Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Green Acres Healthcare Center during CMS and state inspections, most recent first.
Incomplete informed consent for psychotropic medications: The DON found that a resident’s consents for Divalproex Sodium and Olanzapine were missing the prescriber’s signature and date, while two other residents had antipsychotic and antidepressant consent forms that were also missing physician authentication. One resident’s Quetiapine consent also lacked documentation that probable side effects were explained. The residents had psychiatric diagnoses including schizoaffective disorder, schizophrenia, bipolar schizoaffective disorder, and dementia, and were receiving routine psychotropic medications when the incomplete consents were reviewed.
Daily nurse staffing information was not posted accurately in the lobby. Surveyors observed a Census and Direct Care Service Hours per Patient Day form that showed projected staffing hours instead of the actual hours worked for each shift, and it did not list staffing by RN, LVN, or CNA category for the posted shift. The DON said the DSD was responsible for updating the posting, and the DSD said she had been instructed to post projected hours rather than actual hours worked.
Improperly Stored and Unsealed Food in Refrigerator: During a kitchen observation, an open container of grape jelly and a container of preserved fruit cocktail with a cracked, improperly sealed lid were found in Refrigerator #1. The DS stated the fruit cocktail had to be discarded because the cracked lid exposed it to air, and she noted that all food products must be sealed and dated per policy. The facility policy required refrigerated and frozen foods to be covered, labeled, and dated.
Failure to send the required transfer/discharge notice to the LTC Ombudsman for a resident who was discharged home. The resident had COPD and schizoaffective disorder, and the MRD stated the Ombudsman copy was not sent even though facility policy requires the notice be provided to the Ombudsman at the same time as the resident and representative.
A resident with CHF, CAD, bradycardia, and a low EF was hospitalized after a syncopal episode and returned with discharge instructions to follow up with cardiology for possible beta blocker resumption and Zio Patch monitoring, but the facility did not document implementing those instructions or creating a cardiac care plan. The DON and physician also identified no documented plan for treatment refusals or specific heart rate monitoring. Later, after the resident had watery emesis, the physician was notified, but the DON found no documented ongoing monitoring in the notes, and staff stated they were unsure about specific monitoring needs.
Medication pass error rate exceeded the acceptable limit when an LVN administered metoprolol and metformin to a resident without food, despite orders to give both medications with food. The resident had DM2 and hyperlipidemia, and the LVN stated she assumed it was acceptable because breakfast had already been served. The DON confirmed the orders required food with administration, and the facility policy required medications to be prepared and administered correctly.
Expired ABH gel was administered to a resident with dementia, mood disorder, and severely impaired cognition after prefilled syringes were found in the locked med refrigerator past their expiration date. Record review showed multiple doses were given, and the DSD and DON acknowledged the expired medication had been administered and that nurses are responsible for checking expiration dates before use.
Advance directive documentation was missing for two residents, and one resident’s POLST was not completed per policy. A resident with TBI and severely impaired cognition had no signed AD notification form or POLST in the chart because staff could not complete the paperwork after difficulty contacting the RP; the DON, SSD, and BOM all confirmed the documents were absent and unsigned.
The facility failed to monitor and document refrigerator temperatures in the temporary food storage room, risking foodborne illness for residents. Temperature logs for one refrigerator and the freezer were left blank for several days, contrary to the facility's policy requiring daily checks. The Dietary Service Supervisor was unsure if the designated staff had performed the required checks.
A facility failed to obtain informed consent for psychotropic medications for a resident with dementia and schizophrenia, and did not ensure POLST forms for three residents were properly completed and signed. The omissions in documentation could lead to delays in care during emergencies, as POLST forms serve as physician orders. The facility's policies for informed consent and POLST completion were not followed, violating residents' rights to be informed and make decisions about their care.
The facility failed to maintain resident dignity and effective communication, as seen in two cases. A resident with a suprapubic catheter was observed without a urinary bag cover, violating privacy. Another resident, hard of hearing and speaking a foreign language, faced communication barriers due to inadequate tools and methods, leading to frustration and unmet needs. Staff acknowledged these issues, which contravened facility policies on resident rights and dignity.
The facility failed to ensure Advance Directives (AD) were offered and documented for two residents, one with bipolar disorder and schizophrenia, and another with pneumonia and schizophrenia. Despite intact cognition, neither resident had an AD or POLST in their records. Staff interviews revealed confusion about responsibility for ADs, and the medical records director admitted oversight, contrary to facility policy requiring inquiry and assistance with ADs upon admission.
The facility failed to develop comprehensive care plans for two residents, one with aggressive behavior and another with communication barriers. Despite incidents of aggression and communication difficulties, the facility did not create adequate care plans, leading to unmet needs and compromised resident rights.
A resident with hearing difficulties and language barriers did not receive necessary assistive devices or an audiology consult, despite a physician's order. Staff were aware of the resident's communication challenges but did not provide effective solutions, leading to impaired communication and delayed care. The facility's policy on accommodating communication deficits was not followed.
A resident with a suprapubic catheter was at risk for UTIs due to improper catheter care. The drainage bag was observed hanging higher than the bladder, and the tubing was wrapped around the resident's leg, both of which could cause urine backflow. Staff acknowledged these practices were inappropriate, and the facility's policies emphasize proper positioning to prevent infections.
A facility failed to refer a resident with schizophrenia for a psychiatric consultation despite documented aggressive behavior and a care plan intervention. The resident's aggressive actions were noted in assessments, but the facility overlooked the necessary referral, contrary to its behavioral health services policy.
A facility failed to maintain a medication error rate below 5%, reaching 13.79% during a medication pass. An LVN crushed and mixed four medications for a resident with bipolar disorder and schizophrenia, contrary to best practices. The DON confirmed that medications should be administered separately unless preferred otherwise. The facility's policy lacked specific guidance on administering crushed medications.
The facility failed to properly store medications by placing Hydrogen Peroxide Topical Solution, an external medication, on the same shelf as oral medications. This was observed during an inspection with an LVN, who confirmed the improper storage. The DON acknowledged the risk of misidentification and accidental ingestion due to similar container appearances. The facility's policy requires separate storage for oral and external medications.
A resident with a suprapubic catheter on Enhanced Barrier Precautions received high-contact care from an LVN and a CNA who failed to wear isolation gowns and perform hand hygiene, contrary to the facility's Infection Prevention and Control Program. The resident had a history of urinary issues and cognitive impairment, necessitating strict adherence to PPE protocols to prevent infection spread.
The facility was found to have three rooms each accommodating five residents, exceeding the regulatory limit of four residents per room. Despite a waiver request and no reported concerns from residents or staff about space, the setup did not comply with regulations. Interviews confirmed residents had intact cognitive skills and required assistance with daily activities, but the room arrangement still constituted a deficiency.
The facility failed to meet the required room size of 100 sq. ft. for four single resident rooms, with Rooms 4 and 5 measuring 76 sq. ft. and Rooms 16 and 17 measuring 99.75 sq. ft. Despite this, observations and interviews indicated that the room sizes did not affect the care provided. A resident with schizophrenia, hypertension, and anxiety disorder reported having enough space, and staff confirmed sufficient space for care delivery.
The facility failed to provide direct exit access for four resident rooms, requiring residents to pass through other rooms to reach an exit corridor. Although the residents were ambulatory and reported no issues, this arrangement potentially compromised their safety in emergencies. Interviews with staff and a resident confirmed the current setup, and a room variance indicated no adverse effects on residents' health and safety.
Incomplete informed consent for psychotropic medications
Penalty
Summary
The facility failed to obtain complete informed consent before administering psychotropic medications to three residents and failed to keep the required physician signature and date in the clinical record. The deficiency involved Resident 10, Resident 72, and Resident 82, all of whom were receiving psychotropic medications for psychiatric diagnoses and had consent forms that were incomplete or missing prescriber authentication. Resident 10 was admitted with diagnoses including hypertensive heart disease without heart failure and schizoaffective disorder. The resident’s H&P stated the resident was able to make decisions regarding activities of daily living. The order summary showed Divalproex Sodium 375 mg twice daily for schizoaffective disorder with uncontrolled angry outbursts and Olanzapine 2.5 mg at bedtime for psychosis with paranoid delusions. The informed consent forms for both medications had blank prescriber signature and date areas. During interview, the DON stated the prescriber must sign and date psychotropic medication consents immediately upon obtaining consent and that the consent is not valid without the prescriber’s signature and date. Resident 72 was admitted with diagnoses including encephalopathy and schizophrenia, and the H&P indicated the resident had capacity to make decisions for activities of daily living. The resident was receiving Haloperidol 10 mg three times daily, Olanzapine 20 mg at bedtime, and Quetiapine Fumarate 25 mg twice daily and 50 mg at bedtime for schizophrenia-related symptoms. The informed consent forms for Haloperidol, Olanzapine, and both Quetiapine doses were dated 2/18/2026, but none had a physician signature or date. The DON also stated the consent for Quetiapine Fumarate 50 mg did not document that probable side effects were explained to the resident or responsible party. The DON stated the consents had been prepared 22 days earlier and that the resident and responsible party have the right to be informed of the medication’s purpose, potential side effects, and attempted nonpharmacological interventions before antipsychotic medications are started. Resident 82 was admitted and later readmitted with diagnoses including bipolar schizoaffective disorder and dementia, and the MDS indicated severely impaired cognitive skills, delusions, and routine use of antipsychotic and antidepressant medications. The order summary showed Bupropion HCL ER 150 mg daily for depression, Risperdal 2 mg twice daily for bipolar schizoaffective disorder, and Olanzapine 10 mg twice daily for bipolar schizoaffective disorder with hallucinations and angry outbursts. The informed consent forms for these medications were dated 3/6/2026, but the physician signature and date were missing. During interview, the DON stated the resident’s representative signed the antipsychotic informed consents, but the physician signature and date were not present and the resident had been receiving the medications for 6 days.
Daily Nurse Staffing Posting Not Current or Accurate
Penalty
Summary
The facility failed to ensure that accurate and current nurse staffing data were posted daily at the beginning of each shift. During an observation on 3/10/2026 at 1:34 PM in the front lobby, surveyors observed a Census and Direct Care Service Hours per Patient Day document dated 3/09/2026. The posting showed the facility census as 78 and listed projected nursing hours for licensed and unlicensed staff, but it did not include nursing staffing information by category for each shift (11 PM-7 AM, 7 AM-3 PM, and 3 PM-11 PM). It also did not list the actual hours worked for each category, type, or shift of nursing staff on 3/09/2026. During a concurrent interview and record review, the DON stated the DSD was responsible for updating, posting, and filing the daily nurse staffing data in the front lobby, and that the staffing posting should be updated daily at the beginning of the first shift. The DSD stated she had been instructed upon hire to display projected staffing hours in the lobby rather than the actual hours worked for each shift. The facility policy titled Posting Direct Care Daily Staffing Number, revised March 2023, stated that at the beginning of each shift the number of RNs, LVNs, and CNAs directly responsible for resident care shall be posted in a prominent location, and that the form shall include the actual time worked during that shift for each category and type of nursing staff, along with the total number of licensed and non-licensed nursing staff working for the posted shift.
Improperly Stored and Unsealed Food in Refrigerator
Penalty
Summary
The facility failed to ensure foods were properly stored and sealed in accordance with its Policy and Procedure titled Food Receiving and Storage. During a concurrent initial kitchen observation and interview with the Dietary Supervisor, Refrigerator #1 was found to contain an open plastic container of grape jelly that was not sealed and a container of preserved fruit cocktail that was not sealed properly. The lid on the preserved fruit cocktail container had a visible crack approximately 1 inch in length. The Dietary Supervisor stated she observed both items and said the fruit cocktail had to be thrown away because the cracked lid exposed the food to air, which could allow bacteria to enter. She also stated that all food products must be sealed and dated to prevent contamination and spoilage according to the facility policy. The facility policy reviewed by surveyors stated that foods shall be received and stored in a manner that complies with safe food handling practices and that all foods stored in the refrigerator or freezer are to be covered, labeled, and dated with a use by date.
Failure to Notify Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to ensure that the required Notice of Proposed Transfer/Discharge was sent to the Long-Term Care Ombudsman for one sampled resident, Resident 91. The record review and interview showed that Resident 91 was discharged home with Family 1, with all medications and belongings, and with home health follow-up with the primary physician and psychiatrist. Resident 91’s admission record listed diagnoses including chronic obstructive pulmonary disease and schizoaffective disorder. During an interview and record review with the Medical Record Director, it was stated that when a resident is transferred or discharged, the facility must send a copy of the Transfer/Discharge form to the ombudsman and keep the fax confirmation in the medical record. The Medical Record Director stated he did not send the Ombudsman a copy of Resident 91’s Transfer/Discharge Notice. The Director of Nursing stated it was facility policy to send the Ombudsman a copy of a resident’s transfer or discharge notice, and the facility policy and procedure stated that a copy of the notice is sent to the office of the State Long Term Care Ombudsman at the same time it is provided to the resident and representative.
Failure to Follow Cardiac Discharge Instructions and Monitor Change of Condition
Penalty
Summary
The facility failed to provide care and treatment in accordance with orders, resident preferences, and goals for a resident with a complex cardiac history that included CHF, CAD, bradycardia, acute respiratory failure with hypoxia, and bipolar schizoaffective disorder. After the resident was sent to the hospital following a change of condition in which he was found nonresponsive and passed out in the dining room, the hospital documented episodes of bradycardia with heart rates in the 20s and a low EF of 32%. The hospital discharge summary instructed follow-up with outpatient cardiology to consider resuming a beta blocker because of the bradycardia episodes and for outpatient placement of a Zio Patch monitor, but the facility did not document implementation of those discharge instructions or a cardiac consultation order. The record also showed no documented care plan for the resident’s cardiac diagnoses or for refusals of treatment. During interview, the DON stated there was no documented evidence of a care plan related to the resident’s bradycardia or refusals of treatments, and stated it was important to create a care plan for the resident’s cardiac diagnoses to support specific monitoring of heart rate and blood pressure. The physician stated he reviewed transfer documents after readmission but did not see the referral for cardiology heart monitoring and CHF medication regimen, and stated the licensed staff did not inform him about the hospital’s referral for cardiology follow-up and CHF treatments. The facility also failed to adequately follow up on a later change of condition when the resident had one episode of watery emesis. The physician was notified and gave an order to send the resident out to the ER if emesis persisted, but the DON stated there was no documented evidence in the progress notes or licensed nurse notes of continued monitoring for the emesis. Staff interviews indicated the resident’s vital signs were checked once per shift and that there was no specific order for heart rate monitoring, while one LVN stated she forgot to complete a licensed nurse note for the afternoon shift and another stated she did not know whether any specific monitoring was required after the emesis episode.
Medication pass error rate exceeded acceptable threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5 percent during medication pass. During observation, interview, and record review, two medication errors were identified for one sampled resident during 29 medication opportunities, resulting in a 6.9% medication error rate. The resident involved was admitted and later re-admitted to the facility with diagnoses including Type 2 diabetes mellitus and hyperlipidemia, and the H&P stated the resident did not have the capacity to understand and make decisions. Resident 8 had orders for metoprolol tartrate 25 mg once daily for hypertension, to be given with food, and metformin HCL 1000 mg twice daily for diabetes mellitus, to be administered with food. During medication pass observation, an LVN administered both medications with water and without food. In interview, the LVN stated she knew the medications were to be given with food but assumed it was acceptable because the resident had breakfast around 7:00 AM. The DON later stated the LVN should have given a cracker or cookie if it was not mealtime and should not have administered the medications without food. The facility policy titled Med Pass stated to prepare the medication correctly, administer the medication correctly, and chart the med pass correctly.
Expired ABH Gel Administered to Resident
Penalty
Summary
The facility failed to ensure medications were not expired before administration for one sampled resident, who had diagnoses of unspecified dementia and mood disorder and was documented as lacking decision-making capacity with severely impaired cognition. The resident had a telephone order for ABH topical gel (Ativan 1 mg, Benadryl 25 mg, Haldol 1 mg/1 ml) to be applied every 4 hours as needed for agitation/restlessness, rubbed topically to the inner wrist with gloves worn. Record review showed the resident received ABH topical gel on multiple occasions, including one administration on 2/27/2026 and six additional administrations in March 2026. During a medication storage observation, surveyors found three prefilled syringes of ABH gel in the locked medication refrigerator with an expiration date of 2/25/2026. The DSD and LVN both observed the expired medication, and the DSD stated the resident had received expired doses and that licensed nurses should check expiration dates before administration. The DON also acknowledged the resident received expired ABH topical gel and stated nursing staff are responsible for verifying expiration dates and removing expired medications from storage.
Advance directive and POLST documentation missing
Penalty
Summary
The facility failed to ensure advance directives were obtained and accessible in the medical records for two sampled residents, Resident 19 and Resident 30. Their signed Advance Directive acknowledgment forms were not located in the records. For Resident 30, the Physician Orders for Life-Sustaining Treatment (POLST) was also not completed in accordance with facility policy, and the hard chart did not contain the AD notification form or POLST because these documents remained unsigned. Resident 30 was admitted following a motor vehicle accident with altered level of consciousness and traumatic brain injury, and the MDS dated 2/25/2026 indicated severely impaired cognition. The SSD stated attempts were made to contact the RP after admission but were unsuccessful, and she could not recall why further attempts were not made; FM2 was identified as the RP and had a diagnosis of dementia. The BOM stated the facility had an issue identifying the RP, FM1 declined the RP role, and the chart lacked the AD notification form and POLST because they were still unsigned. The DON confirmed the POLST was not in the chart and was not completed due to inability to contact FM2.
Failure to Monitor Refrigerator Temperatures
Penalty
Summary
The facility failed to ensure proper monitoring and documentation of refrigerator temperatures in the temporary food storage room, which placed residents at risk for foodborne illness. During a follow-up kitchen tour, it was observed that the temperature logs for one of the refrigerators and the freezer were not filled out for several days. Specifically, the log for Refrigerator 2 was blank from the afternoon of February 4th to February 6th, and the logs for Refrigerator 3 and the freezer were blank for the same period. The Dietary Service Supervisor (DSS) indicated that the responsibility for checking and logging the temperatures of the refrigerators and freezers fell to the cooks on both the AM and PM shifts. However, the DSS was unsure if the cooks had checked the logs, and acknowledged that the logs should not have been missed. The facility's policy requires daily temperature checks and documentation at the first opening and at closing in the evening, but this procedure was not followed, leading to the deficiency.
Failure to Obtain Informed Consent and Complete POLST Forms
Penalty
Summary
The facility failed to ensure that residents were fully informed and understood their health status, care, and treatments, specifically regarding informed consent for medications and life-sustaining treatment orders. Resident 37, who was diagnosed with dementia, psychotic disorder, and schizophrenia, was prescribed Quetiapine and Divalproex Sodium without obtaining informed consent from the resident's representative or power of attorney. The facility's policy required the prescriber's signature on the informed consent within 24 hours of admission, but this was not completed, leaving the resident's representative unaware of the medication's risks, benefits, and alternatives. Additionally, the facility did not ensure that the Physician Orders for Life-Sustaining Treatment (POLST) forms for Residents 12, 69, and 14 were properly completed and signed by the responsible parties. Resident 12, with a moderately impaired cognitive status, had a POLST indicating DNR status, but it lacked the responsible party's signature, rendering it invalid. Similarly, Resident 69's POLST was missing the responsible party's signature, and Resident 14's POLST was prepared without obtaining the resident's signature. These omissions could lead to delays in care during emergencies, as the POLST forms serve as physician orders for medical professionals. The facility's policies and procedures for informed consent and POLST completion were not followed, resulting in incomplete documentation and potential delays in care. The Director of Nurses and other staff acknowledged the deficiencies, noting the importance of having valid POLST forms and informed consent to ensure residents and their representatives are aware of treatment options and preferences. The lack of proper documentation violated residents' rights to be informed and make decisions about their care, potentially affecting their quality of life and health outcomes.
Deficiencies in Resident Dignity and Communication
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity, as evidenced by two specific incidents involving Resident 3 and Resident 226. Resident 3, who had a suprapubic catheter, was observed without a urinary catheter bag cover, which is a violation of privacy and dignity. The staff, including a CNA and an LVN, acknowledged the absence of the cover and recognized it as a breach of the resident's rights. The facility's policy mandates that urinary catheter bags should be covered to maintain resident dignity. Resident 226, who was hard of hearing and spoke a foreign language, experienced significant communication barriers with the staff. The resident expressed frustration and sadness due to the inability to communicate effectively, as the staff did not provide adequate means of communication such as a communication board or appropriate translation services. Interviews with various staff members, including CNAs and LVNs, revealed that the facility did not have effective communication tools in place, and the staff often resorted to ineffective methods like body language or phone translation, which were not suitable given the resident's hearing impairment. The facility's policies on resident rights and dignity emphasize the importance of treating residents with respect and ensuring effective communication. However, the lack of proper assessment and implementation of communication strategies for Resident 226, along with the failure to maintain privacy for Resident 3, demonstrate a disregard for these policies. The Director of Nursing acknowledged the deficiencies and the impact on resident rights, highlighting the need for comprehensive care plans and effective communication methods.
Failure to Implement Advance Directive Policy
Penalty
Summary
The facility failed to implement its policy and procedure on Advance Directives (AD) by not ensuring that the AD was offered, explained, and signed for two residents. Resident 14, admitted with diagnoses including bipolar disorder and schizophrenia, had intact cognition according to the Minimum Data Set (MDS) but did not have an AD in their medical records or the facility's database. There was no documentation indicating that the facility offered an AD during Resident 14's admission. Similarly, Resident 39, who was readmitted with pneumonia and schizophrenia, also lacked an AD or a Physician's Orders for Life-Sustaining Treatment (POLST) in their records. Although initially noted as lacking decision-making capacity, the MDS indicated intact cognition. Interviews with facility staff revealed a lack of clarity regarding responsibility for ensuring ADs and POLSTs were in place, with the medical records director admitting oversight. The facility's policy requires the social services director or designee to inquire about ADs upon admission and assist in establishing them if needed, which was not followed in these cases.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents, leading to deficiencies in care. Resident 9, who was diagnosed with schizophrenia and had intact cognition, exhibited aggressive behavior towards staff and other residents. Despite multiple incidents of aggression and attempts to take personal belongings from other residents, the facility did not create a care plan to address these behaviors. Interviews with staff revealed that although Change of Condition assessments were initiated, no interdisciplinary team meeting or care plan was developed to ensure the safety and dignity of all residents. Resident 226, who was admitted with Type 2 Diabetes Mellitus, dementia, and hearing difficulties, faced communication barriers due to a language difference and hearing impairment. The resident expressed frustration over the inability to communicate effectively with staff, which was exacerbated by the lack of a communication board or other aids. Staff interviews confirmed that communication methods were inadequate, and there was no documented evidence of translation services or communication aids being provided. The facility's failure to assess and address these communication needs resulted in unmet care needs and compromised resident rights. The facility's policy required the development of a comprehensive, person-centered care plan that includes measurable objectives and timeframes. However, the facility did not adhere to this policy for either resident, resulting in deficiencies that affected the residents' physical, mental, and psychosocial well-being. The Director of Nursing acknowledged the lapses in care planning and communication, emphasizing the importance of effective communication and comprehensive care planning to uphold resident rights and ensure their well-being.
Failure to Provide Hearing Assistive Devices for Resident
Penalty
Summary
The facility failed to ensure that a resident received proper assistive devices to maintain hearing abilities, resulting in a delay of services for the resident. The resident, who was admitted with diagnoses including Type 2 Diabetes Mellitus, unspecified dementia, and abnormalities of gait and mobility, was observed having difficulty hearing and communicating with staff. Despite a physician's order for an audiology consult as needed for hearing problems, the facility did not arrange for this referral, leading to the resident's inability to hear adequately during interactions with staff. Interviews with staff revealed that they were aware of the resident's hearing difficulties and language barriers, yet no effective communication methods or assistive devices were provided. The Social Service Director stated that no hearing disability was reported upon admission, and the Director of Nursing acknowledged the failure to assess and address the resident's communication needs. The facility's policy on accommodating communication deficits was not followed, as the resident's needs for adaptive devices and modifications were not evaluated or addressed, impairing the resident's ability to communicate effectively and maintain dignity.
Improper Catheter Care Leads to Potential UTI Risk
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent urinary tract infections (UTIs) for a resident with a suprapubic catheter. On two separate occasions, the resident's catheter drainage bag was improperly positioned, which could lead to backflow of urine and potential UTIs. On the first occasion, the drainage bag was observed hanging on the wheelchair's armrest, higher than the resident's bladder, contrary to the facility's policy that requires the bag to be positioned lower than the bladder. On another occasion, the resident's catheter tubing was found wrapped around their leg, which could impede urine flow and cause backflow. Both the Registered Nurse and Licensed Vocational Nurse acknowledged that these practices were inappropriate and could lead to UTIs. The facility's Infection Preventionist and Director of Nurses confirmed that the drainage bag should always be below the bladder and the tubing should not be wrapped around the leg to prevent backflow and potential infections. The resident involved had a history of urinary tract infections and was diagnosed with conditions such as benign prostatic hyperplasia and obstructive and reflux uropathy, which necessitated the use of a suprapubic catheter. The facility's policies on suprapubic catheter care and infection prevention emphasize the importance of proper catheter positioning to prevent infections, but these were not adhered to in the resident's care.
Failure to Provide Psychiatric Referral for Aggressive Resident
Penalty
Summary
The facility failed to implement its policy and procedure on behavioral health services by not providing a referral for a psychiatric consultation for a resident exhibiting aggressive behavior. The resident, who was diagnosed with schizophrenia, was readmitted to the facility and had intact cognition according to the Minimum Data Set. Despite the creation of a care plan on January 28, 2025, which included an intervention for a psychiatric consultation, the facility overlooked this intervention and did not refer the resident to a psychiatrist. The resident's aggressive behavior was documented in Change of Condition assessments on January 16 and January 28, 2025, indicating attempts to attack staff and residents and taking personal belongings from another resident. Interviews with Licensed Vocational Nurses and the Director of Nursing confirmed the oversight in referring the resident for psychiatric evaluation. The facility's policy on Behavioral Health Services, revised in February 2019, stated that residents should receive necessary behavioral services to maintain their highest practicable well-being, which was not adhered to in this case.
Medication Error Rate Exceeds Acceptable Limit
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent during a medication pass, resulting in a 13.79% error rate. This was observed during a medication administration for one of the residents, who was diagnosed with bipolar disorder and schizophrenia, and had severely impaired cognition. The resident was prescribed several medications, including Depakote Sprinkles, Docusate Sodium, Multivitamin-Minerals, and Sodium Chloride. During the medication administration, an LVN prepared and crushed four oral medications, mixing them in a single container with applesauce. The surveyor intervened before the medications were administered. The LVN acknowledged the mistake, stating that the resident would not know what medication they were taking if mixed together. The DON later confirmed that medications should ideally be administered separately unless the resident prefers otherwise. The facility's medication administration policy lacked specific instructions on administering crushed medications.
Improper Storage of Medications
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the proper and safe storage of medications and biologicals. During an inspection of the East Wing medication storage room, a bottle of Hydrogen Peroxide Topical Solution, which is an external medication, was found stored on the same shelf as oral medications, such as stool softeners and vitamins. This observation was made in the presence of an LVN, who acknowledged that external medications should not be stored with oral medications to prevent medication errors. The Director of Nursing (DON) confirmed that oral and external medications should be stored separately to avoid the risk of misidentification and accidental ingestion, especially if the containers are similar in appearance. The DON was unaware of who placed the external medication on the shelf with oral medications. A review of the facility's medication storage policy, effective since April 2008, indicated that orally administered medications should be kept separate from externally used medications, such as suppositories, liquids, and lotions.
Failure to Follow Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to its Infection Prevention and Control Program, specifically in the case of a resident with a suprapubic catheter who was on Enhanced Barrier Precautions (EBP). During an observation, it was noted that a Licensed Vocational Nurse (LVN) and a Certified Nurse Assistant (CNA) provided high-contact care to the resident without wearing the required isolation gowns as part of their Personal Protective Equipment (PPE). Additionally, both staff members did not perform hand hygiene after completing the care and proceeded to the nurses' station, which was against the facility's policy. The resident involved had a history of benign prostatic hyperplasia, obstructive and reflux uropathy, and urinary tract infections, and was cognitively impaired, requiring assistance with daily activities. The care plan for the resident included Enhanced Barrier Precautions due to the use of a suprapubic catheter, which required staff to use gloves, gowns, and masks during direct care and to perform hand hygiene before and after care. Despite these clear directives, the staff failed to comply with the necessary precautions. Interviews with the involved staff and facility leadership confirmed awareness of the requirements for PPE and hand hygiene. The LVN admitted to forgetting to wear a gown and perform hand hygiene, while the CNA could not provide a reason for the oversight. The Infection Preventionist and Director of Nurses reiterated the importance of following the EBP policy to prevent the spread of infections, highlighting the potential risk posed by the staff's non-compliance with established protocols.
Facility Exceeds Resident Room Capacity Limits
Penalty
Summary
The facility failed to comply with regulations limiting the number of residents per room, as three rooms (Rooms 6, 15, and 26) each accommodated five residents, exceeding the maximum of four residents per room. This deficiency was identified through observation, interviews, and record reviews. The rooms in question had varying square footage, with Room 6 at 332.5 sq. ft, Room 15 at 441 sq. ft, and Room 26 at 496 sq. ft. Despite the facility's submission of a room waiver request, which claimed no adverse effects on residents' health, safety, or welfare, the setup did not align with the regulatory standards. Interviews with residents and staff revealed that the residents did not express concerns about the room space or sharing with others. Residents 67, 36, and 20, who were interviewed, all had intact cognitive skills and required varying levels of assistance with daily activities. They reported having enough room to perform their activities and did not mind sharing their rooms. Staff members, including a CNA and an LVN, also indicated that they had sufficient space to provide care and had not received complaints from residents regarding room space. However, the facility's arrangement still constituted a regulatory deficiency due to the number of residents per room exceeding the allowed limit.
Deficiency in Room Size Requirements
Penalty
Summary
The facility failed to ensure that four single resident rooms met the required minimum size of 100 square feet per resident. Specifically, Rooms 4 and 5 measured 76 square feet each, while Rooms 16 and 17 measured 99.75 square feet each. This deficiency was identified through a review of the facility's Client Accommodation Analysis and a waiver request submitted by the Administrator. The report indicates that the room sizes did not meet the Centers for Medicare & Medicaid Services (CMS) requirements, potentially affecting the quality of care, health, and safety of the residents due to inadequate space for care, mobility, and privacy. Despite the deficiency, observations and interviews conducted on February 7, 2025, revealed that the room sizes did not negatively impact the care and services provided to the residents. Residents and staff reported having sufficient space for care delivery and daily activities. Resident 8, who has a history of schizophrenia, hypertension, and anxiety disorder, stated she had enough space in her room and did not experience any issues with her care. Similarly, a CNA and an LVN confirmed that they had enough space to perform their duties in the single rooms and had not received any complaints from residents.
Deficiency in Direct Exit Access for Resident Rooms
Penalty
Summary
The facility failed to ensure that four resident bedrooms (Rooms 4, 5, 16, and 17) had direct access to an exit corridor without passing through another resident's bedroom. This deficiency was identified during a facility tour, where it was observed that residents in these rooms had to pass through adjacent rooms to reach the nearest exit corridor. This practice potentially compromised the privacy, health, and safety of the residents, particularly in emergency situations where direct access to an exit is crucial. Despite the lack of direct access, the residents in these rooms were ambulatory and did not express any concerns about their room locations. Interviews with a resident and staff members, including a CNA and an LVN, indicated that the residents were able to move in and out of their rooms without issues. Additionally, a room variance received during the survey period suggested that the residents' needs were accommodated without adverse effects on their health, safety, and welfare. However, the facility's arrangement still posed a potential risk due to the lack of direct exit access.
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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 Rosemead
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| San Gabriel Conv Center | 0 mi | ★★★★★ | 0 | 0 |
| Monterey Healthcare & Wellness Centre, Lp | 0.1 mi | ★★★★★ | 24 | 0 |
| Del Mar Convalescent Hospital | 1.5 mi | ★★★★★ | 19 | 0 |
| Rio Hondo Subacute & Nursing Center | 2.1 mi | — | 78 | 0 |
| Monterey Park Conv Hosp | 2.2 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.