Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Huntington Drive Health And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with dementia, benign prostatic hyperplasia, and an indwelling Foley catheter had a care plan requiring catheter care and catheter/bag changes, but chart review over several months showed no physician order for Foley care and no documentation that such care was provided. The resident was cognitively impaired and dependent for ADLs, including toileting and hygiene. Nursing staff, including treatment nurses and an RN, acknowledged that Foley care (genital cleansing with soap and water, monitoring for infection, ensuring proper catheter positioning and securement, and keeping the drainage bag off the floor) should have been provided and documented for all residents with Foley catheters. Staff also reported there was no facility policy specific to Foley catheter care, despite a general policy requiring comprehensive person-centered care plans with measurable objectives.
A resident with a left abdominal colostomy, partial intestinal obstruction, and CKD required assistance with hygiene and toileting and had physician orders for colostomy care and as-needed emptying of the colostomy bag. Over a multi-week period, the TAR and electronic record contained no entries showing that colostomy care or colostomy bag changes were provided, despite a care plan directing appliance changes per orders. Nursing staff acknowledged that, per facility protocol and the colostomy/ileostomy care policy, such care should include assessment of the stoma and surrounding skin, cleaning, and emptying or changing the bag, and must be documented with date, time, staff identification, skin findings, resident tolerance, and any refusals, but this documentation was absent.
The facility failed to address repeated grievances from two cognitively intact residents regarding a roommate who refused to allow use of a shared restroom or permit CNAs to obtain water there for care of roommates. One resident reported being blocked from using the in-room restroom and call light and stated that complaints to the ADM and at resident council meetings were not resolved. Another resident reported that CNAs had to use her restroom to get water to bathe the controlling resident’s roommate and that leadership was aware through council meetings. Multiple CNAs and the SSD confirmed that previous roommates complained, were redirected to other residents’ restrooms, and often requested room changes, while the DON and an RN acknowledged that roommates had the right to use the shared restroom and that follow-up and closure to the grievances had not occurred, contrary to the facility’s resident rights policy.
A resident with COPD, a history of falls, and identified fall risk had three oxygen tanks stored in the restroom and two additional tanks just outside the restroom near the bed. Staff, including an LVN, RN, and the DON, acknowledged that multiple oxygen tanks in the room and restroom were a safety, trip, and fire hazard and that only one tank for active use should be in the room, with others stored in the designated oxygen storage area. Facility policies on fire safety and resident safety explicitly prohibited storing oxygen cylinders in resident rooms or living areas and required maintaining an environment free from accident hazards, but these policies were not followed in this case.
Staff failed to maintain dignity and privacy for several residents during care and daily interactions. A resident with dementia and dependence for ADLs was exposed while brief care was provided with the curtain partly open, another resident was called “Honey” and “Mama” instead of by name, an ADC entered a room without knocking, a resident with an indwelling catheter was left in urine-soiled clothing and later smelled like urine in the hallway, and another resident’s foley drainage bag was left uncovered and touching the floor.
Call lights not kept within reach or answered promptly. One resident with DM2, HTN, ESRD on dialysis, and moderately impaired cognition had a call light lying out of reach on the floor side of the bed while trying to reach it. Another resident with MDD, anxiety, and bipolar disorder had a call light sounding and visible from the hallway while staff at the nursing station did not respond, and the resident stated nurses don't usually answer the call light.
Failure to provide toileting assistance and bathing support for two residents. One resident with impaired mobility and moderate cognitive impairment reported staff ignored his call light, told him to urinate in his diaper, and left him wet overnight. Another resident, who was continent and needed partial to moderate assistance with ADLs, reported being told to pee in her diaper and not receiving a bath for several days after admission. Staff interviews confirmed the care was not appropriate and that residents should have been assisted with toileting or offered a bedpan and provided bathing support.
Two residents at risk for falls had beds left at approximately three feet from the floor with middle side rails up, despite care plans directing staff to keep the bed in the lowest position. One resident had Parkinson’s disease and the other had epilepsy, hemiplegia, and hemiparesis following cerebral infarction; both had intact cognition and required varying levels of assistance with ADLs. An LVN, RN, and the DON stated the beds should have been lowered for safety, and the facility’s falls policy identified incorrect bed height as a fall-risk factor.
Indwelling catheter care failures affected two residents. One resident’s drainage bag was observed touching the floor and was not covered, while staff stated the bag should have been kept off the floor to avoid contamination. Another resident’s leg bag was not consistently emptied, often disconnected when full, and was changed without aseptic technique; staff also inserted an 18 Fr foley instead of the ordered 16 Fr catheter and did not secure the catheter with a device.
Oxygen therapy was not provided as ordered for two residents with respiratory conditions. One resident with respiratory failure, pulmonary edema, and pneumonia had a nasal cannula found on the head, neck, and later hanging on the bed rail instead of in the nostrils while the O2 concentrator was running. Another resident with chronic respiratory failure with hypoxia, asthma, and morbid obesity was observed with the cannula on the upper lip rather than in the nostrils until an LVN adjusted it.
Two LPNs lacked documented competency for Foley catheter care, and one stated she was never evaluated while the other did not remember being evaluated. The facility assessment identified Foley care training as an action item, and the facility policy required nursing staff to have the skills and competencies needed to provide resident care, including indwelling catheter care.
A dietary staff member prepared fortified cream of wheat without following the facility’s Super Cereal recipe, using an unmeasured amount of brown sugar, the wrong sweetener, and an incorrect amount of evaporated milk, while also adding vanilla flavoring. The RD and DS confirmed the recipe was not followed for residents ordered fortified diets, and the facility policy required standardized recipes to be used in food preparation.
Failure to Honor Resident Food Preferences and Provide Appropriate Meal Substitutes: Two residents with intact cognition were served foods that did not match their stated preferences. One resident repeatedly received red meat and pork despite stating she disliked them and writing her preferences on meal tickets, while the other resident was served wheat bread even after telling the DS she only ate white bread. Staff did not timely document or update dietary preferences, and one resident did not have a care plan addressing her food preferences.
Food storage and tray line sanitation practices were not followed. Unlabeled and undated sandwiches, unlabeled bread, and an improperly rewrapped frozen food item were observed in storage, along with cleaning buckets placed next to food and debris on oven surfaces. During tray line assembly, a dietary staff member did not change gloves or wash hands between tasks, handled documentation items and raw food with the same gloves, and allowed a dirty apron and gloved hand to contact residents' plates.
Unsanitary resident room conditions were observed for three residents. One resident with DM, depression, HTN, and impaired cognition had a used diaper, a cup with chocolate, and a fan with sticky residue in the room. Another resident with DM, HTN, renal dialysis, impaired cognition, and fall risk had used perineal wipes on the floor. A third resident with epilepsy, MDD, and dementia had a curtain with brown stains while CNA care was being provided, despite facility policies requiring clean, sanitary, orderly resident areas.
Failure to Obtain Informed Consent for Bed Rails: A resident with epilepsy, hemiplegia, and hemiparesis following cerebral infarction was observed in bed with bilateral bedside rails in use. RN, MDS Coordinator, and DON stated there was no informed consent for the rails, and the facility policy required staff to inform the resident or representative of the benefits and potential hazards and obtain consent before use.
Incomplete and inaccurate PASRR screenings were found for two residents with psychiatric diagnoses. One resident’s PASRR incorrectly stated there was no serious mental illness and no psychotropic use despite diagnoses of depression, psychosis, and dementia and orders for Duloxetine and Olanzapine. Another resident’s PASRR Level I screening was incomplete and did not reflect major depressive disorder and unspecified psychosis, and the DON stated the screenings should have been reviewed for completeness and accuracy.
Failure to Maintain Resident Cleanliness and Dignity During Breakfast: A resident with epilepsy, MDD, and dementia who was dependent for multiple ADLs was observed during breakfast with white liquid running from her mouth down her chin and white cream-like substance on her blanket and chest towel. An LVN noted the resident was dirty, and a CNA stated the condition was not acceptable because it affected dignity and that the resident should always be kept clean.
Dialysis E-Kit Not Readily Accessible at Bedside: A resident with ESRD on a Tue/Thu/Sat HD schedule had no dialysis E-Kit found in the room during observation. The resident’s care plan addressed AV shunt bleeding with instructions for staff to apply pressure, and an LVN confirmed the kit was not present. The DON stated the facility practice was to keep the E-Kit easily accessible, and the DSD said it should contain clamps, tape, gauze, and a tourniquet.
Medication services were not carried out according to policy for two residents. One resident’s Bactrim DS and Prevymis were left at the bedside even though the resident was not approved for self-administration, and an LVN acknowledged the medications should not have been left there. For another resident with DM, an LVN administered insulin aspart and withdrew the needle immediately instead of waiting about five seconds, then later gave scheduled medications without checking two identifiers or the resident’s armband, despite facility policy requiring resident identification before administration.
Failure to monitor anticoagulant therapy: A resident with respiratory failure, HTN, and Afib was ordered Apixaban for stroke prevention, but the chart lacked documented monitoring for bleeding-related side effects. The resident’s care plan called for monitoring bruising, bleeding, and hematoma, yet the NPNs contained no evidence that this was done, and the MDS Coordinator confirmed there was no order for bleeding surveillance.
Kitchen Trash Can Left Uncovered: A large gray trash can next to the steam table was observed with trash inside and no lid during a kitchen observation. The RD stated trash cans should always be covered for pest control and to prevent cross contamination, and the DS acknowledged the kitchen trash can policy was not followed. The facility policy required garbage and refuse containers to have tight-fitting lids or covers and to be kept covered when not in continuous use.
Failure to Follow EBP Gown and Glove Practices During Resident Care: A CNA provided bed bath and dressing care to a resident with a wound and EBP without wearing a gown, and also handled linen without PPE. An LVN cared for another resident with a G-tube without a gown and repeatedly used the same gloves between tasks, including touching the resident’s blanket, shirt, curtain, medication cart, and G-tube supplies. The LVN stated she did not change gloves between tasks and should have done so because of infection control requirements.
Missing Staff Flu Vaccination Declination Documentation: The facility failed to maintain documentation of screening, education, offering, and current Influenza vaccination status for one sampled CNA. The IPN stated the CNA refused the Flu vaccine but there was no consent or declination documentation showing the staff member declined both vaccinations. The DON stated staff vaccination records should be maintained for Covid-19 and Influenza, and the facility policy required declined vaccinations to be documented on the applicable declination form and placed in the employee health record.
Missing Documentation for Staff COVID-19 Vaccination Status: The facility failed to maintain documentation of screening, education, offering, and current COVID-19 vaccination status for one of four sampled staff members. CNA 1 reportedly refused the COVID-19 vaccine, but the record did not include documentation of consent showing the staff member declined both the COVID-19 and influenza vaccines. The IPN and DON stated staff vaccination records are used to track status, identify staff who must wear masks in resident care areas, and document who was offered and declined vaccination.
A resident with severe cognitive impairment, gait abnormalities, and need for assistance with bed mobility and transfers had physician-ordered bilateral 1/3 bed rails as an enabler for mobility and positioning. During observation, the resident was found in bed with both rails raised, and an LVN discovered the rails were stuck and could not be lowered. A Maintenance Assistant removed and reinstalled the rails but was still unable to lower one side and acknowledged that this type of bed’s rails were not working properly. A CNA stated the rails should function because staff use them during care, and the DON affirmed beds should be in good working order. These findings showed the bed rails were malfunctioning and not maintained per facility policies requiring equipment to be safe, operable, and repaired or replaced when worn or defective.
Two residents were not treated with dignity and did not have their preferences accommodated when one resident was left sitting in a wheelchair for an extended period after a room transfer because clothes and personal belongings were left piled on the bed, preventing use of the bed, and a functional TV remote was never provided. Staff interviews confirmed that CNAs were expected to put belongings away during room moves and that the remote available was incompatible with the resident’s TV. Another resident, who valued keeping up with the news, reported that key news channels on the TV were blurred or nonfunctional, which was confirmed by the maintenance assistant. The DON acknowledged that TV remotes and channels should work so residents can watch their preferred programs.
A resident with bilateral hip osteoarthritis and a right artificial knee joint, who had intact cognition and required assistance with ADLs, had a physician’s order for RNA ambulation services three times per week using a front-wheeled walker and gait belt. Review of RNA logs and documentation, along with staff interviews, showed that ordered RNA ambulation sessions were missed on multiple days and that the resident received fewer sessions than ordered. The resident reported that RNA staff did not come as scheduled, and the DSD confirmed that undocumented RNA services were not performed. The DON stated that RNA services are important to maintain mobility and acknowledged that the resident did not have an RNA care plan, despite facility policy requiring restorative goals and interventions to be outlined in the plan of care.
Two residents with respiratory conditions did not receive oxygen therapy as ordered, with one not wearing the nasal cannula and receiving an incorrect oxygen flow rate, and another experiencing low oxygen saturation levels without physician notification. Facility staff failed to follow physician orders and facility policy regarding oxygen administration and documentation.
The facility did not maintain a safe and sanitary environment by failing to address water leaks in a hallway and a resident's room. Water damage was observed, with water leaking into bins and towels used to absorb excess water. A resident with significant medical needs reported water leaking onto personal items, and staff confirmed the presence of water damage. Maintenance staff were unaware of the issue due to a lack of proper reporting and communication, and required maintenance logs and electronic reports were not completed.
A resident received a Foley catheter without documentation of the medical indication, time of insertion, or required monitoring of intake and output, contrary to facility policy. Nursing staff and the DON confirmed that the order lacked an indication and that documentation and care planning were incomplete at the time of catheter insertion.
A resident with a history of hemiplegia and hemiparesis experienced dizziness and vomiting, which was reported to nursing staff but not documented in the medical record. Licensed staff and the DON confirmed that such symptoms should have been recorded according to the care plan and facility policy, resulting in an incomplete and inaccurate medical record.
A deficiency was cited for not ensuring a resident's right to dignity, self-determination, communication, and the exercise of their rights. The report does not specify the exact circumstances or individuals involved.
A resident prescribed Ambien for insomnia did not have their hours of sleep properly documented, as required by physician orders. Instead of recording the specific number of hours slept, staff only marked check boxes on the MAR, making it unclear whether the medication was effective. Interviews with the resident, an LVN, and the ADON confirmed that this monitoring was incomplete and did not meet facility policy for psychotropic medication management.
A resident with a history of cerebral infarction and dementia reported to the DSD that she hit her head on a grab bar in the bathroom. The DSD did not notify the physician, document an assessment, or initiate a Change of Condition, and there was no evidence of monitoring or treatment in the medical record, contrary to facility policy.
A resident with a history of falls, bilateral leg weakness, and total dependence for bed mobility, who was using a low air loss mattress, experienced a fall during incontinent care when only one CNA was present. The care plan did not specify the required staff assistance or interventions needed to prevent falls during such care, despite facility policy and staff knowledge that two staff should be present for residents on a LALM.
A resident with major depressive disorder and hemiplegia was discouraged from voicing grievances after a CNA told her that continued complaints would result in no one wanting to work with her. This statement violated the facility's policy on resident rights, which ensures grievances can be voiced without fear of discrimination or reprisal. The Director of Staff Development confirmed the CNA's actions were inappropriate and not in line with the facility's policy.
The facility failed to maintain a homelike environment, as 10 resident rooms were found with chipped and peeling paint, contrary to the facility's policy. Observations confirmed the presence of unpainted patched areas, and interviews with staff, including the Maintenance Supervisor and DON, acknowledged the need for repainting. The ADM was aware of the issue, which posed a risk for an unsafe and unclean environment.
The facility failed to follow proper food handling practices, resulting in several opened and expired food items being improperly labeled or not discarded. During a kitchen tour, the Dietary Supervisor identified items like seasoning salt, ground ginger, and pasta that lacked proper labeling, and expired items like browning sauce and food coloring were found in the kitchen. The facility's policy requires labeling with delivery or use-by dates and discarding expired items, which was not adhered to, potentially exposing residents to foodborne illnesses.
The facility failed to adhere to infection control protocols, including enhanced barrier precautions and standard precautions, for multiple residents. Staff did not change gloves or perform hand hygiene after providing care, handling soiled items, or before administering medications. A resident with a permacath lacked proper signage and PPE, and staff were unaware of necessary precautions. These lapses increased the risk of infection spread.
A resident with muscle weakness and spinal stenosis was observed with food particles on their clothing, which they found bothersome. The facility's policy on dignity was not followed, as staff failed to keep the resident's clothes clean, impacting their dignity and self-worth. The RN and DON acknowledged the issue, noting the importance of maintaining cleanliness to uphold residents' dignity.
A facility failed to obtain informed consent from a resident before administering Lorazepam, a psychoactive medication. The resident, who was cognitively independent but required physical assistance, was not informed of the risks and benefits of the medication. The facility's policy requires consent prior to administering such medications, which was not followed, as confirmed by staff and the resident.
A resident with severe cognitive impairment and physical limitations did not receive timely assistance for a diaper change, despite multiple requests. The CNA prioritized other tasks, delaying care and potentially risking the resident's well-being. Facility policies on accommodating resident needs and supporting ADLs were not followed.
A resident with mobility issues was using a wheelchair with torn tires, which posed a risk of falls and injury. The maintenance department was not informed about the damage, and the facility's policy on maintaining safe equipment was not followed.
A resident with respiratory failure and COPD did not receive continuous oxygen as ordered, as the nasal cannula was not replaced after restroom use. The resident had to request assistance to have the oxygen restored, which was confirmed by an LVN as a deviation from the physician's order, risking respiratory complications.
A facility failed to adhere to a physician's order for a fluid restriction of 1200 cc per day for a resident with end-stage renal disease on dialysis. Documentation showed discrepancies in fluid intake records, with missing entries and recorded intakes exceeding prescribed amounts. The resident was observed with a full pitcher of water, and staff interviews revealed a lack of adherence to the fluid restriction protocol. The facility's policy on end-stage renal disease care was not followed.
A facility failed to assess and obtain informed consent for the use of bedside rails for a resident with a history of cerebral infarction and falls. Despite physician orders for the rails as an enabler, no consent was documented, and only two assessments were conducted. The facility's policy requires alternatives, interdisciplinary evaluation, and informed consent before using bed rails, which was not followed, placing the resident at risk.
A facility failed to coordinate hospice care for a resident with severe cognitive impairment and multiple diagnoses, including cirrhosis and congestive heart failure. The CHHA did not follow the physician's order for twice-weekly visits, and no hospice care plan was developed. The DON and DPCS acknowledged these deficiencies, which could impact the resident's comfort and quality of life.
A facility failed to ensure a resident's call light was within reach, as observed when the call light was found on the floor while the resident was in bed. The resident, with a history of cerebral infarction and falls, required substantial assistance with daily activities. Staff interviews confirmed the expectation for call lights to be accessible, aligning with the facility's policy.
A resident with a femur fracture experienced a significant delay in receiving pain medication, despite having a pain management plan in place. The resident requested medication and waited nearly two hours in severe pain before it was administered. The LVN was informed of the request but delayed administration, contrary to facility protocol requiring timely medication delivery. The DON confirmed the importance of prompt pain management and communication with residents.
Failure to Provide and Document Foley Catheter Care per Care Plan
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide and document Foley catheter (F/C) care for a resident with an indwelling urinary catheter, as required by the resident’s care plan. The resident had diagnoses including urethral discharge, dementia, and benign prostatic hyperplasia with lower urinary tract symptoms, and had an order for an 18 Fr F/C related to bladder sphincter dyssynergia due to obstructive uropathy. The resident’s care plan for an indwelling catheter related to obstructive uropathy, revised on 1/26/2026, included interventions to provide F/C care and change the catheter and catheter bag per order. The MDS assessment documented that the resident had severely impaired cognitive skills for daily decision making, was dependent for oral care, toileting, personal hygiene, dressing, and bathing, and had an indwelling urinary catheter. Record review of the resident’s electronic medical chart from 10/1/2025 through 4/8/2026 showed no physician’s order for F/C care and no documentation that F/C care was provided during that period. Treatment Nurse 2 confirmed there was neither an order nor documentation of F/C care and stated that F/C care should have been provided and documented daily by the assigned treatment nurse, describing F/C care as cleaning the genital area with soap and water, monitoring for signs of infection, ensuring the catheter is clean, not kinked, properly secured, and that the drainage bag is not touching the floor. Treatment Nurse 1 stated the resident should have had an order for F/C care and that all residents with F/Cs should receive such care and have it documented. Registered Nurse 2 reported the facility did not have a policy specific to F/C care but stated that F/C care should be provided to every resident with a Foley catheter and that this resident should have been receiving F/C care during the reviewed period. The facility’s Comprehensive Person-Centered Care Plan policy required development and implementation of a comprehensive care plan with measurable objectives for each resident.
Failure to Provide and Document Ordered Colostomy Care
Penalty
Summary
The facility failed to provide and document colostomy care as ordered and per policy for one resident. The resident was admitted with diagnoses including partial intestinal obstruction, colostomy status, and chronic kidney disease, and had a documented left abdominal colostomy. An MDS assessment showed the resident had moderately impaired cognitive skills for daily decision making and required assistance ranging from partial/moderate to total dependence for hygiene, toileting, dressing, and bathing. Physician’s orders dated 8/27/2025 directed that colostomy care be provided and the colostomy bag emptied as needed, and the resident’s care plan instructed that the colostomy appliance be changed per physician’s orders. Review of the Treatment Administration Record from 11/16/2025 through 12/6/2025 showed blank entries for colostomy care and colostomy bag emptying, and concurrent review of the electronic medical record for the same period revealed no documentation that colostomy care or colostomy bag replacement had been provided. The treatment nurse confirmed there was no documentation of colostomy care or bag changes during that time and stated that, per facility protocol, such care should be documented on the TAR or in a progress note. A registered nurse similarly stated that colostomy care includes checking for signs of infection, cleaning the stoma site, and emptying or changing the colostomy bag, and that this care must be documented when done. The facility’s colostomy/ileostomy care policy required documentation of the date and time care was provided, the staff member’s name and title, skin condition and signs of infection, resident tolerance, refusals and reasons, and the signature and title of the person recording the data, which was not present for the identified period.
Failure to Address Grievances and Ensure Equal Access to Shared Restroom
Penalty
Summary
The deficiency involves the facility’s failure to address resident grievances and ensure equal access to a shared restroom and related services for roommates of a cognitively intact resident. One resident with major depressive disorder and anxiety, who required varying levels of assistance with ADLs but had intact decision-making skills, reported that when previously sharing a room with another resident, she was not allowed by that roommate to use the in-room restroom or the call light. She stated she had reported these concerns to the Administrator and raised them multiple times in resident council meetings but did not feel her concerns were heard, and she believed the facility avoided assigning a roommate to the controlling resident because that resident would “raise a fuss.” Another resident with major depressive disorder and COPD, also cognitively intact and requiring assistance with ADLs, reported that the same controlling resident would not allow any roommates to use the shared restroom or allow CNAs to obtain water from that restroom to provide care to the roommates. This resident stated that CNAs instead used the restroom in her room to get water to bathe the controlling resident’s previous roommate, and that the Activity Director was aware of these concerns from resident council meetings but nothing had been done. Staff interviews corroborated that CNAs had to obtain water from other residents’ restrooms because the controlling resident would not permit use of the shared restroom, and that roommates who were able to walk were told by the controlling resident to use other residents’ restrooms rather than the shared one in their own room. The Social Services Director stated that previous roommates who could use the restroom had complained about not being allowed to use the shared restroom and often requested room changes, and acknowledged it was not acceptable for them to have to use another resident’s restroom because they had the same rights to use the shared restroom. The DON acknowledged hearing about the shared bathroom complaints during a recent resident council meeting but had not yet spoken to the controlling resident, and stated there should have been follow-up and closure provided to the residents who raised concerns. The DON and an RN both affirmed that roommates had the right to use the shared restroom and that CNAs should be able to use it to obtain water for care. The facility’s Resident Rights policy stated that residents have the right to communication with and access to services and to voice grievances and have the facility respond, but the reported and observed handling of these complaints showed that the concerns of the affected residents were not addressed or resolved.
Improper Storage of Multiple Oxygen Tanks in Resident Room and Restroom
Penalty
Summary
The deficiency involves the facility’s failure to keep a resident’s environment free from accident hazards by improperly storing multiple oxygen tanks in and near the resident’s restroom and room. The resident, who had COPD, a history of falls, and was assessed as at risk for falls, was cognitively intact and required setup assistance for toileting hygiene, showering, lower body dressing, and footwear, but was otherwise independent with eating, oral and personal hygiene, and upper body dressing. During observation, surveyors noted three oxygen tanks inside the resident’s restroom and two oxygen tanks just outside the restroom near the wall on the left side of the room. Staff present acknowledged that the resident had many oxygen tanks in the room and restroom. In interviews, an LVN stated that the three oxygen tanks in the restroom and two by the foot of the bed should be removed because they could be a safety hazard for the resident. An RN stated that oxygen tanks not in use should be stored in the oxygen storage room, not in a resident’s room, and that only one oxygen tank for the resident’s use should be in the room, further stating that five oxygen tanks in the room should not be allowed because they are a safety and trip hazard. The DON stated that the five oxygen tanks stored in the resident’s room were a big hazard because the resident could trip, fall, and might hit her head on the oxygen tank, and also described them as a fire hazard that should be stored in the oxygen storage room. Review of facility policies showed that the Fire Safety and Prevention policy prohibited storing oxygen cylinders in any resident’s room or living areas, and the Safety and Supervision of Resident policy stated the facility strives to make the environment as free from accident hazards as possible and that resident safety, supervision, and assistance to prevent accidents are facility-wide priorities.
Dignity and Privacy Failures During Resident Care and Interactions
Penalty
Summary
Facility staff failed to promote dignity and respect for five sampled residents during observation and interview. The report documented that Resident 37, who had epilepsy, major depressive disorder, and dementia and was dependent for multiple activities of daily living, was observed on two occasions while staff provided brief changes and morning care with the privacy curtain only halfway open. On both occasions, the resident’s body was visible to others in the room, including the roommate, while care was being provided. Staff later stated the curtain should have been fully closed to protect privacy and dignity, and the facility’s dignity policy required bodily privacy during personal care and treatment. Resident 51, who had sepsis, CKD, GERD, and severely impaired cognitive skills for daily decision making, was addressed by staff using terms such as “Honey” and “Mama” rather than by the resident’s name of choice. During one observation, an LVN told the resident to hold a cup and referred to her as “Honey.” During another observation, a CNA asked the resident, “Do you want something Mama?” and later said, “Good job Mama!” The CNA stated she did not know how to address the resident, and the facility’s dignity policy stated staff should address residents by their name of choice and not label them. Resident 79, who had encephalopathy, DM, and a G-tube and was moderately cognitively impaired, was observed sleeping in bed when an ADC entered the room without knocking and walked to the bedside without acknowledging the resident. The ADC stated she did not knock because the resident was sleeping, but also stated staff need to knock before entering any resident’s room and introduce themselves. Resident 24, who had obstructive and reflux uropathy, hydronephrosis, BPH, moderately impaired cognition, and an indwelling catheter, was observed sitting in a wheelchair in the hallway with pants soiled with urine and later was observed smelling like urine while sitting outside his room. Staff walked by without assisting him at the time of the first observation, and the MDS coordinator later stated staff should change residents when soiled and should not leave them sitting in soiled clothing in the hallway. Resident 47, who had a UTI, dysphagia, orthostatic hypotension, moderately impaired cognition, and an indwelling catheter, was observed with a foley drainage bag touching the floor and not covered with a dignity bag. The CNA stated the drainage bag should not touch the floor and should always be covered with a dignity bag.
Call lights not kept within reach or answered promptly
Penalty
Summary
The facility failed to reasonably accommodate resident needs by not ensuring call light devices were within reach and answered in a timely manner for two sampled residents. Resident 29 was admitted with type 2 diabetes mellitus, hypertension, and dependence on renal dialysis. The MDS dated 2/4/2026 indicated moderately impaired cognitive skills for daily decision making and partial/moderate assistance with oral hygiene, upper body dressing, personal hygiene, lying to sitting on the side of the bed, and chair/bed-to-chair transfer. The care plan initiated 2/3/2026 identified fall risk related to limited mobility, fracture, and history of falls, and stated the resident needed a working and reachable call light. During observation and interview on 2/23/2026 at 10:14 AM, Resident 29's call light was observed on the left side of the bed facing down toward the floor. Resident 29 was trying to reach the call light and stated she could not reach it. Resident 29 also stated that call lights at night shift are not being answered. This observation showed the resident did not have the call light within reach at the time of the surveyor visit. Resident 43 was admitted with major depressive disorder, anxiety disorder, and bipolar disorder. The MDS indicated cognitively intact daily decision making and partial/moderate assistance with upper body dressing, personal hygiene, and rolling left and right. The care plan initiated 1/14/2022 identified potential for fall or injury related to impaired physical mobility and directed staff to orient the resident to the call light, keep it within reach, and answer call lights promptly. During concurrent observation and interview on 2/23/2026 at 10:46 AM, the call light in Room A was on and visible from the hallway while LVN 6 was speaking with the resident's family and two nurses were sitting at the nursing station. LVN 6 stated the two nurses at the nursing station should have answered the call light, but they did not respond. Resident 43 stated nurses don't usually answer the call light and that the resident had to wait for nurses to answer.
Failure to Provide Toileting Assistance and Bathing Support
Penalty
Summary
The facility failed to ensure two residents received assistance with toileting and personal hygiene. Resident 104 was admitted with diagnoses including lack of coordination, gait and mobility abnormalities, and a lumbar fracture. His MDS showed moderate cognitive impairment for daily decision making and dependence for toileting hygiene and showering, with substantial to maximal assistance needed for lower body dressing. Family and resident interviews stated that on the night of 2/23/2026, after the resident pressed the call light and requested help to use the restroom, staff did not respond for more than an hour and told him he could urinate in his diaper. The resident reported he remained in a wet diaper overnight and was changed the next morning, and he stated the same thing happened the prior night as well. Resident 107 was admitted with diagnoses including a displaced midcervical fracture of the right femur, gait and mobility abnormalities, and muscle weakness. Her admission assessment indicated she was continent of bladder and bowel, and her MDS showed intact memory and cognitive skills, with partial to moderate assistance needed for toileting hygiene, bathing, dressing, personal hygiene, and toilet transfer. Documentation showed she did not receive a bath from 2/18/2026 through 2/22/2026, despite the shower schedule listing Room B for Mondays and Fridays. Resident 107 stated that when she asked for help to use the bathroom after admission, an unknown CNA told her to urinate in her diaper, and she reported feeling degraded and wanting to leave the facility. Interviews with staff supported that the care provided was not consistent with the residents’ needs. CNA 4 stated Resident 107 should have been given a bath or shower on 2/20/2026 if admitted on 2/18/2026, that staff should not wait until the scheduled shower day, and that residents’ requests for a bath should be accommodated the same day. CNA 4 and the DSD stated it was not acceptable to tell Resident 107 to pee in her diaper and that staff should have assisted her to the bathroom or offered a bedpan instead. RN 1 and LVN 3 stated telling Resident 104 to urinate in his diaper and leaving him wet was a dignity concern. The facility policy stated residents would be provided care and services to maintain or improve their ability to carry out ADLs, including hygiene support.
Beds Not Kept in Lowest Position for Two Fall-Risk Residents
Penalty
Summary
The facility failed to ensure that the beds for two residents were kept in the lowest position as identified in their care plans. Resident 81 was admitted with Parkinson’s disease and had intact cognitive skills for daily decision making, but required assistance with multiple activities of daily living and was identified on the fall risk assessment as being at risk for falls. The care plan, revised on 2/5/2026, directed staff to keep the bed at the lowest level and check the environment for hazards. During observation on 2/23/2026, Resident 81 was asleep in bed with both middle side rails up and the bed height left at approximately three feet from the floor. An LVN later stated the bed was not in the lowest position and should have been lowered to prevent injuries from falling. Resident 86 was admitted and readmitted with diagnoses including epilepsy, hemiplegia, and hemiparesis following cerebral infarction, and the fall risk assessment identified the resident as being at risk for falls. The resident’s MDS indicated intact cognitive skills for daily decision making and dependence or need for assistance with several activities of daily living. The care plan, revised on 8/26/2025, directed staff to keep the bed at the lowest level and check the environment for hazards. During observation on 2/23/2026, Resident 86 was awake in bed with both middle side rails up and the bed height left at approximately three feet from the floor. RN 1 and the DON stated the residents’ beds should be in the lowest position for safety, and the facility policy on falls identified incorrect bed height as an environmental factor contributing to fall risk.
Indwelling catheter care failures for two residents
Penalty
Summary
The facility failed to provide proper catheter care and services for two residents with indwelling urinary catheters. Resident 47 was admitted and later readmitted with diagnoses including urinary tract infection, dysphagia, and orthostatic hypotension. The resident’s MDS indicated moderately impaired cognitive skills for daily decision making, dependence for oral/toileting hygiene, showering, dressing, and bed mobility, and the presence of an indwelling catheter. During a concurrent observation and interview, Resident 47’s foley catheter drainage bag was observed touching the floor and was not covered with a dignity bag. CNA 9 stated the drainage bag should not touch the floor. TN 1 stated bacteria can enter the drainage bag if it touches the floor, causing infection, and that staff were responsible for ensuring the bag stayed off the floor. The facility’s catheter care policy stated the catheter tubing and drainage bag should be kept off the floor. Resident 24 was admitted and readmitted with diagnoses including obstructive and reflux uropathy, unilateral inguinal hernia, and benign prostatic hyperplasia with lower urinary tract symptoms. The resident’s MDS indicated moderately impaired cognitive skills for daily decision making, need for supervision or touching assistance with toileting hygiene, personal hygiene, sit-to-stand, and toilet transfer, partial/moderate assistance with bathing and dressing, and use of an indwelling catheter. The physician order summary directed use of a 16 Fr/10 cc foley catheter, monthly catheter changes, and leg bag changes every Sunday and as needed. During observation and interview, Resident 24 stated he smelled like urine because staff did not always empty his urine bag when full and that he sometimes had to empty it himself because the leg bag disconnected when it became too full. TN 1 stated the leg bag was frequently changed because it would disconnect, and CNA 5 stated the bag was sometimes full at the start of the shift and should be emptied at least twice per shift to prevent disconnection. During the leg bag change, TN 1 and TN 2 used non-sterile gloves and gowns, but TN 1 did not clean the catheter connection site before disconnecting and reconnecting the new leg bag. TN 1 and TN 2 stated aseptic technique should have been followed, and TN 1 acknowledged the connection site should have been cleaned with alcohol before the change. The record and observation also showed Resident 24 had an 18 Fr foley catheter inserted instead of the ordered 16 Fr catheter, and the catheter was not secured with a device. TN 2 stated the catheter had never been secured, and TN 1 stated she did not know why the larger catheter was inserted. The DON stated the catheter should have been emptied every shift or as needed when full, aseptic technique should have been used, and the catheter should have been secured to prevent tugging and accidental dislodgement.
Oxygen Therapy Not Delivered as Ordered for Two Residents
Penalty
Summary
The facility failed to provide oxygen therapy as ordered for two residents reviewed for respiratory/oxygen care. Resident 71 had diagnoses including respiratory failure, pulmonary edema, and a history of pneumonia, and the MDS indicated severely impaired cognitive skills and dependence in multiple activities of daily living. A physician order dated 2/13/2026 directed oxygen at 2 liters per minute via nasal cannula continuously every shift for shortness of breath and pneumonia, and the care plan directed staff to administer oxygen per order and monitor for effectiveness. During observation on 2/23/2026, Resident 71 was awake in bed and the oxygen tubing was around the resident’s head with the nasal cannula on the neck rather than in the nostrils, while the concentrator was running at 2 liters per minute with humidifier. During interview and record review, an LVN stated the nasal cannula was not on the resident’s nostrils and that the resident was not receiving oxygen as ordered because the cannula had fallen out. A later observation on 2/25/2026 found Resident 71 sleeping with the nasal cannula not on the nostrils and hanging on the bed rail. Resident 15 had diagnoses including chronic respiratory failure with hypoxia, asthma, and morbid obesity. The MDS indicated intact cognitive skills but substantial/maximal assistance was needed for several activities of daily living. A physician order dated 3/10/2025 directed oxygen at 3 liters per minute via nasal cannula continuously, and the care plan also indicated oxygen via nasal prongs/cannula or mask at 3 liters per minute continuously. During observation on 2/26/2026, Resident 15 was lying in bed with the nasal cannula on the upper lip and not in the nostrils while the oxygen concentrator was running at 3 liters per minute; an LVN then adjusted the cannula so it would be in the nostrils for oxygen delivery as ordered.
Missing Foley Care Competency Documentation for Two LPNs
Penalty
Summary
The facility failed to ensure that nursing staff had documented competencies and skill sets for Foley catheter care in accordance with the facility assessment and policy and procedures. During interview and record review, the Director of Staff Development stated that two treatment nurses, both licensed vocational nurses, did not have documented evidence of completed competency and training for Foley catheter care. One nurse stated she was not evaluated for Foley catheter care, and the other nurse stated she did not remember whether she had been evaluated for Foley care. The Facility Assessment, dated 9/1/2025, identified training and competencies as an area informed by the assessment and listed action to be taken that year as providing training on Medication Pass and Foley Care. The facility policy titled, Staffing, Sufficient and Competent Nursing, stated the facility provides sufficient nursing staff with the appropriate skills and competencies necessary to provide nursing and related care and services in accordance with resident care plans and the facility assessment, and that competency is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics needed to perform work roles successfully. The DSD also stated licensed nurses' competencies, including indwelling catheter care, are completed upon hire and as needed.
Fortified breakfast recipe not followed
Penalty
Summary
The facility failed to correctly measure the calorie and sugar content of breakfast meals for 14 of 14 residents ordered to receive a fortified diet. During breakfast tray service, Dietary staff were told the cream of wheat needed to be fortified and then prepared the cereal without following the facility’s Super Cereal recipe. The staff member opened one 12 fl oz can of evaporated milk and poured the entire can into the stock pot, added about half of a 16 oz bag of brown sugar without measuring it, and added vanilla flavoring. The staff member stated she was not familiar with the facility menus, did not look at or follow the fortified cream of wheat menu, and prepared the cereal based on a recipe learned at a previous facility. The Registered Dietician reviewed the menu and stated the recipe called for 1 3/4 cups of evaporated milk, granulated sugar, and no vanilla flavoring. The RD stated the amount of evaporated milk added was only 1 1/2 cups and that the recipe was not followed when the brown sugar was poured directly into the pan. The Dietary Supervisor also stated the recipe should have been followed and that brown sugar should have been measured with a measuring cup. The facility policy titled Standardized Recipes stated standardized recipes shall be developed and used in the preparation of foods.
Failure to Honor Resident Food Preferences and Provide Appropriate Meal Substitutes
Penalty
Summary
The facility failed to provide food that accommodated resident food preferences and failed to offer meal substitutes of the same nutritive value for two residents reviewed for food preferences. Resident 107 was admitted with diagnoses including displaced midcervical fracture of the right femur, abnormalities of gait and mobility, and muscle weakness. Her MDS indicated intact memory and cognitive skills for daily decision making. During interview, she stated staff had not asked her what foods she liked or disliked since admission, that she did not eat red meat or pork, and that the kitchen continued serving her those foods even though she wrote her dislikes on her meal ticket each time she was served them. Resident 107 was observed with a lunch tray containing spaghetti with meat in red sauce, green beans, and garlic bread. Her meal ticket showed spaghetti with meat sauce and did not include her preferred beverage or her food likes and dislikes, although a handwritten note listed that she liked fish, chicken, hot water, and 2% milk and disliked red meat and pork. She stated she had again written her preferences on the meal ticket because she had been served red meat for lunch, and she said staff knew when she did not eat but did not ask why or offer an alternate meal. The MDS Coordinator stated Resident 107's dietary preference form was not documented and signed until 2/24/2026, and the Dietary Supervisor stated she did not assess Resident 107's dietary preference until five days after admission because she was too busy. Resident 75 was initially admitted and later readmitted with diagnoses including polyosteoarthritis, dysphagia, and chronic pain syndrome. Her MDS indicated intact memory and cognitive skills for daily decision making and independence with eating. During observation, an uneaten sandwich with light brown bread was found at the foot of her bed, and she stated she did not eat it because she only ate white bread. On another observation, she was served a sandwich on light brown bread and stated she had been given wheat bread instead of white bread. The Dietary Supervisor stated Resident 75 had told her about a month earlier that she only wanted white bread because it was easier to digest, but the meal ticket had not been updated. The Registered Dietician stated the meal ticket and dietary profile should have been updated when Resident 75 expressed that preference, and the MDS Coordinator stated Resident 75 did not have a care plan addressing her dietary preferences.
Food Storage, Sanitation, and Hand Hygiene Failures During Kitchen Operations
Penalty
Summary
The facility failed to prepare and store food in a sanitary manner in accordance with its policy. During a concurrent observation of the kitchen and interview on 2/23/2026, a green bucket and a red bucket containing liquid with used white towels were observed next to an uncovered bin of yellow and red potatoes. The inside door and bottom of Oven 1 had dried yellow debris and black debris. In Refrigerator 1, seven unlabeled and undated bags of half sandwiches and one unlabeled bag of sandwich were observed, and in Freezer 1 an opened bag of frozen chicken dumplings was tied at the top with clear plastic wrap. Multiple clear plastic bags of unlabeled brown bread were also observed in the dry storage room. The Dietary Supervisor stated the buckets should not have been next to the potatoes, the sandwich bags should have been labeled and dated, the chicken dumplings should have been sealed in a storage bag before being returned to the freezer, and the bread should have been labeled when delivered. During an observation of tray line assembly on 2/25/2026, Dietary staff held a thermometer with gloved hands and checked the temperatures of food items on the steam table. After recording temperatures, the staff member did not change gloves or wash hands before handling the pen and paper used for documentation. The staff member also checked the temperature of oatmeal while holding the thermometer and pen in the same hand, with the hand inside the pot of oatmeal, and then returned to tray line assembly without removing gloves or washing hands. The same gloved hands were then used to open a can of evaporated milk, pour it into a stock pot, turn the oven burner knob, and crack raw eggs into a skillet without changing gloves or washing hands. During the same tray line observation, the staff member's black apron touched residents' clean plates while scooping eggs and sausage from the steam table, and the gloved hand touched the center of the residents' plates while sliding them across the tray line table. In interview, the staff member stated the pen was dirty and that not changing gloves after touching it could contaminate food, and stated bacteria could be passed to residents when gloves were not changed after opening the can, turning the oven knob, and cracking eggs. The Registered Dietician and Dietary Supervisor stated the apron should not have touched the plates, plates should only be touched on the side or edge, gloves should have been changed after touching the pen and before checking food temperatures, and the oven should be cleaned after use. Facility policy required food to be stored covered, labeled, and dated; wrappers of frozen foods to remain intact until thawing; food service areas and equipment to be kept clean and sanitized; and employees to wash hands and change gloves during food preparation and when switching tasks.
Unsanitary Resident Room Conditions
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, sanitary, and home-like environment for three sampled residents. Resident 15, who had type 2 diabetes mellitus, depression, hypertension, and moderately impaired cognitive skills for daily decision making, was observed in the room with a used diaper on the floor under the head of the bed, a cup containing chocolate on the floor, and an electric stand fan with sticky gunk on the bottom and base. Resident 15 was also dependent for lower body dressing and personal hygiene. Resident 29, who had type 2 diabetes mellitus, hypertension, and dependence on renal dialysis, was assessed as having moderately impaired cognitive skills for daily decision making and required partial/moderate assistance with oral hygiene, upper body dressing, personal hygiene, bed mobility, and transfers. The care plan identified a risk for falls with injury related to limited mobility, fracture, and a history of falls, and stated the resident required a safe environment with even floors free from spills and clutter. During observation in the room, two used disposable perineal wipes were found on the floor, appearing crumpled and partially soiled with brown-colored residue. Resident 37, who had epilepsy, major depressive disorder, and dementia, had severely impaired cognitive skills for daily decision making and was dependent for toileting hygiene, bathing, dressing, footwear, personal hygiene, and transfers. While CNA 7 was changing the resident’s briefs, the resident’s curtain was observed with a brownish colored stain. CNA 7 stated the stain was from the resident’s hands and that the resident grabs and pulls the curtain during care. The facility’s policies reviewed during the investigation stated that resident areas should be kept clean, sanitary, orderly, and free of visibly soiled environmental surfaces, but the observed conditions were not maintained.
Failure to Obtain Informed Consent for Bed Rails
Penalty
Summary
The facility failed to inform one resident of the risks and benefits of bilateral bedside rails in accordance with its policy. Resident 86 was initially admitted to the facility and later readmitted with diagnoses including epilepsy, hemiplegia, and hemiparesis following cerebral infarction. The resident’s MDS dated 11/25/2025 indicated intact cognitive skills for daily decision making, dependence for showering, substantial to maximal assistance with toileting, personal hygiene, lower body dressing, and footwear, and partial to moderate assistance with upper body dressing, eating, and oral hygiene. During an observation on 2/23/2026, Resident 86 was in bed with the bilateral middle section of the bedside rails up and refused to answer questions. During interviews and record review, RN 1 stated the resident did not have informed consent for bilateral bedside rail use and that consent should have been obtained before use so the resident understood the risks and benefits. The MDS Coordinator and DON also stated that consent should have been obtained before initiating side rails, and the facility’s Bed Safety and Bed Rails policy required staff to inform the resident or resident representative about the benefits and potential hazards associated with bed rails and obtain informed consent. The Resident Rights policy stated residents have the right to be informed of and participate in their care, planning, and treatment.
Incomplete and inaccurate PASRR screenings for residents with psychiatric diagnoses
Penalty
Summary
The facility failed to ensure that Level I PASRR screenings were completed and accurate for two residents admitted with mental health diagnoses. Resident 71’s record showed diagnoses of depression, psychosis, and dementia, and the MDS indicated severely impaired cognitive skills for daily decision making and dependence with multiple activities of daily living. However, the PASRR dated 1/13/2026 stated Level I was negative for serious mental illness, indicated the resident was not diagnosed with serious mental illness, and stated the resident was not taking psychotropic medications. Resident 71’s physician order summary showed Duloxetine was ordered for depression and Olanzapine was ordered as needed for psychosis and agitation. During interview, the DON stated the PASRR completed at the acute hospital was incorrect because it should have reflected the resident’s diagnoses of psychosis, dementia, and depression, and that the resident was also taking Olanzapine and Duloxetine at the hospital and continued on them at the facility. Resident 81’s record showed diagnoses of major depressive disorder and unspecified psychosis. The medical record contained a negative PASRR Level I screening despite the diagnosis of mental illness, and the screening sections were not filled out completely, including the assessment of mental illness needed before nursing facility placement. The DON stated the PASRR was incomplete and inaccurate because it did not reflect the resident’s psychiatric diagnoses and should have been reviewed for completeness and accuracy upon admission.
Failure to Maintain Resident Cleanliness and Dignity During Breakfast
Penalty
Summary
Facility staff failed to keep Resident 37’s face and blanket clean and free of food particles during breakfast care. Resident 37 was admitted and re-admitted to the facility with diagnoses including epilepsy, major depressive disorder, and dementia. The resident’s MDS dated 1/9/2026 indicated severely impaired cognitive skills for daily decision making and dependence in toileting hygiene, bathing, dressing, personal hygiene, transfers, and related ADLs. During a concurrent observation and interview on 2/26/2026 at 8:44 AM, Resident 37 was sitting on the bed with a breakfast tray in front of her and had a white liquid coming out of her mouth and running down her chin. White cream-like substance was also observed on the resident’s blanket and on the towel placed on her chest. An LVN observed the resident and stated she was dirty and would call a CNA to clean her. During a later interview, the CNA stated it was not acceptable for Resident 37 to have food coming out of her mouth, running down her chin, or food debris on her blanket because it affects dignity, and that she should always be kept clean.
Dialysis E-Kit Not Readily Accessible at Bedside
Penalty
Summary
The facility failed to ensure a hemodialysis emergency kit was readily accessible at the bedside for one resident who required dialysis services. Resident 29 was admitted with type 2 diabetes mellitus, hypertension, and dependence on renal dialysis with end-stage renal disease, and the MDS dated 2/4/2026 indicated moderately impaired cognitive skills for daily decision making and need for partial/moderate assistance with several activities of daily living. The resident’s order summary dated 2/24/2026 showed a hemodialysis schedule of Tuesday, Thursday, and Saturday, and the care plan initiated 2/24/2026 identified renal insufficiency related to dialysis. The care plan also directed staff to apply pressure if bleeding occurred from the AV shunt. During observation on 2/23/2026 at 10:17 AM, no dialysis E-Kit was found in the resident’s room, and during a concurrent interview, LVN 3 confirmed there was no dialysis E-Kit in the room. During later interview and record review, the DON stated the facility’s policy did not indicate that a dialysis E-Kit should be at bedside, although it was the facility’s practice to keep one easily accessible in case of emergency bleeding. The DSD stated the dialysis E-Kit should be easily accessible in residents’ rooms and should include clamps, tape, gauze, and a tourniquet.
Medication Administration and Bedside Storage Deficiencies
Penalty
Summary
Pharmaceutical services were not provided in accordance with facility policy for two sampled residents. One resident was cognitively intact, had diagnoses including type 2 diabetes mellitus, hypertension, and dysphagia, and had a self-administration evaluation indicating the resident did not want to self-administer medications. During an observation in the resident’s room, a clear plastic medication cup was seen at the bedside table containing one pink tablet and one white tablet, both cut in half. The medications were identified in the record as Bactrim DS 800-160 mg and Prevymis 480 mg. The DSD reviewed the facility’s self-administration policy and stated medications should not be left at the bedside if the resident does not meet criteria for self-administration. The LVN stated she left the medications at the bedside because the resident said she would take them later. A second resident had diagnoses including TIA, hydronephrosis, UTI, and diabetes mellitus, and was documented as having intact cognitive skills for daily decision making. During an observation, an LVN prepared and administered insulin aspart for the resident’s diabetes. The LVN injected the insulin into the resident’s right upper abdomen and withdrew the needle right away without waiting approximately five seconds. The LVN later stated she withdrew the needle too fast and should have waited five seconds for the insulin to be absorbed. The DON stated licensed staff should wait five seconds before withdrawing the needle, and the facility’s insulin administration policy stated to depress the plunger and remove the needle after approximately five seconds. The same resident also received scheduled 9 AM medications during the observation, including vitamin C, aspirin, cephalexin, cranberry tablet, multivitamin-minerals, cholecalciferol, calcium carbonate, bethanechol, Clearlax, famotidine, levetiracetam, and rivaroxaban. The LVN entered the room and told the resident she would give the medications, but did not check any resident identifiers and did not check the resident’s armband before administration. The LVN stated she should have checked the armband because it is part of the seven rights of medication administration. The DON stated licensed staff should always have two resident identifiers and verify the medication order in the eMAR while preparing medications and check the resident’s armband before administering them. The facility’s medication administration policy stated residents are identified before medications are administered and that medications are administered at the time they are prepared.
Failure to Monitor Anticoagulant Therapy
Penalty
Summary
Resident 71 was admitted and later re-admitted to the facility with diagnoses including respiratory failure, hypertension, and atrial fibrillation. The resident’s MDS dated 2/17/2026 indicated severely impaired cognitive skills for daily decision making and dependence in multiple activities of daily living, including toileting hygiene, bathing, dressing, footwear, and transfers. During record review and interview with the MDS Coordinator, the resident’s physician orders dated 2/13/2026 showed Apixaban 1 tablet by mouth twice daily for Afib. The resident’s care plan for CVA included interventions to administer anticoagulant medications as ordered and to monitor for side effects such as bruising, bleeding, and hematoma, with notification of the physician for any noted issues. However, the MDS Coordinator stated there was no physician order for monitoring signs and symptoms of bleeding while the resident was on Apixaban, and the nurse’s progress notes from 2/1/2026 through 2/23/2026 contained no documentation of monitoring for anticoagulant side effects, bruising, bleeding, or hematoma. The facility’s anticoagulation clinical protocol stated that staff and the physician will monitor for possible complications in individuals receiving anticoagulation therapy.
Kitchen Trash Can Left Uncovered
Penalty
Summary
The facility failed to ensure that one large gray trash can in the kitchen was covered with a lid while not in use, as required by the facility's policy and procedure. During a concurrent observation of the kitchen and interview with the Dietary Supervisor on 2/23/2026 at 7:47 AM, the trash can was observed next to the steam table with trash inside and no lid covering it. During interviews, the Registered Dietician stated on 2/25/2026 at 1:20 PM that trash cans should always be covered for pest control and to prevent cross contamination in the kitchen. On 2/26/2026 at 9:03 AM, the Dietary Supervisor stated the trash should be covered at all times when not in use and acknowledged that the kitchen trash can policy was not followed. Review of the facility's policy, Food-Related Garbage and Refuse Disposal, revised 10/2017, stated that all garbage and refuse containers must be provided with tight-fitting lids or covers and kept covered when stored or not in continuous use.
Failure to Follow EBP Gown and Glove Practices During Resident Care
Penalty
Summary
The facility failed to ensure standard infection prevention and control practices were followed for two residents on Enhanced Barrier Precautions. Resident 37 was admitted and re-admitted to the facility, had diagnoses including epilepsy, major depressive disorder, and dementia, and was assessed as having severely impaired cognitive skills and dependence for toileting hygiene, bathing, dressing, footwear, personal hygiene, and transfers. During an observation in the resident’s room, CNA 2 was providing a bed bath and dressing care while not wearing a gown, even though the resident had a wound dressing on the left foot and was on EBP. CNA 2 was also observed entering and exiting the room multiple times to handle dirty linen and retrieve clean linen while not wearing a gown. When interviewed, CNA 2 stated she forgot to wear the gown and acknowledged she should have been wearing PPE because she was providing bed bath and dressing care to a resident on EBP with a wound. Resident 4 was admitted and re-admitted to the facility and had diagnoses including hemiplegia and hemiparesis following cerebral infarction, GERD, and DM. The resident’s MDS indicated severely impaired cognitive skills for daily decision making and dependence for eating, oral hygiene, toileting hygiene, bathing, dressing, and footwear, with substantial to maximal assistance needed for multiple transfers and bed mobility. During observation, LVN 1 entered the resident’s room without a disposable gown, disconnected the resident’s G-tube from the tube-feeding connection while wearing disposable gloves, touched the resident’s blanket and shirt, and connected a flush syringe to the G-tube without changing gloves. LVN 1 then checked residual on the G-tube and pulled the curtain using the same gloves. Additional observations showed LVN 1 continued using the same gloves after checking vital signs, pulled the medication cart with a gloved hand, and later changed gloves but again touched the resident’s curtain and handled a flush syringe before connecting it to the G-tube without changing gloves. After administering medications, LVN 1 did not change gloves and touched the resident’s shirt and curtain. During interview, LVN 1 stated she did not change gloves between tasks and should not have touched the resident’s curtains or continued with the same gloves because of infection control requirements. The facility’s EBP policy identified gown and glove use for high-contact resident care activities, including dressing, bathing, linen changes, device care such as feeding tubes, and wound care, and the hand hygiene policy stated disposable gloves should be used when in contact with a resident or the resident’s equipment or environment under contact precautions.
Missing Staff Flu Vaccination Declination Documentation
Penalty
Summary
The facility failed to maintain documentation of screening, education, offering, and current Influenza vaccination status for one of four sampled staff members reviewed for infection prevention, control, and immunizations. During a concurrent interview and record review, the Covid-19 and Influenza staff vaccination record for 2026 was reviewed, and the Infection Prevention Nurse stated that Certified Nursing Assistant 1 refused the Influenza vaccination but did not have documentation of the consent showing that the staff member declined both vaccinations. The Infection Prevention Nurse stated that staff vaccination records were used to track vaccination status and identify staff who were required to wear a mask in resident care areas. The DON stated the facility should maintain records of Covid-19 and Influenza vaccination status for all staff and keep records of staff who were offered and declined vaccinations so they could be offered again if they changed their minds. Review of the facility policy titled Employee Infection and Vaccination, revised 3/2022, indicated that vaccinations declined by an employee would be documented on the applicable declination form and placed in the employee's health record.
Missing Documentation for Staff COVID-19 Vaccination Status
Penalty
Summary
The facility failed to maintain documentation of screening, education, offering, and current COVID-19 vaccination status for one of four sampled staff members reviewed for infection prevention, control, and immunizations. During a concurrent interview and record review, the facility’s 2026 COVID-19 and influenza staff vaccination record was reviewed, and the Infection Prevention Nurse stated that CNA 1 refused the COVID-19 vaccine but there was no documentation of consent showing that the staff member declined both vaccinations. The Infection Prevention Nurse stated that staff vaccination records are used to track vaccination status and identify staff who are required to wear a mask in resident care areas. The DON stated the facility should maintain records of staff COVID-19 and influenza vaccination status, including who was offered and declined vaccination, and the Infection Prevention Nurse stated that documenting staff vaccination is important to implement more precautions for unvaccinated staff and monitor their infection vulnerability. The facility policy titled Employee Infection and Vaccination, revised 3/2022, stated that vaccinations declined by the employee will be documented on the applicable declination form and placed in the employee’s health record.
Malfunctioning Bed Rails Not Maintained in Safe Working Order
Penalty
Summary
The facility failed to ensure that a resident’s bed rails were safe, functional, and in good working condition in accordance with its policies. The resident had diagnoses including lack of coordination and abnormalities of gait and mobility, and an MDS assessment documented severe cognitive impairment and a need for partial/moderate assistance with bed mobility, transfers, and sit-to-stand activities. A physician’s order authorized bilateral 1/3 bed rails as an enabler to aid in mobility, positioning, and transfer. During observation, the resident was found lying in bed asleep with both 1/3 bilateral bed rails in the raised position. When checked by a Licensed Vocational Nurse, both bed rails were found to be stuck and could not be lowered, contrary to the expectation that they should lower easily to allow the resident to get in and out of bed safely. A Maintenance Assistant subsequently examined the bed rails, removed and reinstalled them, and was still unable to lower the left bed rail. The Maintenance Assistant stated that the bed rails on this type of bed were not working properly, despite being reinstalled in the correct holes. A CNA reported that bed rails should be working properly because staff raise and lower them when changing and positioning residents. The DON stated that residents’ beds should be in good working order for residents’ safety and ease of use. Review of the facility’s Maintenance Service policy indicated that the maintenance department is responsible for maintaining equipment in a safe and operable manner at all times, and the Bed Safety and Bed Rails policy required that any worn or malfunctioning bed system components be repaired or replaced using components that meet manufacturer specifications. These observations and statements showed that the resident’s bed rails were malfunctioning and not maintained in accordance with facility policy.
Failure to Maintain Dignity and Accommodate Residents’ TV and Room-Transfer Needs
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to dignity, self-determination, and accommodation of needs related to room transfer and television access. One resident with bilateral primary osteoarthritis of the hip and a right artificial knee joint, who had intact cognition and required varying levels of assistance with ADLs, was transferred from one room to another. During the move, the maintenance assistant placed all of the resident’s clothes and personal belongings from the prior room onto the bed in the new room and moved the resident around 1 PM. Staff, including CNAs and LVNs, acknowledged that CNAs were responsible for putting residents’ belongings away in closets or drawers during a room move so the resident could access the bed. However, the belongings were left on the bed, and the resident reported having to sit in a wheelchair for approximately 2½ hours, unable to lie down. The resident’s caregiver corroborated that, upon arrival, the resident was in the wheelchair with clothes and personal items still on the bed, and that the resident appeared upset and reported having been left waiting. The same resident also reported that he did not read and preferred to watch TV, but the facility never provided a functional TV remote control after the room transfer. The maintenance assistant stated that the remote control available was a universal controller that was not compatible with the resident’s specific TV brand and that the facility did not have a suitable remote for that TV. The DON stated that the TV remote control should be functional so residents can watch the programs they want. As a result, the resident’s stated preference to keep up with the news, documented as somewhat important on the MDS, was not accommodated because he lacked a working remote to operate the TV in his room. A second resident, with generalized muscle weakness and difficulty walking, also had intact cognition and required extensive assistance with ADLs. This resident’s MDS documented that keeping up with the news was very important. During observation and interview, the resident demonstrated that not all TV channels worked, specifically turning to a news channel and another channel that displayed blurred or unclear screens compared to other channels, and stated that it was bothersome not to be able to watch those news stations. The maintenance assistant confirmed that CNN and Channel 5 on this resident’s TV did not work and reported having informed the administrator and attempting to get management to change the cable service/company. The DON stated that all channels should work so residents can watch the programs they want. These conditions showed that the facility did not ensure residents had functional television access consistent with their expressed preferences for news programming.
Failure to Provide Ordered Restorative Nursing Ambulation Services
Penalty
Summary
The deficiency involves the facility’s failure to provide restorative nursing assistant (RNA) services as ordered for a resident with limited range of motion and mobility needs. The resident was admitted with bilateral primary osteoarthritis of the hip and a right artificial knee joint, and an MDS dated 9/11/2025 showed the resident had intact cognition and required varying levels of assistance with ADLs, including substantial/maximal assistance for showering and partial/moderate assistance for lower body dressing and footwear. A physician’s order dated 12/15/2025 directed that the resident receive RNA ambulation services daily, three times per week, for 60 feet with a front-wheeled walker and gait belt as tolerated. Review of RNA documentation for December 2025 and January 2026, along with interviews with RNA staff and the Director of Staff Development (DSD), showed that RNA services were not provided or documented on 12/22/2025, 12/26/2025, and 1/2/2026. During observation and interview, the resident reported that RNA sessions were supposed to occur three times per week but that staff did not come as scheduled. The RNA log and documentation reviewed with the DSD confirmed that the resident received only one RNA session during the week of 12/22/2025–12/28/2025 and two sessions during the week of 12/29/2025–1/4/2026, instead of the ordered frequency. The DSD stated that if RNA services were not documented, they were not done, and acknowledged that RNA services should be consistently provided as scheduled to maintain functional mobility and prevent decline. The DON stated that RNA services are important to help maintain residents’ mobility and that inconsistent provision could potentially cause a decline, and further stated that the resident did not have a care plan for RNA services, which should have been in place to guide staff. Review of the facility’s Restorative Nursing Services policy indicated that restorative goals and objectives are individualized, resident-centered, and outlined in the resident’s plan of care, which was not done in this case.
Failure to Provide Respiratory Care Services per Physician Orders and Facility Policy
Penalty
Summary
The facility failed to provide respiratory care services in accordance with its policy and physician orders for two residents. One resident, with diagnoses including acute and chronic respiratory failure, asthma, and dementia, had a physician order for continuous oxygen at 3 liters per minute (lpm) via nasal cannula. On multiple observations, the resident was found not wearing the nasal cannula, with the oxygen tubing resting on the chest, and the oxygen concentrator set at 2.5 lpm instead of the ordered 3 lpm. Both the DON and an LVN confirmed the incorrect oxygen setting and acknowledged that the resident was not receiving oxygen as ordered. Another resident, diagnosed with COPD, anemia, and dementia, had a physician order for continuous oxygen at 2 lpm via nasal cannula and instructions to notify the physician if oxygen saturation fell below 92%. The resident's oxygen saturation was documented as 91% on three separate occasions, but there was no evidence in the medical record or SBAR documentation that the physician was notified as required. The DON confirmed the lack of documentation and stated that the licensed staff did not call the physician regarding the low oxygen saturation levels. Facility policy on oxygen administration required staff to review physician orders, observe residents to ensure oxygen is being tolerated, and document the rate, route, and assessment data in the medical record. The policy also required reporting relevant information in accordance with professional standards. These requirements were not met for either resident, as evidenced by the lack of proper oxygen administration and failure to notify the physician of low oxygen saturation.
Failure to Maintain Safe and Sanitary Environment Due to Unaddressed Water Leaks
Penalty
Summary
The facility failed to maintain the physical environment in a safe and sanitary condition by not preventing or promptly addressing water leaks in the ceiling of a hallway and a resident's room. Observations revealed a large hole with visible water damage in the ceiling of the hallway in front of the oxygen room, with water leaking into a bin and towels placed on the floor to absorb excess water. Staff interviews confirmed that the water leakage began during a period of rain, and maintenance staff were either unavailable or only began repairs after the issue had persisted for several days. The facility's policy required maintenance to be provided to all areas and for the environment to be kept in good repair, but these standards were not met during the incident. In a resident's room, grayish discoloration and watermarks were observed on the ceiling and wall, and the resident reported that water had leaked from the ceiling the previous night, soaking personal items. The resident, who had significant medical needs including congestive heart failure, chronic respiratory failure with hypoxia, and generalized muscle weakness, was at risk of being directly affected by the leak. Staff confirmed the presence of water damage and acknowledged that the resident could get wet and might not be able to sleep due to the leak. The maintenance assistant was unaware of the issue until it was pointed out during the survey, and there was no documentation of the leak in the maintenance log or the facility's electronic reporting system. Further review of facility policies indicated that maintenance requests should be logged and prioritized, with work orders picked up daily from the nurses' station. However, staff interviews and record reviews revealed that the required reporting and communication procedures were not followed, as no maintenance requests were filed for the leaks, and the maintenance assistant did not check the log as required. The lack of timely reporting and response contributed to the ongoing unsafe and unsanitary conditions in both the hallway and the resident's room.
Failure to Document Indication and Monitoring for Foley Catheter Insertion
Penalty
Summary
Staff failed to follow facility policy and procedures regarding the insertion and documentation of an indwelling (Foley) catheter for one resident. The resident was admitted with diagnoses including hypertension, osteoarthritis, and lack of coordination, and was assessed as having modified independence in cognitive skills and occasional urinary incontinence. The physician's order allowed for an in-and-out catheterization, with a Foley catheter to remain in place if residual urine exceeded 300 milliliters, but the order did not specify the indication for catheter use as required by facility policy. Upon review, there was no documentation of the indication for the Foley catheter, the time of insertion, or monitoring of intake and output in the resident's progress notes. Additionally, there was no documentation regarding the urine output, color, clarity, or the resident's tolerance of the procedure. The care plan for the Foley catheter was not developed at the time of insertion, and the required monitoring and documentation were not completed according to policy. Interviews with nursing staff and the Director of Nursing confirmed that the facility's policy and procedures were not followed. The staff acknowledged that the order lacked an indication and that documentation was incomplete. The Director of Nursing also confirmed that the comprehensive, person-centered care plan was not developed or implemented at the time of catheter insertion, as required by facility policy.
Failure to Document Change in Resident Condition
Penalty
Summary
The facility failed to document an episode of dizziness and vomiting experienced by a resident with a history of hemiplegia, hemiparesis, and left hand contracture following a cerebral infarction. The resident reported feeling dizzy and vomiting a few days prior, and stated that she informed a registered nurse about these symptoms. However, a review of the resident's nurses' progress notes revealed no documentation of these events on the relevant date. Licensed staff confirmed that such symptoms should have been recorded in the medical record to allow for appropriate follow-up and monitoring. Further review of the resident's care plan indicated that any chief complaint of dizziness should be documented, and the facility's policy on charting and documentation required that all changes in a resident's condition be objectively, completely, and accurately recorded in the medical record. The Director of Nursing confirmed that documentation of episodes and frequency of dizziness was necessary according to the care plan. The lack of documentation resulted in an inaccurate representation of the care provided to the resident.
Failure to Honor Resident Rights
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report notes that the facility did not ensure these resident rights were upheld, but does not provide specific details about the actions or inactions that led to this deficiency, nor does it mention any particular events or residents involved.
Failure to Monitor Effectiveness of Psychotropic Medication
Penalty
Summary
A deficiency was identified when the facility failed to ensure that a resident was free from unnecessary drugs by not properly monitoring the effectiveness of Ambien, a psychotropic medication prescribed for insomnia. The resident, who had diagnoses including insomnia and anxiety disorder, was admitted with cognitive skills intact and required varying levels of assistance with daily activities. Physician orders specified that the resident’s hours of sleep should be monitored every evening and night shift, particularly when Ambien was administered as needed for insomnia. Record reviews revealed that the Medication Administration Record (MAR) only included check marks for monitoring sleep, rather than documenting the specific number of hours slept as required by the physician’s order. Interviews with the resident, a Licensed Vocational Nurse, and the Assistant Director of Nursing confirmed that the MAR did not accurately reflect the number of hours of sleep, and staff acknowledged that this information was necessary to determine the medication’s effectiveness. The facility’s policy also required adequate monitoring for efficacy and adverse consequences of psychotropic medications, which was not followed in this case.
Failure to Document, Notify Physician, and Monitor Change of Condition After Resident Head Injury
Penalty
Summary
The facility failed to document an assessment, notify the attending physician, initiate a Change of Condition (CoC), and monitor the CoC for a resident who reported hitting her head in the bathroom. The resident, who had a history of cerebral infarction and dementia but was assessed as having intact cognition, informed the Director of Staff Development (DSD) that she had hit her head on a grab bar. Despite this report, there was no documentation in the resident's progress notes regarding the incident, assessment, or any subsequent monitoring or treatment. Interviews with the DSD and Director of Nursing (DON) confirmed that the DSD did not notify the resident's physician, document an assessment, or initiate a CoC as required by facility policy. The facility's policy mandates prompt notification of the physician and documentation of any changes in a resident's condition, including accidents or incidents. The DON acknowledged that the required steps were not taken, and the incident was not properly managed or recorded in the resident's medical record.
Failure to Develop Comprehensive Fall Prevention Care Plan for High-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to develop and implement a comprehensive, resident-centered care plan to prevent falls for a resident with significant risk factors. The resident had a history of falls, bilateral leg weakness, and was dependent on staff for bed mobility and incontinent care. The resident was also using a low air loss mattress (LALM), which increases the risk of falls due to its shifting surface. Despite these factors, the care plan did not specify the type or number of staff assistance required during incontinent care, nor did it include interventions tailored to the resident's needs while on the LALM. On the day of the incident, a CNA was providing incontinent care to the resident and prompted the resident to turn. The resident subsequently slid off the bed and fell to the floor, sustaining complaints of pain but no visible bruising or discoloration. The CNA was unaware of the recommendation that two staff members should be present during incontinent care for residents on a LALM. Interviews with other staff, including another CNA, the RN, the DON, and the MDS nurse, confirmed that the care plan lacked specific instructions regarding the required assistance and interventions to prevent falls during such care. The facility's own policy required comprehensive, person-centered care plans with measurable objectives and timetables to meet residents' needs. However, the care plan for this resident did not address the specific risks associated with the resident's condition and equipment, nor did it communicate the necessary precautions to staff. This omission directly contributed to the resident's fall during routine care.
Resident's Right to Voice Grievances Violated
Penalty
Summary
The facility failed to ensure that a resident was treated with respect and dignity, as required by their policy, by not allowing the resident to voice grievances without fear of discrimination or reprisal. The resident, who was diagnosed with major depressive disorder, hemiplegia, and hemiparesis, was independent in cognitive skills for daily decision-making but required substantial assistance with personal care. During an interview, the resident reported that a Certified Nursing Assistant (CNA) told her that if she continued to complain about the facility's CNAs, no one would want to work with her. This statement made the resident feel retaliated against and discouraged her from voicing future grievances. The Director of Staff Development (DSD) confirmed that the CNA admitted to making the statement, which was deemed disrespectful and contrary to the facility's policy. The facility's policy, titled 'Resident Rights,' clearly states that residents have the right to voice grievances without fear of discrimination or reprisal and that employees must treat all residents with kindness, respect, and dignity. The DSD acknowledged that the CNA's actions were inappropriate and not in line with the facility's policy, which could potentially prevent the resident from expressing any future concerns.
Facility Fails to Maintain Homelike Environment Due to Chipped and Peeling Paint
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by the presence of chipped and peeling paint in 10 out of 43 resident rooms. Observations revealed that several rooms, including Rooms A, B, C, D, E, F, G, H, I, and J, had areas of chipped or peeling paint, as well as unpainted patched areas. These conditions were noted during various observations conducted by surveyors and confirmed by the Maintenance Supervisor, Director of Nursing, and Administrator. The facility's policy on maintaining a homelike environment, revised in February 2021, emphasizes the importance of providing a comfortable setting for residents, which was not adhered to in this instance. Interviews with facility staff, including the Maintenance Supervisor and Director of Nursing, confirmed the need for repainting to ensure a homelike environment. The Administrator acknowledged the issue, stating awareness of the need for repairs. The facility's maintenance policy, revised in December 2009, outlines the responsibility of maintenance personnel to keep the building in good repair, which was not fulfilled in this case. The deficient practice had the potential to create an unsafe and unclean environment, posing a risk for physical discomfort to the residents.
Improper Food Handling and Labeling Practices
Penalty
Summary
The facility failed to adhere to proper food handling practices as per its policy and procedure, which resulted in several opened and expired food items being improperly labeled or not discarded. During an initial kitchen tour, the Dietary Supervisor (DS) identified several opened items, such as bottles of seasoning salt, ground ginger, pure vegetable oil, and plastic bags of pasta, that were not labeled with a proper open date and used by date. Additionally, expired items like browning and seasoning sauce and food coloring were found in the kitchen, which should have been discarded according to the facility's policy. The DS admitted to not knowing why the food items were not labeled correctly or why expired items were still stored in the kitchen. The facility's policy, as reviewed, indicated that no food should be kept beyond its expiration date and that all items should be labeled with either a delivery date or a use-by date. The failure to follow these procedures has the potential to expose residents to pathogens, increasing the risk of foodborne illnesses.
Infection Control Lapses in LTC Facility
Penalty
Summary
The facility failed to ensure staff adhered to enhanced barrier precautions and standard precautions, leading to potential infection risks among residents. For Resident 6, staff members were observed not changing gloves and not performing hand hygiene after providing peri-care, which involved touching the resident and her wheelchair with the same gloves. This was acknowledged by the staff, who admitted the oversight could spread infection. Similarly, for Resident 88, a staff member failed to doff gloves and perform hand hygiene after emptying a urinal, subsequently touching the resident's personal belongings, which was also recognized as a lapse in infection control. Resident 28, who had a permacath for dialysis, did not have enhanced barrier precaution signage or personal protective equipment available outside the room. A Licensed Vocational Nurse (LVN) was observed taking the resident's blood pressure and heart rate without wearing gloves or a gown and did not perform hand hygiene before preparing and administering medications. The LVN admitted to not being aware of the necessary precautions for residents with central lines, and the Infection Preventionist Nurse confirmed the oversight in not including the resident on the enhanced barrier precautions list. For Resident 18, an LVN failed to perform hand hygiene before and after checking the resident's heart rate and before preparing medications. This was acknowledged by the LVN and the Director of Nursing, who emphasized the importance of hand hygiene in preventing the spread of microorganisms. Additionally, laundry staff were observed handling clean and soiled linens without performing hand hygiene, contrary to the facility's policy. These practices collectively posed a risk of spreading infections among residents and staff.
Resident Dignity Compromised by Unclean Clothing
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 49, was treated with respect and dignity by not keeping the resident's clothes clean and free of food particles. Resident 49, who was admitted with diagnoses of muscle weakness and spinal stenosis, was observed with yellow food particles on their clothing. The resident expressed discomfort with the food particles, indicating that it bothered them. The Minimum Data Set (MDS) assessment indicated that Resident 49 required assistance with eating and dressing, highlighting the need for staff support in maintaining the resident's dignity. During observations and interviews, it was noted that the resident's clothes had food particles, specifically eggs, which were acknowledged by a Registered Nurse (RN) and the Director of Nursing (DON) as inappropriate and not in line with the facility's policy on dignity. The facility's policy emphasized the importance of providing a dignified dining experience and maintaining residents' cleanliness to promote their well-being and self-esteem. The failure to adhere to this policy resulted in a deficiency related to the resident's dignity and self-worth.
Failure to Obtain Informed Consent for Psychoactive Medication
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 88, was informed in advance of the risks and benefits of a proposed care plan involving the use of psychoactive medication. Specifically, the facility did not obtain informed consent prior to administering Lorazepam, an antianxiety medication, to Resident 88. The resident was admitted with multiple diagnoses, including an unspecified fracture of the left fibula, dislocation of the left ankle joint, gout, and unsteadiness on feet. The Minimum Data Set (MDS) indicated that the resident was independent in cognitive skills for daily decision-making but required substantial assistance with certain physical activities. Despite this, the resident was administered Lorazepam without prior consent, as confirmed by both the MDS Coordinator and the resident himself. The deficiency was further highlighted during interviews and record reviews, where it was revealed that the facility's policy and procedure required obtaining consent from the resident or responsible party before placing an order for psychoactive medication. The Director of Nursing acknowledged that the facility should have obtained consent prior to administering the medication. The facility's policy on Resident Rights, revised in February 2021, mandates that residents be informed of and participate in their care planning and treatment, which was not adhered to in this case.
Failure to Prioritize Resident's ADL Needs
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 77, received the necessary care and services to maintain good personal hygiene, specifically in relation to activities of daily living (ADL). Resident 77, who was admitted with diagnoses including generalized muscle weakness, difficulty walking, and neuromuscular dysfunction of the bladder, was observed to have severely impaired cognitive skills and was dependent on assistance for personal hygiene and toileting. On the day of the incident, Resident 77 activated the call light multiple times requesting a diaper change, but the Certified Nursing Assistant (CNA 3) prioritized other tasks over attending to the resident's immediate needs. Despite the resident's repeated requests for assistance, CNA 3 delayed attending to Resident 77, opting instead to assist another resident and change bed sheets in a different room. This delay was noted by other staff members, including the Central Supply Director and the Infection Prevention Nurse, who were involved in trying to locate CNA 3 to address Resident 77's needs. The Director of Nursing later confirmed that staff should prioritize resident care and attend to their needs within five minutes. The facility's policies on accommodating resident needs and supporting ADLs were not adhered to, resulting in a deficiency related to unmet resident needs and potential risks to the resident's well-being.
Wheelchair Maintenance Deficiency
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 88, was free from accident hazards by not providing a wheelchair with properly functioning tires. Resident 88, who was admitted with a fracture of the left fibula, dislocation of the left ankle joint, gout, and unsteadiness on feet, was observed using a wheelchair with torn tires. The resident reported that the wheelchair brakes did not work well, and observations confirmed difficulty in stopping the wheelchair, posing a risk of falls and injury. Interviews with the Maintenance Supervisor and the Director of Nursing revealed that the maintenance department was not informed about the damaged wheelchair tires, which were acknowledged as unsafe for use. The facility's policy indicated that the maintenance department is responsible for ensuring equipment is safe and operable, but this was not adhered to in this instance, leading to the deficiency.
Failure to Administer Continuous Oxygen as Ordered
Penalty
Summary
The facility failed to provide necessary respiratory care services for Resident 294 by not administering oxygen according to the physician's orders. Resident 294, who was admitted with acute and chronic respiratory failure, COPD, and CHF, had a physician's order for continuous oxygen at 2 liters per minute via nasal cannula. However, during an observation, it was noted that the resident's nasal cannula was not in place after being assisted to the restroom by a Certified Nurse Assistant (CNA 6). The nasal cannula was found on the pillow, out of the resident's reach, and the resident had to request assistance to have it replaced. The Licensed Vocational Nurse (LVN 3) confirmed that the oxygen order was for continuous use and emphasized the importance of adhering to the physician's order to prevent complications such as shortness of breath. The facility's policy on oxygen administration requires verification and adherence to physician's orders, which was not followed in this instance. This oversight placed Resident 294 at risk for respiratory distress and other complications due to the interruption in oxygen therapy.
Failure to Implement Fluid Restriction for Dialysis-Dependent Resident
Penalty
Summary
The facility failed to implement the physician's order for a fluid restriction of 1200 cc per day for a resident with end-stage renal disease dependent on dialysis. The care plan specified a breakdown of fluid intake between dietary and nursing, but documentation showed discrepancies in fluid intake records. There were missing entries for breakfast fluids on multiple days, and recorded fluid intakes exceeded the prescribed amounts on several occasions. Additionally, the resident was observed with a full pitcher of water at the bedside, contrary to the fluid restriction order. Interviews with the resident and staff revealed a lack of adherence to the fluid restriction protocol. The resident was aware of the fluid restriction but reported receiving pitchers of water daily, which were refilled by staff. A Licensed Vocational Nurse confirmed the risk of shortness of breath from excess fluid and acknowledged the error in providing a full pitcher of water. A Certified Nursing Assistant admitted to not knowing the exact fluid restriction amount and emphasized the importance of accurate documentation of fluid intake. The facility's policy on end-stage renal disease care was not followed, as the comprehensive care plan did not reflect the resident's needs related to dialysis care.
Failure to Assess and Obtain Consent for Bedside Rail Use
Penalty
Summary
The facility failed to properly assess and obtain informed consent for the use of bedside rails for one resident, identified as Resident 15. The resident, who had a history of cerebral infarction, major depressive disorder, and falls, was observed with both middle sections of the bedside rails up. Despite the presence of physician orders for the use of bedside rails as an enabler for mobility, positioning, and transfer, there was no documented consent from the resident or their family. The MDS nurse confirmed the absence of consent and stated that the family should have been informed of the risks and benefits before the use of the rails. The Director of Nursing confirmed that only two Bedside Rail Utilization Assessments were conducted, and no consent was obtained prior to the use of the rails. The facility's policy, revised in August 2022, prohibits the use of bed rails unless specific criteria are met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed consent. The failure to adhere to these protocols placed the resident at risk for potential accidents, such as entrapment or falls, due to improper use of the bedside rails.
Failure to Coordinate Hospice Care for Resident
Penalty
Summary
The facility failed to ensure proper coordination of care between the facility and hospice staff for a resident, identified as Resident 76, who was receiving hospice services. The deficiency involved the failure of the Certified Home Health Agency (CHHA) staff to adhere to the physician's order to visit and provide care to the resident twice per week. The review of records indicated that the CHHA only visited once a week during two specific weeks, which was not in compliance with the physician's order. Additionally, there was no hospice care plan developed for Resident 76, which is essential for guiding hospice staff in providing appropriate care. Resident 76 was admitted to the facility with diagnoses including cirrhosis of the liver, congestive heart failure, and alcohol dependence. The resident was severely impaired in cognitive skills and required substantial assistance with daily activities. The facility's Director of Nursing acknowledged the discrepancy in the frequency of CHHA visits and the absence of a hospice care plan in the resident's hospice binder. The Director of Patient Care Service confirmed the missed visits and emphasized the importance of following the physician's order to ensure the resident received the necessary hospice care and services to promote comfort and quality of life.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call light was within reach for one of the sampled residents, specifically Resident 15. This deficiency was identified during an observation where the call light was found on the floor, out of the resident's reach, while the resident was sleeping in bed. The facility's policy requires that call lights be within reach to allow residents to call for assistance, especially during emergencies. Interviews with staff, including a CNA, an RN, and the Director of Nursing, confirmed that call lights should be accessible to residents. Resident 15 had a history of cerebral infarction, major depressive disorder, and a history of falling, which necessitated the need for the call light to be within reach as part of their care plan. The resident's Minimum Data Set indicated they required substantial assistance with various activities of daily living, including toileting and personal hygiene, and supervision with oral hygiene. The failure to have the call light within reach could have impeded the resident's ability to call for help when needed, as outlined in the facility's policy.
Failure to Provide Timely Pain Management
Penalty
Summary
The facility failed to provide timely pain management for a resident who verbalized experiencing significant pain. The resident, who was admitted with a displaced subtrochanteric fracture of the left femur, difficulty in walking, and anxiety disorder, was on a pain management regimen that included opioid medications. Despite having orders for pain medications such as oxycodone and tramadol, the resident experienced a delay in receiving pain relief after requesting medication. On the day of the incident, the resident requested pain medication and had to wait almost two hours before receiving it, during which time the resident was in severe pain, rated 7 out of 10 on the pain scale. The Licensed Vocational Nurse (LVN) was informed of the request but did not administer the medication promptly, citing the resident's engagement with a surveyor as a reason for the delay. The facility's protocol required that pain medications be administered as soon as possible when requested, but this was not adhered to in this instance. Interviews with the Director of Nursing (DON) and review of the facility's policies confirmed that the facility's protocol was to administer pain medication promptly and to communicate with residents about any delays. The failure to follow these protocols resulted in the resident experiencing unnecessary pain and distress. The facility's policies emphasized the importance of timely pain management and communication with residents to prevent anxiety and discomfort while waiting for medication.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 6,309 citations issued within 25 miles in the last 12 months — including the 26 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Arcadia
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Arcadia Care Center | 0.8 mi | ★★★★★ | 8 | 0 |
| San Marino Healthcare Center | 1.3 mi | ★★★★★ | 23 | 0 |
| Baldwin Gardens Nursing Center | 1.8 mi | ★★★★★ | 16 | 0 |
| Santa Anita Convalescent Hospital | 1.9 mi | ★★★★★ | 17 | 0 |
| Monrovia Gardens Healthcare Center | 2.3 mi | ★★★★★ | 31 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Huntington Drive Health And Rehabilitation Center.
100% money-back within 48 hours.
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.