Not rated by CMS — ratings are suppressed for new or low-volume facilities.
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 Greenfield Care Center Of Fairfield during CMS and state inspections, most recent first.
A resident with intact cognition and diagnoses including CHF, COPD, diabetes, and muscle weakness reported that her cell phone went missing after admission. Staff documented some searching, but the SSD stopped following up and the complaint was left unresolved, despite the facility’s theft and loss and grievance policies calling for investigation and resolution within 72 hours.
Improper Medication Storage and Labeling: A facility failed to keep medications properly labeled and stored when DuoNeb vials were found outside their foil packaging, loose pills were found in a medication cart drawer, and expired Vitamin B12 bottles were stored in the medication room. An LPN confirmed the findings, and the DON and consultant pharmacist stated the medications should have been stored in their proper packaging and expired stock should not have been kept for use.
Dietary Supervisor Lacked Required Qualifications: The facility failed to ensure the Dietary Supervisor met the job qualifications listed in the facility policy. The DS confirmed she did not have a Certified Dietary Manager credential and was not enrolled in a training program, yet she was responsible for training, hiring, scheduling dietary staff, and ordering food and kitchen supplies. The ADM confirmed the job description required a Certified Dietary Manager, and the facility document listed either a Certified Dietary Manager or Certified Food Protection Professional as the qualification.
Infection control failures were identified when EBP signage was not posted for two residents who were ordered on EBP for devices and wound care, personal items were found stored in a medication cart next to medications and controlled meds, and a dietary aide was observed without the required beard restraint while working in the kitchen. The DON, IP, and other staff confirmed the observations, and facility policies required EBP signage, proper medication cart storage, and facial hair restraints.
A resident with type 2 DM, gastrostomy, and severe cognitive impairment had a care plan directing fluid intake and output to be monitored and recorded every shift, but staff did not carry out the intervention. An LN confirmed the care plan requirement, stated there was no documentation or orders for fluid monitoring, and confirmed it was not happening; the DON stated staff were expected to follow care plans.
A resident with CHF and COPD was observed receiving oxygen via nasal cannula at 2.5 lpm and later 2 lpm, despite a physician’s order for 3 lpm. The resident stated she used oxygen all the time and that the setting should be 3 lpm, and a CNA confirmed the lower setting. The TN and DON both confirmed the order should have been followed, and the facility’s oxygen therapy policy required oxygen to be administered as ordered by the physician.
A resident with hemiplegia, hemiparesis, gout, neuralgia, and neuritis had an active PRN order for hydrocodone-acetaminophen for moderate to severe pain. Nursing staff signed out Norco in the CDR but did not document administration in the MAR on two occasions, and both the LN and DON confirmed the MAR was not accurately completed when the controlled medication was given.
A resident with DM, CHF, muscle weakness, and dependence for personal care received sliding-scale insulin lispro after a blood sugar of 185 mg/dl, but the meal tray was not delivered until later and the resident did not begin eating until about 20 minutes after the insulin was given. The LPN, CP, and DON all confirmed that rapid-acting insulin should be given with food or within 10 to 15 minutes, and the facility policy required insulin administration to follow the MD order.
A resident with CHF, ESRD on dialysis, and HTN was ordered a CCHO/renal diet with soft and bite-size texture and thin liquids, but during a meal observation a packet of iodized salt was found on the tray. The resident stated the salt packet was served with the meal, and staff confirmed the resident was on a renal diet and should not have received salt packets. The DS, DON, and facility policy all indicated that salt packets should not be provided with a renal diet.
A resident with pneumonia and acute/chronic respiratory failure, normally cognitively intact and full code, developed hypoxia, shortness of breath, and altered level of consciousness. An LN found the resident repeatedly saying the same sentence, with O2 sat in the low 80s on supplemental O2, increased the O2 flow, and called the on-call physician, who ordered an ER transfer via non-emergency transport. The resident was transferred without documented escalation to a non-rebreather mask and without calling 911, despite facility policy and the DON’s and NP’s statements that O2 sat below 88% with decreased consciousness requires activation of emergency response/911. ER records later showed a GCS of 7 and intubation for acute respiratory failure, and the facility’s policies and the state Nursing Practice Act require initiation of emergency procedures based on such observed abnormalities.
Controlled medication administration was not documented consistently for two residents. A resident with gout, neuralgia, and neuritis and another resident with dementia had active Norco orders, but doses were signed out of the CDR without being recorded in the MAR on multiple occasions. An LPN confirmed the discrepancy, and the CP and DON stated controlled meds should be signed in both the CDR and MAR.
Medication administration errors exceeded the allowed rate when surveyors found 3 errors in 36 opportunities, resulting in an 8.33% error rate. An LPN gave a resident’s scheduled aspirin-dipyridamole ER, docusate sodium, and buspirone about 2 hours late even though the MAR showed they were due at 9:00 a.m.; the LPN acknowledged the delay, and the CP and DON stated scheduled meds should be given within 1 hour before or after the ordered time.
Expired wound dressings, an expired medicated shampoo prescribed for a resident, and an out-of-package syringe needle were found stored in a treatment cart. The TN confirmed the items were present, and the DON and DSD stated the expired items should not have been stored there and the needle should have been discarded in a sharps container because of needle-prick risk.
Fortified Diet Meals Not Enriched as Ordered: A dietary staff member plated meals for residents with fortified diet orders but omitted the melted butter used to add extra calories to several trays. The omission was observed during the lunch tray line, and the DS later confirmed that several residents did not receive their fortified meals as usual.
Food service staff failed to follow sanitation standards when wet steamtable pans were stored on ready-to-use shelves, a cook placed a cooked ready-to-eat beef roast in a sink, and a dietary aide set a clean, sanitized dish rack on the kitchen floor before it was used for dirty dishes. The DS and RD confirmed the improper handling and stated the actions contaminated items and did not meet food safety procedures.
Shared BP equipment, a stethoscope, and a pulse oximeter were used on residents and only wiped briefly instead of being disinfected per label instructions. During wound care for a resident with a surgical wound, a nurse’s bracelet touched the wound while PPE was in use. Staff also failed to follow EBP requirements for two residents by performing direct care and linen changes without the required gown.
Failure to follow restorative nursing and PT referral processes for two residents. One resident with hemiplegia, hemiparesis, and contractures did not receive PROM at the ordered frequency, and the RNA confirmed the exercises were not provided as scheduled. Another resident with fractures, weakness, and mobility impairment had a PT referral for RNA ambulation services, but no order or care plan was entered and the referral was not implemented.
Failure to Flush G-Tube Before Medications and Feeding: A resident with a G-tube, dysphagia, and hemiplegia had orders and a care plan directing water flushes before and after meds and feedings, with additional flushes between meds. During observation, an LPN provided tube feeding and medication administration without flushing the tube first, and the flow was sluggish. The LPN confirmed the omission, and the DON and DSD stated the tube was supposed to be flushed before meds and feeding.
A resident with arthritis and muscle spasm had PRN pain meds ordered by pain scale, but MAR review showed hydrocodone-acetaminophen was given for pain scores outside the ordered 4-7 range on multiple occasions. The resident said the meds helped only a little, and LN, DSD, and DON confirmed nurses should follow the MD’s parameters when giving pain meds.
Failure to Follow Food Preferences and Allergy Orders: A resident who disliked meat was served pot roast, another resident who disliked brussels sprouts was served that item, and a resident with a documented corn allergy was given polenta made from cornmeal. LN and dietary leadership confirmed the meal tickets listed the dislikes and allergy, and the residents had intact cognition or normal BIMS scores.
A resident with multiple medical and cognitive issues was not permitted to return to the facility after a hospital transfer, despite not exhibiting behaviors that endangered herself or others. Facility staff cited safety concerns due to the resident's confusion and attempts to leave, but there was no physician documentation or evidence that the facility could not meet her needs. The refusal to readmit led to the resident remaining in the hospital unnecessarily.
A resident with confusion, impaired mobility, and a history of wandering was inaccurately assessed as low risk for elopement, resulting in the absence of a wander guard and insufficient supervision. The resident left the facility unnoticed, crossed a busy street, and was found wandering at another location, exposing her to significant health hazards.
Surveyors found that the facility did not have a required remote manual stop station for its propane emergency power supply system and could not provide documentation of a four-hour load test, as confirmed by observation, record review, and staff interview. These deficiencies affected all residents and smoke compartments.
Surveyors observed that a relocatable power tap was connected to another relocatable power tap at the nursing station, in violation of electrical safety codes. Maintenance staff were unaware of this connection, and the deficiency affected multiple residents and a smoke compartment.
A long-term care facility failed to administer medications timely for several residents, leading to severe pain and potential health risks. Delays were due to late orders, missing prescriptions, and administrative issues, affecting residents' comfort and well-being.
Four residents did not receive prescribed pain medications as ordered due to delays in order transcription, lack of valid prescriptions, and medication unavailability, leading to unnecessary pain, emotional distress, and impaired comfort, activity, and sleep.
The facility failed to properly dispose of garbage, as the dumpster was observed overflowing and unable to close, which could attract pests. This was confirmed by a kitchen staff member and the facility's RD, who emphasized the importance of keeping dumpster lids closed. The facility's policy requires garbage to be stored in a manner inaccessible to vermin, with dumpsters kept closed.
The facility failed to protect resident privacy by improperly disposing of meal tray tickets containing personal and medical information. Staff routinely discarded these tickets into regular trash, which was then taken to unsecured dumpsters, risking unauthorized access to sensitive information. The facility's policy required shredding of these tickets, but this was not followed, affecting 54 residents.
Two residents in an LTC facility did not receive appropriate pain management as per physician orders and facility policy. One resident with multiple diagnoses, including osteoarthritis and chronic pain syndrome, received inconsistent pain medication, leading to severe pain and distress. Another resident with a fracture and neuralgia received medication for moderate pain instead of severe pain, contrary to orders. The facility's policies emphasize adherence to prescriber orders, which was not followed, resulting in unnecessary pain and emotional distress.
The facility failed to provide timely pharmaceutical services, resulting in residents not receiving prescribed medications on time. Delays were due to late receipt of orders by the pharmacy and subsequent delivery issues. Residents with chronic conditions experienced adverse effects, and the facility did not follow procedures for medication delivery and accountability, increasing risks of drug diversion.
The facility had a medication error rate of 10% due to improper administration practices. Two residents received Polyethylene Glycol powder with insufficient water, contrary to manufacturer instructions. Additionally, a resident's G tube was not flushed between medications, violating protocol. These errors contributed to the facility's high error rate.
A facility failed to safely store medications in Medication Cart C, where unused medications from a discharged resident and an expired narcotic were found. A nurse acknowledged the error and removed the medications. The DON stated that nurses are expected to check expiration dates and remove expired or unused medications. The facility's policy requires disposal of such medications according to laws.
The facility failed to fill a full-time Dietary Manager/Supervisor position with a qualified individual after the current manager went on medical leave. A kitchen staff member without the necessary training and qualifications was placed in the role, potentially risking the nutritional status of 60 residents. The part-time RD confirmed the lack of proper credentials for the acting manager, and the facility Administrator acknowledged the issue.
The facility failed to maintain sanitary conditions in the kitchen, affecting 54 residents. The sanitizing solution was below effective concentration, and a dietary aide worked without a beard cover. Food items were improperly stored and labeled, with some lacking use-by dates. Dishware was stored wet, and some cookware was unsanitary. These practices could lead to foodborne illness, as confirmed by the Registered Dietician.
The facility failed to maintain effective infection control, with staff not adhering to Enhanced Barrier Precautions (EBP) and proper hand hygiene. A resident on EBP received wound care without required PPE, and another resident's family member provided care without PPE. Additionally, staff failed to perform hand hygiene during medication administration, and glucometers were not properly disinfected. The Infection Preventionist and Director of Nursing confirmed these lapses, highlighting the need for adherence to infection control protocols.
The facility failed to conduct mandatory Effective Communications in-services for direct care staff, affecting 60 residents. The Director of Staff Development confirmed that no communication training was included in the 2024/2025 In-Service Calendar, and none had been conducted in 2024 or 2025. This failure contradicts the facility's policy to develop and improve staff skills through ongoing in-service training.
The facility did not provide training on resident rights and facility responsibilities to indirect staff members, as confirmed by the Director of Staff Development. The in-service training calendar for 2024/2025 lacked this essential training, despite the facility's policy requiring ongoing development for all personnel. This oversight affected a census of 60 residents.
The facility failed to conduct mandatory training on its QAPI program for all staff, as confirmed by the DSD during a review of the 2024/2025 in-service calendar. The absence of QAPI training sessions was contrary to the facility's policy on ongoing staff development, potentially leading to poor communication and compromised resident care.
The facility did not conduct required behavioral health training for staff, as confirmed by the Director of Staff Development (DSD) during a review of the 2024/2025 In-Service Calendar. An in-service on the needs of aged and ill patients was scheduled but not conducted, violating the facility's policy for ongoing staff development.
Two residents with significant physical and cognitive impairments were left without appropriate or functional call light systems. One was unable to use the standard call light due to limited hand mobility, and the other was given a nonfunctional alternative after being moved to a room with a broken call light. Staff and maintenance confirmed the deficiencies, and facility policy required prompt repair or replacement of call systems.
The facility failed to maintain dignity and respect for three residents. A resident was humiliated by a CNA's demeaning comments about her use of a commode. Two residents with severe cognitive impairments were assisted with meals in a disrespectful manner, as CNAs stood over them instead of sitting. The inappropriate actions were acknowledged by the CNAs and confirmed by the Director of Nursing.
The facility failed to ensure accessible call light systems for three residents, leading to potential unmet needs. A resident with multiple sclerosis had a call light out of reach due to a contracted hand. Another resident with hemiplegia was without a call light while on a Geri chair, and a third resident with cerebral infarction had a call light on the floor. Staff confirmed these deficiencies, which contradicted care plans and facility policy.
The facility failed to provide a written transfer agreement with a local GACH, as required by federal regulations. The DON was unable to produce the agreement during multiple interviews, acknowledging the requirement but failing to locate it. This deficiency could potentially risk residents' continuity of care and treatment.
A resident's Foley catheter drainage bag was observed on the floor, contrary to the facility's infection control policy. Staff confirmed that this practice increases infection risk, as the policy requires the bag to be kept off the floor to prevent bacterial contamination.
The facility failed to ensure call lights were within reach for two residents, leading them to yell for help. Staff confirmed the call lights were inaccessible, which is against facility policy. The deficiency involved residents with muscle weakness, neuromuscular dysfunction, hyperlipidemia, and anemia.
A resident experienced a 22-day delay in UTI treatment, risking acute kidney failure, while three others missed critical medications due to pharmacy delays. One resident with respiratory issues was transferred to higher care after missing medications, and another with heart conditions missed doses for two days. The DON acknowledged failures in medication administration and pharmacy delivery adherence.
The facility failed to notify two residents and their Responsible Parties (RPs) of changes in their medical conditions or treatment plans. One resident with severe cognitive impairment was not informed about changes in skin condition, while another resident was not notified about the extension of intravenous antibiotic therapy. Staff interviews confirmed the facility did not follow its policy of notifying residents and RPs, violating their rights and potentially impacting care quality.
A facility failed to ensure timely administration of insulin for a diabetic resident and did not implement a nurse practitioner's treatment plan for another resident. The insulin was administered late on multiple occasions, and the NP's recommendations for pressure ulcer prevention were not followed. Staff interviews confirmed the importance of adhering to orders, but the facility's policies were not followed, leading to deficiencies in resident care.
A licensed nurse in an LTC facility reused an alcohol wipe on a resident's abdomen after administering insulin, contrary to infection control protocols. The resident, dependent on staff for care and with a history of diabetes, requested the site be wiped again, leading the nurse to reuse the wipe due to a lack of extras. Staff interviews confirmed this practice poses a risk of infection, violating the facility's infection prevention policy.
The facility failed to ensure all CNAs were CPR certified, as required by policy. Interviews revealed that four CNAs lacked CPR certification and were unfamiliar with emergency procedures, relying on licensed nurses for assistance during emergencies. The DSD confirmed the absence of a CPR team, and the facility's policy indicated that key clinical staff should maintain CPR certification.
Unresolved Missing Cell Phone
Penalty
Summary
The facility failed to follow its theft and loss policy and grievance procedures for a resident who had an intact cognition with a BIMS score of 15 out of 15 and diagnoses including CHF, COPD, diabetes, muscle weakness, and need for assistance with personal care. The resident reported that her cell phone, which she brought to the facility on admission, went missing and that she immediately notified staff, but the item was not resolved for an extended period. The resident stated she felt annoyed and upset because there had been no resolution and she was unable to use her personal property. Record review showed the resident’s inventory sheet listed one cell phone, and the theft and loss record documented the missing iPhone 14 Max and staff attempts to search the resident’s room and purse. The Social Services Director confirmed the resident had one cell phone on admission, that there had been no resolution, and that the matter had been left unresolved after follow-up stopped. The DON stated staff should follow the policy and discuss the complaint conclusion within 72 hours, including reimbursement, but the resident’s complaint was dropped instead of being resolved within the facility’s stated process.
Improper Medication Storage and Labeling
Penalty
Summary
The facility failed to ensure medications were properly labeled and stored in accordance with accepted professional principles and current standard of practice. During observation, two boxes containing multiple DuoNeb vials were found stored outside of the foil package on a medication cart. One box had an opened date of 1/27/26, and the other box was not labeled with an opened date. The licensed nurse confirmed the observation and stated DuoNeb should always be stored inside the foil pack and should have an open-date label to show when it was first used. The consultant pharmacist stated DuoNeb is sensitive to light and heat and should remain inside the foil package, and the director of nursing stated nurses were expected to follow proper storage and that DuoNeb should be kept inside the foil package because it could be affected by light. A separate observation found five loose pills inside the first and second-right drawer of medication cart D wing. The licensed nurse confirmed the loose pills and stated they should not be inside the cart because they could contaminate medications and, if they fell out, a resident might take them. In addition, two bottles of Vitamin B12, each containing 30 tablets and bearing an expiration date of 12/2025, were found stored in the medication room and ready to be used. The licensed nurse confirmed the expired bottles and stated expired medications should have been discarded. The consultant pharmacist and director of nursing both stated expired medications should not be stored in the medication room, and the facility policy required medications no longer in use or expired medications to be disposed of in accordance with Federal and State laws.
Dietary Supervisor Lacked Required Qualifications
Penalty
Summary
The facility failed to ensure the Dietary Supervisor met the required job qualifications listed in the facility policy and procedures. During an interview, the Dietary Supervisor confirmed she had worked at the facility for one year in that role, but did not have a Certified Dietary Manager certification and was not enrolled in a Dietary Manager training program. She also stated that she was responsible for training, hiring, and scheduling dietary staff, as well as ordering food and kitchen supplies. During an interview with the Administrator, the Administrator confirmed the current job description for Dietary Supervisor required a Certified Dietary Manager, and acknowledged that the current Dietary Supervisor did not possess the required certificate. A facility document titled Job Description and Performance Standards, Position Title Dietary/Food Service Supervisor, revised February 2018, listed the qualifications as either a Certified Dietary Manager or Certified Food Protection Professional.
Infection Control Failures With EBP Signage, Medication Cart Storage, and Facial Hair Restraints
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program when Enhanced Barrier Precautions (EBP) signage was not posted for two residents who were ordered to be on EBP. Resident 1 was admitted in February 2026 with diagnoses including stage 5 chronic kidney disease and dependence on renal dialysis, and his physician’s order and care plan dated 2/9/26 directed EBP related to a Foley catheter, hemodialysis access site, and wound treatment. During observation, Resident 1 was seen with a dialysis access site on the left chest and reported having a wound on the left foot, but no EBP signage was observed in or outside the room. Resident 8, admitted in December 2025 with diagnoses including obstructive and reflux uropathy, muscle weakness, and need for assistance with personal care, also had an active order and care plan for EBP related to Foley catheter use, yet no EBP signage was observed in or outside the room. During a concurrent observation, CNA 3 confirmed there was no signage in front of either resident’s room indicating EBP. CNA 3 stated Resident 1 usually went to dialysis three times a week but was not sure whether he was on any infection control precaution. The facility’s EBP program document indicated both residents were still on EBP, and the Infection Preventionist and DON stated that EBP signage should have been placed in front of the residents’ rooms to indicate and remind staff to wear gloves and gowns for high-contact care. The facility policy titled Enhanced Barrier Precautions Policy stated that EBP requires posting clear signage on the door or wall outside the resident room. The facility also failed to keep non-pharmaceutical personal items out of a medication cart and failed to ensure kitchen staff wore required facial hair restraints. During observation of medication cart D wing, two nail clippers were found in the top right drawer next to prescribed medications and a black and silver flash drive was found next to controlled medications; LN 3 confirmed the items and stated personal items should not be stored in medication carts because they could contaminate medications. In the kitchen, Dietary Aide 1 was observed washing dishes with facial hair above the lips exposed and no covering, and the Dietary Supervisor confirmed the facial hair was not adequately covered. The facility’s dress code required beard restraints for facial hair, and the FDA Food Code cited in the report required beard restraints for food employees.
Failure to Follow Care Plan for Fluid Monitoring
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for one sampled resident when the care plan interventions for recording and monitoring fluid intake and output were not carried out. Resident 3 was admitted in March 2016 with multiple diagnoses including type 2 diabetes mellitus and gastrostomy, and the MDS dated 1/15/26 indicated severe problems with thinking and memory. The care plan initiated 1/20/26 directed staff to monitor and record fluid intake and output every shift. During interview and record review on 3/11/26, LN 5 reviewed the medical record and confirmed the care plan required fluid intake and output to be recorded and monitored. LN 4 stated there was no documentation or orders for monitoring fluid intake and output found and confirmed it was not happening. The DON stated all nursing staff have access to residents' care plans and that the expectation was for staff to follow them.
Oxygen Therapy Not Delivered as Ordered
Penalty
Summary
Safe and proper respiratory care was not provided for one resident with diagnoses including CHF, COPD, diabetes, muscle weakness, and need for assistance with personal care. The resident’s MDS indicated intact cognition and that she had received continuous oxygen therapy on admission and while in the facility. Her care plan directed staff to use oxygen routinely at 3 l/min via nasal cannula and to observe oxygen precautions, and a physician’s order dated 2/26/26 specified oxygen at 3 liters/minute via nasal cannula for shortness of breath, wheezing, and chest pain, with notification of the MD every shift. During observations on 3/9/26 and 3/10/26, the resident was seen using oxygen via nasal cannula with the concentrator set below the ordered 3 lpm, first at 2.5 lpm and later at 2 lpm. The resident stated she used oxygen all the time and that the setting should be 3 lpm, and also stated that nurses usually adjusted the setting of her oxygen. A CNA confirmed the oxygen was set at 2 lpm. The TN confirmed the physician’s order was for 3 lpm and stated the order should always be followed. The DON stated nurses were expected to follow the doctor’s order for oxygen administration, and the facility’s oxygen therapy policy required oxygen to be administered as ordered by the physician.
Controlled Medication Administration Not Documented in MAR
Penalty
Summary
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist was not met when controlled medication use and removal were signed out in the Controlled Drug Record but were not documented in the Medication Administration Record for one resident. The resident was admitted in May 2020 and had diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, gout, neuralgia, and neuritis. The resident’s MDS dated 1/16/26 showed a BIMS score of 13 out of 15, indicating intact cognition, and also indicated the resident received scheduled and as needed pain medications and non-medication interventions for pain. The resident had an active order dated 2/6/26 for HYDROcodone-Acetaminophen 5-325 mg, 1 tablet by mouth every 8 hours as needed for moderate to severe pain. Review of the February 2026 MAR and CDR showed nursing staff signed out Norco in the CDR but did not document administration on the MAR on two occasions: 2/20/26 at 12:30 a.m. and 2/23/26 at 3:20 a.m. During interview and record review, LN 4 confirmed the CDR showed removal of Norco but the MAR was not accurately documented on those two occasions. The CP stated nurses should sign both the CDR and MAR when administering controlled medications, and the DON stated the nurse should remove the medication, sign the CDR, administer it, then sign the MAR.
Insulin Lispro Given Before Delayed Meal
Penalty
Summary
Resident 60, who was admitted in February 2026 and had diagnoses including diabetes mellitus, congestive heart failure, muscle weakness, and need for assistance with personal care, was found to have a medication administration issue involving prescribed insulin lispro. The physician’s order directed insulin lispro 100 UNIT/ML to be given by sliding scale with meals, including 4 units for a blood sugar reading of 170 to 199 mg/dl. During a medication administration observation on 3/9/26 at 11:38 a.m., Licensed Nurse 1 obtained a finger stick blood sugar of 185 mg/dl and administered 4 units of insulin lispro to Resident 60. Later that day, at 12:34 p.m., Resident 60’s lunch tray was delivered and left on the bedside table, and at 12:58 p.m. Certified Nurse Assistant 2 began assisting Resident 60 with lunch and confirmed that Resident 60 required total assistance with eating and needed encouragement and cueing. During interview, LN 1 confirmed that the insulin lispro had been administered too early if the resident did not eat until 12:58 p.m., and stated the resident should have eaten within 15 minutes after the insulin was given. The consultant pharmacist and DON both stated that insulin lispro should be given with food or within 10 to 15 minutes after administration, and the facility policy required medications to be administered in accordance with physician orders and insulin to follow the MD order.
Salt Packet Served With Renal Diet Meal
Penalty
Summary
The facility failed to provide food in accordance with the physician-prescribed therapeutic diet for one resident who was ordered a CCHO/renal diet with soft and bite-size texture and thin liquids. During a lunch meal observation, the resident was seen eating with a packet of iodized salt on the meal tray, and the resident stated the salt packet had been served with the meal. The meal ticket was checked and indicated a renal, CCHO diet. The resident’s record showed diagnoses including CHF, ESRD with dialysis dependence, HTN, and need for assistance with personal care. The care plan directed staff to inform all staff of the resident’s special dietary needs and follow the MD order. Staff interviews confirmed that the resident was on a renal diet and that salt packets should not be provided to residents with renal diet orders. The Dietary Supervisor and DON also stated that extra salt should not be provided because it could affect the resident’s salt and fluid balance and medical condition. The facility policy titled Liberal Renal Diet stated no salt packet on tray.
Failure to Initiate Emergency Response for Resident in Respiratory Distress
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate emergency treatment and care according to physician orders, resident preferences, and established policies when a resident experienced acute respiratory distress and altered mental status. The resident had been re-admitted with diagnoses including pneumonia and acute and chronic respiratory failure with hypoxia and had a POLST indicating full code status. An MDS assessment documented intact cognition at baseline. On the date of the incident, an SBAR noted hypoxia, altered level of consciousness, and shortness of breath. According to the nurse’s notes, at approximately 9 p.m. a licensed nurse entered the resident’s room to administer bedtime medications and found the resident awake, able to take medications, but repeatedly saying the same sentence. The nurse documented that when asked if he was okay, the resident opened his eyes and then closed them again. The resident’s O2 saturation was 84% on 3 L O2 via nasal cannula; the nurse increased the oxygen to 4 L, but the O2 saturation remained low at 82–83%. The nurse contacted the on-call physician at 9:30 p.m., obtained an order to send the resident to the emergency room for hypoxia, and arranged a non-emergency transport that arrived at 9:45 p.m., with transfer out at 10 p.m. There was no documentation that staff changed the nasal cannula to a non-rebreather mask. In interviews, the licensed nurse stated she noted the resident’s difficulty breathing, continuous oxygen use, low O2 saturation, and behavior not consistent with baseline, and that she called the on-call physician, who ordered transfer to the ER. The DON stated that respiratory distress with O2 saturation below 88% and decreased level of consciousness requires activation of the emergency response system by calling 911, and confirmed that the resident’s condition warranted a 911 transfer. The nurse practitioner, after reviewing the case and ER records, stated the resident should have been transferred via 911 due to hypoxia, altered responsiveness, and continued desaturation despite oxygen, and noted that ER records showed a GCS of 7 on arrival and subsequent intubation for acute respiratory failure. The facility’s policies on Emergency Procedures and Change of Condition require immediate medical care and initiation of emergency procedures, including calling 911 and providing first aid until emergency personnel arrive, and the California Nursing Practice Act requires initiation of emergency procedures based on observed abnormalities. The failure to call 911 and initiate an emergency response in accordance with these standards constituted the deficiency.
Controlled Medication Administration Not Documented in MAR
Penalty
Summary
Safe and effective pharmaceutical services were not ensured when controlled medication administration for two residents was not documented consistently in the MAR after the medication was signed out from the CDR. Resident 41, who had diagnoses including gout, neuralgia, and neuritis and was not capable of giving informed consent or participating in the treatment plan, had an active order for Norco 5-325 mg every 6 hours as needed for moderate to severe pain. A review of the MAR and CDR for August and September 2025 showed Norco was signed out from the CDR but not documented on the MAR on three occasions. Resident 47, who had diagnoses including dementia, muscle weakness, and need for assistance with personal care, also had an active order for Norco 5-325 mg every 6 hours as needed for moderate to severe pain. Review of the MAR and CDR for August and September 2025 showed Norco was signed out from the CDR but not documented on the MAR on two occasions. During interview and record review, LN 2 confirmed the discrepancy and stated controlled medication administration should be signed out in the CDR and signed in the MAR. The CP and DON both stated they would expect nurses to sign both records when administering controlled medications.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure safe medication administration practices were followed when its medication error rate exceeded 5% for a census of 55 residents. Medication administration observations were conducted over multiple days, at varied times, and in random locations throughout the facility. Surveyors identified three errors out of 36 opportunities, resulting in a facility-wide medication error rate of 8.33% in one of nine residents observed for medication administration. During an observation on 9/8/25, an LN administered six pills to Resident 32, including aspirin-dipyridamole ER 25-200 mg, docusate sodium 100 mg, and buspirone 5 mg. The resident’s physician orders showed these medications were scheduled for 9:00 a.m., but they were given about two hours late. During interview, the LN acknowledged the medications were administered late and stated they were supposed to be given within one hour before or after the scheduled time to maintain therapeutic levels. The CP and DON both stated scheduled medications should be administered within the 1-hour window, and the facility did not provide the requested medication administration policy and procedure discussing timing, although a policy titled Medication Administration stated medications are administered within 60 minutes of scheduled time.
Expired wound supplies, expired medicated shampoo, and loose syringe needle found in treatment cart
Penalty
Summary
The facility failed to ensure pharmaceutical products were properly handled and stored in accordance with its policies and procedures and accepted professional principles. During a concurrent observation and interview with Treatment Nurse 2, five silicone wound dressings and six occlusive petrolatum gauze wound dressings were found stored in the treatment cart with expired dates. Treatment Nurse 2 confirmed the observation and stated the expired wound dressings should be discarded because they would have less effectiveness in treating wounds. An expired medicated shampoo prescribed for a resident was also found stored in the treatment cart, and Treatment Nurse 2 confirmed it should have been discarded because the resident would be at risk for side effects and the treatment would not be as effective as desired. During the same observation, an out-of-package syringe needle with a cap on was found in the treatment cart. Treatment Nurse 2 confirmed the observation and stated the facility does not use syringe needles in treatments and questioned why it was there, adding that it should not have been in the cart because of safety issues. The Director of Staff Development and the Director of Nursing both stated expired wound dressings and the expired medicated shampoo should not be stored in the treatment cart because they would not be effective, and that an opened syringe needle should not be stored there because of the risk for needle prick. The facility policy on medication storage stated biologicals are to be stored properly to maintain integrity and support safe, effective administration, and the sharps disposal policy stated needles and syringes are to be placed into puncture-resistant sharp disposal containers immediately after use.
Fortified Diet Meals Not Enriched as Ordered
Penalty
Summary
The facility failed to enrich the caloric content of meals for five residents with fortified dietary orders when the cook omitted the scoop of melted butter used for fortification. Resident 3 had an order for a fortified diet and was admitted with MS. Resident 4 had an order for a fortified diet and was admitted with a Stage 3 pressure injury. Resident 10 had an order for a fortified diet and was admitted with UTI and severe protein calorie malnutrition. Resident 37 had an order for a fortified diet and was admitted with Parkinson's disease and dysphagia. Resident 42 had an order for a fortified diet and was admitted with MS. During observation of the lunch tray line, a dietary staff member was plating resident meals and several trays with fortified diet tickets were noted to have no additional calories added. When the surveyor observed this, the staff member acknowledged the omission and added a scoop of melted butter to the plate. The staff member did not check whether other fortified diet meals had also been missed. The Dietary Supervisor later confirmed that several residents had not received their fortified meals that day and stated that melted butter was usually added for extra calories.
Food items and sanitized equipment were handled in an unsanitary manner
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety when four steamtable pans were observed wet and stacked on the ready-to-use shelves in the food preparation area. During interview, the Dietary Supervisor stated that wet nesting is not desirable and confirmed the pans were wet, then instructed the dishwasher to re-wash them. The facility policy on sanitation stated that the Food and Nutrition Services Director is responsible for instructing employees in sanitation fundamentals and appropriate techniques, and the FDA Food Code cited in the report required equipment and utensils to be air-dried after cleaning and sanitizing. The facility also failed to follow food safety and sanitation procedures when a cook placed a cooked ready-to-eat beef roast in a sealed bag in the sink during food preparation. The cook stated the roast was already cooked and sealed, while the Dietary Supervisor later stated it should have been placed in a bowl on the counter and that placing the cooked roast in the sink had the potential for food borne illness to residents. In a separate observation, a dietary aide placed a clean and sanitized dish rack on the kitchen floor after emptying clean glasses, and the dishwasher then picked it up and loaded dirty dishes on it. The Dietary Supervisor and Registered Dietician both stated that placing the rack on the floor contaminated it and that it should not be placed there.
Infection Control Failures With Shared Equipment, Wound Care, and EBP
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program when a shared manual blood pressure machine, stethoscope, and pulse oximeter were used on residents and then wiped quickly between uses. During two observations, a licensed nurse used the shared equipment on residents and then cleaned each item with a germicidal disposable wipe for only about 5 to 10 seconds before placing the items on top of the medication cart to dry. The nurse later confirmed the equipment should have been wiped for 2 minutes each to disinfect it properly. The Infection Preventionist stated the shared equipment should be disinfected after each resident use and that the wipe should remain visibly wet for 2 minutes, and the DON stated shared equipment should always be properly disinfected after each resident use. The facility also failed to maintain infection control during wound care for a resident with diagnoses including surgical aftercare, hidradenitis suppurativa, sick sinus syndrome with pacemaker, and sepsis. During a dressing change for the resident’s left buttock surgical wound, the treatment nurse wore a gown and gloves, but a bracelet slipped down the nurse’s arm and became visible outside the PPE. The bracelet touched the wound while the nurse was wiping the wound with gauze, and the nurse continued the dressing change. The nurse later stated jewelry should be removed or tucked under the gown to avoid contact with the wound, and the Infection Preventionist and DON confirmed jewelry should be removed during dressing changes to avoid contact with the wound. The facility further failed to follow Enhanced Barrier Precaution guidelines for residents on EBP. One resident with cellulitis and a gastrostomy tube was on EBP, and a CNA performed direct care, including a Hoyer lift transfer from bed to recliner, without wearing a gown. Another resident with a history including sepsis, dialysis, and a stage 4 pressure injury was also on EBP, and a CNA changed pillowcases in the resident’s room while wearing gloves but no gown. The CNAs acknowledged the gown was not worn, and the DON stated staff should have worn gown and gloves for direct care and that changing linens is considered direct care. The facility policy stated that changing linens is a high-contact resident care activity requiring gown and gloves.
Failure to Follow Restorative Nursing and PT Referral Processes
Penalty
Summary
The facility failed to provide appropriate treatment and services to maintain or improve mobility and prevent decline in ROM for two residents. One resident had diagnoses including hemiplegia, hemiparesis following cerebral infarction, and contractures of the left hand and right knee. The resident’s MDS showed severe cognitive impairment and dependence for eating, hygiene, dressing, transfers, and rolling. The resident had active physician orders for PROM to both lower extremities and the left upper extremity three times per week with one-person assist, and the care plan included the same restorative interventions. During review of the restorative nursing documentation, the resident received PROM on only selected days in August and September, and the restorative nurse assistant confirmed the resident did not receive the exercises in accordance with the ordered frequency of three times per week. The restorative nurse assistant stated the ordered frequency should have been followed. The DSD and DON also stated the frequency should have been followed and that documentation should have been present when exercises were not completed. A second resident had diagnoses including multiple rib fractures, traumatic pneumothorax, muscle weakness, history of falls, gait abnormalities, and mobility impairment. The resident’s MDS showed intact cognition and inability to walk ten feet, with use of a walker or wheelchair. PT wrote an RNA referral for ambulation with a front wheeled walker approximately 150 feet or as tolerated, every day, three times per week with one-person assist to maintain functional levels. The record showed no order was placed for the referral and no care plan was initiated for the RNA program. PT stated the referral was placed on the RNA’s desk, while the RNA stated the referral was not seen and therefore was not implemented. The DON stated the RNA should implement the order once entered, and the facility policy stated restorative services are to be provided to prevent deterioration and maintain optimal functioning.
Failure to Flush G-Tube Before Medications and Feeding
Penalty
Summary
Resident 2, who was admitted in November 2023 with diagnoses including gastrostomy status, dysphagia, and hemiplegia, had an active order indicating the resident was capable of giving informed consent and participating in the treatment plan. The resident’s care plan and physician orders directed that the G-tube be flushed with water before and after medication administration and before and after feedings, with additional flushing between each medication to prevent tube clogging. During an observation on 9/9/25, a licensed nurse was seen providing tube feeding and medication administration to Resident 2. The nurse positioned the resident, checked residual, and checked tube placement, but did not flush the G-tube with water before starting medication administration and enteral feeding. The medication and feeding formula were observed to flow sluggishly during the procedure. In interview, the nurse confirmed the tube had not been flushed and stated it should have been flushed before medication administration and enteral feeding. The DSD and DON also stated the tube was supposed to be flushed with water before starting medication administration and enteral feeding, and the facility policy stated the tube will be flushed with water before and after medication administration.
Pain Medication Orders Not Followed
Penalty
Summary
The facility failed to ensure appropriate pain management for one resident whose pain medication order was not consistently followed. The resident was admitted in January 2025 with diagnoses including arthritis, muscle spasm, and need for assistance with personal care. Her MDS dated 7/22/25 showed a BIMS score of 15 out of 15, indicating intact cognition, and also noted that she received scheduled and as needed pain medications and non-medication interventions for pain. During interview, the resident stated she frequently experienced pain, had a high pain tolerance, and that the medications she was receiving helped a little but were not enough. The resident’s care plan identified her as at risk for pain or discomfort related to muscle spasm and arthritis and directed staff to administer pain medications as ordered and evaluate effectiveness. Her physician ordered hydrocodone-acetaminophen 5-325 mg, 1 tablet every 6 hours as needed for pain rated 4-7, and oxycodone 5 mg, 1 tablet every 4 hours as needed for pain rated 8-10. Review of the July and August 2025 MAR showed hydrocodone-acetaminophen was given on several occasions when the documented pain scores were 8 or 10, which was outside the ordered parameters. During interview, LN 2 confirmed the pain medication orders were not consistently followed and stated nurses should follow the physician’s order when administering pain medication. The DSD and DON also stated that pain medications should be given as ordered by the physician.
Failure to Follow Resident Food Preferences and Allergy Information
Penalty
Summary
The facility failed to follow resident food preferences and allergy information for three sampled residents during meal service. Resident 32, who was admitted with diagnoses including hypertension and hyperlipidemia and had an intact cognitive score on MDS, was observed in the dining room being served pot roast even though the meal ticket indicated she disliked meat. Resident 32 stated she had told staff in the past that she did not like meat, but it was still served to her. LN 3 confirmed the pot roast was on her plate and that the meal ticket listed meat as a dislike. Resident 4, who had diagnoses including a stage 3 sacral pressure ulcer, adult failure to thrive, and gastro-esophageal reflux, and whose MDS indicated intact cognition, was observed in her room with brussels sprouts on her plate even though she stated she did not like brussels sprouts. LN 3 confirmed the item was on her plate and that it was listed as a dislike on her meal ticket. The DON, dietary staff, and the Dietary Supervisor stated that meal trays were checked against meal tickets and that residents' likes and dislikes should be followed during tray line, but the observed tray still contained the disliked food item. Resident 42, who had diagnoses including multiple sclerosis, muscle weakness, and epilepsy, and had a BIMS score indicating normal thinking and memory, had corn documented as an allergy on the face sheet and allergy view, with a recorded reaction of loose stools. During tray line observation, the resident was given polenta, a cornmeal-based side dish, and the food ticket identified corn as an allergy. The Dietary Supervisor stated the corn polenta should not have been placed on the resident's tray and that staff should review allergies documented on the ticket.
Failure to Permit Resident Return After Hospitalization
Penalty
Summary
The facility failed to permit a resident to return after a hospitalization, in violation of federal requirements for permitting residents to return to the facility following a hospital stay or therapeutic leave. The resident, who had been admitted with multiple diagnoses including stroke, depression, and muscle weakness, was described as friendly but disoriented, requiring staff assistance for personal care, eating, transfer, and ambulation. After admission, the resident eloped from the facility and was found at another facility across the street. Upon return, the resident was placed on one-on-one supervision and later sent to the emergency room for evaluation. Despite repeated requests from the hospital, the facility refused to readmit the resident, citing concerns about the resident's safety due to confusion, agitation, and a tendency to attempt to leave the facility. Interviews with facility staff, including the Administrator and DON, revealed that the decision to refuse readmission was based on the belief that the resident was not safe at the facility, particularly given its proximity to a busy street. However, staff interviews and documentation indicated that the resident did not exhibit physical aggression, agitation, or behaviors that endangered herself or others. The resident was described as confused, talking about wanting new slippers, and attempting to get up from her wheelchair, but not combative or aggressive. The facility's own policies required that discharges or refusals to readmit be based on documented evidence that the resident's needs could not be met or that the resident posed a danger to themselves or others, with physician documentation supporting such decisions. In this case, there was no documentation from a physician indicating that the resident's needs could not be met or that transfer was necessary. The DON acknowledged the lack of clinical records supporting the decision and agreed that interventions such as a wander guard and adequate supervision might have prevented the elopement and subsequent transfer. The failure to permit the resident's return resulted in the resident remaining unnecessarily in the hospital while awaiting placement.
Failure to Prevent Resident Elopement Due to Inadequate Assessment and Supervision
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including depression, muscle weakness, difficulty walking, and acute encephalopathy caused by stroke, was admitted to the facility. The resident was documented as confused, disoriented to time, place, and person, and required staff assistance for personal care, eating, transfer, and ambulation. Despite these factors, the facility's elopement assessment rated the resident as low risk for elopement, which was later acknowledged by the Director of Nursing to be inaccurate. On the day following admission, the resident was observed by a licensed nurse standing by her room door with a walker, expressing confusion and searching for slippers. Later that day, a concerned citizen notified facility staff that the resident had been found wandering in the parking lot of another facility across a busy street. The resident had left the facility without staff knowledge, crossed a dangerous roadway, and was found confused and wearing only socks, insisting she needed to buy new slippers. Interviews with facility staff, including the Administrator and Director of Nursing, confirmed that the resident had no wander guard in place due to the inaccurate elopement assessment. Staff acknowledged that the resident was confused, wandered frequently, and required significant redirection and supervision. The facility's own policy required identification and intervention for residents with exit-seeking behavior, but these procedures were not effectively implemented, resulting in the resident's unsupervised elopement and exposure to significant health hazards.
Failure to Maintain Emergency Power Supply System
Penalty
Summary
The facility failed to maintain its Emergency Power Supply System (EPSS) in accordance with regulatory requirements. During a tour and review of records, it was observed that the facility did not have a remote manual stop station for its five-kilowatt propane EPSS. The absence of this stop station was confirmed through observation and interview with the Maintenance Staff, who stated they were unaware of the requirement for such a device. Additionally, the facility was unable to provide documentation of a required four-hour load test for the EPSS when requested. The Maintenance Staff confirmed that no such documentation was available for review. This indicates that the facility did not perform or could not verify the performance of the four-hour load test as required by NFPA 110 standards. These deficiencies affected all 57 residents and three smoke compartments within the facility. The lack of a remote manual stop station and the absence of documentation for the four-hour load test were directly observed and confirmed through staff interviews and record review.
Plan Of Correction
K 918 - Electrical Systems - Essential Electric System. Continue A. 1. C. Bates Electric company installed the remote manual stop station for the five-kilowatt propane EPSS on 4/11/25. 2. The annual service and the four-hour load bank test for the generator is scheduled on 4/18/25 by the C and D Power company. B. There is only one generator in the building. No other concerns with this deficient practice. C. The Administrator provided an in-service on 4/14/25 to the Maintenance Staff regarding the requirements of the Life and Safety findings K 918 Electrical Systems - Essential Electric System including but not limited to: 1. Remote manual stop station for the five-kilowatt propane EPSS. 2. The Administrator provided an in-service to the Maintenance Staff regarding the annual service and the four-hour load bank test for the facility generator. D. Monitoring 1. Maintenance Staff will monitor and test the remote manual stop station for the five-kilowatt propane EPSS once a month during generator test and by the facility contracted vendor that provides service to do the four-hour load bank test for the generator. It will be recorded on the "Generator Log." 2. The Maintenance Staff and Administrator will monitor to make sure that the annual service and the four-hour load bank test for the generator is conducted annually by the facility contracted vendor for the generator preventative maintenance. A log will be maintained to record the annual generator service on the "Generator Log." The log will be kept by the Maintenance Staff and is available for inspection when requested. E. QUALITY ASSURANCE: The Administrator and the Quality Assurance Performance Improvement (QAPI) team members will discuss system effectiveness of the plan of correction for this deficient practice of K 918 Electrical Systems and Essential Electric System; remote manual stop for the generator is maintained and the four-hour generator load test is performed annually. Completion Date: April 18, 2025
Improper Use of Relocatable Power Taps in Nursing Station
Penalty
Summary
During a facility tour, surveyors observed a deficiency related to the improper use of electrical equipment and wiring. Specifically, at the nursing station, a relocatable power tap was found connected to another relocatable power tap, which is not compliant with NFPA 101 and NFPA 70 standards. The maintenance staff, when interviewed, stated that he was not aware that the relocatable power taps were connected to each other. This non-compliant use of electrical equipment was found to affect 16 out of 57 residents and one of three smoke compartments. The report documents that the facility failed to ensure that electrical equipment, including power strips and extension cords, was used in accordance with applicable codes and standards. The improper connection of power taps was directly observed by surveyors, and the maintenance staff's lack of awareness contributed to the deficiency. No information about corrective actions or follow-up measures is included in the report.
Plan Of Correction
K 920 Electrical Equipment - Power Cords and Extensions A. The Maintenance Supervisor immediately removed the relocatable power tap that was connected to another relocatable power tap being used at the nursing station. The two relocatable power taps are now both connected directly to the electrical power outlet. The facility is now in compliance with the use of a relocatable power tap. B. The Maintenance Staff made rounds in the facility and checked the extension cords and electrical equipment in the building to ensure compliance. No other problems were identified, same as this deficient practice. C. The Administrator provided an in-service to the Maintenance Staff regarding compliance with this deficiency regarding proper use of extension/power cords and to ensure compliance with the use of relocatable power taps; (plug directly to the wall electrical outlet and not with another power tap). D. The Maintenance Staff will monitor appropriate use of extension cords and to ensure compliance with the use of the relocatable tap during his weekly maintenance rounds. It will be documented on the "Extension Cord Monitoring Log." E. QUALITY ASSURANCE: The Administrator and the Quality Assurance Performance Improvement (QAPI) team members will discuss system effectiveness of the plan of correction for this deficient practice, such as appropriate use of extension cords and to ensure compliance with the use of the relocatable tap during his weekly maintenance rounds. Completion Date: April 18, 2025
Medication Administration Delays in LTC Facility
Penalty
Summary
The facility failed to ensure timely administration of medications for nine residents, leading to significant discomfort and potential health risks. Residents experienced delays in receiving prescribed medications due to late orders, lack of valid prescriptions, and administrative oversights. For instance, Resident 265 did not receive morphine sulfate on time, resulting in severe pain and sleep disturbances. Similarly, Resident 60 and Resident 267 faced delays in receiving their medications, which posed risks to their health conditions. The report highlights multiple instances where medication orders were either sent late to the pharmacy or lacked necessary authorizations, causing delays in delivery. Resident 264's pain medication was not administered for several days due to a missing valid prescription, leading to severe pain and limited daily activities. Resident 266 also experienced delays in receiving pain and respiratory medications, resulting in severe pain and potential breathing difficulties. Additionally, the facility's failure to administer medications as per physician's orders and professional standards was evident in the case of Resident 48, where a licensed nurse did not safely administer medications via a gastrostomy tube. These deficiencies indicate systemic issues in medication management and order processing within the facility, adversely affecting residents' well-being and comfort.
Failure to Provide Timely Pain Medication Results in Significant Medication Errors
Penalty
Summary
The facility failed to ensure that four residents received their prescribed pain medications in accordance with physician orders, resulting in significant medication errors. For each resident, there were delays or omissions in administering pain medications such as morphine sulfate, pregabalin, Qulipta, and buprenorphine. These failures were due to issues such as delayed transcription and faxing of medication orders to the pharmacy, lack of valid prescription orders, and the absence of certain pain medications in the facility's emergency kit. In several cases, the pharmacy did not receive the necessary orders in a timely manner, which led to delays in medication delivery and administration. Residents affected by these deficiencies had medical histories that included fractures, neuralgia, neuritis, osteoarthritis, chronic pain, migraines, and diabetes with neuropathy. Upon admission, these residents experienced moderate to severe pain, as documented in their clinical records and pain assessments. The medication administration records (MARs) showed that scheduled doses of pain medications were marked as held and not given, and progress notes indicated that medications were not available or pending delivery from the pharmacy. Interviews with residents confirmed that they experienced severe pain, difficulty sleeping, and emotional distress due to not receiving their pain medications as ordered. Staff interviews and record reviews revealed that delays in processing and transmitting medication orders contributed to the problem. The admissions coordinator acknowledged that it could take several hours for nurses to transcribe and fax orders, and that issues with electronic transmission from hospitals further complicated timely medication access. The facility's policies required prompt verification, transcription, and communication of medication orders, but these procedures were not consistently followed, resulting in residents experiencing unnecessary pain and discomfort.
Improper Garbage Disposal
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse, as observed during an inspection of the kitchen and garbage dumpster area. The dumpster was found to be overflowing, preventing the lid from closing, which was acknowledged by a kitchen staff member. This situation was confirmed during an interview with the facility's Registered Dietitian, who stated that dumpster lids should be closed to prevent attracting pests. A review of the facility's policy on food-related garbage disposal indicated that all garbage and food waste should be kept in containers and stored in a manner inaccessible to vermin, with outside dumpsters kept closed.
Improper Disposal of Resident Meal Tray Tickets
Penalty
Summary
The facility failed to protect the privacy and confidentiality of residents' personal and medical records by improperly disposing of meal tray tickets. During observations and interviews, it was noted that Dietary Aide 2 and Cook 2 routinely discarded used resident meal tray tickets into the regular kitchen trash, which was then taken to the dumpsters outside the facility. The dumpsters were observed to be overflowing and unsecured, posing a risk of unauthorized access to the residents' protected health information. The meal tray tickets contained sensitive information such as residents' names, room numbers, diet orders, and other personal details. The facility's policy required that resident meal tray tickets be shredded when no longer needed, but this procedure was not followed. The Registered Dietician confirmed that the tickets should be shredded to comply with HIPAA regulations. Observations on subsequent days revealed that identifiable information from residents was still being discarded improperly, indicating a systemic issue with the facility's handling of confidential information. This failure affected 54 out of 60 residents who consumed facility-prepared meals, exposing their personal and protected health information to potential unauthorized access.
Inadequate Pain Management for Two Residents
Penalty
Summary
The facility failed to provide appropriate pain management services for two residents, Resident 264 and Resident 265, as per professional standards, facility policy, and physician orders. Resident 264, who was admitted in February 2025, had multiple diagnoses including osteoarthritis, diabetes mellitus, neuropathy, chronic pain syndrome, and major depressive disorder. Despite having an intact cognition and experiencing frequent pain that affected her daily activities, Resident 264 did not receive her prescribed pain medications consistently upon admission. Her medication administration records indicated that she received oxycodone for moderate pain and hydrocodone-acetaminophen for severe pain, contrary to the physician's orders. Resident 265, admitted in February 2025, had a moderately impaired cognition and diagnoses including a fracture of the left humerus, neuralgia, and neuritis. Her care plan indicated a need for pain management due to her fracture. However, her medication administration records showed that she received hydrocodone-acetaminophen for moderate pain, although it was prescribed for severe pain. This inconsistency in medication administration was confirmed by a licensed nurse, who acknowledged the risk of over-medication or drug dependence when the medication was given for moderate pain. The Director of Nursing confirmed that staff should adhere to physician orders when administering medications. The facility's policies on pain management and medication administration emphasized the importance of following prescriber orders to ensure safe and effective pain management. The failure to adhere to these policies and physician orders resulted in unnecessary pain and emotional distress for the residents, affecting their physical comfort and psychosocial well-being.
Delayed Medication Administration and Policy Non-Compliance
Penalty
Summary
The facility failed to provide timely pharmaceutical services to meet the needs of its residents, as evidenced by multiple instances where residents did not receive their prescribed medications in accordance with physician orders. Residents, including those with diabetes mellitus, respiratory conditions, and other chronic illnesses, experienced delays in receiving critical medications such as metformin, insulin glargine, and various inhalers. These delays were often due to late receipt of medication orders by the pharmacy and subsequent delayed deliveries, which were not aligned with the facility's policy of timely medication administration. The report highlights specific cases where residents were adversely affected by these delays. For instance, a resident with diabetes did not receive metformin on time, posing a risk of elevated blood sugar levels. Another resident with chronic obstructive pulmonary disease did not receive their inhaler, leading to difficulty breathing. In several cases, the facility's emergency medication kit did not contain the necessary medications, further exacerbating the issue. Interviews with residents revealed dissatisfaction and discomfort due to the lack of timely medication administration. Additionally, the facility's procedures for medication delivery and accountability were not followed. Medication delivery manifests were not signed by two licensed staff members, which is a requirement for accountability. Furthermore, the facility did not adhere to its policies and procedures for the destruction of controlled medications, increasing the risk of drug diversion. These systemic issues contributed to unsafe and untimely medication use, as well as potential risks to resident health and safety.
Medication Administration Errors Lead to High Error Rate
Penalty
Summary
The facility failed to ensure safe medication administration practices, resulting in a medication error rate of 10%, which is above the acceptable threshold of 5%. During observations, it was noted that Licensed Nurse 2 and Licensed Nurse 3 did not follow the manufacturer's directions for reconstituting Polyethylene Glycol powder, as they used less than the recommended 4 to 8 ounces of water. This error affected Resident 48 and Resident 16, as the medication was not prepared according to the guidelines, potentially impacting its effectiveness. Additionally, during a medication administration observation, Licensed Nurse 2 administered four medications via a gastrostomy tube to Resident 48 without performing water flushes between medication boluses or after the final medication. The Director of Nursing and the Director of Staff Development confirmed that the facility's protocol and evidence-based practice require flushing the G tube with water between each medication to ensure proper medication delivery. This oversight in following the correct procedure for G tube medication administration contributed to the facility's high medication error rate.
Unsafe Medication Storage in Med Cart
Penalty
Summary
The facility failed to ensure the safe storage of medications, as observed during an inspection of Medication Cart C. Unused medications from a discharged resident were found stored in the bottom drawer of the cart, including Pantoprazole 40 mg tablets and Nifedipine 30 mg tablets. Additionally, an expired narcotic, Morphine Sulfate Oral Solution, was also found in the same drawer. Licensed Nurse 4 acknowledged that these medications should not have been stored there and proceeded to remove them immediately. The Director of Nursing stated that the expectation is for licensed nurses to check expiration dates during medication counts and to remove any expired medications or those belonging to discharged residents from the cart. The facility's policy on labeling and storing medications indicates that medications no longer in use or expired should be disposed of according to Federal and State Laws. These failures had the potential to contribute to unsafe medication use and storage, as well as the potential for diversion.
Inadequate Staffing in Dietary Management
Penalty
Summary
The facility failed to ensure that a full-time Dietary Manager/Supervisor position was filled appropriately when the current Dietary Manager went on medical leave in mid-November 2024. During this period, a kitchen staff member, who lacked the necessary training and qualifications, was placed in the role to cover for the Dietary Manager. This staff member, referred to as CK 1, acknowledged not having the regulatory training and certification required for the Dietary Manager/Supervisor position. The facility employs a part-time Registered Dietician (RD) who works on a consultant basis and is present at the facility only once a week. The RD confirmed that CK 1 was covering the Dietary Manager/Supervisor role without the required credentials, which could potentially risk the residents' nutritional status. Interviews with the facility Administrator (ADM) and the part-time RD revealed that the facility was aware of the absence of a qualified full-time Dietary Manager/Supervisor. The ADM acknowledged the differences in roles and qualifications between CK 1 and the Dietary Manager/Supervisor, and admitted that CK 1 did not have the necessary regulatory training and credentials. The facility's job descriptions outlined the qualifications required for the Dietary Supervisor role, which CK 1 did not meet. This situation had the potential to impact the nutritional needs of the facility's 60 residents adversely.
Sanitation Deficiencies in Kitchen Affecting Resident Safety
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, affecting 54 out of 60 residents who received food from the kitchen. During an observation, it was found that the sanitizing solution used in the kitchen was below the manufacturer's minimum effective concentration, posing a risk for foodborne illness. The acting Dietary Manager confirmed the issue and acknowledged the need for a new solution. Additionally, a dietary aide was observed working in the kitchen without a beard cover, which was against the facility's policy and could negatively impact the kitchen's sanitary conditions. Further inspection revealed that food items were not stored properly. A clear plastic bin containing Jello was found with an unsealed lid, and an opened box of pancake mix was not tightly sealed. The facility's Registered Dietician acknowledged that these practices could compromise the kitchen's sanitary conditions. Moreover, food items were not labeled with use-by dates, including a partial loaf of bread and a box of pancake mix, which were only marked with the date they were opened or received. This lack of proper labeling was against the facility's policy and could lead to the use of expired food. The inspection also uncovered unsanitary conditions in the storage of dishware. Food preparation and storage bins were stored wet and stacked, preventing them from air drying and increasing the risk of bacterial growth. Cooking and baking pans were found with blackened debris that could not be removed, indicating they were unsanitary. The Registered Dietician confirmed that these practices could lead to foodborne illness and acknowledged the need for proper drying and replacement of cookware that could not be cleaned effectively.
Infection Control Deficiencies in PPE Use and Hand Hygiene
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple instances of staff not adhering to Enhanced Barrier Precautions (EBP) and proper hand hygiene protocols. Resident 13, who was on EBP due to an indwelling catheter and a wound on the left knee, received wound care from the Staff Development Director without the required gown. This was confirmed by the Infection Preventionist, who stated that proper PPE, including gowns, masks, and gloves, was necessary to prevent the spread of infection. Resident 17, who was on EBP due to a gastric tube, received care from his wife without the use of PPE. The Infection Preventionist confirmed that all caregivers, including family members, should wear PPE when providing direct care to residents on EBP. Additionally, Resident 53, who had a severe sepsis diagnosis and was on EBP due to a urinary catheter and feeding tube, was repositioned by staff without the required PPE. The Director of Nursing confirmed that staff should wear gowns and gloves when repositioning residents on EBP to prevent cross-contamination. Furthermore, several licensed nurses failed to perform hand hygiene before and after medication administration, as observed with multiple residents. The Director of Nursing and the Infection Preventionist emphasized the importance of hand hygiene in preventing infections. Additionally, a licensed nurse did not properly disinfect glucometers between uses, lacking understanding of the necessary dwell time for disinfectants to be effective. This oversight was acknowledged by the Infection Preventionist, who was unaware of the dwell time requirements and planned to address this issue with the nursing staff.
Failure to Conduct Mandatory Communication Training
Penalty
Summary
The facility failed to ensure that Effective Communications in-services were conducted as mandatory training for direct care staff, affecting a census of 60 residents. During an interview and record review with the Director of Staff Development (DSD), it was confirmed that the 2024/2025 In-Service Calendar for [NAME] Care Center of Fairfield did not include any communication in-service training. The DSD acknowledged that no communication training had been conducted in 2024 or 2025. The facility's policy, revised in January 2025, stated that the in-service training program is intended for the development and improvement of staff skills, with classes scheduled by the in-service coordinator. However, the absence of communication training indicates a failure to adhere to this policy, potentially impacting the quality of care provided to residents.
Indirect Staff Not Trained on Resident Rights
Penalty
Summary
The facility failed to ensure that indirect staff members, who do not provide direct resident care, were educated on the rights of the residents and the responsibilities of the facility to properly care for its residents. This deficiency was identified during an interview and record review with the Director of Staff Development (DSD), where it was confirmed that the 2024/2025 in-service training calendar did not include training on resident rights and facility responsibilities for indirect staff. The facility's policy on in-service training, revised in January 2025, states that the training program is intended for the development and improvement of skills for all personnel, yet this training was not conducted for indirect staff members, affecting a census of 60 residents.
Failure to Conduct Mandatory QAPI Training
Penalty
Summary
The facility failed to conduct mandatory training for all staff on the elements and goals of its Quality Assurance and Performance Improvement (QAPI) program, which is essential for maintaining and improving safety and quality in nursing homes. During an interview and record review with the Director of Staff Development (DSD), it was confirmed that the 2024/2025 in-service calendar for the facility did not include any QAPI training sessions. Furthermore, the DSD admitted that no such training had been conducted in 2024 or 2025. The facility's policy on in-service training, revised in January 2025, emphasizes the importance of ongoing training programs for staff development and skill improvement, yet this policy was not adhered to in the case of QAPI training. This deficiency had the potential to result in poor communication among staff, a lack of awareness of facility updates, insufficient collaborative work, and compromised resident care, as the staff was not adequately informed about the QAPI program.
Failure to Conduct Behavioral Health Training
Penalty
Summary
The facility failed to conduct staff training on behavioral health, which was required as part of their facility assessment. This deficiency was identified during an interview and record review with the Director of Staff Development (DSD). The review of the 2024/2025 In-Service Calendar for [NAME] Care Center of Fairfield revealed that an in-service training on the problems and needs of aged, chronically ill, acutely ill, and disabled patients was scheduled for April 2024 but was not conducted. The DSD confirmed this omission. Additionally, the facility's policy and procedure for the In-Service Training Program, revised in January 2025, stated that the facility is committed to developing an effective in-service training program to improve the skills of all personnel. However, the planned training was not executed, leading to a deficiency in staff preparedness to care for residents with behavioral health issues.
Failure to Provide Functional Call Light Systems for Dependent Residents
Penalty
Summary
The facility failed to provide reasonable accommodation for the needs of two residents by not ensuring they had access to appropriate and functional call light systems. One resident, who was dependent on staff for all activities of daily living and had severe cognitive and physical impairments, was provided with a standard call light button that he was unable to use due to his inability to move his fingers. Multiple staff members confirmed that the resident could not operate the call light and required an alternative system, such as a soft touch pad, but this was not provided. Another resident, who was bedbound and at high risk for falls and decline in activities of daily living, was moved to a new room where the call light system was broken. As an alternative, the resident was given a blue string to pull for assistance, but the string was tangled with bed wires and was not functional. The resident was unable to use this makeshift system to call for help, and staff confirmed that the alternative provided was not a functional call light system. Maintenance records indicated the call light was reported as broken, but the issue was not resolved at the time of observation. Facility policy required that residents be provided with a means of communication with nursing staff and that defective call lights be promptly reported and repaired or replaced. Despite these policies, both residents were left without effective means to request assistance, as confirmed by staff interviews and direct observation.
Failure to Maintain Resident Dignity and Respect
Penalty
Summary
The facility failed to maintain dignity and respect for three residents. Resident 160, who had no cognitive impairment, was humiliated when CNA 2 made demeaning comments about her use of a commode instead of the restroom. CNA 2 acknowledged the inappropriate nature of her comments, which left Resident 160 feeling embarrassed and disrespected. The Director of Staff Development confirmed the interaction was inappropriate. Additionally, two residents with severe cognitive impairments, Resident 45 and Resident 6, were assisted with meals in a manner that lacked respect. Both residents were reclined in Geri chairs while CNAs stood over them during meal assistance. CNA 6 and CNA 3 admitted to standing over the residents, acknowledging that they should have been seated to promote respect. The Director of Nursing confirmed the inappropriate positioning of the CNAs, which was contrary to the facility's policy on treating residents with dignity and respect.
Inaccessible Call Light Systems for Residents
Penalty
Summary
The facility failed to ensure that the call light system was accessible for three residents, leading to potential unmet needs and communication barriers for assistance. Resident 13, who has multiple sclerosis and generalized muscle weakness, was observed with a call light button out of reach due to his contracted right hand. Both the resident and a licensed nurse confirmed the inaccessibility of the call light, which contradicted the care plan that required the call light to be within easy reach. Resident 48, diagnosed with hemiplegia, epilepsy, and dysphagia, was found without a call light within reach while lying on a Geri chair. The call light was tied to the bed's side rail, making it inaccessible. Both a family member and staff confirmed the resident's inability to reach the call light, emphasizing the need for it to be on the left side due to the resident's right-side paralysis. Resident 263, with cerebral infarction, diabetes mellitus, and atherosclerosis, was observed with the call light button on the floor, out of reach. The resident's care plan also required the call light to be within easy reach. Staff confirmed the call light's inaccessibility, which was against the facility's policy that mandates call lights to be within reach when residents are in bed.
Failure to Provide Written Transfer Agreement with Local Hospital
Penalty
Summary
The facility failed to ensure there was a written transfer agreement with a local General Acute Care Hospital (GACH), as required by federal regulations. During an interview on March 12, 2025, the Director of Nursing (DON) was unable to provide a copy of the facility's transfer agreement with a local hospital upon request. Despite multiple follow-up interviews on the same day and the following day, the DON confirmed that she was still unable to locate the transfer agreement. The DON acknowledged the requirement for such an agreement but was unable to produce it, potentially placing residents at risk for inadequate continuity of care and treatment.
Infection Control Lapse with Foley Catheter Management
Penalty
Summary
The facility failed to adhere to appropriate infection prevention and control measures for a resident with a Foley catheter. During an observation, it was noted that the resident's Foley catheter drainage bag was left on the floor, which is against the facility's policy. The resident confirmed that this was a recurring issue, indicating a lapse in maintaining proper infection control practices. Interviews with staff, including an unlicensed staff member, the Director of Staff Development, and the Director of Nursing, confirmed that the drainage bag should not be on the floor as it increases the risk of infection. The facility's policy explicitly states that catheter tubing and drainage bags should be kept off the floor to prevent bacterial contamination, yet this protocol was not followed, putting the resident at risk for a urinary tract infection.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that two out of six sampled residents had their call lights within reach, which is essential for residents to communicate with staff when they need assistance. Resident 1, admitted with muscle weakness and neuromuscular dysfunction of the bladder, did not have his call light within reach, as it was found on the floor by the foot of his bed. Resident 2, admitted with hyperlipidemia and anemia, had her call light wrapped around the left side rail of her bed, making it inaccessible. Both residents reported having to yell for help due to the unavailability of their call lights. During observations and interviews, staff members, including Unlicensed Staff A, Licensed Staff B, and the Director of Staff Development, acknowledged that the call lights were not within reach and confirmed that this was not acceptable practice. The facility's policy and procedure on call lights, revised in January 2024, states that call lights should only be out of reach during resident care and must be placed within reach immediately after care or when the resident is back in bed. The Director of Nursing also emphasized the importance of having call lights within reach to prevent delays in care and ensure resident safety.
Delayed Treatment and Medication Unavailability in LTC Facility
Penalty
Summary
The facility failed to provide timely and appropriate care for four residents, leading to significant health risks. One resident experienced a 22-day delay in the treatment of a urinary tract infection. The resident was admitted with a history of urinary tract infections, diabetes, acute kidney failure, and high blood pressure. A urinalysis with culture and sensitivity was ordered, but the antibiotic treatment was not prescribed until 11 days after the test results were available, despite the nurse practitioner visiting the facility multiple times during this period. This delay in treatment posed a risk of acute kidney failure for the resident. Three other residents did not receive their prescribed medications due to unavailability, which had the potential to result in serious health issues. One resident, with a history of respiratory failure and COPD, did not receive medications for high blood pressure, fluid overload, and breathing problems. This resident became anxious and was eventually transferred to a higher level of care. Another resident, with a history of atrial flutter and transient ischemic attack, missed doses of medications for high blood pressure and stroke prevention over two days. A third resident, with a history of high blood pressure and heart failure, did not receive medications for blood pressure and potassium supplementation due to pharmacy delivery delays. The Director of Nursing acknowledged the medication administration failures and the lack of timely delivery from the pharmacy. The facility's policies required timely specimen collection and medication administration, but these were not followed, leading to the deficiencies. The DON noted that the pharmacy had scheduled delivery times to ensure medications were available, but these were not adhered to, resulting in residents missing critical medications.
Failure to Notify Residents and RPs of Changes in Condition
Penalty
Summary
The facility failed to notify residents and their Responsible Parties (RP) of changes in their medical conditions or treatment plans, leading to deficiencies in care. For Resident 2, who has severe cognitive impairment and multiple health issues including Parkinson's Disease and Bipolar disorder, the facility did not inform the RP about changes in the resident's skin condition. Despite the presence of scattered scabs, open wounds, and other skin issues, there was no documentation or communication to the RP about these changes, which is a violation of the resident's rights as per facility policy. Similarly, Resident 3, who is cognitively intact and self-responsible, was not informed about the extension of his intravenous antibiotic therapy. The resident was initially supposed to receive the therapy until a certain date, but the treatment was extended without notifying him or explaining the reason for the extension. This lack of communication led to the resident feeling frustrated and upset, as he was unaware of the changes in his treatment plan. Interviews with various staff members, including the Director of Nursing and Licensed Nurses, confirmed that the facility did not follow its policy of notifying residents and their RPs about changes in condition or treatment. The facility's policy clearly states that it is the residents' right to be informed and involved in their care planning and treatment decisions. The failure to communicate these changes not only violated the residents' rights but also potentially impacted the quality of care they received.
Failure to Follow Physician and NP Orders
Penalty
Summary
The facility failed to ensure that a Licensed Nurse (LN A) followed the Physician's Order for administering long-acting insulin to a resident with diabetes mellitus. The insulin was supposed to be administered at 9 a.m., but LN A injected it at 11:18 a.m. on one occasion, and there were multiple instances where the insulin was administered late on other dates. During interviews, LN A admitted to not following the prescribed administration time, and other staff members, including LN B and the Infection Preventionist (IP), confirmed that administering medication late could pose a safety risk to the resident. The Director of Nursing (DON) also emphasized the importance of timely medication administration as per Physician's Orders. The facility also failed to follow the nurse practitioner's (NP) treatment plan and recommendations for another resident. The resident's Electronic Treatment Administration Record (ETAR) did not reflect the NP's treatment plan, which included the use of an alternating pressure pad (APP) and heel protectors to prevent pressure ulcers. Observations revealed that the resident was not using these devices, and interviews with staff, including LN B, the IP, and the DON, confirmed that the NP's treatment plan was not implemented. The DON acknowledged that the NP's recommendations should have been followed to prevent further skin breakdown. The facility's policy and procedure documents indicated that medications and treatments should be administered in accordance with prescriber orders. However, the failure to adhere to these policies resulted in deficiencies in the care provided to the residents. The staff, including the Director of Staff Development (DSD) and LN E, recognized that the NP's treatment plan and recommendations were considered valid orders and should have been followed, but they were not carried out as required.
Improper Reuse of Alcohol Wipe After Insulin Injection
Penalty
Summary
The facility failed to adhere to proper infection control protocols when a licensed nurse (LN) reused an alcohol wipe on a resident's abdomen after administering insulin. The resident, who was admitted with diagnoses including Diabetes Mellitus, chronic pain, and hyperlipidemia, was dependent on staff for all care. During an observation, LN A was seen using an alcohol wipe to clean the resident's abdomen before injecting insulin. After the injection, the resident requested the site be wiped again, and LN A reused the same alcohol wipe, acknowledging that it was not acceptable practice and citing a lack of extra wipes as the reason. Interviews with other staff members, including another licensed nurse, the infection preventionist, and the director of nursing, confirmed that reusing an alcohol wipe is against infection control protocols due to the risk of cross-contamination and infection. The facility's policy on infection prevention emphasizes the importance of educating staff and ensuring adherence to proper techniques, which was not followed in this instance.
Lack of CPR Certification Among CNAs
Penalty
Summary
The facility failed to ensure that all Certified Nursing Assistants (CNAs) were trained and certified in Cardiopulmonary Resuscitation (CPR), which is a critical life-saving procedure. During interviews, it was revealed that four CNAs did not have CPR certifications and were not familiar with the facility's policy and procedure for CPR. The Director of Staff Development (DSD) acknowledged that some CNAs were not CPR certified and stated that these CNAs would seek a licensed nurse in the event of a resident experiencing a heart attack or breathing failure. The Director of Nursing (DON) confirmed that CNAs without CPR certification would be unable to assist residents during emergencies such as cardiac or respiratory arrest. Interviews with individual CNAs further highlighted the deficiency. CNA 2 admitted to not being CPR certified and unable to identify cardiac or respiratory arrest, indicating she would look for a licensed nurse or supervisor during an emergency. CNA 3 and CNA 4 also confirmed their lack of CPR certification and uncertainty about the facility's emergency procedures. The DSD confirmed the absence of a designated CPR team within the facility. A review of the facility's policy and procedure document indicated that key clinical staff, including non-licensed personnel, should obtain and maintain CPR certification, which was not adhered to in this case.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 402 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Fairfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Emmanuel Care Center - Travis | 0 mi | — | 21 | 0 |
| Fairfield Post Acute Rehabilitation | 0 mi | ★★★★★ | 18 | 0 |
| Laurel Creek Health Center | 3.6 mi | ★★★★★ | 15 | 0 |
| Vacaville Ranch Post Acute | 7.3 mi | ★★★★★ | 3 | 0 |
| Vacaville Convalescent And Rehabilitation Center | 9 mi | ★★★★★ | 12 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.