Above average — CMS composite of the measures below.
The next survey window likely opens around January 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 Harvard Creek Post Acute during CMS and state inspections, most recent first.
A resident with pneumonia, type 2 DM, dysphagia, and severe cognitive impairment experienced a fever, after which the NP ordered monitoring of vital signs. The DON stated that following such a change in condition, staff should obtain vital signs every 2–4 hours. An LVN reported checking the resident's vital signs multiple times during the subsequent night shift but did not document them because they were within normal limits. Review of records showed no documented vital signs after the change in condition, despite facility policies requiring monitoring and documentation of objective observations, changes in condition, and responses to treatment.
Failure to develop individualized care plans for two residents was identified. One resident had UTI, bronchitis, impaired cognition, and extensive assistance needs, but no specific CP addressed the infection or respiratory issues. Another resident had liver carcinoma, pancreatic malignancy, heart failure, major depressive disorder, impaired cognition, and a Remeron order for depression, but no resident-specific CP was initiated for the depression treatment. The DON and MDS nurse stated the CPs should have been comprehensive, specific, and resident centered.
Kitchen Handwashing Sink Not Draining. The kitchen handwashing sink was observed half-full of soapy, dirty water, and the DS stated it was draining slowly and may be clogged. The facility's Plumbing Policy states that kitchen sinks and drains are checked weekly, enzymatic solutions are used monthly to prevent buildup, and staff are trained to report clogged or slow-draining sinks immediately.
Failure to obtain informed consent for a psychotropic medication: A resident with liver carcinoma, pancreatic malignancy, heart failure, and moderately impaired cognition was ordered an increased dose of Remeron for depression, but the chart lacked written informed consent from the resident or RP. During record review, the ADON confirmed consent had not been obtained or updated for the new dose and target behavior, despite facility policy requiring documented informed consent before administration and a new consent for dosage increases.
A resident with metabolic encephalopathy, anxiety disorder, and severely impaired cognition had a PRN lorazepam order written for 30 days. The OSR did not show documentation of the physician’s rationale for the extended duration, and the ADON and DON stated PRN psychotropic meds were limited to 14 days unless the prescriber documented the reason and duration in the record.
Failure to Complete Quarterly MDS Assessment: A resident admitted with PVD, DM, and protein-calorie malnutrition did not have the required quarterly MDS completed after the initial comprehensive assessment. The MDS Nurse confirmed the quarterly assessment was not done within the required 3-month timeframe, and the facility policy states the MDS Coordinator is responsible for completing and submitting MDS assessments within required timeframes.
MDS Did Not Accurately Document Dialysis Treatment: A resident with ESRD, heart failure, and dependence on dialysis had care plan, H&P, and order records showing ongoing HD, but the MDS failed to indicate the dialysis treatment. The MDS nurse confirmed the resident was receiving dialysis and acknowledged the assessment submitted to CMS was not accurate, while the DON stated the MDS must be submitted accurately to reflect the resident’s current needs.
Care Plan Not Updated for Current Fluid Restriction: A resident with HF, ESRD, and HD had an active order for a 1,000 ml fluid restriction, but the care plan still listed a 1,500 ml restriction. An LVN confirmed the current restriction, and the ADON and DON stated the plan had not been updated to match the resident’s current order and condition.
A resident with a suprapubic catheter and history of UTI was observed in bed with the drainage bag touching the floor. The IPN and ADON stated the bag should be kept off the floor because of cross contamination and bacteria transfer, and the facility’s catheter care policy required catheter tubing and drainage bags to be kept off the floor to prevent CAUTI.
Failure to Provide Ordered Continuous Oxygen Therapy: A resident with COPD and dependence on supplemental O2 had an order for continuous 2 LPM via NC, but during observation the NC prongs were not in the resident’s nares while the concentrator was still running. The IPN and ADON both confirmed the resident should have been receiving oxygen continuously as ordered, and the facility’s Oxygen Administration policy required staff to verify and follow the physician’s order.
A resident with ESRD and dependence on HD had an order to remove the dressing over the left upper arm AV access 4-6 hours after dialysis. Records showed the resident returned from HD with the dressing intact, staff endorsed removal to the next shift, and the dressing was still in place the next morning. The LVN confirmed the order and the DON stated the dressing should be removed as ordered to prevent infection and blood clotting at the site.
Resident not properly identified before medication administration. A resident with dysphagia and HTN, who had intact cognition and could understand and make decisions, was observed receiving meds without the nurse checking any resident identifier first. The resident did not have an ID band on both arms, and the LPN administered meds after greeting the resident by first name, checking vital signs, and discussing symptoms without verifying identity using the ID band, MAR photo, DOB, or another identifier as described by facility staff and policy.
Failure to Use Required PPE During EBP Catheter Care: A resident with an indwelling suprapubic catheter was placed on EBP due to MDRO risk, and the care plan directed staff to use proper PPE during high-contact care. During observation, the IPN assessed the catheter bag and tubing without wearing a gown. The IPN stated a gown was not needed, while the ADON and DON stated staff needed to wear gown and gloves when touching the resident’s medical device, consistent with the facility’s EBP policy.
Failure to Post Nurse Staffing Information in a Readily Accessible Location: The facility failed to ensure the Nurse Staffing Sheet, showing current resident census and nursing hours, was posted in a prominent location accessible to residents and visitors. Surveyors observed the sheet only on an enclosed bulletin board across from Nursing Station 2, and the DSD and DON stated it was not posted in common areas where it could be readily viewed by residents, family, and staff. The facility policy required the staffing numbers to be posted in a prominent, accessible, clear, and readable format.
Insufficient Resident Room Square Footage: The facility failed to provide the required square footage per resident in 18 of 24 rooms, including multiple double- and quadruple-occupancy rooms. The ADM said the facility wanted to request a room waiver and confirmed the bed occupancy had not changed. Surveyors observed that the rooms had enough space for resident movement and for use of wheelchairs, walkers, and Hoyer lifts, and a resident, a CNA, and an LVN all stated there was adequate space for care and treatment.
A resident with hemiplegia and severe cognitive impairment did not receive passive range of motion (PROM) exercises to the left arm as required by the care plan and facility policy. Staff provided PROM to other limbs but omitted the left arm, resulting in pain and joint stiffness when PROM was eventually performed, indicating a decline in range of motion.
A resident with severe cognitive and physical impairments repeatedly crawled on the floor, a behavior observed by staff and another resident. Despite this, the care plan did not include interventions or goals to address the crawling, focusing only on general fall precautions. Staff confirmed the behavior was frequent, and the DON acknowledged the care plan should have been updated to include it.
A resident with a history of falls, confusion, and impaired mobility was not assessed for injury when found crawling on floor mats, and their care plan was not updated to address repeated crawling behavior. Staff, including a CNA and the DON, confirmed the resident frequently crawled on the floor and into the hallway, but this was not reflected in the care plan. An LVN also failed to document a wander guard device trial in the medical record, contrary to facility policy. These failures placed the resident at risk for harm.
A nurse did not document a wander guard trial for a resident with severe cognitive impairment and high fall risk, despite facility policy requiring such documentation. The omission led to incomplete medical records and risked miscommunication among the care team regarding the resident's condition and interventions.
A resident with acute respiratory failure and end-stage renal disease experienced diarrhea, prompting a physician's order for a stool sample to test for C. difficile. The facility failed to collect the sample, potentially delaying care. Interviews with the ADON and DON highlighted the importance of following physician orders, which was not done in this case.
The facility failed to ensure call lights were within reach for three residents, all of whom had severe cognitive impairments and were at high risk for falls. Observations revealed that the call lights were positioned out of reach, contrary to the facility's policy and care plans. Staff confirmed the inaccessibility and the importance of having call lights within reach for residents to request assistance.
The facility failed to follow its policy on the use of side rails for three residents, leading to deficiencies in care. A resident with a history of falls did not have alternative interventions attempted or informed consent obtained before bed rail installation. Another resident with severe cognitive impairment had side rails installed without documentation of alternative measures. A third resident, with intact cognition, had side rails installed without understanding their purpose, and no alternative interventions were documented.
The facility failed to label and date food items when opened, as observed in a refrigerator containing unlabeled tortillas. The Lead Cook and Dietary Supervisor confirmed the requirement for labeling to track food lifespan, as per the facility's policy.
A facility failed to obtain informed consent from a resident before administering an increased dosage of Mirtazapine, a psychoactive medication. The resident, who had the capacity to understand and make decisions, did not sign or date the consent form for the medication increase. The facility's policy required informed consent before administering or increasing the dosage of psychotropic medications, which was not followed in this case.
A resident with surgical aftercare and chronic kidney disease was inaccurately recorded in the MDS as discharged to an acute hospital, despite being discharged home with home health services. The MDS Coordinator admitted the error, and the DON highlighted the importance of accurate documentation for CMS reporting.
A resident with Parkinson's disease and dementia, assessed as high risk for falls, did not have bilateral landing mats properly positioned as ordered. The mats were intended to minimize injury in case of a fall, but one was found placed a foot away from the bed. Interviews with the ADON and DON confirmed the mats should be closer to the bed, as per the facility's fall risk policy.
A resident with respiratory failure was observed receiving five liters of oxygen per minute instead of the prescribed two liters. The facility staff failed to document the resident's oxygen usage as required, and the licensed nurse did not monitor the oxygen levels to ensure compliance with the physician's order. The facility's policy for oxygen administration was not followed, resulting in a deficiency.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident undergoing hemodialysis with a permacatheter, despite the facility's policy requiring EBP for residents with indwelling medical devices. The resident, with end-stage renal disease and other conditions, was not placed on EBP, which was confirmed by the ADON and acknowledged by the DON. This oversight had the potential to expose the resident to infection.
The facility did not meet the required 80 square feet per resident in multiple resident rooms for 18 out of 24 rooms. Despite this, staff reported being able to provide care without difficulty. A room waiver request was submitted, indicating compliance with care and privacy standards.
Failure to Monitor and Document Vital Signs After Change in Condition
Penalty
Summary
Facility nurses failed to provide treatment and care in accordance with professional standards of practice when they did not monitor and document a resident's vital signs after a documented change in condition. The resident was admitted with pneumonia, type 2 diabetes mellitus, and dysphagia, and had severe cognitive impairment and dependence on staff for most activities of daily living. On 2/28/2026 at 6:21 PM, the resident had an elevated temperature of 100.2°F, and the nurse practitioner was contacted. The SBAR form and progress note indicated that the nurse practitioner ordered monitoring of the resident's vital signs following this elevated temperature. The DON stated that nurses normally monitor residents' vital signs once a day, but when instructed to monitor vital signs after a change in condition, staff should check them every 2–4 hours. The nurse practitioner confirmed that orders included monitoring vital signs. An LVN reported checking the resident's vital signs 2–3 times during the night shift following the fever but acknowledged not documenting them because they were within normal limits. The DON stated that if vital signs were not documented, then staff did not monitor them. Review of facility policies on acute condition changes and charting/documentation showed that staff were required to monitor and document the resident's progress, responses to treatment, and any changes in condition, including objective observations and services performed.
Failure to Develop Resident-Centered Care Plans for Medical and Psychosocial Needs
Penalty
Summary
The facility failed to develop and implement individualized and resident-centered care plans for two residents. For Resident 26, the admission record showed diagnoses including UTI and bronchitis, and the H&P indicated the resident lacked capacity to understand and make decisions. The MDS dated 1/23/2026 showed moderately impaired cognition, supervision needed for eating, maximal assistance needed for oral hygiene, and dependence for toileting hygiene, showering/bathing, and bed-to-chair transfers. During a concurrent record review and interview with MDS Nurse 1, all of Resident 26's care plans were reviewed and there were no specific care plans addressing the resident's UTI or bronchitis. MDS Nurse 1 stated the licensed nurse should have developed care plans for these conditions and that they should have been specific and resident centered, including monitoring for signs and symptoms of recurrent infection and respiratory issues. The DON stated the care plan should have been comprehensive, completed within two weeks of admission, and adjusted with each medical diagnosis and medication. For Resident 53, the admission record showed diagnoses including liver carcinoma, malignant neoplasm of the pancreas, and heart failure. The Initial Psychiatric Evaluation identified major depressive disorder, and the MDS showed moderately impaired cognition with dependence or need for assistance in several activities of daily living. A physician order dated 12/5/2025 increased Remeron 22.5 mg at bedtime for depression manifested by self-report of sadness. During interview and record review, the ADON stated there was no care plan initiated and implemented for the management of Resident 53's depression and use of Remeron, and the DON stated a resident-specific and resident-centered care plan should have been initiated and implemented for that depression treatment.
Kitchen Handwashing Sink Not Draining
Penalty
Summary
The facility failed to ensure the kitchen handwashing sink was draining. During an observation on 2/10/2026 at 8:59 AM in the kitchen, the handwashing sink was half-full of soapy, dirty water. During an interview on 2/10/2026 at 9:00 AM, the Dietary Supervisor stated the sink drains slow and could be clogged, and said the sink should be draining smoothly or it might overflow and contaminate the surrounding kitchen area. A review of the facility's Plumbing Policy, updated 1/8/2026, showed that Environmental Services performs weekly checks of all kitchen sinks and drains, maintenance staff uses enzymatic solutions monthly to prevent buildup, and staff are trained to report clogged or slow-draining sinks immediately.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain written informed consent for the use of Remeron, a psychotropic medication, for one sampled resident. Resident 53 was admitted with diagnoses including liver carcinoma, malignant neoplasm of the pancreas, and heart failure. The resident’s MDS dated 10/9/2025 indicated moderately impaired cognition and dependence or need for assistance with several activities of daily living, including bathing, dressing, footwear, oral hygiene, and personal hygiene. A physician order dated 12/5/2025 directed an increase in Remeron to 22.5 mg by mouth at bedtime for depression manifested by self-report of sadness. During interview and record review on 2/11/2026, the ADON stated informed consent had not been obtained from Resident 53 or the resident’s RP before administration of Remeron 22.5 mg. The ADON stated consent should have been updated for the new dosage and target behavior, and that the physician should have obtained informed consent and the licensed nurse should have verified it. The facility policy stated that informed consent must be documented in the resident’s record before administering psychotropic medication and that an increase in dosage requires a new informed consent.
PRN Lorazepam Order Exceeded 14-Day Limit
Penalty
Summary
The facility failed to ensure that a PRN lorazepam order for one resident was limited to a 14-day duration. Resident 5 was admitted and later readmitted with diagnoses including metabolic encephalopathy and anxiety disorder. The resident’s care plan for anti-anxiety medication, revised on 1/25/2026, stated the goal was for the resident to be free from discomfort or adverse reactions related to anti-anxiety therapy. The resident’s H&P dated 1/28/2026 stated the resident did not have the capacity to understand and make decisions, and the MDS dated 1/28/2026 showed severely impaired cognition and dependence on staff for multiple activities of daily living. The OSR showed an active physician order dated 2/4/2026 for lorazepam every six hours PRN for anxiety for 30 days. During record review and interviews, the ADON stated there were no documentations showing the physician’s rationale for the 30-day PRN lorazepam order and stated it was standard practice for PRN psychotropic medication orders to be limited to 14 days. The ADON also stated staff should have clarified the order with the physician and documented it in the progress notes. The DON reviewed the facility’s Psychotropic Drug policy and stated PRN psychotropic medications were limited to 14 days unless the prescribing physician documented the rationale and duration in the resident’s medical record.
Failure to Complete Quarterly MDS Assessment
Penalty
Summary
The facility failed to complete the quarterly MDS for Resident 41. Resident 41 was admitted with diagnoses including peripheral vascular disease, diabetes mellitus, and protein-calorie malnutrition. The resident’s H&P dated 11/28/2025 indicated multiple medical problems and that the resident had the capacity to understand and make decisions. The resident’s initial comprehensive MDS assessment was completed on 10/8/2025. A review of the resident’s MDS assessments showed that a quarterly assessment was not completed by January 2026. During interview on 02/11/2026 at 11:12 AM, the MDS Nurse stated the quarterly assessment was not completed three months after the initial comprehensive assessment and explained that MDS quarterly assessments must be completed every three months or when there is a change of condition to assess the resident’s overall physical function and needs. The facility policy titled, MDS Completion and Submission Timeframes, dated July 2017, stated the MDS Coordinator is responsible for completing and submitting MDS assessments in accordance with federal and state submission timeframes.
MDS Did Not Accurately Document Dialysis Treatment
Penalty
Summary
The facility failed to ensure that Resident 43’s MDS dated 12/24/2025 accurately documented the resident’s dialysis treatment. Resident 43’s admission record showed diagnoses including heart failure, ESRD, and dependence on dialysis. The care plan revised on 7/24/2025 identified a need for hemodialysis related to ESRD, and the H&P dated 7/26/2025 stated the resident was receiving HD three times a week. The OSR dated 1/31/2026 listed active orders for HD on Mondays, Wednesdays, and Fridays, with extra dialysis on Saturdays. During interviews, LVN 1 stated Resident 43 had been receiving dialysis since admission, and Resident 43 stated the resident was receiving dialysis treatments. The MDS Nurse stated the resident was receiving dialysis but that it was not indicated on the MDS assessment dated 12/24/2025. The MDS Nurse also stated the MDS was submitted to CMS and was a reference of the resident’s current needs that needed to be accurate. The DON stated the MDS needed to be submitted accurately to CMS to allow the facility to provide the correct care to residents. The facility policy required the RN coordinating the MDS to complete and certify the assessment, and the CMS RAI Manual stated the assessment must accurately reflect the resident’s status.
Care Plan Not Updated for Current Fluid Restriction
Penalty
Summary
The facility failed to ensure Resident 43’s care plan was revised to reflect a current fluid restriction of 1,000 ml over 24 hours. Resident 43 was admitted with diagnoses including heart failure, ESRD, and dependence on dialysis. The care plan revised on 7/24/2025 identified the resident as having dehydration or potential for fluid deficit related to ESRD, hemodialysis, and a 1,500 ml fluid restriction, but the order summary later showed an active order for a 1,000 ml fluid restriction ordered on 12/30/2025. During interview and record review, LVN 1 confirmed the resident was receiving dialysis and had a current 1,000 ml daily fluid restriction, but the care plan still reflected the older 1,500 ml restriction. The ADON stated the care plan was not updated from the previous order and should have been revised to match the current order. The DON stated care plans should be updated when there is a change in the resident, with new orders, quarterly, and annually, and the facility policy stated care plans are revised as resident information and conditions change.
Suprapubic Catheter Bag Left Touching the Floor
Penalty
Summary
The facility failed to ensure that a resident’s suprapubic catheter drainage bag was kept off the floor. Resident 1 was admitted with diagnoses including UTI, fitting and adjustment of urinary device, and neuromuscular dysfunction of the bladder. The resident’s record also showed a suprapubic catheter order for bedside drainage and that the resident had intact cognition and was dependent on staff for oral hygiene, toileting, bathing, dressing, and personal hygiene. During an observation with the Infection Prevention Nurse, Resident 1 was lying in bed and the suprapubic catheter bag was touching the floor. The IPN stated the bag should not touch the floor because it could cause cross contamination and lead to UTI. The ADON later stated the catheter bag should not be touching the floor because the floor was dirty and bacteria could travel from the floor to the bag and could lead to UTI. The facility policy on urinary catheter care stated that catheter tubing and drainage bags should be kept off the floor to prevent catheter-associated urinary tract infections.
Failure to Provide Ordered Continuous Oxygen Therapy
Penalty
Summary
The facility failed to administer continuous oxygen therapy for one sampled resident with COPD and dependence on supplemental oxygen. The resident was admitted with an order dated 1/7/2026 for 2 L/min of oxygen via nasal cannula continuously every shift, and the care plan identified the resident as being at risk for respiratory distress related to shortness of breath and irregular respirations. The resident’s history and physical indicated the resident had the capacity to understand and make medical decisions, and the MDS showed intact cognition with assistance needs for several activities of daily living. During an observation on 2/10/2026 at 9:47 a.m., the resident was asleep in bed with oxygen flowing at 2 LPM via concentrator, but the nasal cannula tubing was hanging on the side of the bed and the prongs were not in the resident’s nares. During a concurrent observation and interview, the IPN stated the nasal cannula was on top of the bed and the concentrator was running at 2 LPM, and stated the cannula should be placed inside the bag if not in use and the concentrator should be turned off if not in use. During a later interview and record review, the ADON confirmed the resident had an order for continuous 2 LPM oxygen via nasal cannula and stated the resident should have been on continuous oxygen at all times as ordered. The facility policy on Oxygen Administration directed staff to verify a physician order and review the physician’s orders or facility protocol for oxygen administration.
HD Access Dressing Not Removed as Ordered
Penalty
Summary
The facility failed to ensure hemodialysis access dressing was removed as ordered for Resident 43, who had diagnoses including ESRD, dependence on renal hemodialysis, and CHF. The resident’s order summary required hemodialysis on Mondays, Wednesdays, Fridays, and extra dialysis on Saturdays, and also directed staff to remove the dialysis dressing to the left upper arm 4-6 hours after dialysis treatment. The resident’s MDS indicated moderately impaired cognition and varying levels of independence with activities of daily living. Records showed the resident returned from dialysis with an intact dressing on the left upper arm, and a nurse documented that the next shift was endorsed to remove the dressing. During observation the following morning, the resident was still sitting in bed with gauze taped around the left upper arm AV shunt site. The LVN confirmed the dressing should have been removed 4-6 hours after dialysis and stated it remained in place the next morning. The DON stated HD device dressing should be removed as ordered to prevent infection and blood clot to the site clogging the device, and the facility policy stated the goals of care were preventing infection and maintaining patency of the catheter.
Resident not properly identified before medication administration
Penalty
Summary
The facility failed to ensure that one sampled resident was properly identified during medication administration. Resident 19 was admitted with diagnoses including dysphagia and hypertension, and records showed the resident had the capacity to understand and make decisions, with intact cognition noted on the MDS. During a medication administration observation in the resident’s room, Resident 19 was lying in bed and did not have an ID band on both arms. The LVN greeted the resident by first name, checked blood pressure and pulse, and then returned with medications, raised the head of the bed, asked about bowel movement and pain, and explained the medications being given without checking any resident identifier before administering them. During interviews, the LVN stated resident identification should include asking for the resident’s last name and DOB or cross-referencing the MAR photo, and that the ID band should be checked if the resident was alert. The ADON stated licensed nurses should use the resident’s ID band, MAR photo, and DOB as identifiers, and that if nurses failed to do this, they were not identifying the resident correctly. The DON stated that if the resident could speak, the nurse should check the name band and ask the resident to state the resident’s name, and if there was no ID band, the MAR photo should be used. The facility policy titled Administrating Medications stated the individual administering medications verified the resident’s identity before giving medications by checking the identification band, checking the photograph attached to the medical record, or verifying identification with other facility personnel.
Failure to Use Required PPE During EBP Catheter Care
Penalty
Summary
The facility failed to implement and follow infection prevention procedures for one resident who was on Enhanced Barrier Precautions (EBP) due to an indwelling suprapubic catheter. The resident was admitted with diagnoses including encounter for urinary tract infection, encounter for fitting and adjustment of urinary device, and neuromuscular dysfunction of the bladder. The resident’s record showed an order to place the resident on EBP to reduce the spread of MDRO because of the indwelling catheter, and the care plan directed nursing staff to observe proper donning and doffing of PPE during procedures and high-contact activities. During observation, the Infection Prevention Nurse assessed the resident’s suprapubic catheter bag and tubing without wearing a gown. In interview, the IPN stated a gown was not worn because the activity was not considered high contact and stated staff do not need to wear a gown when touching a foley catheter. The ADON stated staff needed to wear gown, gloves, and mask before touching the resident who was on EBP due to the indwelling device, and the DON stated staff needed to wear gloves and gown when touching medical devices. The facility’s Infection Control: Enhanced Barrier Precautions policy stated EBP includes targeted gown and glove use during high-contact resident care activities and is indicated for residents with indwelling medical devices, including urinary catheters, during device care or use.
Failure to Post Nurse Staffing Information in a Readily Accessible Location
Penalty
Summary
The facility failed to ensure that the Nurse Staffing Sheet, which contains the facility's current resident census and the total number and actual hours worked by licensed and unlicensed nursing staff, was posted in a prominent place readily accessible to residents and visitors. During observation on 2/11/2026 at 9:27 am, the Nurse Staffing Sheet was only posted on an enclosed bulletin board across from Nursing Station 2. During a concurrent observation and interview on 2/12/2026 at 1:10 pm, the Director of Staff Development stated there were no other postings within the facility, which did not allow the information to be readily accessible to all residents and visitors. The Director of Staff Development stated that posting the sheet where it was accessible allowed residents and visitors to determine if the facility had adequate staffing and ensured compliance with required nurse staffing hours. During an interview on 2/12/2026 at 3:37 pm, the Director of Nursing stated the Nurse Staffing Sheet should be displayed in common areas where visitors, family, and staff could view it. The facility policy titled, Posting Direct Care Daily Staffing Numbers, revised 7/2016, stated that within two hours of the beginning of each shift, the number of licensed nurses and unlicensed nursing personnel directly responsible for resident care would be posted in a prominent location accessible to residents and visitors in a clear and readable format.
Insufficient Resident Room Square Footage
Penalty
Summary
The facility failed to provide a minimum of 80 square feet per resident area in eighteen of twenty-four resident rooms, including Rooms 101, 103, 104, 105, 106, 107, 108, 109, 110, 111, 112, 114, 115, 116, 117, 118, 119, and 122. During the survey, the Administrator stated the facility wanted to request a room waiver for these rooms and confirmed that nothing had been changed in the number of bed occupancies in the 18 rooms. A review of the waiver request letter dated 2/10/2026 showed the facility stated there was ample room for wheelchairs and other medical equipment, as well as space for mobility and movement of ambulatory residents, and that there was adequate space for nursing care and resident health and safety was not in jeopardy. During the Health Recertification Survey, surveyors observed that the affected rooms had adequate space, nursing care, comfort, and privacy, and residents were able to move freely inside the rooms. The rooms were observed to have enough space for wheelchairs, walkers, and Hoyer lifts, and each resident had beds and bedside tables with drawers. In interviews, a resident stated there was enough space to move around with no concerns, a CNA stated there was enough space to provide resident care, and an LVN stated there was space to provide care and treatment and to move wheelchairs, Hoyer lifts, and walkers inside the rooms.
Failure to Provide PROM to Prevent Decline in Range of Motion
Penalty
Summary
The facility failed to provide appropriate treatment to prevent further decrease in range of motion (ROM) for a resident with a history of hemiplegia and hemiparesis following a cerebral infarction affecting the left side. The resident, who was severely cognitively impaired and dependent on staff for activities of daily living, was not given passive range of motion (PROM) exercises to the left arm as required by the care plan and the facility's policies. Record reviews and staff interviews confirmed that PROM was only provided to the resident's right arm, right leg, and left leg, omitting the left arm despite documented impaired mobility in the left shoulder. During an observation, when PROM was finally provided to the resident's left shoulder, the resident exhibited pain and joint stiffness, indicating a decline in ROM. The care plan specifically identified the risk for decline in ROM and included interventions for PROM to both arms and legs, but these interventions were not implemented for the left arm. The facility's own policies required that residents with limited ROM receive appropriate treatment to prevent further decline, which was not followed in this case.
Failure to Address Crawling Behavior in Resident Care Plan
Penalty
Summary
The facility failed to update and implement a comprehensive care plan that addressed all of a resident's needs, specifically omitting the resident's behavior of crawling on the floor. Despite multiple assessments and staff observations indicating that the resident had a history of confusion, impaired cognition, decreased coordination, and required extensive assistance with mobility and activities of daily living, the care plan only addressed general fall risk interventions such as floor mats and call light accessibility. The care plan did not include specific interventions or goals related to the resident's repeated behavior of crawling on the floor, which was observed and reported by both staff and another resident as occurring multiple times daily, including instances where the resident crawled into the hallway and attempted to pull himself up using hallway rails. Interviews with staff, including a CNA and LVN, confirmed that the resident frequently crawled out of bed and onto the floor, requiring staff assistance to return him to bed or his wheelchair. The DON acknowledged that the care plan should have been updated to reflect this behavior, in accordance with facility policy, but it was not. As a result, there were no nursing interventions in place to address the resident's crawling behavior, which was a significant omission given the resident's cognitive and physical impairments.
Failure to Implement Fall Risk Policy and Update Care Plan for Resident with Repeated Crawling Behavior
Penalty
Summary
The facility failed to implement its Falls and Fall Risk Management Policy and Procedure for one resident who was at high risk for falls due to a history of falls, confusion, impaired gait and balance, and use of antihypertensive medication. The resident's care plan included interventions such as providing bilateral floor mats, keeping the call light within reach, and maintaining a safe environment. However, staff did not assess the resident for injury whenever he was found crawling on the floor mats, as required by the care plan. Additionally, the resident's care plan was not updated to reflect his repeated behavior of crawling on the floor, despite multiple staff observations and reports from a roommate that the resident crawled out of bed and around the room several times a day. Staff, including a CNA and the DON, confirmed that the resident frequently crawled on the floor and sometimes into the hallway, but the care plan did not address this specific behavior. Furthermore, an LVN failed to document the use of a wander guard device trial in the resident's medical record, contrary to facility policy. The DON acknowledged that documentation and care plan updates were not completed as required, and that staff did not consistently follow procedures for monitoring and assisting the resident when found on the floor. These failures placed the resident at risk for harm and injury.
Failure to Document Wander Guard Trial for High-Risk Resident
Penalty
Summary
Licensed Vocational Nurse 1 (LVN 1) failed to document a wander guard trial for one resident in the medical record, as required by the facility's Charting and Documentation policy. The resident, who had a history of cerebral infarction, cognitive communication deficit, and was assessed as a high fall risk due to confusion, balance problems, and use of antihypertensive medication, was admitted with multiple care interventions in place to prevent falls. Despite these risks and the use of a wander guard device, LVN 1 did not record the trial in the resident's medical record during assigned shifts. This omission was confirmed during interviews with LVN 1 and the Director of Nursing (DON), both of whom acknowledged that documentation and staff endorsement of the wander guard trial should have occurred according to facility policy. The lack of documentation resulted in incomplete medical records for the resident and created a risk of miscommunication among the interdisciplinary team regarding the resident's condition and response to care.
Failure to Follow Physician's Order for Stool Sample Collection
Penalty
Summary
The facility failed to follow a physician's order to collect a stool sample for a resident, which had the potential to delay care and services. The resident, who was admitted with acute respiratory failure with hypoxia, end-stage renal disease, and dependence on renal dialysis, was experiencing signs and symptoms of diarrhea. A physician's order was issued for a stool sample to be collected to test for C. difficile, but this order was not completed by the facility staff. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) confirmed the importance of following physician orders to provide proper care and interventions. The facility's policy and procedure for stool specimen collection, which includes verifying physician orders and documenting the procedure, was not adhered to. This oversight was identified during a review of the resident's records and interviews with facility staff.
Call Lights Inaccessible to Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for three residents, leading to a deficiency in accommodating the needs and preferences of each resident. Resident 17, who had severe cognitive impairment and required assistance with daily activities, was found to have their call light positioned behind the headboard, making it inaccessible. This was confirmed during an observation and interview with the Activity Director, who acknowledged that the call light should be within easy reach to allow the resident to request help. Similarly, Resident 13, who had severe cognitive impairment and was assessed as high risk for falls, was observed with their call light clipped to the upper right side of the bed, out of reach. A Certified Nursing Assistant confirmed that the resident could not reach the call light and emphasized the importance of having it accessible for the resident to call for assistance. The resident's care plan also indicated the need for the call light to be within easy reach. Resident 35, who also had severe cognitive impairment and was at high risk for falls, was found with their call light hanging on top of the headboard, making it unreachable. The Assistant Director of Nursing confirmed the inaccessibility of the call light and reiterated the necessity for it to be within reach. The facility's policy on answering call lights also stated that call lights should be within easy reach when residents are in bed or confined to a chair.
Failure to Implement Bed Rail Policy for Three Residents
Penalty
Summary
The facility failed to implement its Policy and Procedure on the use of side rails for three residents, leading to deficiencies in care. For Resident 21, the facility did not ensure that appropriate alternative interventions were attempted before installing side rails. Additionally, there was no assessment for the risk of entrapment, nor was informed consent obtained prior to the installation of the bed rails. Resident 21 had a history of falls and was capable of giving informed consent, yet the necessary evaluations and consents were not documented. For Resident 33, the facility did not document any attempts at alternative interventions before the automatic installation of side rails upon readmission. Resident 33 had severely impaired cognition and was dependent on staff for various activities of daily living. Despite these conditions, the facility failed to follow its policy of attempting less restrictive measures before resorting to side rails. Similarly, for Resident 48, there was no documentation of alternative interventions being attempted before the installation of side rails. Resident 48, who had intact cognition, was not using the side rails and was unaware of their purpose. The facility's policy required an assessment of the resident's symptoms, risk of entrapment, and the reason for using side rails, along with obtaining consent after discussing potential benefits and risks, none of which were documented for Resident 48.
Failure to Label and Date Opened Food Items
Penalty
Summary
The facility failed to adhere to proper food handling practices by not labeling and dating food items when they were first opened, as observed in one of the facility's refrigerators. During an inspection, an unlabeled bag of tortillas and a 2-pound open bag of corn tortillas were found without any labels or dates indicating when they were opened. The Lead Cook acknowledged that the tortillas were not labeled or dated and stated that the staff responsible for opening food items should label them with the date opened to track their duration. The Dietary Supervisor confirmed that all food items should be labeled with the date opened to determine their use-by date and lifespan. The facility's Policy and Procedure on Labeling and Dating of Goods, dated 2020, requires newly opened food items to be closed and labeled with a delivery and open date, as well as a use-by date.
Failure to Obtain Informed Consent for Psychoactive Medication
Penalty
Summary
The facility failed to ensure that a resident was informed in advance about the risks and benefits of a psychoactive medication, specifically Mirtazapine, which was prescribed to treat depression. The resident, who had the capacity to understand and make decisions, was admitted with diagnoses including diabetes mellitus, anemia, and dysphagia. Despite having moderately impaired cognition, the resident was capable of making informed decisions. However, the informed consent for the increased dosage of Mirtazapine from 30 mg to 45 mg was neither signed nor dated by the resident, indicating a lack of informed consent. The facility's policy required that informed consent be obtained and documented before administering psychotropic medications or increasing their dosage. The Assistant Director of Nursing acknowledged that the resident should have consented prior to the medication use, emphasizing the importance of informed consent for psychotropic medications. The facility's failure to obtain and document informed consent before administering the increased dosage of Mirtazapine violated the resident's right to make an informed decision regarding their treatment.
Inaccurate MDS Discharge Coding for a Resident
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) accurately reflected the discharge status of a resident, identified as Resident 51. The resident was admitted with diagnoses including surgical aftercare following digestive system surgery and chronic kidney disease. According to the Physician's Order, the resident was scheduled to be discharged home with home health services, including nursing, physical therapy, occupational therapy, and mobility aids. However, the MDS inaccurately recorded the resident's discharge status as being transferred to an acute hospital. During a review of the Licensed Personnel Progress Notes, it was confirmed that the resident was discharged home in stable condition. The MDS Coordinator acknowledged the error, stating that the discharge status was incorrectly coded in the MDS. The Director of Nursing emphasized the importance of accurate assessments and documentation for proper reporting to the Centers for Medicare and Medicaid Services (CMS). The facility's policy on resident assessments requires the interdisciplinary team to conduct timely and appropriate assessments, which was not adhered to in this case.
Failure to Properly Position Fall Prevention Mats
Penalty
Summary
The facility failed to utilize bilateral landing mats as ordered for a resident with a history of falls. The resident, who was admitted with diagnoses including Parkinson's disease and unspecified dementia, was assessed as being at high risk for falls due to disorientation, being chair-bound, and requiring assistive devices. The resident's care plan and order summary report both indicated the need for bilateral floor mats as a fall precaution. However, during an observation, it was noted that one of the floor mats was placed approximately one foot away from the resident's bed, which was not in accordance with the care plan. Interviews with the facility's Assistant Director of Nursing and Director of Nursing confirmed that the floor mats needed to be placed closer to the resident's bed to effectively minimize injury in the event of a fall. The facility's policy and procedure on fall risk assessment emphasized the importance of using landing mats to minimize potential injuries. The failure to properly position the floor mats as ordered had the potential to result in serious consequences for the resident, who had severely impaired cognition and was dependent on staff for daily activities.
Failure to Administer Oxygen as Prescribed
Penalty
Summary
The facility staff failed to ensure that a resident received the prescribed two liters of oxygen per minute as needed, according to the physician's order. Instead, the resident was observed receiving five liters per minute of oxygen through a nasal cannula on multiple occasions. The resident, who was admitted with diagnoses including sepsis, respiratory failure, and a urinary tract infection, had an order to maintain oxygen saturation above 92% for acute respiratory failure with hypoxia. Despite this, there was no documentation in the Medication Administration Record (MAR) for the use of two liters per minute of oxygen as needed for the month of December. Interviews with the Licensed Vocational Nurse (LVN) and the Assistant Director of Nursing (ADON) revealed that the licensed nurse was responsible for monitoring the resident's oxygen levels to ensure compliance with the physician's order. The ADON emphasized the necessity of monitoring the resident's oxygen levels to check for respiratory distress and determine the effectiveness of interventions. The facility's policy and procedure for oxygen administration required reviewing the physician's orders, adjusting the oxygen delivery device to the proper flow, and recording oxygen administration in the resident's medical record. However, these procedures were not followed, leading to the deficiency.
Failure to Implement Enhanced Barrier Precautions for Resident on Hemodialysis
Penalty
Summary
The facility failed to ensure a safe and sanitary environment to prevent the transmission of communicable diseases for a resident undergoing hemodialysis with an indwelling medical device. The resident, who was admitted with end-stage renal disease and other conditions, required hemodialysis through a permacatheter in the right upper chest. The facility's care plan for the resident included monitoring the dialysis access site for signs of infection. However, during an observation, it was noted that the resident was not placed on Enhanced Barrier Precautions (EBP), which are necessary to prevent the spread of multidrug-resistant organisms. The Assistant Director of Nursing confirmed that the resident was not on EBP, and the Director of Nursing acknowledged that the resident should have been placed on EBP due to the presence of a central line. The facility's policy on infection control clearly stated that EBP should be used for residents with indwelling medical devices, such as central lines. This oversight had the potential to expose the resident to infection, as the necessary precautions were not implemented as per the facility's policy.
Facility Fails to Meet Room Size Requirements
Penalty
Summary
The facility failed to meet the regulatory requirement of providing at least 80 square feet per resident in multiple resident rooms for 18 out of 24 rooms. Specifically, rooms 101, 103, 104, 105, 106, 107, 108, 109, 110, 111, 112, 114, 115, 116, 117, 118, 119, and 122 did not meet the minimum space requirement. The deficiency was identified through observations, interviews, and record reviews. During observations, it was noted that rooms with two beds had only 154 square feet instead of the required 160 square feet, and rooms with four beds had 280 square feet instead of the required 320 square feet. Interviews with the facility's Administrator confirmed the deficiency, and a room waiver request was submitted, indicating that the rooms had enough space for care and did not negatively affect residents' dignity or privacy. Further interviews with Certified Nurse Assistants revealed that despite the space deficiency, staff were able to move equipment and provide care without difficulty. However, the facility's failure to meet the square footage requirement had the potential to affect residents' privacy and the adequacy of space for nursing care and emergency services.
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.
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What surveyors actually found near you
We read the 5,085 citations issued within 25 miles in the last 12 months — including the 16 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.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Covina
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Rowland | 0.5 mi | ★★★★★ | 5 | 0 |
| Covina Rehabilitation Center | 0.6 mi | ★★★★★ | 0 | 0 |
| Emanate Health Inter-community Hospital- D/p Snf | 0.6 mi | ★★★★★ | 0 | 0 |
| Glendora Grand, Inc | 1.8 mi | ★★★★★ | 3 | 0 |
| Clara Baldwin Stocker Home For Women | 2.2 mi | ★★★★★ | 25 | 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.