during interviews with a licensed nurse (LN) and the Director of Nursing (DON), who both acknowledged that the lack of identifying information would necessitate performing a full code (CPR) in the event of a medical emergency, contrary to the resident's documented wishes on the incomplete POLST form. Resident 64 was admitted to the facility with diagnoses including diabetes and dependence on renal dialysis. The failure to complete and properly file the POLST form had the potential to delay treatment or result in the administration of incorrect life-sustaining measures. The facility's policy on POLST forms, which requires them to be completed based on the patient's expressed treatment preferences and signed by both the physician and the patient or their legally recognized healthcare decision-maker, was not adhered to in this case. This deficiency was identified through a review of Resident 64's medical records and confirmed through staff interviews, highlighting a significant lapse in ensuring the resident's treatment preferences were accurately documented and accessible in their EHR.
Failure to Ensure Accessible Bathroom Doors
Penalty
Summary
The facility failed to ensure that two residents, Resident 75 and Resident 81, received care and services safely when they were unable to open bathroom door #7. Resident 75, who had a diagnosis of muscle weakness and used a manual wheelchair and walker, reported difficulty in opening the heavy and sticky bathroom door. Observations confirmed that the door was difficult to open and close, and the door latch did not completely engage, leaving the door slightly ajar. The Maintenance Director verified that the door knob was loose and the door was heavy, possibly a fire door, which should have been accessible to residents independently according to the Director of Nursing's expectations. Resident 81, who had muscle weakness and had lost his right leg, also reported difficulty in opening the same bathroom door. He had informed the staff about the problem and expressed concerns about being trapped in the bathroom, especially in case of a fire. Observations showed that Resident 81 struggled to open the door due to its heaviness and the incline leading up to it. He had to use the call light for assistance to exit the bathroom. The Licensed Nurse and the Director of Nursing acknowledged that the door was too heavy for Resident 81 to open independently, posing a risk for falls and feelings of claustrophobia. The facility's policy on Resident Accommodation of Needs was not followed, as residents did not have easy access to the bathroom. The Director of Nursing confirmed that the expectation was for residents to open bathroom doors independently to maintain their level of independence and dignity. The failure to ensure accessible bathroom doors led to feelings of entrapment and the inability to maintain independence with activities of daily living for the affected residents.
Failure to Develop and Implement Care Plans for Psychotropic and High-Risk Medications
Penalty
Summary
The facility failed to develop and implement care plans for psychotropic and high-risk medications for three residents. Resident 80's care plan did not include monitoring for the use of duloxetine and cariprazine, both psychotropic medications, nor did it address the use of high-risk blood thinner medications apixaban, ticagrelor, and naproxen. This lack of documentation meant that licensed staff were not guided on how to monitor the resident's progress and potential adverse effects of these medications. The Director of Nursing (DON) and a Licensed Nurse (LN) acknowledged these findings during a review of the resident's medical records. Similarly, Resident 57's care plan did not include monitoring for the use of blood thinner medications clopidogrel and aspirin, which had been prescribed for stroke prevention. The absence of a care plan meant that nursing staff were not provided with guidelines on how to manage the safe use and monitoring of these medications. The DON confirmed that the care plan should have reflected the necessary nursing care and how the medications were being addressed. Resident 28's care plan also lacked documentation for monitoring the use of duloxetine, an antidepressant medication. The medical records did not indicate a plan of care for depression or how the nursing staff should monitor the resident's progress and safety. This deficiency was confirmed by LN 2 during a review of the resident's medical records. The facility's policies on care plans and chemical restraints were not followed, as they require comprehensive care plans to meet residents' medical, nursing, and psychosocial needs, including monitoring for adverse reactions and ensuring mental well-being.
Failure to Ensure Safe Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure a safe environment and adequate supervision for Resident 72, who had a history of epilepsy, Merrf syndrome, and muscle weakness. The fall risk assessment for Resident 72 was not completed accurately, as the section on medications was left blank, resulting in an incorrect fall risk score. Despite multiple falls in February 2024, the fall interventions were not updated, and necessary measures such as a fall mat were not implemented. The Director of Nursing acknowledged that the fall risk assessment score should have been higher, indicating a high fall risk, and that additional interventions should have been in place. Resident 72 experienced multiple falls, including incidents on 2/5/24, 2/11/24, and 2/16/24, where she was found on the floor by staff or her roommate. Despite being identified as a high fall risk, the interventions in place were inadequate, and the care plan was not updated to reflect new measures after each fall. The use of a body alarm was attempted but was unsuccessful as Resident 72 removed it, and this failed intervention was not updated in the care plan. Additionally, Resident 72 eloped from the facility on 1/29/24, and staff were unaware of her absence until contacted by the police. The elopement risk evaluation indicated a moderate risk, but no care plan was initiated to address this risk. The facility's policy and procedure for elopement were not followed, as the staff did not monitor Resident 72's whereabouts effectively. The Director of Nursing confirmed that the process for handling elopements was not properly executed, leading to Resident 72's unsupervised departure from the facility.
Failure to Follow Physician's Orders for Supplemental Oxygen
Penalty
Summary
The facility failed to follow the physician's orders for supplemental oxygen administration for Resident 80, who has a diagnosis of Chronic Obstructive Pulmonary Disease (COPD) and asthma. The physician's order dated 1/17/2024 specified that Resident 80 should receive 2 liters (L) of supplemental oxygen via nasal cannula. However, observations on 3/4/2024 and 3/6/2024 revealed that Resident 80 was receiving 5 L and 3.5 L of supplemental oxygen, respectively. Additionally, a review of the resident's clinical records indicated multiple instances in January and February 2024 where Resident 80 was administered 3 L of supplemental oxygen instead of the ordered 2 L. Interviews with licensed nurses confirmed that the facility was not adhering to the physician's orders, and the Director of Nursing acknowledged that the facility's policy and procedure on oxygen therapy were not followed. Resident 80's care plan, dated 1/24/2024, indicated that the resident was at risk for injury related to respiratory problems and included an intervention to administer oxygen as ordered by the physician. Despite this, the facility failed to consistently follow the prescribed oxygen flow rate. Licensed Nurse 6 admitted that the current oxygen administration did not align with the physician's orders and stated that she would contact the physician to update the order. Licensed Nurse 4 also confirmed that any changes in oxygen support should be preceded by a call to the physician for a new order. The Director of Nursing reviewed the facility's policy and procedure on oxygen therapy and acknowledged that it was not adhered to, leading to the deficiency in care for Resident 80.
Inappropriate Use of Full Siderails for Resident
Penalty
Summary
The facility failed to apply appropriate siderails for Resident 63, who was ordered half siderails but was found with two full bed siderails in use. This discrepancy was observed on multiple occasions, with Resident 63 lying in bed with full siderails up bilaterally. Resident 63's medical records indicated a high risk for falls and specified the use of half siderails for bed mobility and transfers. However, the facility did not adhere to this order, and full siderails were installed instead, without proper assessment, care plan, or consent for their use. During interviews, both a licensed nurse and the Director of Nurses confirmed the presence of full siderails and acknowledged the order for half siderails. The Director of Nurses reviewed the resident's siderail assessment, care plan, and consent, confirming that they only supported the use of half siderails. The facility's policy required a thorough assessment and interdisciplinary team involvement to determine the appropriateness of siderail use, which was not followed in this case.
Failure to Monitor Adverse Effects of High-Risk Medications
Penalty
Summary
The facility failed to monitor the adverse effects of high-risk medications in two residents. Resident 80 was prescribed multiple blood thinners and a pain medication known to have bleeding side effects, including apixaban, ticagrelor, and naproxen. A review of Resident 80's medical records revealed no documented monitoring of these medications for adverse effects. During an interview, the Director of Nursing (DON) acknowledged the oversight and the increased risk of bleeding due to the combination of these medications. Similarly, Resident 57 was prescribed aspirin and clopidogrel for stroke prevention, both of which have potential bleeding side effects. A review of Resident 57's medical records also showed no documented monitoring for adverse effects. The DON confirmed that nursing monitoring should have been part of daily care and resident assessment. The facility's policy on medication monitoring and management was reviewed and found to be lacking in specific guidelines for newer blood thinner medications used in the facility.
Failure to Monitor Psychotropic Medication Side Effects and Behaviors
Penalty
Summary
The facility failed to develop and implement psychotropic medication side effect and behavior monitoring for one out of five sampled residents (Resident 80). Resident 80 was prescribed duloxetine and cariprazine to treat anxiety, but the nursing staff did not monitor for adverse effects or targeted behaviors as required by manufacturer instructions and standards of practice. This oversight was confirmed during a review of Resident 80's medical records, which showed no documented daily monitoring for the use of these medications. During an interview and record review with a Licensed Nurse and the Director of Nursing, it was confirmed that the monitoring for duloxetine and cariprazine was overlooked. The facility's policy on chemical restraints requires that psychotropic drug assessments include monitoring for adverse drug reactions and behavioral manifestations. However, this policy was not followed in the case of Resident 80, leading to a failure in ensuring safe medication use and proper mental health care monitoring.
Failure to Conduct Annual Facility Assessment Review
Penalty
Summary
The facility failed to ensure a review of the Facility Assessment was conducted at least annually. The last review and update of the Facility Assessment was on January 17, 2018. During an interview and record review with the Administrator and Director of Nurses on March 7, 2024, the Administrator confirmed that the Facility Assessment had not been updated since January 17, 2018. The facility policy mandates that the Facility Assessment be reviewed and updated annually and as necessary. This failure had the potential to negatively affect the health and well-being of all residents residing in the facility.
Room Size Deficiency
Penalty
Summary
Four rooms in the facility did not meet the required square footage per resident, as observed and confirmed by the Maintenance Director and the Administrator. Specifically, room 5, a 3-bed room, measured 236.73 square feet instead of the required 240 square feet; room 18, a 3-bed room, measured 238 square feet instead of 240 square feet; room 22, a 3-bed room, measured 231.2 square feet instead of 240 square feet; and room 45, a 2-bed room, measured 140 square feet instead of 160 square feet. Despite these deficiencies, residents in these rooms reported no concerns about the space, and staff members indicated they could perform their duties effectively in the smaller rooms. During interviews, residents expressed satisfaction with the space provided, and staff members, including certified nursing assistants and a licensed nurse, stated they had no issues working in the smaller rooms. The Administrator confirmed the measurements and acknowledged the shortfall in required square footage. The facility recommended continuing the room waiver, contingent upon compliance with federal regulations regarding Resident Rights and Physical Environment.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Stockton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lincoln Square Post Acute Care | 0.3 mi | ★★★★★ | 24 | 0 |
| Hampton Post Acute | 0.8 mi | ★★★★★ | 17 | 0 |
| Noble Care Center | 0.9 mi | ★★★★★ | 5 | 0 |
| Fulton Gardens Post Acute, Llc | 1.4 mi | ★★★★★ | 20 | 0 |
| Brookside Care Center | 1.8 mi | ★★★★★ | 22 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.