Below average — CMS composite of the measures below.
The next survey window likely opens around April 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 Healthcare Centre Of Fresno during CMS and state inspections, most recent first.
INRs for controlled meds were not maintained accurately for multiple residents. An LPN transferred pregabalin for one resident and another resident to ALF without the required two-LN signatures or complete disposition documentation, and controlled meds for other residents, including morphine, phenobarbital, and buprenorphine, were checked off on the MAR but not properly signed in the INR. The INR also showed repeated missing signatures and incomplete shift count entries, despite staff stating two LNs were expected to count and sign each shift.
A facility failed to prevent significant med errors when insulin was given too early for five residents. MAR review and staff interviews showed fast-acting and regular insulin were administered after BG checks but more than an hour before meals or before the meal tray was available, despite orders for insulin with meals or before meals. The DON and nursing staff acknowledged that the timing did not match the physician orders.
Two residents were found with room environment issues that were not homelike. One resident with a hx of stroke, intracerebral hemorrhage, hemiplegia/hemiparesis, dysphagia, and muscle weakness had a bedside table with a pulled-away plastic strip and jagged edges. Another resident with significant mobility impairment after a fall had an overhead bed light without a pull string, and staff noted her call light was broken, leaving her dependent on CNA assistance to turn the light on and off.
A facility failed to develop and implement person-centered care plans for two residents. One resident with pain and multiple chronic diagnoses had a generic pain plan that did not identify which medication to give for 7/10 pain, and the DON said staff would not know how to effectively treat the resident without a care plan. Another resident with severe cognitive impairment had the bedside table and water kept out of reach due to family safety concerns, but staff could not locate a care plan reflecting that preference or the current service being provided.
A resident with severe cognitive impairment and diagnoses including nicotine dependence, asthma, and schizophrenia had a box of cigarettes kept on his nightstand and staff were unaware it was in his room. The resident stated he kept his cigarettes at bedside and nurses provided a lighter when he needed to smoke, while CNA and LVN interviews confirmed cigarettes were supposed to be stored by nurses and not left accessible in the room. The DON also stated the nightstand was not a safe place to store cigarettes.
A meal service failed to provide palatable, attractive food when polenta ran out and watery mashed potatoes were placed on the tray line without a temperature check. The CDM and RCDM stated the potatoes were too runny and should not have been served, and three residents reported the lunch was unappetizing, with one resident with severe cognitive impairment refusing the meal and another resident with quadriplegia and protein calorie malnutrition describing it as runny dog food.
A resident with DM II, PVD, and dysphagia was served orange juice despite a clearly documented allergy to oranges and dislike of orange juice. The resident, who was cognitively intact, stated the kitchen knew about the allergy and the juice had to be set aside. The meal ticket and care plan both documented the allergy, and the CDM confirmed the resident should not have received orange juice or any citrus on the tray.
Incomplete POLST Forms in Resident Records: Two residents had incomplete POLST documentation in their charts. One resident with hemiplegia, diabetes, dysphagia, and moderate cognitive impairment had a POLST with the artificial nutrition section left blank. Another resident with dysphagia, dementia, Alzheimer's disease, quadriplegia, and severe cognitive impairment had an undated POLST with no resident or conservator signature in the record. Staff and the MR confirmed the forms were incomplete and stated POLSTs should be fully completed to reflect end-of-life treatment wishes.
Infection control failures were identified involving four residents. A resident with a urinary catheter had the drainage bag and tubing on the floor, a resident with a g-tube had feeding tubing left open to air without a cap, a CNA entered a contact precaution room without a gown and handled contaminated items and hallway spillage, and a resident with a PICC line had dressing care that did not match the ordered weekly schedule and documentation. Staff stated these conditions were not consistent with infection control expectations and could allow contamination or infection.
A facility failed to ensure a working call system was available for two residents. One resident stated the call light did not work and staff confirmed it had not been documented as broken or repaired, while another resident’s call light was clipped to the bed but dangled on the floor and was out of reach while the resident lay in bed and needed help. Records showed both residents had significant medical and functional impairments, and staff interviews confirmed the call lights should have been functional and within reach.
A resident with Parkinson’s disease, orthostatic hypotension, anemia, muscle weakness, and moderate cognitive impairment was found with extensive bruising on both legs, thighs, buttocks, knees, and an ankle, along with small scabs on toes, which the resident associated with a fall in the facility. A CNA reported having seen and reported these bruises earlier, but the EMR contained no documentation of falls, injuries, or skin changes, and recent nurse skin checks recorded the skin as within normal limits with no new issues. Despite facility policies requiring weekly licensed nurse progress notes, immediate assessment and documentation of new skin integrity changes, and adherence to professional documentation standards, nursing staff did not accurately assess, record, or monitor the resident’s skin changes or reported falls.
Two residents experienced deficiencies in care planning and coordination when staff failed to develop a care plan for one resident’s repeated refusals of showers and bed baths and did not arrange transportation for another resident’s scheduled urology appointment to evaluate urinary catheter removal for discharge. Nursing staff and the DON confirmed that the resident who frequently refused bathing had no care plan addressing these refusals, despite multiple documented shower refusals and partially completed shower review forms lacking nurse assessment and interventions. Social Services staff acknowledged that a urology appointment for another resident was known at admission but was never entered on the transportation calendar, resulting in a missed appointment and no care plan addressing transportation needs, contrary to facility policies on person-centered care planning, referrals to outside services, and resident rights.
Surveyors found that three cognitively impaired residents with hemiplegia, mobility limitations, and dependence on staff for ADLs did not receive consistent oral hygiene and grooming assistance as required by their care plans and facility policy. Observations showed long, dirty fingernails, facial hair, and teeth with visible buildup and foul odor, while residents reported that staff did not routinely offer tooth brushing or grooming and sometimes cited lack of time. ADL records either conflicted with the residents’ observed condition or lacked any oral care documentation, despite staff, including CNAs, an LVN, the DON, and the DSD, stating that daily oral care and personal hygiene before breakfast were expected for all residents. Residents reported feeling dirty and experiencing oral pain associated with inadequate tooth brushing.
The facility failed to secure medication destruction bins (MDBs) in two medication rooms, leading to potential drug diversion risks. Observations revealed that the MDB lids were loose, allowing access to discarded medications, including narcotics. The Nurse Supervisor, LVN, Pharmacy Consultant, and Infection Preventionist all acknowledged the issue, highlighting the risk of drug diversion and infection control concerns. The Director of Nursing confirmed that facility policies for medication storage and disposal were not followed.
The facility failed to store drugs safely in two medication rooms, where seven unidentifiable pills were found on the floor. Staff members, including an NS, LVN, PC, IP, and DON, acknowledged the potential for drug diversion and the failure to adhere to the facility's medication storage policy.
The facility failed to serve meals according to the menu for first-floor residents, as the kitchen ran out of spinach bake and other items, leading to alternate foods being served. Residents expressed dissatisfaction, noting that they often received different meals than those listed on the menu. The CDM and RRD were unaware of these issues, but acknowledged that the kitchen should not run out of food. Substitution lists confirmed the discrepancies between planned and served meals.
The facility failed to serve meals at regular times, with lunch and dinner being served significantly later than scheduled, affecting all sampled residents. Interviews with residents and staff confirmed the consistent delay, with meals being served as late as 8:00 p.m. The Director of Nursing acknowledged the lack of a formal audit system to monitor meal distribution, and resident grievances highlighted dissatisfaction with cold and late meals.
A facility failed to implement comprehensive care plans for two residents, leading to potential health risks. One resident with a chronic indwelling catheter was not properly monitored for infection signs, while another resident with PTSD did not have a timely care plan addressing their condition. Staff admitted to not following care plans and lacking training in trauma-informed care, resulting in potential risks to residents' well-being.
The facility failed to update care plans for several residents, including one who fell and was hospitalized, another with a progressing pressure ulcer, and a resident with significant weight loss. Care plans for medication and infection precautions were also delayed, potentially impacting resident care.
The facility failed to properly assess and document changes in condition for several residents, including a resident with worsening pressure ulcers and another with significant weight loss. Additionally, a resident's oxygen order was not followed, and activities documentation was compromised by improper use of credentials. These deficiencies indicate lapses in communication and adherence to care standards.
The facility failed to serve food at appropriate temperatures, leading to resident complaints about cold, undercooked, and flavorless meals. Observations and interviews revealed that food items were often below the required temperature, and the facility's policy for food temperatures was not consistently followed. A lunch test tray audit confirmed that several food items were under temperature, and a resident grievance report highlighted issues with reheated meals. These deficiencies in food service practices resulted in resident dissatisfaction and potential health risks.
The facility failed to provide a safe and comfortable environment, with non-functional blinds compromising privacy, a hole with exposed wiring posing safety risks, and inadequate lighting in a resident's room. The DOM acknowledged these issues, but they were not recorded in the maintenance log, and staff were unaware until the survey.
The facility failed to maintain the dignity and privacy of two residents by leaving their urinary catheter bags uncovered and visible. One resident with severe cognitive deficits had their catheter bag on the mattress, while another resident's bag was on the floor. Staff interviews confirmed that the bags should have been covered and hung on the bed, as per facility policy.
A resident with asthma was not assessed for the ability to self-administer her albuterol inhaler, despite being her own responsible party and having no cognitive impairment. Staff were unaware of the policy allowing self-administration with a prescriber's order. The facility's policy permitted bedside medication storage for capable residents, but no assessment or order was made for this resident.
A resident developed a facility-acquired Stage 3 pressure ulcer on the left buttock, but the facility failed to complete a Significant Change of Condition Assessment as required by the Minimum Data Set (MDS). The resident's medical history included hypertensive heart disease, morbid obesity, quadriplegia, and spinal stenosis. Despite the worsening of the pressure ulcer from Stage 2 to Stage 3, no change of condition assessment was documented, which is necessary to monitor wound progress and prevent further decline.
A facility failed to update the PASRR for a readmitted resident with depressive disorder and psychosis. The PASRR from the acute care hospital did not reflect the resident's mental health conditions or the use of psychotropic medications. The MDSN did not review or update the PASRR, despite the facility's policy requiring a new assessment upon significant changes in condition.
A resident with paraplegia and hand contractures experienced pain and potential infection risk due to untrimmed fingernails curling into his palms. Despite being cognitively intact and expressing discomfort, staff failed to document or address the issue, and the DON was unaware of the situation. The facility did not follow its grooming policy, leading to inadequate nail care.
A resident with muscle weakness and dementia experienced pain due to long, jagged toenails, which the facility failed to address. Despite the resident's requests and staff observations, toenail care was not provided, and a podiatry referral was delayed. The facility's policy on nail care was not followed, leading to the deficiency.
A resident with a documented lactose allergy was served milk, despite her preferences being noted in her records. The facility staff, including CNAs and dietary management, failed to ensure her dietary needs were met, as her allergy was not listed on her Meal Ticket. This oversight was contrary to the facility's policy requiring resident preferences to be reflected in medical records and tray cards.
A resident was not provided with the prescribed mechanical soft diet, receiving whole kernel corn instead, despite having no teeth and being at risk for choking. The Registered Dietician confirmed the error, and the Director of Nursing acknowledged the responsibility of the nursing staff to ensure dietary compliance.
A resident's POLST form was found incomplete, missing critical information such as physician signature and date, risking the resident's end-of-life wishes not being honored. The resident, with severe cognitive impairment and multiple medical conditions, was listed as DNR, but the incomplete form could lead to confusion in emergencies. Facility staff acknowledged the oversight, noting the form should have been completed within 72 hours of admission.
A resident with COPD and asthma had their oxygen nasal cannula and nebulizer mask improperly stored on a nightstand without protective bags, contrary to infection control practices. Staff interviews confirmed the expectation to store these items in labeled bags to prevent infection, but the facility's policy lacked guidance on storage, leading to this oversight.
A resident with a history of falls and requiring assistance with personal care was left unsupervised outside the facility, leading to an accident. Despite being cognitively intact, the resident left the premises unsupervised and was involved in an auto versus pedestrian accident, resulting in severe injuries. Interviews revealed a lack of clarity in monitoring processes, with no staff assigned to supervise residents outside before the receptionist's arrival.
A resident with a dependency on supplemental oxygen did not receive the prescribed oxygen levels due to LVNs administering 2 liters per minute instead of the ordered 3 liters per minute. This occurred over several days, with missing documentation in the Treatment Administration Record. The DON and ADON were informed of the issue but failed to ensure compliance with physician orders, leading to a deficiency in care.
Two residents were subjected to involuntary seclusion when an LVN closed their room door, leaving their basic care needs unmet. One resident felt sad and angry due to the inability to leave the room, while the other was yelling. Communication barriers with staff prevented the residents' needs from being addressed, despite available resources like a language line.
A resident with a history of mental health disorders jumped from a second-story window after expressing suicidal ideations, which were not reported by a CNA. The facility failed to ensure window screws were secure, allowing the resident to open the window and jump, resulting in severe injuries.
A resident with a complex medical history, including major depressive disorder and PTSD, removed a loose window screw and jumped from the second floor, resulting in serious injuries. The facility failed to ensure window screws were secure, as maintenance checks were undocumented, and the fire marshal had advised against using screws to secure windows.
A severe roach infestation was found in the kitchen's dishwashing area, with roaches observed in the sink, on walls, and in the dishwasher. Staff and residents were aware of the issue, but it was not addressed effectively. Pest control reports indicated ongoing problems, and the facility failed to maintain proper sanitation, leading to an unsanitary environment.
A resident with multiple medical conditions did not receive prescribed pain medication for three days after returning from a hospital stay. Despite a physician's order for Ibuprofen, the medication was not recorded or administered, leading to unmanaged pain. Staff interviews revealed a lack of communication and documentation regarding the medication order, which was not clarified with the resident's physician upon return.
A resident with severe cognitive impairment and dependency on staff for care fell out of bed and sustained significant injuries when a CNA provided care without the required assistance from another staff member. The care plan and visual indicators for two-person assistance were not followed, leading to the fall and injuries.
Incomplete Controlled Medication Records and Shift Counts
Penalty
Summary
The facility failed to maintain Individual Narcotic Records (INRs) accurately for controlled medications for five sampled residents. For Resident 26, the INR for pregabalin 100 mg showed the medication was moved to another cart, but there was no date of transfer, no signatures from the giving or receiving LNs, and no disposition documented for unused medication. For Resident 158, the INR for pregabalin 50 mg showed 24 capsules were given to ALF when the resident transferred, but only one LN signature was present and there was no date documenting the transfer. Staff interviewed stated that two LNs were expected to sign when controlled medications were transferred and that the disposition section should be completed by both the giver and receiver. The facility also failed to ensure controlled medications administered to Residents 74, 139, and 159 were signed in the INR according to policy. Resident 74’s INR for morphine sulfate ER 30 mg showed the medication was last documented as administered with one tablet remaining, but there was no documentation of the medication administered or wasted and no documentation that it was returned to the DON. Resident 139’s INR for phenobarbital 30 mg showed the medication was last documented as administered with three tablets left, but there was no documentation of the medication administered or wasted and no documentation that it was returned to the DON. Resident 159’s INR for buprenorphine patch 5 mg/hr showed one patch remaining and no documentation of the patch administered or wasted and no documentation that it was returned to the DON. In each case, the MAR showed the controlled medication had been checked off as administered, while staff stated the missing INR documentation meant the medication was not properly signed out. The facility further failed to reconcile controlled medications at the beginning and end of shifts as required. The INR review showed multiple unsigned entries and uncompleted entries across several months, including missing signatures and missing count documentation. Staff stated that two LNs were expected to count controlled medications on every shift and both were expected to sign the controlled log. The DON stated the expectation was for both LNs to sign the controlled log at the beginning and end of each shift, and also stated the auditing of controlled medications was not done effectively. The facility policy required controlled medications to be immediately entered on the accountability record and MAR when administered, and required two licensed nurses to conduct and document a physical inventory at each shift change.
Insulin Given Before Meals
Penalty
Summary
The facility failed to ensure that five sampled residents were free from significant medication errors when insulin was administered more than an hour before meals. Resident 18, Resident 86, Resident 92, Resident 119, and Resident 131 all received insulin before their meals were available, despite orders indicating insulin should be given with meals or before meals. The report states this failure had the potential to result in hypoglycemic episodes for these residents. For Resident 119, the MAR showed blood glucose was checked and 1 unit of insulin lispro was administered at 11:47 a.m. During interview, LVN 3 stated the blood glucose check occurred at 11:30 a.m. and lunch was usually between 12:30 p.m. and 1:30 p.m. Resident 119’s record showed diagnoses including type 2 DM, hyperlipidemia, CKD, essential hypertension, and history of falling, and the active order was for insulin lispro to be injected subcutaneously twice a day for DM. For Resident 18, Resident 86, and Resident 92, the MARs showed insulin was administered after blood glucose checks at 11:22 a.m., 11:18 a.m., and 10:54 a.m., respectively. LVN 5 stated the blood glucose levels for these residents were checked between 11:15 a.m. and 11:30 a.m. and insulin was given afterward. Resident 18 had an order for regular insulin 14 units subcutaneously three times a day with food; Resident 86 had an order for insulin lispro before meals; and Resident 92 had orders for regular insulin before meals and at bedtime, and later regular insulin 4 units three times a day with meals. For Resident 131, the MAR showed blood glucose was checked and 16 units of insulin aspart were administered at 7:33 a.m., while breakfast was served between 8:00 a.m. and 8:30 a.m. LVN 6 stated the resident had not yet gotten the meal and that the insulin should not have been administered. Resident 131’s order was for insulin aspart 16 units three times a day for diabetes, take with food. Staff interviews confirmed that insulin lispro and aspart are fast-acting insulin and that the nurses should follow the physician’s order. The DON stated nurses were expected to follow physician orders and that if the order indicated with meals, it should be given with the meal.
Broken bedside table and missing bed light pull string
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for two residents when Resident 11's bedside table had a plastic strip pulled away from the edge with jagged, rough edges. Resident 11 was observed in her room standing by her wheelchair and stated she had been at the facility since February 2026 after a stroke. Her admission record showed diagnoses including intracerebral hemorrhage, dysphagia, hemiplegia and hemiparesis affecting the left side, morbid severe obesity, encephalopathy, abnormalities of gait and mobility, and muscle weakness. Her MDS indicated a BIMS score of 13, suggesting she was cognitively intact. During observation, Resident 11's bedside table was seen with the side strip coming off the edge and the wood chipped. CNA 1 stated the resident could get hurt or pinched by the broken bedside table and said a broken table was not a homelike environment. CNA 1 also stated staff informed maintenance through an electronic system and a maintenance binder if something needed repair. LVN 1 stated residents or staff notified nurses when something was broken and that repair requests were entered into a binder, an electronic system, or reported verbally to maintenance. The Maintenance Director stated the broken table was a risk for injury and did not create a homelike environment, and the DON stated her expectation was to replace the broken table. The facility also failed to ensure Resident 69 had an overhead bed light that she could turn on and off. Resident 69 was observed lying in bed and stated she had been at the facility since January 2026 after a bad fall. She reported weakness in her right arm and inability to move her right leg, and said she needed assistance with some activities. Her admission record listed diagnoses including fall from or off a toilet, abnormalities of gait or mobility, dysphagia, peripheral vascular disease, peripheral autonomic neuropathy, morbid obesity due to excess calories, muscle weakness, and need for assistance with personal care. Her MDS showed a BIMS score of 14 and significant functional impairment in multiple areas. During observation, Resident 69's overhead bed light was seen without a pull string, and she stated she needed a CNA or staff to turn the light on and off. CNA 1 stated she should have had an overhead bed light and that calling for assistance was difficult because her call light was broken. LVN 1 reviewed the maintenance binder and stated there was no documentation of repairs needed for Resident 69's room. LVN 1 and the Maintenance Director stated staff were expected to notify maintenance through the binder, computer system, or verbally, and both stated Resident 69 should have been able to turn her light on and off. The DON stated the overhead bed light should have had a string so the resident could turn it on and off and not have to ask staff.
Incomplete Person-Centered Care Plans for Pain and Bedside Table Preferences
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident 5’s pain. Resident 5 was admitted with diagnoses including diabetes mellitus type II, malignant neoplasm of the bone, generalized osteoarthritis, and depression, and had a BIMS score of 14, indicating cognitive intactness. During record review, the resident’s care plan dated 5/7/26 did not contain a detailed, person-centered plan for pain medication. An LVN stated the generic pain medication care plan in the chart did not identify which medication should be given when the resident was experiencing 7 out of 10 pain, and said it was important for the medication to be clearly indicated in the care plan to prevent the wrong medication from being given and possibly delaying pain relief. The Director of Nursing reviewed the same care plan and stated it was her expectation for the resident’s pain medication to be care planned. The DON stated that if a care plan is not created, staff will not know how to effectively treat the resident. The facility’s Person-Centered Care Planning policy stated that the facility focuses on the resident as the center of control, supports resident choices, and must develop and implement a comprehensive person-centered care plan describing services to be furnished to attain or maintain the resident’s highest practical physical, mental, and psychosocial well-being. The facility also failed to develop a care plan for Resident 125 reflecting the family’s preference that the bedside table not be within reach because of safety concerns. Resident 125 had diagnoses including central cord syndrome, Alzheimer’s disease, encephalopathy, muscle weakness, protein-calorie malnutrition, and major depressive disorder, and had a BIMS score of 05 indicating severe cognitive impairment. During observation, the resident was lying in bed with the bedside table and water pitcher off to the side and not within reach, and the resident stated she could not get out of bed independently and could not reach her water. Staff stated the table was kept out of reach due to family concerns about the resident’s frequent arm movements and the possibility of items falling on her, but an LVN stated this was a verbal and informal request and could not locate a care plan reflecting the family’s request and the current services being provided.
Unsafe Storage of Smoking Materials
Penalty
Summary
The facility failed to ensure the safe storage, supervision, and control of smoking materials for one sampled resident. During observation and interview, the resident was seen in his room with a box of cigarettes containing cigarettes placed on top of his nightstand, and he stated staff were unaware the cigarette box was in his room. On another observation, the resident was again seen with the cigarettes on the nightstand and stated he went on smoke breaks with staff supervision, kept his cigarettes at bedside, and that nurses provided a lighter when he needed to smoke; he also stated he had previously kept a lighter in his room but had misplaced it. Record review showed the resident was admitted with diagnoses including dysarthria following cerebral infarction, type 2 diabetes mellitus with other specified complications, asthma, generalized muscle weakness, nicotine dependence-cigarettes-uncomplicated, extrapyramidal and movement disorder, and paranoid schizophrenia. The MDS dated 3/13/26 indicated a BIMS score of 07, consistent with severe cognitive impairment. Staff interviews confirmed that residents were not allowed to smoke inside the building, that cigarettes and lighters were supposed to be stored by nurses and given to residents when requested, and that cigarettes on the resident’s nightstand were accessible to other residents and should not have been in the room. The DON stated residents’ cigarettes were expected to be kept by nurses at the nursing station and that the resident’s nightstand was not a safe place to store cigarettes.
Unacceptable meal texture and temperature during lunch service
Penalty
Summary
The facility failed to ensure food was palatable, attractive, and served at a safe and appetizing temperature when polenta ran out during lunch service and was replaced with mashed potatoes. During observation in the kitchen, a square metal pan of potatoes was placed on the tray line even though the cook stated the potatoes were too runny, he could not tell his boss another batch was needed, and no one had taken the temperature. The cook continued placing the watery potatoes onto plates, and the potatoes spread to cover half the plate when served. The lunch menu for that meal included Hawaiian pork, polenta, ginger carrots, a wheat roll, and ice cream. The Regional Certified Dietary Manager stated there was not enough polenta to finish serving residents, so mashed potatoes were made and placed on the tray line, but the staff did not take the temperature and the texture and consistency were not acceptable. The CDM stated he should not have placed the potatoes on the tray line, that he had forgotten to take the temperature before doing so, and that all food needed temperature checks prior to tray line placement. Three sampled residents reported the meal was not acceptable. One resident with a history of cerebral infarction, DM, and severe cognitive impairment said she did not eat the potatoes, carrots, or pork and ate ice cream for lunch because the potatoes were runny and she did not care for the taste of the other items. Another resident with quadriplegia, pressure ulcers, and protein calorie malnutrition said the lunch looked like runny dog food and called his wife to bring him food. A third cognitively intact resident with quadriplegia, DM, and depression said the food was often cold, watered down, and strange, and described the lunch as horrible.
Failure to Honor Documented Orange Allergy on Meal Tray
Penalty
Summary
The facility failed to accommodate a resident’s food allergy and meal preferences when a container of orange juice was placed on the resident’s bedside table during lunch, despite the resident being allergic to orange juice. The resident stated that the kitchen was aware of the allergy and that the orange juice had to be set aside because the resident did not want to drink it and die. The resident was cognitively intact with a BIMS score of 14 and had diagnoses including DM II, PVD, and dysphagia. Record review showed the resident’s meal ticket clearly listed “NO ORANGES,” with allergies to oranges and a dislike of orange juice, and the care plan identified altered respiratory status related to allergies to oranges. The CDM reviewed the meal ticket and stated the resident should not have had orange juice or any citrus on the meal tray. The facility policy stated the Dietary Department would provide meals consistent with resident preferences and physician orders as indicated on the tray card, and if a preferred item was not available, a suitable substitute would be provided.
Incomplete POLST Forms in Resident Records
Penalty
Summary
The facility failed to ensure that the medical records for two sampled residents were complete and accurately documented in accordance with accepted professional standards of practice because their POLST forms were incomplete. For Resident 6, the admission record showed multiple serious diagnoses, including left-sided hemiplegia and hemiparesis, type 2 diabetes mellitus, contracture of the left thigh, acquired absence of the left leg above the knee, acute kidney failure, dysphagia, and cognitive communication deficit. The MDS indicated a BIMS score of 9, reflecting moderate cognitive impairment. During review of Resident 6's POLST, Section C regarding artificially administered nutrition was not marked. Staff interviewed about Resident 6's POLST stated that the form was an advance directive and that all sections should have been completed. The LVN stated the POLST guided staff in what to do if the resident's heart stopped beating and that if it was not complete, staff could do the wrong thing for the resident's end-of-life wishes. The MR also confirmed that Section C was not filled in and stated that the section determined whether the resident would use artificial nutrition during end-of-life care. The MR further stated that all sections of the POLST should be completed. For Resident 83, the admission record showed diagnoses including dysphagia following cerebral infarction, aphasia, dementia, Alzheimer's disease, major depressive disorder, acute kidney failure, quadriplegia, multiple contractures, and adult failure to thrive. The MDS indicated a BIMS score of 1, showing severe cognitive impairment. The OSR showed CPR with full treatment as the active order status, but the POLST reviewed for Resident 83 was undated and did not contain a signature from the resident or the resident's conservator. The MR stated there should have been a signed copy in the chart, but none could be found, and noted that someone needed to call the conservator to see if a signed copy existed. The MR and DON both stated that all sections of the POLST should be complete and that the form was used to guide staff on whether to perform CPR or follow the resident's or responsible party's wishes for life-sustaining treatment.
Infection Control Failures With Catheter, Feeding Tube, Contact Precaution, and PICC Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for four sampled residents. Resident 58, who had a history of traumatic brain injury, quadriplegia, contractures, obstructive and reflux uropathy, artificial openings of the urinary tract, and severe cognitive impairment, was observed in bed with a urinary catheter drainage bag and tubing on the floor. The resident stated she was not feeling well and had a fever. Staff later stated the catheter tubing and bag should not have been on the floor, that the drainage bag should have been secured in a dignity bag and hung off the floor, and that the condition created a risk for cross-contamination and infection. The resident was also started on levofloxacin for a urinary tract infection. Resident 17, who was cognitively intact and had dysphagia with enteral feeding via g-tube, was observed with feeding pump tubing whose connector end was left open to air without a tube cover cap. Nursing staff stated the tubing should have been capped or covered when not connected to the resident to prevent contamination and infection. Staff identified that the open tubing could allow the tube to become dirty and expose the resident to gastrointestinal infection. Resident 31, who had severe cognitive impairment and diagnoses including suprapubic catheter, resistant organisms, sepsis due to MSSA, UTI, E. coli, pseudomonas, bacteremia, and bed confinement, was on contact precautions. During observation, a CNA entered the room without a gown, handled dirty linen, moved a shower gurney out of the room, and cleaned fecal contamination and water from the hallway floor with towels while moving back into the resident’s room. Staff stated the CNA should have worn PPE before entering the room and that the hallway contamination should have been disinfected by housekeeping to prevent spread of infection. Resident 59, who was cognitively intact and had a PICC line in the right upper extremity, had a PICC dressing that was not documented or observed as being changed in accordance with the physician’s order for weekly dressing and cap changes. The dressing was observed dated 4/27/26, while the chart contained documentation indicating dressing changes on later dates that did not match the observed dressing date. Staff stated the dressing should have been changed every 7 days, that the observed date did not align with the record, and that the dressing was not changed as ordered. The facility’s records and staff statements showed discrepancies between the documented PICC care and the actual observed dressing date.
Call System Not Working or Out of Reach for Two Residents
Penalty
Summary
The facility failed to ensure that a working call system was available in residents’ rooms for two residents. One resident had a call system that was not working, and another resident was unable to reach the call button while lying in bed because the call light was on the floor and dangling under the mattress. The deficiency was identified through observation, interview, and record review. One resident was observed lying in bed and stated that the call light did not work and that it could take a while to get help. The resident had been admitted after a fall and had diagnoses including gait and mobility abnormalities, dysphagia, peripheral vascular disease, peripheral autonomic neuropathy, morbid obesity, muscle weakness, and need for assistance with personal care. The resident’s MDS showed a BIMS score of 14, indicating cognitive intactness, and functional impairment in both upper and lower extremities. The care plan directed staff to keep the call light within reach and to provide prompt response to requests for assistance. Staff interviews confirmed awareness that the call light was not working, and the Maintenance Director stated there was no documentation that the broken call light had been reported or repaired. A second resident was observed lying in bed with the call light clipped to the head of the bed but dangling under the mattress and on the floor, out of reach. The resident stated she was unable to reach the call light and needed to be changed. The resident’s record showed diagnoses including CHF, atrial fibrillation, hemiplegia/hemiparesis following cerebrovascular disease, and muscle wasting and atrophy. The resident’s MDS showed a BIMS score of 8, indicating moderate impairment. Staff interviews confirmed that the call light was not within reach and should have been clipped so the resident could use it for assistance and safety. The facility policy stated that residents must have a means to call for staff assistance from their rooms and toileting/bathing facilities and that the call alert device must be placed within the resident’s reach.
Failure to Assess and Document Extensive Bruising and Possible Falls
Penalty
Summary
The deficiency involves the facility’s failure to assess, document, and monitor significant skin changes and possible injury for a resident in accordance with professional standards of practice and the facility’s own policies on Licensed Nurse Weekly Progress Notes and Skin Integrity Management. The resident was admitted with diagnoses including Parkinson’s disease, syncope, orthostatic hypotension, anxiety, muscle weakness, and anemia, and had a BIMS score indicating moderate cognitive impairment. Despite these conditions and the resident’s report of needing assistance with transfers and ambulation due to dizziness and fall potential, the electronic medical record (EMR) contained no documentation of falls, skin changes, or injuries since admission. On multiple observations on the same day, surveyors and staff noted extensive bruising on the resident’s body, including both lower legs, upper legs, thighs, buttocks, both knees, and the right ankle, with pain on movement and small scabs on the right toes. The complainant reported first seeing multiple bruises on the resident’s lower and upper legs and buttocks the day before, stating these bruises had not been present earlier. The resident reported that bruises on the arms were from a medical procedure and bruises on the legs were from a fall in the facility, though she could not recall the date or time. At another point, the resident stated she had a fall in her room early in the morning and also described a fall at night when staff were assisting her back to bed from the restroom. CNA staff reported observing the bruises several days earlier and stated they had reported them to a nurse, but could not recall which nurse, and did not recall any fall being reported. The CNA also stated that facility process required CNAs to report and document new conditions as alerts in the EMR. LVN staff acknowledged seeing bruises on the resident’s arms but denied seeing other bruises and stated the resident had no history of falls since admission. When the bruises were jointly observed by the LVN, CNA, and Nurse Unit Manager, the LVN confirmed there was no documentation in the EMR of bruises, falls, or injuries, and the Nurse Unit Manager and DON both stated that nurses were expected to document new changes, including falls, skin issues, and injuries, and to complete skin evaluations when there was a change in skin integrity. Review of the resident’s skin check forms dated two and one days prior to the surveyor’s observation showed entries of “skin within normal limits” and “no new skin issues noted,” despite the extensive bruising observed on the day of survey. The facility’s policies required weekly licensed nurse progress notes to reflect observations of physical limitations, behavioral changes, skin problems, and other factors, and required licensed nurses to complete a skin evaluation when there was a change in skin integrity, to complete weekly skin evaluations, and to notify the physician and responsible party when there was a change in skin condition. Professional guidance from the American Nurses Association emphasized that documentation must be clear, accurate, complete, and timely. In this case, there was no documentation of the resident’s reported falls, no documentation of the extensive bruising and skin changes, and no evidence of the required nursing assessments or progress notes addressing these changes, constituting a failure to meet professional standards of quality and the facility’s own documentation and skin integrity policies.
Failure to Care Plan for Bathing Refusals and Coordinate Transportation for Outside Urology Care
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement person-centered care plans and follow policies related to resident refusals of care and referrals to outside services. For one resident with progressive neuropathy, type 2 diabetes mellitus, and congestive heart failure, the facility did not create a care plan addressing repeated refusals of showers and bed baths. Documentation on Skin Monitoring Comprehensive CNA Shower Review forms from late January through late February showed that the resident refused all nine offered showers and accepted only three bed baths, with several additional partial bed baths documented due to shower refusals. Despite these repeated refusals, the sections on the forms for charge nurse assessment, interventions, and forwarding to the DON were left blank, and the DON, RN, and LVN all confirmed there was no care plan in place for the resident’s ongoing refusal of bathing. Staff interviews further confirmed that the resident frequently refused showers and bed baths and that the facility’s expectation was that residents receive bathing at least twice a week. LVN 1 stated that all residents should receive two showers or baths weekly and that a care plan should be started if a resident refused. RN 1 similarly stated that a care plan should have been developed for the resident’s repeated refusals. The DON reviewed the resident’s care plans and shower documentation and acknowledged that the resident had no care plan, past or present, addressing the refusal of showers, even though the facility’s policy on comprehensive person-centered care planning requires care plans to include services to be furnished and services not provided due to a resident’s exercise of the right to refuse treatment. The deficiency also includes the facility’s failure to coordinate transportation for another resident’s outside urology appointment, as required by the facility’s policies on referrals to outside services and resident rights. This resident, who had a history of cerebral infarction with hemiplegia and hemiparesis, type 2 diabetes mellitus, major depressive disorder, urinary retention, anxiety disorder, and UTI, had a scheduled follow-up urology appointment to assess removal of a urinary catheter in preparation for discharge to an assisted living facility. The Social Service Director stated that the process for arranging transportation required nurses to place appointments on a calendar that Social Services used each morning to set up transportation. However, the Social Service staff member responsible for the calendar admitted that, although she was informed of the urology appointment at admission and told the nurse she would put it on the calendar, she forgot to do so. As a result, the resident did not have transportation and missed the appointment. The DON confirmed that the resident missed the appointment because transportation was not provided and that there was no care plan addressing transportation to outside appointments or ensuring the resident attended those appointments, despite facility policies stating that the Director of Social Services coordinates referrals to outside services and that the facility assists residents in exercising their rights, including arranging transportation and supporting participation in treatment decisions. A professional reference from the American Nurses Association regarding the nursing process was also cited, stating that nursing care is implemented according to the care plan, that continuity of care must be assured, and that both the patient’s status and the effectiveness of nursing care must be continuously evaluated with the care plan modified as needed. This reference underscores that the facility’s failure to develop and implement appropriate care plans for the resident refusing showers and for the resident requiring transportation to an outside urology appointment was inconsistent with professional standards of nursing practice and the facility’s own policies on comprehensive person-centered care planning, referrals to outside services, and resident rights.
Failure to Provide Daily Oral Hygiene and Grooming Assistance for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary assistance with activities of daily living (ADLs), specifically oral hygiene and grooming, to three residents who required staff support. Resident 1, admitted with hemiplegia affecting the left side, multiple contractures, muscle weakness, and moderate cognitive impairment (BIMS score 10/15), was observed with long fingernails containing brown substance, visible white buildup on teeth, foul breath, and long facial hair. Resident 1 reported not remembering the last time his teeth were brushed or nails trimmed, stated he had a history of refusing showers but not oral care, shaving, or nail care, and said staff did not offer daily tooth brushing or grooming and that he had not received grooming assistance from any staff at the time of the interview. CNA 1 and RN 1 both observed that Resident 1’s appearance suggested personal hygiene had not been completed for more than a few days, with RN 1 noting the resident appeared not to have been shaved for a few weeks and that nails were dirty, long, and uncut, despite ADL documentation indicating recent nail care, oral hygiene, and shaving. Resident 2, admitted with visuospatial deficit, hemiplegia affecting the left side, muscle weakness, GERD, and a need for assistance with personal care, also had moderate cognitive impairment (BIMS 12/15). Resident 2 stated she had been in the facility for a few months and that tooth brushing and grooming were part of her care plan but were not offered. She reported that her teeth were not brushed often because staff had previously said they did not have time, and she expressed a desire to have her teeth brushed every morning and night as part of her routine. She stated she felt dirty and believed the lack of tooth brushing had caused tooth pain because her teeth were dirty. During a later interaction in the hallway, Resident 2 stated she had not had her teeth brushed and was unable to open her mouth due to oral pain. ADL documentation for Resident 2 indicated oral hygiene was recorded as completed on two consecutive days in the review month. Resident 3, admitted with spastic hemiplegia affecting the left side, arthritis, muscle weakness, and wheelchair dependence, also had moderate cognitive impairment (BIMS 12/15). During observation and interview, Resident 3’s teeth showed white and yellow buildup and foul breath. Resident 3 stated he had not been offered supplies or staff assistance to brush his teeth daily, and that tooth brushing was part of his care that should have been completed without him having to request it. He reported feeling dirty and being able to smell a foul odor on himself, and stated he wanted help brushing his teeth every day. Review of Resident 3’s ADL documentation showed no entries for oral hygiene since admission. Staff interviews with a CNA, LVN 1, the DON, the administrator, and the DSD consistently described the facility’s expectation that CNAs complete all personal hygiene and ADLs daily, including tooth brushing, grooming, shaving, and nail care, generally before breakfast unless residents requested otherwise. Facility policies on Resident Rights, Oral Care, Grooming Care of Fingernails and Toenails, and Showering and Bathing stated that residents should receive daily oral care, nail care, and personal care consistent with their preferences and care plans, but the observed conditions and resident reports demonstrated that these services were not consistently provided to the three residents. The failure to provide daily oral care and grooming as required by the residents’ care plans and facility policies resulted in the three residents feeling unclean and, as stated by LVN 1 and the DON, placed them at risk for tooth decay, oral and respiratory infections, skin infections, skin breakdown, and other preventable issues. The discrepancy between the ADL documentation and the observed condition of Resident 1, as well as the absence of oral hygiene documentation for Resident 3, further demonstrated that the documented provision of care did not match the actual care delivered. The residents’ own statements that they were not offered oral care or grooming, combined with staff acknowledgments that these tasks had not been completed and that residents should not have to request such basic care, directly contributed to the identified deficiency in providing necessary services for ADLs to maintain personal and oral hygiene.
Unsecured Medication Destruction Bins Pose Risk of Drug Diversion
Penalty
Summary
The facility failed to adhere to its policies and procedures regarding medication storage and disposal, specifically concerning the secure sealing of medication destruction bins (MDBs) in two medication rooms. During observations and interviews, it was noted that the MDB lids were loose and not properly sealed, which could allow staff to access discarded medications, including narcotics and other controlled substances. This was confirmed by the Nurse Supervisor and a Licensed Vocational Nurse, who both acknowledged the potential for drug diversion due to the unsecured bins. Further interviews with the Pharmacy Consultant and the Infection Preventionist highlighted the risks associated with the unsecured MDBs. The Pharmacy Consultant emphasized that the best practice would be to have the MDBs sealed to prevent unauthorized access to discarded medications, including those in powder form. The Infection Preventionist also noted that the unsecured bins posed an infection control issue and reiterated the potential for drug diversion, as anyone with access to the medication rooms could potentially take medications from the bins. The Director of Nursing confirmed that the facility's policies and procedures for medication storage and disposal were not followed, as the MDB lids were not properly secured in both medication rooms. The facility's policy, dated 2019, requires medications to be stored safely and securely, and controlled medications to be disposed of in a designated waste container. The unsecured MDBs were in violation of these policies, as well as federal regulations that require collection receptacles to be securely locked and maintained in a secured area.
Unsafe Medication Storage in Facility
Penalty
Summary
The facility failed to store drugs safely in two medication rooms, where a total of seven unidentifiable pills were found on the floor. In the second-floor medication room, five different pills were observed on the floor during an interview with the Nurse Supervisor, who confirmed that the pills were unidentifiable and could potentially be narcotics. Similarly, in the third-floor medication room, two different pills were found on the floor during an interview with an LVN, who acknowledged that the pills were random and should not have been on the floor. Both staff members expressed concerns about the safety and potential for drug diversion due to the presence of these unaccounted pills. Interviews with the Pharmacy Consultant, Infection Preventionist, and Director of Nursing further highlighted the failure to adhere to the facility's policy and procedure for medication storage. The Pharmacy Consultant noted the risk of staff or residents picking up the pills, while the Infection Preventionist emphasized the potential for drug diversion and the safety issues posed by the unsecured medications. The Director of Nursing confirmed that the medications were not secured and acknowledged the potential for drug diversion, indicating that the facility's policy and procedure for medication storage was not followed.
Meal Service Discrepancies on First Floor
Penalty
Summary
The facility failed to ensure that the meals served to residents on the first floor matched the menu items, as observed on January 7, 2025. Specifically, the kitchen ran out of spinach bake, which was supposed to be served to 49 out of 54 residents on that floor, and instead served green beans as an alternative. This discrepancy was noted during observations and interviews with residents and staff, revealing that the first-floor residents often received alternate meals when the kitchen ran out of menu items. Interviews with residents indicated dissatisfaction with the meal service, as they frequently did not receive the food items listed on the menu. Resident 48 reported that dessert options were unavailable because the kitchen prioritized serving other floors first, and mentioned that the facility ran out of food three times a week. Resident 78 corroborated this, stating that the first-floor residents were served last and often received alternate foods. Resident 112 expressed frustration when served a bun with cheese instead of the turkey burger listed on the menu, as the kitchen had run out of meat. The Certified Dietary Manager (CDM) and the Regional Registered Dietician (RRD) were unaware of the incidents of running out of food, but acknowledged that the kitchen should not run out of food. The CDM admitted that the cook did not prepare enough burgers, despite having more in the freezer. The facility's substitution lists and diet spreadsheet menus confirmed the discrepancies between the planned and served meals, highlighting a pattern of insufficient food preparation and substitution without proper adherence to the menu.
Late Meal Service in LTC Facility
Penalty
Summary
The facility failed to provide meals at regular times comparable to normal mealtimes in the community or in accordance with resident requests and preferences. On specific dates, lunch and dinner were served significantly later than the scheduled times, affecting all 141 sampled residents. Observations and interviews with residents and staff revealed that meals were consistently served late, with lunch being served as late as 2:00 p.m. and dinner as late as 8:00 p.m. This delay in meal service was corroborated by multiple residents who expressed dissatisfaction and frustration with the timing of their meals. Interviews with staff, including Licensed Vocational Nurses and Certified Nurse Assistants, confirmed the late meal service, with meals being delivered to different floors at staggered times, often much later than the posted schedules. The Director of Nursing acknowledged the issue, noting that while meal schedules were posted, there was no formal audit system in place to track and monitor meal distribution. The Certified Dietary Manager also noted that meals should be delivered within 15 to 30 minutes of the scheduled time to avoid affecting medication administration and resident satisfaction. Resident grievances further highlighted the issue, with complaints about meals being served cold and late, sometimes as late as 10:00 p.m. The facility's policy and procedure for meal service emphasized the importance of timely meal delivery, yet the facility failed to adhere to these guidelines. The deficiency in meal service timing had the potential to impact residents' nutritional and hydration needs, as well as their overall satisfaction and well-being.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents, leading to potential health risks. For Resident 94, who was admitted with paraplegia and neuromuscular dysfunction of the bladder, the care plan included monitoring for signs of urinary tract infections due to a chronic indwelling catheter. However, licensed nurses did not follow the care plan, as evidenced by observations of cloudy and sediment-filled catheter tubing, which was not properly assessed or reported to a physician. This oversight was acknowledged by the Licensed Vocational Nurse (LVN) and the Wound Nurse (WN), who admitted to not conducting accurate assessments or notifying the physician, potentially exposing Resident 94 to infection risks. Resident 63, diagnosed with Post Traumatic Stress Disorder (PTSD), did not have a comprehensive care plan addressing this condition. Despite the resident's expressed discomfort with loud noises due to PTSD, the care plan was not developed until months after admission. The Social Services Director (SSD) acknowledged that a PTSD care plan should have been initiated earlier to address the resident's needs. Interviews with staff, including the LVN and the Director of Nursing (DON), revealed a lack of awareness and training regarding trauma-informed care, which contributed to the delay in developing an appropriate care plan for Resident 63. The facility's policies and procedures for comprehensive person-centered care planning were not adhered to, as evidenced by the lack of timely and accurate care plans for both residents. The DON and other staff members recognized the importance of following these procedures to ensure residents' health and safety. The failure to implement these care plans as required by the facility's policies resulted in potential risks to the residents' physical and mental well-being.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to follow its policy and procedure to ensure care plans were reviewed and revised for five of 23 sampled residents. Resident 45's care plan was not updated after a fall and subsequent hospitalization, which increased the risk of further falls. The Licensed Vocational Nurse (LVN) acknowledged the oversight and emphasized the importance of care plans in notifying staff about residents' conditions and necessary preventative measures. Resident 67's care plan was not updated when a pressure ulcer progressed to a stage III wound. The Wound Nurse noted that the care plan for the pressure ulcer was not initiated upon identification, which could delay care and treatment. The Director of Nursing (DON) stated that care plans must be developed and updated to prevent worsening of wounds. Resident 74 experienced significant weight loss, but the care plan was not revised to reflect this change. The Registered Dietitian confirmed the weight loss and the need for the care plan to be updated. Additionally, Resident 74's care plan was not updated after a fall, and the DON stated that care plans should be revised after each fall to prevent further incidents. Resident 76's care plan was not updated upon returning from the hospital with a pressure ulcer, and Resident 392's care plans for apixaban and Enhanced Barrier Precaution were not initiated in a timely manner, which could have led to inadequate monitoring and care.
Deficiencies in Resident Care and Documentation
Penalty
Summary
The facility failed to meet professional standards of quality care for several residents, as evidenced by the lack of proper assessment and documentation of changes in their conditions. Resident 67, who was admitted with multiple diagnoses including hypertensive heart disease and quadriplegia, developed facility-acquired pressure ulcers that were not properly assessed or documented. Despite the worsening of a Stage 2 pressure ulcer to Stage 3, there was no change of condition assessment or interdisciplinary team (IDT) note completed, which is crucial for monitoring and preventing further deterioration of the wounds. Resident 74 experienced significant weight loss, exceeding five percent in one month, which was not documented or addressed by the facility's staff. The resident, who had a history of diabetes mellitus and cirrhosis of the liver, reported an inability to tolerate the facility's food, yet no change of condition assessment or IDT note was completed. This oversight in communication and documentation could have led to further weight loss, as the necessary interventions were not implemented. Additionally, Resident 55's prescribed oxygen order was not followed, as the resident was observed receiving a higher oxygen level than ordered without a documented change in condition or emergency situation. Furthermore, the Activities Director allowed assistants to document resident activities using her credentials, compromising the accuracy of records. These deficiencies highlight a pattern of inadequate documentation and communication within the facility, potentially impacting the quality of care provided to residents.
Facility Fails to Serve Food at Appropriate Temperatures
Penalty
Summary
The facility failed to ensure that food was palatable and served at an appetizing temperature, as evidenced by complaints from five residents about cold, undercooked, and flavorless meals. Residents reported that the food was often served cold, and when reheated, it did not improve in quality. One resident mentioned that the food was so unappealing that it caused weight loss, and another resident described the food as being colder than ice cream. These issues were corroborated by staff interviews, where a CNA acknowledged that residents frequently complained about the food's lack of taste and temperature. Observations and interviews revealed that the facility's food service practices were inadequate. A lunch test tray audit conducted by the Regional Registered Dietician showed that the temperatures of the food items were below the facility's policy requirements, with the beef patty and roasted potatoes being particularly under temperature. The facility's policy stated that hot food should be served above 145 degrees Fahrenheit, but the audit found that the beef patty was only 119.8 degrees, and the potatoes were 108 degrees. Additionally, the Dietary Quality Control Review audits consistently indicated that the standard for serving food at appropriate temperatures was not met. The facility's failure to maintain proper food temperatures was further highlighted by a resident grievance report, where a resident received a cold and soggy dinner. The investigation into this complaint revealed that the grilled cheese sandwich served was not freshly made but reheated from the lunch shift. The Registered Dietitian confirmed that food served under temperature could lead to foodborne illnesses and impact resident satisfaction and intake. Despite these findings, the facility's policy and procedure for food temperatures were not adhered to, resulting in ongoing resident dissatisfaction and potential health risks.
Facility Fails to Maintain Safe and Comfortable Environment
Penalty
Summary
The facility failed to maintain a safe, functional, and comfortable environment for residents, staff, and the public, as evidenced by several deficiencies observed during a survey. In five out of 23 residents' rooms on the first floor, vertical blinds were found to be non-functional, lacking handles, missing slats, or stuck, which compromised the residents' privacy. Resident 31 expressed concerns about feeling unsafe due to the inability to properly close the blinds, which allowed people from outside to look into her room. The Director of Maintenance (DOM) acknowledged that the majority of the blinds on the first floor were not working properly, yet there was no record of these issues in the maintenance log. In another instance, a hole with exposed wiring was observed in Resident 103's room, posing a potential safety hazard. The DOM confirmed the presence of the hole and expressed concerns about the possibility of pest infestation and the risk of electrocution if the wires were live. Despite the potential dangers, there was no prior report of this issue, and the Licensed Vocational Nurse (LVN) was only made aware of it during the survey. The administrator acknowledged the risks associated with the hole and emphasized the importance of maintenance rounds to ensure safety. Additionally, Resident 55's room was found to have inadequate lighting due to missing light bulbs in both the ceiling fixture and the overhead light. This lack of proper lighting resulted in decreased visibility and eye strain for the resident, who had to go to the lobby to read. The DOM was aware of the issue but had not yet resolved it, and the LVN highlighted the importance of adequate lighting for providing quality care. The administrator reiterated the expectation for the maintenance department to address lighting issues promptly.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to ensure the dignity and privacy of two residents by not covering their urinary catheter bags, which were left visible to other residents and visitors. Resident 69, who has severe cognitive deficits and quadriplegia, was observed with an uncovered urinary catheter bag placed on top of the mattress. Resident 191, who has no cognitive impairment, expressed a preference for his catheter to be covered, yet it was found on the floor under the bed. Both instances were not in accordance with the facility's policy and procedure, which requires catheter bags to be covered and hung on the side of the bed. Interviews with facility staff, including CNAs, a Nurse Supervisor, an Infection Preventionist, and the Director of Nursing, confirmed that the urinary catheter bags should have been placed in privacy bags and hung appropriately to maintain dignity and prevent infection. The facility's policy on indwelling catheters and resident rights emphasizes the importance of covering catheter bags to protect residents' privacy and dignity. The failure to adhere to these policies resulted in a violation of the residents' rights to privacy and dignity.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to uphold a resident's right to self-administer medication, specifically for Resident 92, who was not assessed for her ability to keep her albuterol inhaler at bedside and self-administer it as needed. Resident 92, who was her own responsible party and had no cognitive impairment, expressed a desire to keep her inhaler at bedside for her asthma condition. However, staff members, including CNAs and an RN, indicated that residents were not allowed to keep medications at bedside or self-administer them, and they were unaware that nurses could permit this. The facility's policy allowed for bedside medication storage for residents capable of self-administration upon a prescriber's written order and the interdisciplinary team's judgment. Despite this, Resident 92's Order Summary Report showed no orders for self-administration, and LVN 1 acknowledged that Resident 92 was a good candidate for self-administration. The Director of Nursing confirmed that residents had the right to self-administer medication and that an assessment should have been conducted for Resident 92. The failure to assess and provide the necessary order for self-administration potentially compromised Resident 92's ability to manage her asthma effectively.
Failure to Complete Significant Change of Condition Assessment for Pressure Ulcer
Penalty
Summary
The facility failed to complete a Significant Change of Condition Assessment for a resident who developed a facility-acquired Stage 3 pressure ulcer on the left buttock. This assessment is part of the Minimum Data Set (MDS), a federally mandated resident assessment tool. The deficiency was identified during an observation and interview with the resident, who was alert and oriented, and confirmed the presence of a wound being treated by nurses. The resident's medical history included hypertensive heart disease with heart failure, morbid obesity, quadriplegia, and spinal stenosis. The Wound Doctor assessed the resident's wounds and diagnosed a Stage 3 pressure ulcer on the left buttock and a Stage 2 pressure ulcer on the right thigh. The Wound Nurse confirmed that the pressure ulcer on the left buttock had worsened from Stage 2 to Stage 3, but no change of condition assessment was documented. The Nurse Supervisor and Registered Nurse also reviewed the resident's records and confirmed the absence of a change of condition assessment, which is required to monitor the progress of wounds and prevent further decline. The Director of Nursing and the Minimum Data Set Nurse both stated that a new change of condition assessment should have been completed when the wound worsened from Stage 2 to Stage 3. The facility's policy and procedures require a new MDS assessment within 14 days if there is a significant change in condition. The failure to document the change of condition assessment could have resulted in a delay in care and treatment, potentially worsening the resident's wounds.
Failure to Update PASRR for Readmitted Resident with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure the accurate completion of the Level I Preadmission Screening and Resident Review (PASRR) for a resident who was readmitted to the facility. The resident, who had diagnoses of depressive disorder and psychosis, was readmitted without an updated PASRR assessment reflecting these mental health conditions and the use of psychotropic medications. The PASRR completed at the general acute care hospital did not indicate a diagnosis of mental illness, which was inaccurate given the resident's condition upon readmission. The Minimum Data Set Nurse (MDSN) did not review the PASRR assessment, which was dated prior to the resident's readmission, and failed to update it to reflect the resident's current mental health diagnoses and treatment. The Director of Nursing (DON) confirmed that it was the responsibility of the MDSN to review and update the PASRR as needed upon readmission. The facility's policy required a new PASRR to be completed if there was a significant change in the resident's condition, which was not adhered to in this case.
Failure to Provide Adequate Nail Care for Resident with Contractures
Penalty
Summary
The facility failed to provide adequate personal hygiene care for a resident, specifically in the grooming of fingernails, as per the facility's policy and procedure. The resident, who was admitted with paraplegia and contractures in both hands, had long fingernails that were curling into his palms, causing pain and potential for infection. Despite the resident's cognitive intactness and his complaints about the discomfort caused by his nails, the staff did not trim them. The Licensed Vocational Nurse (LVN) and Certified Nursing Assistant (CNA) were aware of the issue but did not document the resident's refusal of care or the condition of his nails, and the Director of Nursing (DON) was not informed of the situation. The Infection Preventionist highlighted the importance of regular nail care, especially for residents with contractures, to prevent potential infections. However, the facility's records, including skin assessments and shower reviews, did not accurately reflect the resident's condition. The Social Services Assistant was also not informed of the issue, which could have warranted external medical intervention. The facility's failure to adhere to its grooming policy resulted in the resident's nails not being trimmed, which could have led to wounds or infections.
Failure to Provide Appropriate Foot Care
Penalty
Summary
The facility failed to provide appropriate foot care for Resident 40, who was admitted with diagnoses including muscle weakness and unspecified dementia. The resident's toenails were observed to be long and jagged, causing pain during ambulation. Despite the resident expressing a desire for his toenails to be cut, the facility did not provide this service. The resident's Brief Interview for Mental Status (BIMS) score indicated moderate cognitive impairment, which may have affected his ability to consistently communicate his needs. Licensed Vocational Nurse (LVN) 3 acknowledged that Resident 40's toenails should have been cut and that Certified Nursing Assistants (CNAs) were responsible for evaluating toenails during showers. However, the toenails were not addressed, and LVN 3 admitted to not having assessed the resident's toes. The Social Services Assistant (SSA) received a podiatry referral form for the resident but had not arranged for a podiatrist visit. CNA 14, who had showered the resident, noted the long and thick toenails but did not perform nail care, misunderstanding the documentation requirements for abnormal findings. The Director of Nursing (DON) was unaware of the issue and stated that the staff should have escalated the need for toenail care. LVN 8 also observed the overgrown toenails and submitted a referral for podiatry, but did not cut the nails due to their thickness. The Medical Doctor of Podiatry confirmed that the toenails should have been trimmed every two months to prevent infection and injury. The facility's policy on grooming care of fingernails and toenails was not followed, contributing to the deficiency.
Failure to Accommodate Resident's Dietary Allergies and Preferences
Penalty
Summary
The facility failed to provide food that accommodated the allergies and preferences of a resident, identified as Resident 92, who had a documented allergy to lactose. Despite this, Resident 92 was served milk with her lunch, which she stated she did not want and was given daily. The resident's Admission Record indicated an allergy to lactose, and her Minimum Data Set showed no cognitive impairment, suggesting she was capable of communicating her needs. During an observation and interview, it was confirmed that her Meal Ticket listed a dislike for lactose, but her allergy was not noted, leading to the inappropriate serving of milk. Interviews with facility staff, including a CNA, the Certified Dietary Manager, the Director of Staff Development, and the Director of Nursing, revealed a breakdown in communication and procedure adherence. The CNA acknowledged that kitchen staff should have noticed the resident's allergies and preferences, and the CDM admitted that the allergies were not indicated on the Meal Ticket. The DSD and DON both confirmed that CNAs were trained to check meal trays for accuracy, and the DON stated that the kitchen staff should have ensured the resident received her preferred meal. The facility's policy required that resident preferences be reflected in the medical record and tray card, which was not followed in this instance.
Failure to Provide Prescribed Mechanical Soft Diet
Penalty
Summary
The facility failed to provide a mechanical soft diet as prescribed by the attending physician for Resident 83, who was one of the 32 sampled residents. Resident 83, who had been at the facility for three years, was observed to have been served whole kernel corn instead of the prescribed mechanical soft diet. This was despite the resident's admission record indicating a need for a mechanical soft diet due to her medical conditions, including cerebral infarction, Type 2 Diabetes Mellitus, protein-calorie malnutrition, dementia, major depressive disorder, muscle weakness, and a history of falling. The resident, who was moderately cognitively impaired and had no teeth, reported that the facility often provided food she could not chew, such as whole kernel corn, which she had to swallow whole. The Registered Dietician confirmed that Resident 83 should have been served creamed corn instead of whole kernel corn, acknowledging that the latter was not acceptable and increased the risk of choking. The Director of Nursing stated that it was the nurse's responsibility to ensure the resident's meal matched the dietary requirements, and any discrepancies should have been addressed by consulting the Certified Dietary Manager. The failure to adhere to the prescribed mechanical soft diet placed Resident 83 at risk for choking and aspiration.
Incomplete POLST Form for Resident
Penalty
Summary
The facility failed to maintain accurate and complete medical records for one of the sampled residents, specifically regarding the Physician Orders for Life-Sustaining Treatment (POLST) form. The POLST form for Resident 137 was found to be incomplete, missing critical information such as artificially administered nutrition, physician signature, physician license, physician phone number, and date. This deficiency was identified during a review of the resident's records and interviews with facility staff, including a Licensed Vocational Nurse (LVN), Nursing Supervisor (NS), Medical Records Coordinator (MR), and the Director of Nursing (DON). Resident 137 was admitted to the facility with several medical conditions, including pneumonia, pleural effusion, cognitive communication deficit, dysphagia, failure to thrive, and dementia. The resident's Minimum Data Set (MDS) indicated severe cognitive impairment, with a Brief Interview for Mental Status (BIMS) score of seven out of 15. Despite the resident being listed as Do Not Resuscitate (DNR) in the computer system, the incomplete POLST form posed a risk of not honoring the resident's end-of-life wishes in an emergency situation. Interviews with facility staff revealed that the POLST form should have been completed within 72 hours of admission, but it remained incomplete from December to the date of the survey. The staff acknowledged the importance of a completed POLST to ensure the resident's treatment preferences are respected. The facility's policy and professional standards require that all fields in the POLST form be filled out and signed by a physician to be valid, which was not adhered to in this case.
Infection Control Deficiency Due to Improper Storage of Respiratory Equipment
Penalty
Summary
The facility failed to maintain a sanitary environment to prevent the transmission of infections for a resident with chronic respiratory conditions. The resident's oxygen nasal cannula and nebulizer mask were found lying on the nightstand without being stored in a protective bag, which is against the facility's infection control practices. The resident, who has Chronic Obstructive Pulmonary Disease (COPD) and asthma, uses these devices daily as part of their treatment. During observations and interviews, it was noted that the oxygen concentrator and nebulizer were not stored properly, posing a risk of bacterial contamination. Interviews with various staff members, including a CNA, Wound Nurse, Nursing Supervisor, Infection Preventionist, and the Director of Nursing, confirmed that the standard practice was to store oxygen and nebulizer tubing in labeled protective bags to prevent infection. The facility's policy on oxygen therapy, however, did not address the storage of these items, which contributed to the oversight. The staff acknowledged that leaving the tubing unprotected was an infection control issue, and the expectation was to follow the standard of practice to ensure sanitary conditions.
Lack of Supervision Leads to Resident Accident
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents for a resident who had a history of falls and required assistance with personal care. Despite the resident's known preference to sit outside and engage in daily exercises around the facility perimeter, staff did not provide supervision while the resident was outside. On the morning of the incident, the resident left the facility premises unsupervised and was involved in an auto versus pedestrian accident, resulting in multiple severe injuries. The resident, who was considered cognitively intact with a BIMS score of 13 out of 15, had a complex medical history including hypertensive heart and kidney disease, peripheral vascular disease, end-stage renal disease, and a history of falls. The resident's care plan indicated a need for supervision during activities of daily living, including toileting and transfers. However, the facility's staff, including the receptionist and nursing staff, were not specifically assigned to monitor residents outside, leading to a lack of awareness of the resident's departure from the facility. Interviews with facility staff revealed a lack of clarity and consistency in the monitoring process for residents who were outside. The receptionist, who was responsible for identifying elopement risks, was not present before 8:00 a.m., and no staff were assigned to monitor residents outside during this time. The facility's policies on leave of absence and resident safety were not effectively implemented, contributing to the resident's unsupervised departure and subsequent accident.
Failure to Administer Oxygen as Prescribed
Penalty
Summary
The facility failed to provide services that met professional standards of quality for a resident when Licensed Vocational Nurses (LVNs) did not administer oxygen as per the physician's order. The resident, who was admitted with diagnoses including Type 2 Diabetes Mellitus, Adult Failure to Thrive, Shortness of Breath, Hypoxemia, and Dependence on Supplemental Oxygen, was prescribed oxygen at 3 liters per minute via nasal cannula to maintain oxygen saturation at or above 93%. However, the LVNs administered only 2 liters per minute on multiple occasions, and there were several days with no documentation of oxygen administration in the Treatment Administration Record (TAR). Interviews and record reviews revealed that the physician's order was not followed for numerous days across May, June, and July, with the resident receiving less oxygen than prescribed. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) acknowledged the failure to follow physician orders and the lack of oversight in ensuring compliance. The Medical Records Director (MRD) had informed the DON and ADON about the missing documentation, but no follow-up actions were taken to address the issue. The facility's policies and procedures for oxygen therapy and physician orders emphasize the importance of administering oxygen as prescribed and verifying the completeness and accuracy of physician orders. Despite these guidelines, the LVNs did not adhere to the physician's orders, and the DON admitted to not providing the necessary oversight. This deficiency in care had the potential to impact the resident's health and well-being, as the resident was dependent on supplemental oxygen.
Failure to Prevent Involuntary Seclusion
Penalty
Summary
The facility failed to protect two residents from involuntary seclusion, which was not required to treat their medical symptoms. This deficiency occurred when an LVN closed the door to the room shared by the two residents, leaving them isolated and with unmet basic care needs. One resident expressed feelings of sadness, anger, and being unheard when she was unable to leave her room to a quieter area of her choice, while the other resident was yelling with the door closed. The incident was observed and reported by the first resident, who recalled the events of a particular night when the second resident was yelling, preventing her from sleeping. Despite using the call light to request assistance, communication barriers with the CNA and LVN led to the resident's needs being unmet. The LVN exited the room without addressing the resident's concerns and closed the door, leaving the resident to attempt to crawl to the door to seek help. Interviews with staff members revealed that the facility had resources, such as a language line, to assist in communication with residents who spoke different languages. However, these resources were not utilized in this instance. The facility's policy on abuse prevention and resident rights emphasized the importance of treating residents with dignity and ensuring their rights are respected, which was not adhered to in this case.
Resident Jumps from Second Story Due to Inadequate Supervision and Window Security
Penalty
Summary
The facility failed to ensure an environment free of accident hazards for a resident who removed a window screw, opened the window, and jumped from the second story, resulting in severe injuries. The resident, who had a history of mental health disorders including major depressive disorder and borderline personality disorder, expressed suicidal ideations to a Certified Nursing Assistant (CNA) but the CNA did not report these changes to the licensed staff. The resident was found outside by the sidewalk with multiple fractures and other injuries. The CNA, who was familiar with the resident's care, noted a change in the resident's demeanor and heard her expressing that she was done with everything. Despite these observations, the CNA did not report the change in behavior to the charge nurse, believing the resident was preparing to leave the facility for personal reasons. The facility's process required CNAs to report any changes in residents' behavior to the charge nurse immediately, which was not followed in this case. Additionally, the facility's maintenance department failed to ensure that window screws were securely in place, as evidenced by the observation of loose window screws in multiple rooms. The maintenance supervisor claimed that window screws were checked daily, but there was no documentation to support this. The facility's policy required the maintenance department to maintain the building in a safe and operable manner, which was not adhered to, contributing to the resident's ability to open the window and jump out.
Unsafe Window Conditions Lead to Resident Injury
Penalty
Summary
The facility failed to provide a safe environment for 28 of 134 residents due to loose window screws in 15 resident rooms on the second and third floors. This deficiency was highlighted when a resident, identified as Resident 1, was able to remove a protective screw from her window, push out the screen, and jump from the second floor, resulting in serious injuries. The resident was found outside by facility staff and was transferred to an acute hospital for further evaluation. Resident 1 had a complex medical history, including systemic lupus erythematosus, neuropathy, spinal stenosis, major depressive disorder, borderline personality disorder, anorexia, muscle weakness, PTSD, adult failure to thrive, homelessness, and noncompliance with medical treatment. Despite these conditions, Resident 1 was assessed as cognitively intact with a BIMS score of 14 out of 15. The resident reported suicidal ideations and attributed her actions to the treatment she received at the facility, although she could not specify the treatment. Interviews with facility staff, including CNAs, RNs, and the maintenance supervisor, revealed that the maintenance department was responsible for ensuring window screws were secure. However, there was no documentation of regular checks on window screws, and the maintenance supervisor admitted that while it was implied windows were checked during rounds, there was no specific record of this. The facility's administrator acknowledged that the screws should not have been easily removable and that the fire marshal had informed the facility that using screws to secure windows was not allowed.
Severe Roach Infestation in Kitchen
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in a significant infestation of roaches in the dishwashing area of the kitchen. On the day of the survey, roaches were observed crawling in the sink with dirty dishes, on the walls, and in the dishwasher, with some even swimming in the sanitizing water. The infestation was so severe that roaches were nesting in the corners of the dishwashing room and crawling into dish racks on the floor. This unsanitary condition was acknowledged by the dietary aide and the dietary services supervisor, who admitted to having seen roaches previously but did not recognize the extent of the infestation. Interviews with various staff members, including the administrator, dietary aides, and the infection preventionist, revealed that the presence of roaches in the kitchen was a known issue. The administrator and dietary supervisor were aware of roaches being seen in the kitchen but did not consider it an infestation. The infection preventionist incorrectly stated that roaches are sanitary and do not spread infections, despite acknowledging their presence in the kitchen. Residents also reported seeing roaches in the hallways and dining areas, indicating that the infestation was not limited to the kitchen. The facility's pest control service reports from previous months indicated ongoing issues with roaches, with recommendations for improved sanitation and sealing of cracks and crevices. Despite these recommendations, the facility failed to implement effective measures to control the pest problem. The pest control representative confirmed that sanitation plays a crucial role in keeping roaches away, as they thrive in cluttered and dirty environments with food debris. The facility's failure to address these issues led to an unsanitary environment that posed a risk of cross-contamination and potential harm to residents.
Failure to Administer Prescribed Pain Medication
Penalty
Summary
The facility failed to provide necessary care according to professional standards for a resident who did not receive prescribed pain medication for three days. The resident, who was admitted with conditions including hemiplegia, aphasia, major depressive disorder, facial weakness, and type 2 diabetes, was observed in pain and guarding her abdomen. Despite a physician's order for Ibuprofen 800 mg every six hours as needed for pain, this medication was not administered following the resident's return from an acute care hospital. The resident had been discharged from the hospital with a prescription for pain management, but the order was not recorded in the facility's medication administration records. Interviews with staff, including a CNA and an LVN, revealed that the resident had returned from a leave of absence complaining of abdominal pain after an alleged attack. The LVN acknowledged that the medication order was not completed or added to the resident's orders, which was crucial for managing the resident's pain. The Director of Nursing confirmed that the order for Ibuprofen was not clarified with the resident's physician upon her return to the facility. The facility's policy required licensed nurses to ensure physician orders are clear and documented, but this was not followed. The administrator also stated that it was expected for nurses to clarify and input new orders into the resident's medication records, which did not occur in this case.
Failure to Provide Adequate Supervision and Assistance During Care
Penalty
Summary
The facility failed to ensure adequate supervision and assistance to prevent accidents for a resident who fell out of bed during care provided by a CNA without the required assistance from another staff member. The resident, who had severe cognitive impairment and was dependent on staff for various activities, sustained significant injuries including a fractured occipital condyle, a laceration to the nose, and swelling to the left eye. The resident's care plan clearly indicated the need for two-person assistance during care, which was not followed by the CNA, leading to the fall and subsequent injuries. The incident occurred when the CNA attempted to change the resident's brief alone, despite the care plan and visual indicators (a picture of two hands shaking) outside the resident's room that signified the need for two-person assistance. The CNA admitted to not following the care plan, resulting in the resident rolling out of bed and falling to the floor. The resident was found face down, bleeding, and in pain, and was subsequently diagnosed with a fractured occipital condyle at the hospital. Interviews with various staff members, including the ADON, DON, and other CNAs, confirmed that the resident required two-person assistance for care and that the failure to follow this protocol directly led to the fall and injuries. The facility's policies on fall management and resident safety were not adhered to, as the CNA did not follow the established care plan designed to prevent such accidents and ensure the resident's safety.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 313 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Fresno
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Fresno Postacute Care | 1.1 mi | ★★★★★ | 16 | 0 |
| Community Subacute And Transitional Care Center | 2.5 mi | ★★★★★ | 12 | 0 |
| Sierra Vista Healthcare | 2.5 mi | ★★★★★ | 18 | 0 |
| Oakwood Gardens Care Center | 2.8 mi | ★★★★★ | 2 | 0 |
| Covenant Post Acute | 2.8 mi | ★★★★★ | 5 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.