Average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Greenhaven Healthcare Center during CMS and state inspections, most recent first.
A resident with atrial fibrillation, esophageal cancer, and Parkinson’s disease was ordered to have a PIV placed and to receive daily IV Ertapenem for a UTI, but staff did not develop a care plan addressing IV care. Record review confirmed the absence of an IV care plan despite active IV orders, and the DON acknowledged that an IV care plan would be expected. Facility policy requires care plans to include goals and objectives for specific resident problems, yet no such plan was created for this resident’s IV therapy, creating a potential risk for infection and bleeding.
A resident with multiple diagnoses, including atrial fibrillation, esophageal cancer, and Parkinson’s disease, had a PIV placed for IV Ertapenem to treat a UTI. The clinical record contained orders for IV therapy but no documentation that the PIV was removed before discharge, as required by facility policy. An LN reported he was unaware the resident had an IV and noted there was no order to discontinue it, learning from the family after discharge that the IV remained in place. The DON confirmed the absence of documentation of PIV removal and stated she would have expected the line to be removed prior to discharge.
A resident with ESRD and DM was sent to the hospital for evaluation and treatment of a left big toe infection with suspected osteomyelitis. The resident’s bed-hold period expired while hospitalized, and the facility recorded a discharge at that time. When hospital case management later determined the resident was medically stable and began planning for return, the facility administrator, DON, and Admissions Coordinator all indicated the resident would not be readmitted due to an insurance lapse, despite a LTC bed being available. No 30-day discharge notice, appeal rights, or discharge planning were provided before the transfer, and the facility’s own policy required priority readmission from hospital and equal application of readmission procedures regardless of payment source.
Controlled substance records were not accurately reconciled for two residents, with oxycodone doses signed out in the CDR that did not match MAR documentation and MAR doses that did not match CDR removals. In addition, the central medication room ADC had three unresolved discrepancies, including a morphine solution discrepancy that remained open for 21 days. The ADON, DON, and consultant pharmacist confirmed the discrepancies were still open or had not been communicated as required.
Medication Storage and Labeling Deficiencies: An unlocked treatment cart was left unattended, and multiple medication storage errors were found in resident carts, a med room, and a med refrigerator. Staff identified an expired insulin pen and an expired inhaler in carts, an opened and undated levalbuterol pouch in a med room, and discontinued compounded IV daptomycin still stored in refrigeration. The DON confirmed the items were expired, undated, or should not have remained stored as found.
Improper Preparation of Texture Modified Diets: Kitchen staff prepared pureed and minced and moist foods that did not meet IDDSI standards. A staff member processed turkey with an unmeasured broth and margarine mixture, and meal observations showed chunky minced and moist vegetables, thin pureed vegetables and turkey, and a sticky pureed bread item that failed the spoon tilt test. The SLP and RD reviewed the trays and stated the textures were inconsistent with the required diet standards.
Food prep and storage areas were not maintained in sanitary condition. Surveyors observed ice buildup in the walk-in refrigerator and freezer, rust-colored substance on kitchen racks and a wall surface, dirty resident cups and meal trays left on nourishment room counters, holes and chipped paint in the kitchen wall, and an opened bottle of Pedialyte in a unit refrigerator without a resident name or open date. Staff and leadership acknowledged the conditions, and the IP stated dirty dishes should not be stored in nourishment rooms.
Inconsistent handling of food brought by family or visitors led to a deficiency when staff gave conflicting directions on storage timeframes and reheating practices. A CNA, an LN, an ADON, and the DON each described different rules for how long outside food could be kept and whether it could be reheated, while the facility policy gave minimal guidance on storage, reheating, and determining a food’s use-by date. The DON acknowledged variations across nursing stations, and resident food was being managed differently on the units.
An LN failed to perform hand hygiene multiple times while providing wound care to a resident with a sacrum wound and diabetes, including after removing gloves and before putting on new gloves. In a separate event, two CNAs assisted a resident on EBP with dressing and transferring without wearing gowns, and the DON confirmed staff should follow infection control protocols for residents on EBP.
Missing Advance Directive in Resident Record: The facility failed to obtain and maintain a copy of an advance directive in a resident's medical record. The resident was admitted for hospice care, had moderate cognitive decline, and had a DNR order and documented lack of decision-making capacity. The resident's representative said the advance directive had been created years earlier, but the facility never asked for a copy, and the DON confirmed it was not in the chart.
Resident-to-resident verbal abuse occurred when one resident repeatedly insulted another resident about her weight and told her to die and go to h*ll over three nights. The victimized resident, who had intact cognition, became upset and cried, and a CNA and the DON confirmed the abuse. Progress notes show the resident reported the abuse to staff, requested a room change, and was later moved to a separate room.
An LPN handled Xeljanz without gloves during preparation and bedside administration even though the label said to use gloves when handling. The same LPN also did not stay with a resident to ensure MiraLAX was fully taken, leaving part of the mixed dose unfinished after the med pass. The DON stated staff were expected to observe administration of all medications.
A resident with cataracts and hearing difficulty was not assisted in obtaining prescribed eyeglasses, and a hearing consult was not scheduled promptly. The SSD found no documentation that the glasses were obtained and no completed hearing consult, while the resident reported repeatedly asking staff for eye and ear doctor visits and said he did not remember wearing eyeglasses at the facility.
Failure to Place Ordered Floor Mats for a Resident at High Fall Risk: A resident with repeated falls, right hemiplegia, and CVA-related impaired mobility was identified as high risk for falls, with an MRR directing staff to keep floor mats on both sides of the bed every shift. Surveyors observed the mats were not in place during multiple checks, and an LN later confirmed the mats were absent despite documenting that they had been placed.
A resident with chronic pain and depression was observed moaning during turning, repositioning, and wound care, and later stated her back was hurting. The LPN confirmed the resident was in pain but did not offer PRN pain medication before the treatment, and the MAR showed pain was not assessed every shift. The DON confirmed there was no pain assessment in the orders and expected nurses to assess pain and offer medication before wound care.
Expired Insulin Pen Used for Daily Doses A resident ordered insulin glargine 15 units SC daily for diabetes received 12 doses from a Lantus Solostar pen that had been opened past the manufacturer’s 28-day limit. During observation and record review, an LPN confirmed the pen’s open date and that it had expired, and the DON confirmed the resident received doses from the expired pen. The facility policy required opened medications to be dated and discarded within 28 days unless the manufacturer specified otherwise.
A resident with significant cognitive and physical impairments, including a high risk for falls, was left unsupervised in an outdoor patio area. Despite care plans and assessments indicating the need for supervision and fall prevention, the resident accessed the area alone, resulting in a fall that caused a fatal head injury. Staff interviews confirmed that supervision was not provided at the time of the incident, and facility policies requiring individualized supervision were not followed.
A resident with severe cognitive impairment and a history of traumatic brain injury was admitted with a physician order for a CT scan, which was not entered or implemented until 15 days after admission. Staff interviews confirmed the delay, and facility policy required timely entry and follow-up of such orders. This resulted in a delay of ordered care.
A resident with multiple sclerosis and intact cognition was punched on the arm by another resident with vascular dementia and moderate cognitive impairment following a verbal altercation. Staff witnessed the incident, and records showed there was no care plan in place to address the aggressor's risk for aggressive behavior, resulting in a failure to protect residents from physical abuse.
A resident with cognitive impairment and a history of aggressive behavior physically struck another resident who had no cognitive deficits. Despite staff intervention and moving the victim to a different room, the aggressor continued to access the victim's new room, causing ongoing fear and distress. Staff interviews confirmed that increased supervision and separation were not implemented as required, resulting in the victim feeling unsafe and avoiding activities.
A resident with severe cognitive impairment physically struck another resident, who has multiple sclerosis, in a common area. Staff observed the altercation, which involved slapping and attempted punches, and intervened to separate the residents. Facility policy defines such actions as physical abuse.
A resident with severe cognitive impairment and a high fall risk was repeatedly found with their call light out of reach due to a broken clip, preventing them from calling for assistance as required by their care plan and facility policy. CNAs and the DON confirmed the deficiency during interviews.
A resident with multiple venous ulcers, lymphedema, and diabetes was discharged without a documented skin assessment, despite facility policy requiring this step. The Discharge Instruction Form and Discharge Summary lacked information on the resident's skin condition, and staff interviews confirmed the assessment was not completed or documented before discharge.
A resident with diabetes and total dependence for ADLs sustained a skin tear that was not assessed or treated according to facility policy. The wound was not reported to the treatment nurse, no physician orders were obtained, and no care plan was developed or implemented, as confirmed by both the treatment nurse and DON.
A resident with dysphagia was not provided with the ordered nectar thick liquids and no straw, as regular water with a straw was found at their bedside. The CNA confirmed providing the water and straw, contrary to the physician's orders. The DON acknowledged the risk of aspiration due to this oversight.
A resident with hemiplegia and severe cognitive impairment did not consistently receive the prescribed application of a left hand splint, as documented in their care plan. The facility failed to document the application and duration of the splint on several occasions, as confirmed by the Director of Rehabilitation and the Director of Staff Development. The Director of Nursing acknowledged that this inconsistency could lead to a decline in the resident's condition.
The facility failed to account for controlled medications for three residents, resulting in missing doses of Hydrocodone-Acetaminophen and Oxycodone. Despite procedures for handling these medications, audits revealed missing medication cards and count sheets, raising concerns about potential misuse. Additionally, two doses of Hydrocodone-Acetaminophen for a resident were unaccounted for, with no documentation of administration or disposal.
A resident with severe cognitive impairment was admitted without their representative signing the admission agreement, as required by facility protocol. This oversight meant the representative was not informed of the resident's rights, potentially affecting decision-making for the resident's care.
A resident reported that a nurse took her cell phone and call light, placing them out of reach after she refused a blood sugar check, leaving her unable to call for assistance. Despite being informed, the facility's Administrator did not initiate an investigation or document any actions, failing to follow the policy for investigating allegations of abuse or mistreatment.
The facility failed to maintain proper food temperatures, with uncalibrated thermometers and milk served above acceptable temperatures. Multiple residents complained of cold food, and observations confirmed that meals were often not palatable. The removal of a microwave further hindered the ability to reheat food, as acknowledged by staff.
The facility failed to follow the recipe for pureed bread rolls for 25 residents on a pureed diet, resulting in bread that was dry and lumpy instead of the required pudding-like consistency. The Dietary Director and Registered Dietician acknowledged the issue, noting the importance of achieving the correct consistency to prevent aspiration risks.
The facility failed to follow proper infection control practices for four residents, including not wearing gowns during care, and not cleaning enteral feeding equipment and CPAP/BiPAP masks as required. These actions increased the risk of infection spread among residents.
A resident with a history of inappropriate behavior was not adequately monitored, leading to an incident where he allegedly touched another resident's breast. Despite care plans requiring supervision, the resident was moved to a less monitored area, resulting in the failure to protect the victim, who has cerebral infarction and aphasia, from abuse.
The facility failed to treat residents with dignity by referring to those needing meal assistance as 'feeders.' Staff, including an LN and a CNA, used this term, contrary to the facility's policy, which emphasized treating residents with respect and avoiding such labels. The DON stated that residents should be referred to as 'assisted diners.'
A resident's room had a large hole in the wall above the bed, which had been present since admission. The resident, with a history of stroke and depression, confirmed the disrepair. A nurse acknowledged the issue, and the Maintenance Supervisor emphasized the importance of a homelike environment. However, only one maintenance request was logged, with no follow-up, contrary to the facility's policy.
A resident with Type 2 Diabetes Mellitus did not receive care in accordance with professional standards due to the facility's failure to accurately document blood glucose readings and notify the physician of readings below 100 as ordered. This issue persisted for nine days, potentially compromising the resident's care. The licensed nurse confirmed a documentation error, and the DON emphasized the importance of following physician orders and accurate documentation.
A resident with muscle weakness and unsteadiness was not assisted to his wheelchair for meals, contrary to physician orders and facility policy. This oversight was confirmed by staff and linked to the resident's recent weight loss and difficulty in eating. The facility's policy on supporting ADLs was not followed, impacting the resident's ability to feed himself.
A resident with a tongue ulcer, under palliative and hospice care, did not receive proper coordination of care when the ulcer was not communicated to the physician. Despite the resident's complaints and requests for evaluation, there was no evidence of notification to the physician or hospice, leading to potential pain and discomfort.
A facility failed to ensure clear and consistent documentation for a resident's left hand splint, leading to potential misuse. The resident had conflicting orders for the splint's duration, with staff unaware of the updated order. Observations showed the splint was applied daily, but the duration was not documented, and the resident's family noted it was only occasionally seen. The facility's policies on individualized care plans and documentation were not effectively implemented, resulting in a deficiency.
The facility failed to document daily glucometer calibration, with only six entries recorded for two machines in September. Interviews with staff confirmed missing entries and emphasized the importance of daily checks for accurate blood glucose readings. The facility's policy mandates daily calibration by night shift nurses, monitored monthly by the DON or Unit Manager.
Two residents were prescribed Seroquel without adequate indication or target behaviors. Resident 18, with Alzheimer's, showed no aggressive behavior or psychosis, yet was on Seroquel. Resident 117, with dementia, was given Seroquel for sleep issues, despite no aggressive behavior. Facility policy required specific conditions and non-pharmacological attempts before antipsychotic use, which were not documented.
Expired medications, including glucose tablets and an inhaler, were found in a medication cart, indicating a failure to follow the facility's medication storage policy. A licensed nurse confirmed the expiration, and the DON acknowledged that expired medications should not be in the cart. The facility's policy requires outdated drugs to be returned or destroyed.
A resident's medical records were found to be inaccurate, with discrepancies in the documentation of a PICC line and surgical site status. Observations and interviews revealed that the resident did not have a PICC line, and the surgical site details were outdated. The DON acknowledged the importance of accurate documentation to prevent misleading care decisions.
The facility's QAPI Committee failed to include the Medical Director (MED) in its meetings from November 2023 to October 2024, as required by policy. The DON confirmed the MED's absence, and the ADM emphasized the importance of the MED's role in guiding healthcare decisions.
A loose round plate with a large bolt in the D wing hallway posed a trip hazard, potentially endangering residents. Both a Licensed Nurse and a Maintenance Assistant acknowledged the hazard, noting the plate covers a drain used for pipe maintenance. The facility's maintenance policy requires all areas to be safe and operable, which was not met in this case.
A resident with Alzheimer's disease eloped from the facility due to inadequate supervision and monitoring. Despite being on elopement protocol and wearing a wander guard, the resident exited through the front door, triggering an alarm that was not heard by staff. The resident was found in a nearby apartment complex courtyard by a former employee. Video footage showed the resident leaving the facility before staff responded.
A resident with diabetes experienced multiple instances of low blood glucose levels, falling below the ordered threshold of 70 mg/dl. Despite the facility's policy requiring notification of the physician in such cases, there was no documentation that the physician was informed. The Director of Nursing confirmed the lack of notification, which could have delayed necessary medical care.
A resident with Alzheimer's Disease and a history of altercations slapped another resident at the nurse's station due to inadequate supervision and lack of behavior monitoring in the care plan. The CNA present was unaware of the resident's aggressive history, and the incident could have been prevented with proper care plan updates and monitoring.
A facility failed to report an allegation of abuse within the required timeframe. A resident reported inappropriate touching by another resident to an LPN, who did not document or report the incident. This led to a four-day delay in the investigation, causing the resident to feel fearful and unsafe.
A resident was not treated with dignity and respect when a CNA did not honor her wish to be changed later, resulting in the resident being accidentally hit on the face with a dirty diaper. The resident, who had speech impairment following a stroke, communicated the incident through writing and gestures, expressing fear and upset. The facility's policies on resident rights and dignity were reviewed, indicating that residents should be treated with respect and dignity at all times.
Failure to Develop Care Plan for Resident Receiving IV Antibiotic Therapy
Penalty
Summary
Surveyors identified that the facility failed to implement a comprehensive, person-centered care plan for a resident who had a peripheral IV (PIV) placed for IV antibiotic therapy. The resident was admitted in January 2026 with multiple diagnoses, including atrial fibrillation, malignant neoplasm of the esophagus, and Parkinson’s disease. On 3/20/26, physician orders directed staff to place a PIV for IV antibiotics and to administer Ertapenem Sodium 1 gram IV once daily for seven days to treat a UTI. Record review showed that, despite these orders and the presence of the PIV, no care plan addressing IV care was developed for this resident. In a telephone interview on 4/13/26, the DON confirmed that there was no IV care plan in the resident’s record and stated she would have expected a care plan regarding the resident’s IV. The facility’s policy on Goals and Objectives, Care Plans, revised April 2009, states that care plans shall incorporate goals and objectives that lead to the resident’s highest obtainable level of independence and defines care plan goals and objectives as the desired outcome for a specific resident problem. This failure to develop an IV care plan for the resident’s PIV had the potential to cause an increased risk of infection and bleeding, as noted in the survey findings.
Failure to Discontinue Peripheral IV Prior to Resident Discharge
Penalty
Summary
The deficiency involves the facility’s failure to ensure a peripheral IV (PIV) was discontinued prior to a resident’s discharge. The resident was admitted in January 2026 with multiple diagnoses, including atrial fibrillation, malignant neoplasm of the esophagus, and Parkinson’s disease. On 3/20/26, there was a physician’s order to place a PIV for IV antibiotics and to administer Ertapenem 1 g IV once daily for seven days for a UTI. Review of the clinical record showed no documentation that the PIV was removed before the resident left the facility. The facility’s policy on Peripheral IV Catheter Removal, revised October 2024, required documentation of the date and time of removal, resident tolerance, catheter location, reason for removal, complications and interventions, and any communication with the physician or oncoming shift. During an interview, an LN stated he did not know the resident had an IV and confirmed there was no physician’s order to discontinue the IV. He reported that the resident’s family called him after discharge to inform him that the resident still had an IV in her arm. In a concurrent interview and record review, the DON confirmed there was no documentation that the PIV had been discontinued prior to discharge. In a subsequent interview, the DON stated she would have expected the PIV to be removed before discharge and acknowledged that the PIV would be at risk for infection or becoming dislodged.
Failure to Readmit Hospitalized Resident Due to Insurance Lapse
Penalty
Summary
The facility failed to allow a resident to return after a hospital transfer, despite the resident being medically stable and a bed being available. The resident had been admitted with ESRD and DM and was transferred to the emergency department on 2/18/26 for evaluation and treatment of a left big toe infection with suspected osteomyelitis, as documented in the IDT note. The resident’s admission record showed a discharge date of 2/25/26 at 10:30 a.m., coinciding with the expiration of a seven-day bed-hold period while the resident remained hospitalized. Hospital case management correspondence on 3/9/26 indicated the resident was medically stable and ready to leave the hospital, and planning began for the resident to return to the facility. According to an online complaint to CDPH, the facility administrator stated the facility was refusing to readmit the resident after hospitalization due to an insurance lapse. In interviews, the DON confirmed the resident was still considered a resident at the time of transfer to the hospital, that the facility refused readmission due to insurance issues, that there was a LTC bed available, and that there was no 30-day discharge notice, no appeal rights provided, and no discharge planning prior to hospitalization. The Admissions Coordinator also confirmed the resident was not readmitted because of lack of insurance. The facility’s own policy on readmission stated that residents discharged to the hospital would be given priority for readmission, that residents whose hospitalization exceeded the state bed-hold period would be readmitted upon first bed availability if they required the facility’s services, and that readmission procedures would apply equally regardless of payment source.
Controlled Substance Records and ADC Discrepancies Not Reconciled
Penalty
Summary
The facility failed to ensure safe and effective medication management for controlled substances when two residents’ controlled medication records did not match between the Medication Administration Record (MAR) and the Controlled Drug Record (CDR). For one resident, PRN oxycodone orders were in place for moderate and severe pain, and the DON confirmed that two tablets were signed out from the CDR on three occasions, while the MAR documented only one tablet administered at those times. The DON acknowledged that three oxycodone tablets were signed out but not documented as administered on the MAR. For another resident, a PRN order for half-tablet oxycodone was active, and the DON confirmed that one half-tablet was signed out from the CDR without a corresponding MAR entry. The DON also confirmed that two MAR administrations of half-tablet oxycodone had no corresponding CDR removals. The DON acknowledged that this resident’s CDR did not reconcile with the MAR and stated there was a risk for diversion and inaccurate charting. The facility also had unresolved automated dispensing cabinet (ADC) discrepancies in the central medication room. During observation, three active discrepancies were present for gabapentin, morphine solution, and vancomycin, and both the ADON and LN confirmed they were still open in the system. The DON stated she had not been notified of the discrepancies and confirmed the morphine discrepancy had remained unresolved for 21 days. The consultant pharmacist stated he investigated ADC discrepancies monthly and could not resolve one without a physical count, and he confirmed he had not been notified by the DON of the controlled substance discrepancies.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure medications were properly stored, labeled, and maintained according to its policy and/or manufacturer specifications. During observation, a treatment cart containing supplies and medications was left unlocked and unattended while residents and staff were present in the hallway. The DON later stated medication and treatment carts should always be locked and secured when nurses are away from them, and the facility policy stated all medications and biologicals are to be stored in locked compartments under proper environmental controls. Medication storage issues were also identified in resident-specific carts. In one cart, a Lantus Solostar insulin pen for one resident was found with an open date of 1/13 and was confirmed to have expired on 2/10; the DON acknowledged the resident had the potential to receive ineffective insulin. In another cart, an opened Wixela inhaler for another resident was found with an open date of 1/5 written on the box, and the manufacturer instructions indicated it should be discarded one month after opening the foil pouch; the DON confirmed it was expired and stated it might not be effective. Additional storage problems were found in a medication room and refrigerator. An opened, undated foil pouch containing levalbuterol unit-dose vials for a resident was observed in a medication room; staff confirmed there was no open date and could not verify whether it was expired or safe to use, and the DON stated its stability could have been compromised. In a medication refrigerator, two compounded IV daptomycin preparations for another resident were found stored after the order had been discontinued; the DON confirmed the antibiotic had been discontinued earlier and acknowledged it should not have remained in the refrigerator. The facility policy stated discontinued, outdated, or deteriorated medications are to be handled through the dispensing pharmacy for return or destruction.
Improper Preparation of Texture Modified Diets
Penalty
Summary
The facility failed to ensure texture modified diets were prepared in accordance with IDDSI guidelines when pureed and minced and moist trays did not meet the required texture standards. During a concurrent observation in the kitchen, a staff member removed turkey from the oven and used a food processor to prepare texture modified diets. After processing the turkey for the minced and moist diet, the staff member placed that portion in a steam table pan, then continued processing the remaining turkey with an unmeasured amount of chicken broth and margarine mixture. The turkey mixture was processed twice, additional broth/margarine was added, and the finished product appeared thin. The staff member stated it would thicken while on the steam table. During lunch meal plating, the minced and moist vegetable texture was observed to be chunky and did not appear to fit through the prongs of a fork as required for IDDSI Level 5. The pureed vegetables were liquid in consistency and did not hold their shape on the plate, and the pureed roasted turkey was also thin and spread across the plate. A test tray later showed the pureed bread item was thick and sticky and failed the spoon tilt test because it adhered to the spoon and did not slide off with gentle tilt. Tray tickets showed 17 residents were receiving pureed diets and eight residents were receiving minced and moist diets. The SLP and RD reviewed the tray pictures and stated the textures appeared inconsistent with IDDSI standards, including concern that the minced and moist vegetable was not finely ground enough and that the pureed items were too thick or sticky.
Food Prep and Storage Areas Not Maintained in Sanitary Condition
Penalty
Summary
The facility failed to maintain the food preparation and storage areas in a sanitary condition. During observation, surveyors found significant ice buildup on an insulated black pipe in the walk-in refrigerator, frozen drops of water on the freezer ceiling, and a large amount of ice buildup on the bottom of the freezer cooling unit. The Plant Operations Director confirmed the ice buildup, and the Registered Dietitian stated the buildup had been present for a while. The facility could not produce the refrigerator/freezer manual during the interview. Surveyors also observed rust-colored substance on the interior wall beneath the ice-covered pipe and on two metal racks in the kitchen, including one near the ovens and dishwashing sink and another under the stainless-steel dishwashing deck. The Plant Operations Director acknowledged the discoloration, and the Dietary Manager stated the rust-colored substance could serve as a mechanism for bacteria to spread to food. In addition, dirty resident coffee cups and meal trays were left on counters in nourishment rooms on multiple occasions, with no signage designating the area for soiled dishes. The Infection Preventionist stated nourishment rooms should not store dirty dishes and that dirty dishes were expected to be brought back to the kitchen. Surveyors further observed a hole in the wall under the handwashing sink during lunch meal plating, along with damaged drywall and chipped paint exposing drywall in multiple areas. The Dietary Manager stated the hole had remained since the previous sink was replaced and that carts likely caused some of the wall damage. In a nourishment room refrigerator, an opened bottle of Pedialyte was found without a resident name or open date. Staff stated the item was not correctly labeled and that without a name it could be given to the wrong resident. The facility policy required containers to be labeled with the resident's name, the item, and the use-by date.
Inconsistent Handling of Food Brought by Family or Visitors
Penalty
Summary
The facility failed to ensure resident food and beverages brought from outside the facility were consistently stored and managed under sanitary conditions for a census of 144 residents. During observation and interview, the nourishment rooms were inspected with the Dietary Manager, and no microwaves were observed on the nursing units. The DM stated staff could heat residents’ food using the microwave in the dining room. Resident 133 stated she and her previous roommate used to order food from an outside delivery source and share the meal, and otherwise if she ordered by herself it was too much food and would be thrown out in 48 hours as per facility policy. Staff gave inconsistent information about how outside food was to be handled. A CNA stated food brought from home could only be eaten for two hours before being discarded and that staff were not allowed to store or reheat it. An ADON stated residents’ food could not be reheated in the dining room microwave and expected staff to bring food to dietary for heating. An LN stated families could bring food, but staff could not reheat it and the facility would store food for 24 hours before discarding it, and showed instructions on the wing refrigerator. The DON acknowledged variations in how different nursing stations managed food from home and stated she and the ADONs had provided education to staff on Foods Brought by Family/Visitor dated March 2022. The DON also showed education pieces for families indicating food would be stored for 72 hours and could be reheated, while the facility policy provided minimal guidance on storage and reheating practices and did not specify where to reheat resident foods or how to determine the 'use by' date.
Failure to Maintain Hand Hygiene During Wound Care and PPE Use During EBP Care
Penalty
Summary
Proper infection control measures were not followed during wound care for a resident with a sacrum wound and diabetes. The resident’s record showed an order to cleanse the wound with vashe, pat dry, apply triad to the wound bed, place silver alginate, and cover with a foam dressing every evening shift and as needed. During observation, an LN prepared wound care supplies and placed them directly on the bed without a barrier, then cleaned the resident’s buttock after a bowel movement and changed gloves multiple times without performing hand hygiene after removing the used gloves and before putting on new gloves. The LN also cleaned the sacrum wound and again changed gloves without hand hygiene. The LN later confirmed the lack of hand hygiene, and the DON stated hand hygiene was expected after removing gloves and before donning new gloves.
Missing Advance Directive in Resident Record
Penalty
Summary
The facility failed to ensure that a copy of an advance directive was obtained and maintained in the medical record for one sampled resident who was admitted for hospice care. Resident 87's admission record showed the resident entered the facility in January 2026, and the MDS dated 1/8/26 indicated a BIMS score of 8 out of 15 with moderate decline in mental capacity. During interviews, Resident 87 was unable to be interviewed, and the resident's representative stated the advance directive had been created in 2014 and the facility never asked for a copy of it. Record review showed Resident 87 had a DNR order as per the resident/representative's wishes and was documented as lacking the capacity to understand choices and make health care decisions. A concurrent review by an LN confirmed the advance directive had been prepared in March 2014 but a copy was not available, and the DON also confirmed that no copy of the advance directive was present in the resident's medical records. The facility policy stated that if a resident or representative has executed an advance directive, copies are to be obtained and maintained in the medical record and readily retrievable by staff.
Resident-to-Resident Verbal Abuse
Penalty
Summary
The facility failed to ensure a resident was free from abuse when a roommate verbally abused her for three consecutive nights. Resident 72 was admitted in January 2026 with obesity and had a BIMS score of 15 out of 15, indicating intact memory. Resident 91 was also admitted in January 2026 with a diagnosis of cerebral infarction and had a BIMS score of 13 out of 15. Resident 72 stated that Resident 91 began calling her a "big fat b*tch," said she did not know how she got so fat, and repeatedly told her she wished she would die a long death and go to h*ll. Resident 72 reported the verbal abuse occurred from 2/3/26 through 2/5/26, caused her to cry, and left her worried that Resident 91 might come to her bed and hurt her. Resident 91 admitted being verbally abusive and referred to Resident 72 as a "275-pounds b*tch," stating the conflict began over whether the door should be closed for privacy. A CNA reported hearing Resident 91 verbally attack Resident 72 about her weight and say she hoped she would die, and the progress notes documented that Resident 72 reported ongoing verbal abuse for three days, causing stress and anxiety. The notes also show the Social Services Director met with Resident 72 because she wanted to move to another room, and a nurse later relocated her to a separate room. The DON confirmed the verbal abuse occurred and stated staff were expected to recognize abuse between residents and ensure the victim felt safe and did not experience ongoing stress.
Improper Handling of Hazardous Medication and Incomplete Observation of Laxative Administration
Penalty
Summary
Licensed Nurse 1 administered Xeljanz (tofacitinib) to Resident 74 without following the required hazardous drug handling procedures. During medication preparation on Unit D, the nurse was observed preparing 13 medications for Resident 74, including Xeljanz, without wearing gloves. At the bedside, the nurse administered the Xeljanz with a spoon and still was not wearing gloves. When the bottle label was reviewed, it stated, "Use gloves when handling," and the nurse confirmed she had not worn gloves during preparation or administration and acknowledged that gloves were required to reduce exposure to hazardous medications. Licensed Nurse 1 also did not remain with Resident 148 to ensure MiraLAX was taken as prescribed. The nurse prepared MiraLAX mixed with eight ounces of water along with other medications, then administered the medications at the bedside. After the medication pass, half of the MiraLAX solution remained on the bedside table. In follow-up interview, the nurse confirmed the remaining half-cup of MiraLAX and acknowledged she did not observe Resident 148 taking the rest of the medication. The DON stated nursing staff were expected to observe the administration of all medications.
Failure to Provide Vision and Hearing Services
Penalty
Summary
The facility failed to ensure ancillary services were provided for one resident when the resident’s prescribed eyeglasses were not obtained and a hearing consultation was not scheduled promptly. The resident was admitted with diagnoses including severe protein-calorie malnutrition and repeated falls. During an observation and interview, the resident stated he had been asking staff to see an eye and ear doctor to improve his vision and hearing, and he expressed concern that a delay in consultation could result in losing vision in one eye. Review of the resident’s optometry consultation notes showed limited vision due to cataracts and a prescription for new glasses to improve eyesight. The resident’s MDS indicated he did not wear eyeglasses and had difficulty hearing. The SSD confirmed there was no documentation that the resident had been assisted in obtaining the prescribed eyeglasses and no record of a completed hearing consultation. During room observation, no eyeglasses, magnifying devices, or amplifiers were found, and the resident stated he did not remember wearing eyeglasses at the facility. The DON stated staff were expected to assist residents in obtaining needed assistive devices and consultations, and facility policies stated staff would assist residents with locating resources, scheduling appointments, and arranging transportation for needed vision and hearing services.
Failure to Place Ordered Floor Mats for a Resident at High Fall Risk
Penalty
Summary
The facility failed to provide a safe environment for one resident who was at risk for falls. The resident was admitted with repeated falls related to right hemiplegia and had a care plan dated 11/18/25 identifying impaired mobility related to CVA with right hemiplegia as a fall risk. A Medication Regimen Review dated 11/21/25 stated the resident was at high risk for falls and that staff should ensure floor mats were in place on both sides of the bed every shift for fall prevention. During observations on 2/25/26 at 8:07 a.m., 11:15 a.m., and 12:10 p.m., floor mats were not present on either side of the resident's bed. The resident's MAR showed that an LN signed on the morning shift of 2/25/26 indicating the floor mats had been placed, but during a concurrent observation, interview, and record review at 12:15 p.m., the LN confirmed the mats were not in place and acknowledged the signature on the MAR. The DON stated staff were expected to follow the physician's order for placing floor mats to prevent injury if a fall occurred.
Failure to Assess and Treat Pain Before Wound Care
Penalty
Summary
The facility failed to provide pain management for a resident with chronic pain and depression when the licensed nurse did not assess the resident’s pain and did not administer pain medication before wound care. The resident’s record showed some memory impairment on the MDS, and the MAR indicated orders for acetaminophen 325 mg, two tablets by mouth every four hours as needed for mild pain, and oxycodone 5 mg, half a tablet by mouth every six hours as needed for moderate to severe pain before wound care. The MAR also showed the resident’s pain was not assessed every shift in February 2026. During observation, the resident was moaning when turned and repositioned before wound care, and continued moaning while the nurse cleaned the buttock wound. After wound care, the resident stated her back was hurting. The nurse confirmed the resident was moaning and in pain during wound care and acknowledged she did not offer pain medication before the treatment. The DON confirmed there was no pain assessment in the orders and stated nurses were expected to assess pain and offer pain medications prior to wound care.
Expired Insulin Pen Used for Resident’s Daily Doses
Penalty
Summary
The facility failed to prevent a significant medication error for one resident who was ordered insulin glargine 15 units subcutaneously daily for diabetes. During a concurrent observation and interview, a Lantus Solostar insulin pen assigned to the resident was found on the medication cart with a handwritten open date of 1/13 on the prescription label. The nurse confirmed that the pen had been opened on that date and calculated that it expired 28 days later. A review of the resident’s February MAR showed that the resident received 12 doses from that same pen after its expiration date. During follow-up interview and record review, the nurse confirmed the resident had only one insulin glargine pen available for administration and that it was the same pen observed on the cart. The DON also reviewed the February MAR and confirmed the pen had expired and that the resident received 12 doses from the expired pen. The manufacturer’s prescribing information for Lantus Solostar states the pen should be discarded after 28 days of use, and the facility’s Medication Labeling and Storage policy states opened medications are to be dated and discarded within 28 days unless the manufacturer specifies otherwise.
Failure to Provide Adequate Supervision Resulting in Resident Fall and Death
Penalty
Summary
A deficiency occurred when a resident with significant medical and cognitive impairments was left unsupervised outdoors, resulting in a fall that led to hospitalization and subsequent death. The resident had a history of hemiplegia, hemiparesis, aphasia, impaired vision, cognitive dysfunction, and was assessed as being at high risk for falls. Care plans and assessments indicated the need for supervision, cues, and fall prevention interventions due to the resident's impaired mobility, cognition, and vision, as well as a history of falls and other risk factors. Despite these documented needs, the resident was able to access the outdoor patio area alone and without supervision. Staff interviews confirmed that the resident frequently went outside by himself, and on the day of the incident, no staff were present to supervise him in the patio area. The resident was found on the ground with his wheelchair tipped backwards, having struck his head on the concrete. Staff acknowledged that supervision was required, especially when the resident was outside, but no evidence was found that supervision was provided at the time of the fall. Facility policies required individualized supervision and interventions based on assessed risks, including fall prevention for high-risk residents. However, the facility failed to implement these interventions, as there was no documentation or evidence that the resident was considered safe to be alone in the patio, nor were frequent checks or supervision provided. This lack of supervision directly contributed to the resident's unwitnessed fall and subsequent fatal injury.
Delayed Implementation of Physician-Ordered CT Scan
Penalty
Summary
The facility failed to ensure that physician orders were followed in accordance with professional standards of care and facility policy for a resident who was admitted with multiple diagnoses, including a traumatic hemorrhage of the cerebrum and severe cognitive impairment. Upon admission, the resident had a physician order for a CT scan of the head to be completed within two weeks. However, the order for the CT scan was not entered into the system until 15 days after admission, despite the expectation that all orders and follow-up appointments for new admissions be entered on the day of admission. Interviews with facility staff, including the DON and Unit Secretary, confirmed that the CT scan order was present in the admission documents but was not processed in a timely manner. The Unit Secretary acknowledged the delay and stated that not entering orders on time could potentially result in delayed care. Review of facility policy indicated that nurses are responsible for gathering information and contacting outside services, such as diagnostic services, upon admission. The failure to timely implement the physician's order for a CT scan resulted in a delay of ordered care for the resident.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A deficiency occurred when a resident with multiple sclerosis and intact cognition was physically abused by another resident diagnosed with vascular dementia and moderate cognitive impairment. The incident took place when the resident with dementia punched the other resident on the left arm after a verbal altercation, which was witnessed by staff. The assaulted resident reported being punched, and the aggressor admitted to the action, stating it was in response to perceived disrespect toward his deceased wife. Record review revealed that there was no documented evidence of a person-centered care plan addressing the potential risk of aggressive behavior for the resident with vascular dementia prior to the incident. The facility's policy states that residents have the right to be free from all forms of abuse, including physical abuse, but this right was not upheld in this case.
Failure to Prevent Resident-to-Resident Abuse and Ensure Resident Safety
Penalty
Summary
A deficiency occurred when a resident with no cognitive impairment was physically struck on the arm by another resident who had significant mental and cognitive impairment and a documented history of aggressive behaviors and resident-to-resident altercations. The incident took place in the resident's shared room, where a CNA witnessed the aggressor sitting on the victim's bed and attempting to make physical contact. The CNA intervened immediately, and the resident was assessed with no visible injuries. However, the victim expressed fear and concern for her safety following the incident. Despite being moved to a different room on a separate unit, the victim reported that the aggressor entered her new room on multiple occasions after the initial altercation. This ongoing access caused the victim to feel unsafe, leading her to request that her door be kept closed and to express fear that the aggressor would find her again. The victim became too fearful to leave her room or participate in activities, and staff interviews confirmed that the aggressor had further contact with the victim after the incident. Interviews with facility staff, including the Social Services Director and the DON, revealed that there was a lack of increased supervision and separation between the two residents following the altercation. Staff acknowledged that the abuser should have been separated from the victim to prevent further emotional distress and that residents have the right to feel safe. The facility's policy also required protection of residents from further harm during investigations, which was not fully implemented in this case.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse when one resident, who had severe cognitive impairment due to Alzheimer’s disease, slapped another resident on the left cheek and head. The incident occurred in a common area, where the cognitively impaired resident was observed swinging and making contact with the other resident, who was attempting to defend himself by blocking the hits. Staff, including the activities director and a certified nursing assistant, witnessed the altercation and intervened to separate the residents. The resident who was struck had multiple sclerosis and was cognitively intact at the time of the incident. Documentation and interviews confirmed that the altercation involved physical contact, including slapping and attempted punches. The facility’s policy defines such actions as physical abuse, including slapping and punching, and staff acknowledged that resident-to-resident altercations are not tolerated.
Call Light Not Accessible for High-Risk Resident
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment and a high risk for falls was found to have their call light placed out of reach on multiple occasions. The resident, who had a history of Alzheimer’s disease and a low BIMS score indicating severe cognitive impairment, was observed in their room with the call light on the floor atop a fall mat, rather than within easy reach as required by their care plan. The resident expressed an inability to call for assistance without the call light. Certified Nursing Assistants (CNAs) confirmed during interviews that the call light was not accessible to the resident and noted that the clip used to attach the call light was broken. The Director of Nursing acknowledged that the expectation was for call lights to be within reach and recognized the risk if this was not maintained. Facility policy also required that call lights be accessible to residents when in bed, but this was not followed in this instance.
Failure to Conduct Required Skin Assessment Prior to Discharge
Penalty
Summary
The facility failed to provide professional standards of care for a resident when a required skin assessment was not conducted prior to discharge. The resident, who had a history of chronic venous hypertension with ulcers on both lower extremities, lymphedema, and type 2 diabetes mellitus, was discharged without documentation of their skin condition or management. Both the Discharge Instruction Form and Discharge Summary lacked information regarding a skin assessment at the time of discharge. Interviews and record reviews revealed that the Treatment Nurse was aware of the resident's multiple venous ulcers, fragile skin, and a deep tissue injury on the left heel, which was later classified as unstageable. Despite these significant skin issues, the Unit Manager did not perform the required skin assessment before the resident left the facility, and there was no documentation explaining the missed assessment. The Director of Nursing confirmed that the facility's process for conducting a skin assessment prior to discharge was not followed in this case. The facility's policy, revised in December 2016, requires an assessment and documentation of the resident's condition, including a skin assessment, at discharge. The lack of a documented skin assessment and omission of skin condition details on discharge forms directly contributed to the deficiency identified by surveyors.
Failure to Assess and Treat Skin Tear According to Standards
Penalty
Summary
A resident with a history of diabetes, memory impairment, and respiratory failure was admitted in mid-2024 and was totally dependent on activities of daily living. The resident sustained a skin tear on the right forearm, which was documented in the SBAR summary and nurse progress notes. Despite this, there were no physician treatment orders or a nursing care plan developed or implemented for the skin tear. The treatment nurse was not made aware of the injury and therefore did not assess the wound, develop a treatment plan, or submit it to the physician. The Director of Nursing confirmed that the standard protocol was not followed, as the care plan for the skin tear was not initiated and treatment orders were not obtained. Facility policy required that any new skin tear be reported, assessed, and managed according to professional standards, including obtaining a physician's order and updating the care plan. Interviews with staff revealed a breakdown in communication and failure to follow established procedures for wound care. The absence of a care plan and treatment orders for the resident's skin tear was verified by both the treatment nurse and the Director of Nursing, in direct contradiction to facility policy and professional standards of practice.
Failure to Follow Liquid Consistency Orders for Resident with Dysphagia
Penalty
Summary
The facility failed to provide necessary care for a resident with dysphagia, as the ordered liquid consistency was not followed according to the physician's orders. The resident, who was admitted with a diagnosis of dysphagia following a stroke, had a physician's order for nectar thick liquids and no straw due to aspiration precautions. However, during an observation, the resident was found with regular water and a straw at their bedside, which was confirmed by a CNA who provided the water and straw, stating it was to prevent dripping from the resident's mouth. Further interviews revealed that the Licensed Nurse and the Speech Therapist confirmed the resident's diet order for nectar thick liquids and no straw, which was not adhered to. The Director of Nursing stated that the expectation was for staff to follow the physician's orders, and acknowledged the potential risk of aspiration if the ordered liquid consistency was not provided. The facility's policy on dysphagia emphasized the importance of identifying and addressing swallowing disorders, which was not followed in this instance.
Inconsistent Documentation and Application of Hand Splint
Penalty
Summary
The facility failed to ensure consistent documentation and application of a left hand splint for a resident with hemiplegia and hemiparesis following a nontraumatic intracerebral hemorrhage. The resident, who also had severe cognitive impairment, was admitted with a care plan that included the application of a left resting hand splint by a Restorative Nursing Assistant (RNA) seven times a week for up to four hours a day. However, there was no documented evidence that the splint was applied on several days, and when it was applied, the duration was often not recorded. This inconsistency in documentation and application was confirmed by the Director of Rehabilitation and the Director of Staff Development. The deficiency was further highlighted during interviews and record reviews, where it was confirmed that there was no documentation of the splint being applied on specific dates, and the RNA program was not consistently followed. The Director of Nursing stated that the expectation was for the RNA program to be adhered to and documented, and acknowledged that failure to do so could result in a decline in the resident's condition. The facility's policy on Restorative Nursing Services emphasized the importance of individualized and resident-centered care plans, which were not consistently implemented in this case.
Controlled Medication Accountability Failure
Penalty
Summary
The facility failed to ensure accurate accountability of controlled medications for three residents, resulting in missing and unaccounted medications. Controlled medications delivered by the pharmacy for three residents were reported missing, including Hydrocodone-Acetaminophen for two residents and Oxycodone for another. The medications were signed for upon delivery by the nursing staff, indicating receipt, but subsequent audits revealed the absence of medication cards and count sheets, leaving the facility unable to track the medications' whereabouts. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed the procedures for handling controlled medications, which include signing delivery receipts and storing medications in a locked narcotic box. Despite these procedures, the facility was unable to locate the controlled drug sheets for the medications delivered to the residents. The lack of documentation and accountability raised concerns about potential misuse or diversion of these medications. Additionally, the facility's Controlled Drug Record (CDR) for one resident indicated that two doses of Hydrocodone-Acetaminophen were missing, with no documentation of administration or disposal. The facility's policy on controlled substances requires reconciliation upon receipt, administration, and at the end of each shift, but the absence of records for the missing doses suggests a failure to adhere to these protocols.
Failure to Inform Resident Representative of Rights
Penalty
Summary
The facility failed to ensure that the resident representative for a resident with severe cognitive impairment was informed of the resident's rights due to the admission agreement not being signed. The resident, who was admitted in early December 2024 with a diagnosis of spine fusion, had a Brief Interview for Mental Status (BIMS) score indicating severe cognitive impairment. The Health Information Manager confirmed that the resident lacked capacity, and the admission packet was not signed by the resident's representative. The Admissions Manager stated that the protocol required the admission packet to be signed by the third day of admission, but this was not completed before the resident was sent to the hospital 14 days later. The facility's policies on admission criteria and resident rights emphasize the importance of informing residents and their representatives about their rights and responsibilities. However, the failure to obtain the representative's signature on the admission agreement meant that the representative was not adequately informed, potentially impacting their ability to make informed decisions regarding the resident's care.
Failure to Investigate Allegation of Mistreatment
Penalty
Summary
The facility failed to adhere to its policy and procedure for investigating allegations of abuse or mistreatment when an allegation involving a resident was not investigated. The resident, who was cognitively intact and required substantial assistance with mobility, reported that a licensed nurse took her cell phone and call light, placing them out of reach after she refused a blood sugar check. This left the resident unable to call for assistance, which was reported to the Director of Nursing and the Administrator by the resident's family and the Ombudsman. Despite being informed of the allegation, the Administrator did not initiate an investigation or document any actions taken. The facility's policy requires that all allegations of abuse, neglect, or misappropriation be thoroughly investigated and documented, with specific steps outlined for the investigation process. However, the Administrator confirmed that no investigation had been started, and the resident had not been interviewed, indicating a failure to follow the established procedures for protecting residents and ensuring a safe environment.
Failure to Maintain Proper Food Temperatures
Penalty
Summary
The facility failed to ensure that food served to residents was maintained at proper temperatures and was palatable. The kitchen staff did not calibrate thermometers used to measure food temperature during meal tray assembly, and there was no documentation of when the last calibration occurred. The Dietary Director (DD) acknowledged the lack of records and stated that calibration should occur at least weekly. The Registered Dietician (RD) confirmed the importance of this step to ensure food safety and palatability. During observations, it was found that milk on residents' trays was not at acceptable holding temperatures, with readings of 46 and 43 degrees Fahrenheit, which were above the facility's policy of 40 degrees Fahrenheit or below. The DD acknowledged the milk temperatures were out of range and discarded the milk. Additionally, Resident 19's tray contained menu items not at the proper temperature, with pureed meatballs at 102 degrees Fahrenheit and milk at 53 degrees Fahrenheit, both of which were not palatable. The RD stated that food temperatures should be checked before leaving the kitchen to ensure they are appetizing and safe. Multiple residents, including Residents 75, 53, 77, 86, and 107, complained of cold food. During a resident council meeting, several residents expressed that cold food was a persistent issue, particularly for breakfast and lunch. Observations during meal service confirmed that food was often served cold, and residents reported that the removal of a microwave made it difficult to reheat food. Staff interviews corroborated these complaints, with both a Certified Nursing Assistant (CNA) and a Licensed Nurse (LN) acknowledging the issue of cold food and the lack of a microwave for reheating meals.
Failure to Follow Recipe for Pureed Bread Rolls
Penalty
Summary
The facility failed to ensure that the recipe for preparing pureed bread rolls was followed for 25 residents who had chewing or swallowing difficulties and were on a pureed diet. The pureed bread served to these residents was observed to be dry and lumpy, which did not meet the required pudding-like consistency. The facility's recipe for pureed breads directed kitchen staff to gradually add milk to achieve a consistency similar to applesauce. However, during the preparation, the staff member added milk but did not test or taste the mixture to ensure the correct consistency before serving it. The Dietary Director acknowledged that the pureed bread was too thick, dry, and lumpy, failing to meet the smooth consistency required. The Registered Dietician confirmed that the pureed bread rolls needed to be properly pureed with enough liquid to achieve the right consistency, emphasizing that residents on a pureed diet are at risk for aspiration if the food is not of the correct consistency. The facility's 'Standardized Recipes' policy indicated that standardized recipes should be developed and used in food preparation, which was not adhered to in this instance.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to adhere to proper infection control practices for four residents, leading to potential infection risks. A Certified Nursing Assistant (CNA) was observed changing a soiled brief for a resident without wearing a gown, despite the resident being on Enhanced Barrier Precautions (EBP) due to the presence of wounds. The CNA acknowledged the requirement to wear a gown to prevent the spread of germs and diseases, which was confirmed by the Infection Preventionist, who emphasized the importance of EBPs in preventing the spread of multi-drug resistant organisms (MDROs). Resident 97's enteral feeding pump and pole were found with multiple brown crusted spots, indicating they were very soiled. A Licensed Nurse confirmed the pump's condition and acknowledged that a dirty pump increases the risk of infection by potentially contaminating the tube feeding formula or lines. The facility's policy on infection prevention and control emphasizes maintaining a clean and sanitary environment, which was not adhered to in this instance. Additionally, Resident 79's CPAP nasal mask was observed with residue and discoloration, and the resident reported never seeing staff clean the mask. Licensed Nurses confirmed the mask was not cleaned as ordered, which could lead to respiratory infection or bacterial growth. Similarly, Resident 13's BiPAP mask was found hazy with condensation and had not been cleaned for weeks, as confirmed by the resident and a Licensed Nurse. The facility's policy requires daily cleaning of CPAP/BiPAP equipment, which was not followed, and there was no documentation of cleaning in the resident's records until after the surveyor's observation.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect a resident from abuse when another resident inappropriately touched her breast. Resident 14, who has cerebral infarction and aphasia, was admitted to the facility in October 2024. Resident 93, who has multiple sclerosis and cognitive intactness, was admitted in August 2022 and has a history of inappropriate behavior towards female residents. Despite this history, Resident 93 was moved to a wing with less staff monitoring, which led to the incident where he allegedly touched Resident 14's breast in the lobby. The incident was reported by a speech therapist after being informed by Resident 14's family member. Resident 14, who uses an electronic device for communication, identified Resident 93 as the perpetrator. Interviews with staff, including the Social Services Director, revealed that Resident 93's care plans, which required monitoring and not leaving him alone with female residents, were not followed. The facility's policy on abuse prevention was not effectively implemented, leading to this deficiency.
Failure to Treat Residents with Dignity
Penalty
Summary
The facility failed to treat residents with dignity and respect by referring to those who required assistance with eating as 'feeders.' This was observed during interviews with staff members, including a Licensed Nurse (LN 3) and a Certified Nursing Assistant (CNA 9), who used the term 'feeders' to describe residents needing help with meals. The Director of Nursing (DON) later clarified that the expectation was to refer to these residents as 'assisted diners.' The facility's policies on Assistance with Meals and Resident Rights emphasized the importance of treating residents with dignity and avoiding labels such as 'feeders.'
Failure to Maintain Homelike Environment for Resident
Penalty
Summary
The facility failed to provide a homelike environment for Resident 106, as evidenced by a large hole in the wall at the head of the resident's bed. This deficiency was identified during an observation and interview conducted on November 5, 2024, where Resident 106 confirmed that the wall had been in disrepair since his admission. The resident's medical history includes a stroke and depression, conditions that could be exacerbated by an unwelcoming environment. Licensed Nurse 6 verified the presence of the hole and acknowledged that it should be repaired to maintain a suitable environment for the resident. The Maintenance Supervisor indicated that maintenance concerns are documented in a binder and addressed promptly, emphasizing the importance of a comfortable and homelike setting for residents. However, a review of the Maintenance Log from July 9, 2024, to November 7, 2024, revealed only one request to repair the wall, submitted on July 25, 2024, with no subsequent follow-up requests. The facility's policy on providing a homelike environment, dated February 2021, underscores the importance of maintaining a clean and sanitary setting, which was not upheld in this instance.
Failure to Document and Notify Physician of Low Blood Glucose Levels
Penalty
Summary
The facility failed to ensure that a resident with Type 2 Diabetes Mellitus received treatment and care in accordance with professional standards of practice. The licensed staff did not accurately document the blood glucose (BG) readings and failed to notify the physician of BG readings below 100 as ordered. This issue persisted for a total of nine days, during which the resident's care could have been compromised due to the lack of necessary medication adjustments. The resident was cognitively intact, and the physician's order specifically required holding medication and notifying the physician if the BG was below 100. Interviews and record reviews revealed that the licensed nurse confirmed a documentation error in the medication administration records (MAR), where a BG reading was incorrectly recorded as 29 instead of 129. Additionally, there was no documentation to indicate that the physician was notified of BG readings below 100 on multiple occasions. The Director of Nursing confirmed the lack of documentation and emphasized the expectation for staff to follow physician orders and document accurately. The facility's policy and procedure on charting and documentation required complete and accurate records, including notifying the physician when indicated.
Failure to Assist Resident with Meal Positioning
Penalty
Summary
The facility failed to promote and maintain the ability to perform Activities of Daily Living (ADLs) for a resident, identified as Resident 348, who was not assisted to his wheelchair prior to meals. Resident 348 was admitted with diagnoses including muscle weakness, lack of coordination, and unsteadiness on feet, but had no cognitive impairment. Physician orders indicated that Resident 348 should be up in a chair or wheelchair for all meals and 30 minutes after meals to prevent pneumonia. However, during an observation, Resident 348 was found sitting in bed with his breakfast tray, expressing difficulty in eating due to his position. A Certified Nursing Assistant (CNA) confirmed that the resident was not in his wheelchair. Further interviews revealed that a Licensed Nurse acknowledged the resident's recent weight loss and the potential impact of meal positioning on food intake. The Director of Rehabilitation stated that repositioning was a CNA task, and they should assist Resident 348 to his wheelchair. The Registered Dietitian also indicated that not assisting the resident to his wheelchair could affect his food intake. The facility's policy on ADLs emphasized providing appropriate care to maintain or improve residents' ability to carry out ADLs, including mobility and dining, but this was not adhered to in Resident 348's case.
Failure to Coordinate Care for Resident's Tongue Ulcer
Penalty
Summary
The facility failed to ensure proper coordination of care for a resident with an ulcer on the tongue. The resident, who was receiving palliative and hospice care, had a care plan for an open area on the tongue and was previously treated with clobetasol cream. However, the treatment was discontinued, and the ulcer persisted. Despite the resident's complaints of pain and requests for a physician's evaluation, there was no documented evidence that the physician or hospice was notified about the ulcer from late October to early November. Observations and interviews revealed that the resident was alert and oriented, and had communicated the issue to staff, who failed to follow up appropriately. The Director of Nursing confirmed that the expectation was for the licensed nurse to notify the physician and hospice, but this did not occur. The lack of communication and follow-up increased the potential for the resident to experience pain and discomfort due to the unaddressed ulcer.
Inconsistent Documentation and Implementation of Splint Orders
Penalty
Summary
The facility failed to ensure clear and consistent documentation and implementation of orders and care plans for the use of a left hand splint for a resident with hemiplegia and hemiparesis due to a stroke. The resident, who was severely cognitively impaired, had conflicting orders regarding the duration the splint should be worn. One order indicated the splint should be worn for 7 hours a day, while another order specified 4-5 hours twice a day. This inconsistency was not addressed, leading to potential misuse of the splint. Observations and interviews revealed that the splint was applied daily, but the duration was not documented. The resident's family member noted the splint was only occasionally seen on the resident, and the CNA responsible for applying the splint was unsure of the exact duration it should be worn. The Director of Nursing and the Director of Staff Development acknowledged the conflicting orders and the lack of documentation regarding the splint's application duration. The Restorative Nurse Assistants (RNAs) were following the care plan, which indicated a 7-hour application, but were unaware of the updated order for a shorter duration. The facility's policies on resident mobility and restorative nursing services emphasized the need for individualized care plans and documentation of progress, but these were not effectively implemented in this case, leading to a deficiency in care for the resident.
Failure to Document Daily Glucometer Calibration
Penalty
Summary
The facility failed to document the calibration of glucometers, which are essential for measuring blood sugar levels accurately. Specifically, the Quality Control Record for two glucose machines on Unit C showed only six entries for the entire month of September 2024, indicating a lack of daily calibration checks. This was confirmed during interviews with a Licensed Nurse, the Infection Preventionist, and the Assistant Director of Nursing, all of whom acknowledged the missing entries and the importance of daily checks to ensure accurate blood glucose readings. The facility's policy requires that glucometer calibration be completed daily by the night shift nurse, with logs monitored monthly by the Director of Nursing or the Unit Manager for accuracy and compliance. However, the absence of documentation raised concerns about whether the checks were performed properly, potentially leading to inaccurate blood glucose management for residents. The staff interviewed emphasized the necessity of these checks to ensure the machines function correctly and provide reliable readings.
Unnecessary Use of Psychotropic Medications for Two Residents
Penalty
Summary
The facility failed to ensure that two residents, Resident 18 and Resident 117, were free from unnecessary psychotropic medications. Resident 18 was prescribed Seroquel for a disturbed thought process related to dementia, despite having no documented episodes of psychosis or aggressive behavior. Observations and interviews revealed that Resident 18 was calm, non-aggressive, and did not exhibit behaviors warranting the use of antipsychotic medication. The care plan included non-pharmacological interventions, but these were not documented in the Medication Administration Record (MAR) for the relevant months. Resident 117 was admitted with a diagnosis of dementia without behavioral disturbance and was initially prescribed Seroquel as needed for disturbed thought processes. The prescription was later changed to a routine dose at bedtime for inability to sleep. Despite this, there were no documented episodes of aggressiveness or behaviors that justified the use of Seroquel. Observations and interviews indicated that Resident 117 was nonverbal, communicated through body language, and was not combative when redirected. The facility's policy required that antipsychotic medications be used only when necessary to treat specific conditions and after non-pharmacological approaches had been attempted. The facility's policy and the nationally recognized drug reference, DailyMed, indicated that Seroquel is not approved for the treatment of dementia-related psychosis. The Pharmacy Consultant recommended reviewing the diagnosis and indication for the use of Seroquel, as the current justification was not specific enough. The facility's failure to adhere to its policy and the lack of documented non-pharmacological interventions contributed to the unnecessary use of psychotropic medications for both residents.
Expired Medications Found in Medication Cart
Penalty
Summary
The facility failed to adhere to its medication storage policy by not removing expired medications from a medication cart. During an observation and interview, a licensed nurse identified an expired bottle of glucose tablets and an inhaler that had been opened beyond its recommended use date. The nurse confirmed that these medications were expired and acknowledged that medications could lose effectiveness if used past their expiration or manufacturer's use-by date. The Director of Nursing and a Nurse Consultant confirmed that inhalers should be dated when opened and that expired medications should not be present in the medication cart. The facility's policy and procedure on medication storage, dated November 2020, stated that discontinued, outdated, or deteriorated drugs should be returned to the dispensing pharmacy or destroyed. However, the presence of expired medications in the cart indicated a failure to implement this policy, potentially compromising the safety and potency of medications administered to residents.
Inaccurate Medical Record Documentation for a Resident
Penalty
Summary
The facility failed to ensure the accuracy of medical records for one resident, identified as Resident 49, which could potentially lead to inappropriate care. Resident 49 was admitted with diagnoses including an infection following a procedure and sepsis. A review of the admission nursing note dated November 5, 2024, indicated that Resident 49 had a PICC line in the right upper arm and a surgical site with staples on the right hip. However, during an observation on November 6, 2024, it was noted that Resident 49 did not have a PICC line in either arm. Further interviews and record reviews revealed discrepancies in the documentation. Licensed Nurse 2 confirmed that the admission note inaccurately reflected Resident 49's current status, as the PICC line was not present. Additionally, Licensed Nurse 3 stated that the resident's hip incision was open to air and did not have staples, and the coccyx wound had resolved, contradicting the information in the admission note. The Director of Nursing acknowledged that the notes were expected to be accurate and that inaccurate documentation could mislead staff in providing care. The facility's policy on charting and documentation emphasized the need for complete and accurate records.
QAPI Committee Lacks Medical Director Attendance
Penalty
Summary
The facility failed to ensure that the Quality Assurance and Performance Improvement (QAPI) Committee met with the required members, specifically the Medical Director (MED), for a census of 134 residents. A review of the facility's QAPI monthly meeting sign-in sheets from November 2023 to October 2024 revealed that the MED or their designee were not present during these meetings. During an interview, the Director of Nursing (DON) confirmed that the MED did not attend the QAPI meeting in October 2024 or the last QAPI quarter meeting. The Administrator (ADM) acknowledged the importance of the MED's attendance to guide healthcare decisions in the facility. The facility's policy and procedure indicated that the Medical Director is a required member of the committee.
Unsafe Environment Due to Loose Plate in Hallway
Penalty
Summary
The facility failed to provide a safe environment for residents, staff, and the public due to a maintenance issue in the D wing hallway. A loose round plate, approximately 6 inches in diameter, with a large bolt extending from it, was observed in the center of the floor. This condition was identified as a potential trip hazard for residents, which could lead to falls and injuries. During an observation and interview, a Licensed Nurse and a Maintenance Assistant both acknowledged the hazard. The Maintenance Assistant explained that the drain underneath the plate is used for cleaning out clogs in the pipes, and confirmed the need for repair. The facility's Policy and Procedure for Maintenance Service, revised in December 2009, requires the maintenance department to keep the building, grounds, and equipment safe and operable at all times, which was not adhered to in this instance.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate monitoring and supervision for a resident diagnosed with Alzheimer's disease, major depressive disorder, and age-related cataracts, who eloped from the facility. The resident, who was at high risk for elopement as indicated by a Wandering Risk Assessment score of 7, managed to exit the facility in a wheelchair through the front door. The alarm system was triggered, but staff did not respond promptly as the alarm was not heard in Station A, and there were no staff members present in the front office at the time. The resident was eventually found in the courtyard of a nearby apartment complex by a former employee who notified the facility. Interviews with staff revealed that the alarm was reset by a maintenance worker, and the staff assumed the resident exited through the front door. The Director of Nursing acknowledged that the staff did not meet expectations for monitoring residents at risk for elopement. Video surveillance confirmed that the resident exited the facility at 6:34 a.m., and staff followed at 6:55 a.m. The facility's policies on emergency procedures and wandering and elopements, which require monitoring of residents at risk, were not effectively implemented in this instance.
Failure to Notify Physician of Low Blood Glucose Levels
Penalty
Summary
The facility failed to notify a resident's physician when the resident's blood glucose levels fell below the ordered threshold of 70 mg/dl. This deficiency was identified for one resident who was admitted with diagnoses including protein-calorie malnutrition, muscle weakness, and diabetes. The resident was cognitively intact and able to communicate effectively. The physician's orders required notification if the blood glucose levels were below 70 mg/dl or above 300 mg/dl. However, on multiple occasions, the resident's blood glucose levels were recorded below 70 mg/dl, yet there was no documentation indicating that the physician was notified as required. The Director of Nursing confirmed during an interview that the physician was not notified on the specified dates when the resident's blood glucose levels were below the threshold. The facility's policy on acute condition changes required nursing staff to collect pertinent details and contact the physician based on the urgency of the situation. Despite this policy, the necessary communication with the physician did not occur, potentially delaying medical care and treatment for the resident.
Inadequate Supervision Leads to Resident Altercation
Penalty
Summary
The facility failed to provide adequate supervision to ensure the safety of residents, resulting in an incident where one resident slapped another at the nurse's station. Resident 1, who has severe cognitive impairment due to Alzheimer's Disease, was involved in the altercation with Resident 2. Despite having a history of altercations with other residents, Resident 1's care plan did not reflect this history, nor did it include behavior monitoring interventions. The incident occurred when Resident 1 blocked Resident 2's path and demanded payment to pass, subsequently slapping Resident 2 on the face. The Certified Nursing Assistant (CNA) present at the scene was unaware of Resident 1's history of aggressive behavior, although she had previously experienced Resident 1 hitting her with a broom. The Licensed Nurse (LN) and the Social Service Director (SSD) confirmed that Resident 1 had a history of altercations, but this information was not included in the care plan, which could have helped staff anticipate and prevent such incidents. The Director of Nursing (DON) acknowledged that Resident 1 should have been monitored more closely due to her history of altercations. The facility's policies on care plans and resident-to-resident altercations emphasize the need for ongoing assessments and revisions to care plans as residents' conditions change. However, these policies were not effectively implemented, as evidenced by the lack of behavior monitoring and care plan updates for Resident 1.
Failure to Report Allegation of Abuse
Penalty
Summary
The facility failed to ensure an allegation of abuse was reported to the authorities as required by their abuse policy and regulations. A Licensed Nurse (LN 2) did not report an incident where Resident 1 alleged that Resident 2 touched her inappropriately. This incident was reported to LN 2 by Resident 1 and her daughter on 4/20/24, but LN 2 did not document or report the incident to the administrator or authorities. The incident was only reported on 4/24/24 when Resident 1 inquired about the status of the report, leading to a four-day delay in the investigation. This delay caused Resident 1 to feel fearful and unsafe in the facility, resulting in her staying in her room to avoid further incidents with Resident 2. Interviews with the Director of Nursing (DON), Director of Staff Development (DSD), and Assistant Director of Nursing (ADON) confirmed that LN 2 did not follow the facility's policy, which mandates that such incidents be reported within two hours. The facility's policy, revised in September 2022, clearly states that any suspicion of abuse must be reported immediately to the administrator and other officials as per state law. The failure to report the incident promptly and the lack of documentation by LN 2 were identified as significant deficiencies in the facility's handling of the abuse allegation.
Failure to Treat Resident with Dignity and Respect
Penalty
Summary
The facility failed to ensure that a resident was treated with dignity and respect when a Certified Nursing Assistant (CNA) did not honor the resident's wish to be changed later and instead proceeded with the care, resulting in the resident being accidentally hit on the face with a dirty diaper. The resident, who was cognitively intact but had speech impairment following a stroke, communicated the incident by writing on a clipboard and through gestures. The resident expressed feeling scared and upset, and the Social Service Director confirmed that the resident had never been combative before and was tearful for hours after the incident. The CNA involved stated that the resident was combative during the diaper change and accidentally hit herself with the dirty diaper. However, the Director of Nursing indicated that the CNA should have called for assistance when the resident became combative and crying. The facility's policies on resident rights and dignity were reviewed, indicating that residents should be treated with respect and dignity at all times, and demeaning practices are prohibited.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 599 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Sacramento
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Acc Care Center | 1.6 mi | ★★★★★ | 23 | 0 |
| Cedarwood Post Acute | 2.1 mi | ★★★★★ | 0 | 0 |
| Capital Post Acute | 3.3 mi | ★★★★★ | 28 | 0 |
| Double Tree Post Acute Care Center | 3.5 mi | ★★★★★ | 22 | 0 |
| River Bend Nursing Center | 4.9 mi | ★★★★★ | 31 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release June 2026) and official state health department websites.