Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Huntington Valley Healthcare Center during CMS and state inspections, most recent first.
Surveyors found multiple respiratory care deficiencies involving oxygen therapy and CPAP use. Several residents had unlabeled or undated oxygen tubing, one resident was receiving continuous oxygen without a physician order, another was receiving oxygen at a higher flow rate than ordered, and two residents lacked required oxygen signage. For one resident using CPAP and continuous oxygen, the room lacked oxygen signage, the CPAP water chamber cleaning instructions were not reflected in the orders, and no care plan was developed for the CPAP or oxygen therapy.
The facility failed to ensure complete and accurate dialysis care documentation for two residents with ESRD receiving hemodialysis. One resident’s records had missing or conflicting AV fistula assessments, missing post-dialysis weights and vital signs, and no documented physician notification when thrill was absent. Another resident’s records showed blank or inconsistent access-site, bruit, and thrill documentation, and the resident’s fluid intake was not monitored or documented despite a fluid restriction order.
A facility failed to follow up on Consultant Pharmacist medication regimen review recommendations for four residents. The unresolved issues involved duplicate or excessive GERD medications, unclear duration or indication for anticoagulant and steroid therapy, and missing lab monitoring for phenobarbital. RN staff and the DON/ADON verified that the records did not show physician follow-up or responses to the pharmacy recommendations.
Kitchen sanitation and equipment maintenance deficiencies were identified when surveyors observed a grease-covered stove hood, damaged utensils with melted, chipped, and cracked surfaces, and multiple food-contact items with fuzzy films, watermarks, and crusted residue. Cutting boards were heavily marred and deeply grooved, and a blender plus clear food-storage containers were stored while still wet. The DSS verified the findings, and the DON and ADON were later informed and acknowledged them.
Inaccurate medical record documentation affected one resident’s advance directive status and four residents’ BP records. A resident’s POLST conflicted with an advance directive already in the chart, and several residents with ESRD and AV access sites had BP readings documented on the same arm that had orders to avoid BP, venipuncture, injections, and other restrictions. Staff interviews confirmed the charted arm locations and the documentation errors.
Infection surveillance program not fully implemented. The facility’s IPCP policy required outcome surveillance using standard criteria, but the IP stated the process depended on residents being prescribed antimicrobials before McGeer’s Criteria were considered. Review of the monthly surveillance logs showed only residents on antimicrobials were documented, and there was no documentation that residents with signs and/or symptoms of infection who were not prescribed antimicrobials were evaluated for McGeer’s Criteria.
Incomplete Informed Consent for Psychotropic Medication: A resident with moderately impaired cognition was prescribed valproic acid for an unspecified mood disorder and seizure disorder, but the psychotherapeutic drug informed consent form did not include the resident’s manifested behaviors for use of the medication. RN verified the omission during record review, and the DON stated informed consent for psychotropic meds should include the medication details, indications, and manifested behaviors.
Failure to Assess Safe Self-Administration of Medication: A resident was observed with an Equate nasal spray at the bedside and stated it was his medication. An LVN confirmed the resident should not have medication at the bedside, and the record showed no MD order, self-administration assessment, or care plan for the nasal spray or for self-administration of meds. The DON later verified the same findings.
A resident’s record lacked evidence that the facility inquired about an advance directive or provided and documented written information about the right to formulate one. The chart showed a POLST indicating the resident had capacity and no AD, but the social history/discharge planning assessment did not document that AD formulation was offered, and no Advance Directive Acknowledgement form was found. The SSD acknowledged the missing documentation, and the ADON and DON were informed.
A resident with moderately impaired cognition was prescribed quetiapine for unspecified mood disorder and had weekly orthostatic BP monitoring ordered while on the medication. Facility records showed the lying and sitting BP checks were documented as NA or the same value on multiple occasions, and an RN confirmed the readings should not have been identical or left as NA, with no progress note documentation explaining the missed measurements.
Failure to Provide Transfer and Bed-Hold Notifications: The facility did not follow its transfer/discharge notice process for two residents sent to acute care hospitals. One resident’s bed-hold form was left blank and the record did not show the resident was given bed-hold information or that the Ombudsman was notified. For the other resident, the record also lacked proof that the Ombudsman was notified of the transfer. Interviews with the SSD and DON confirmed the missing notifications.
Inaccurate MDS coding affected two residents. One resident’s MDS listed schizophrenia even though the psychiatric eval and MDS Coordinator confirmed the resident did not have that diagnosis and had not shown signs or symptoms of it in the facility. Another resident’s MDS coded lamotrigine use but omitted Bipolar disorder, despite the MAR/order summary showing the medication was ordered for Bipolar disorder and an LVN confirming that use.
A resident with Bipolar disorder and an order for divalproex sodium had an inaccurate PASRR Level I screening that stated there was no serious mental illness and no psychotropic medication. During record review, the MDS Coordinator confirmed the PASRR information was incorrect and noted the screening is used to identify residents who may need a PASRR Level II MH evaluation.
A resident with chronic pulmonary edema had a care plan calling for oxygen administration as ordered, with a physician order for continuous O2 at 2 LPM via NC. During observation, the resident was receiving continuous oxygen at 3 LPM, and an LPN confirmed the resident had been on 3 LPM throughout the day shift, which did not match the order or care plan.
A facility failed to keep several care plans current for residents with changing needs. One resident’s pressure injury plan did not include the Wound Consultant’s instruction to limit sitting time, another resident’s anticoagulant plan still referenced enoxaparin instead of current Eliquis therapy, a third resident’s dehydration/enteral feeding plan did not match the current tube feeding rate and water flush orders, and a fourth resident’s PEG/enteral nutrition plan remained in place even though the resident was no longer receiving enteral feeding.
Insulin Injection Sites Not Rotated: A resident with Type 2 DM and hyperglycemia had a physician order for regular insulin with instructions to rotate injection sites, but MAR review showed repeated injections in the same abdominal areas instead of rotated sites. The RN verified the pattern during record review and stated that insulin sites should be rotated to prevent skin complications when injections are given at the same site repeatedly.
A resident at risk for skin breakdown was observed on a LAL mattress with the pump set at different comfort levels that did not match the resident’s documented weight. The resident had a care plan for pressure reduction, an order for an air mattress set according to weight, severe cognitive impairment, and no capacity to make medical decisions. The facility’s P&P required support surfaces to accommodate the resident’s weight and remain inflated to an appropriate pressure.
A resident with ESRD/HD experienced significant weight loss while on a regular CCHO diet. The RD recommended a Renal-CCHO diet and sugar-free liquid protein, and the IDT documented the same interventions, but the record did not show a physician order for the supplement or documentation that the physician was notified. RN and DON interviews confirmed the recommendations were not followed up or documented, and the resident remained on the CCHO diet without the protein supplement order.
IV access and medication labeling deficiencies: A resident with a PICC line had no documented admission measurement of external catheter length or arm circumference, another resident’s IV tubing was observed without the required date, time, and RN initials, and a third resident’s meropenem IV bag was not labeled with the date, time, and initials. Facility policy required labeling of IV solutions and documentation of PICC measurements.
Medication administration errors exceeded the allowed rate, with two LPNs observed making errors during med pass. One LPN withheld an ordered diltiazem dose for a resident whose BP was within the prescriber’s parameters, and another LPN gave metformin to a resident without meals even though the order required it to be taken with food. The facility policy required meds to be given safely, timely, and as prescribed.
Surveyors found expired and improperly stored medications in a medication room and Medication Cart A. A resident’s nystatin was still present after it was no longer ordered, an opened insulin pen was kept in the refrigerator past its expiration date, expired culture swabs were present, and an opened levalbuterol box was expired. Oral medications and a supplement were also stored with bisacodyl suppositories instead of being separated by route, and staff verified the storage issues.
A resident with severely impaired cognition and an IDDSI Level 6 soft and bite sized order was observed at lunch receiving a meal that did not match the therapeutic menu. The menu called for boiled potatoes, but the resident was served rice instead, and the DSS verified the discrepancy.
A resident did not receive a fresh fruit cup that was listed in the Notes section of the lunch meal ticket as a food preference. During the meal observation, the tray did not include the fruit cup, and the resident stated she wanted it. An LVN verified the meal ticket, and the DSS stated items in the Notes section were resident preferences that should be included with the meal.
Improperly Stored Garbage in Outside Dumpsters: Two of four outside garbage dumpsters had lids partially propped open by garbage bags, preventing the lids from fully closing. Surveyors observed the condition with the DSS, and the Maintenance Director verified that the lids should be fully closed for pest control and infection control purposes. The facility’s policies and USDA Food Code requirements called for covered, secured, and vermin-proof refuse storage.
A resident receiving hospice for CVA had a hospice plan of care listing aide, SN, and spiritual counselor visit frequencies, but the facility did not integrate those details into the care plan. IDT notes showed continued hospice services and intent to integrate care, yet hospice staff were not documented as participating in the IDT meetings, and the facility RN and hospice RN did not complete the integrated plan of care. The SSD verified the hospice team was not included in the resident's IDT process and that the facility care plan was not updated to reflect the hospice plan.
Glucometer Quality Control Documentation Was Incomplete and Mismatched: The facility failed to maintain Medication Cart A’s glucometer in safe operating condition when the serial number was not documented on the QC record, the test strip lot number in use did not match the lot number on the QC record, and the documented control test results were not found in the meter’s stored history. LVN 3 verified the discrepancies during inspection, and the DON stated QC testing was intended to confirm proper glucometer function and accurate blood glucose measurements.
Surveyors found that staff stopped CPR on a full-code resident who remained unconscious, barely breathing, and without a blood pressure, resulting in a period without compressions before paramedics arrived and resumed resuscitation. A resident with severe cognitive impairment and post-fall hip pain did not have a PT-recommended hip/femur and knee x-ray promptly communicated to the physician, and when imaging was ordered, only hip films were completed; the same resident’s critically low Hgb was not promptly reported to the physician or family, and transfer to the ER was delayed. For this resident, staff also failed to obtain a urine specimen after a physician recommendation despite lethargy and sediment in the urine, and the resident was later hospitalized with AKI and catheter-associated UTI. In addition, several residents did not receive ordered wound, skin, and device care on multiple days, as shown by missing nurse initials on TARs and MARs, with one family member reporting a visibly cloudy catheter and filthy dressing; staffing records showed that treatment nurse coverage was missing or unsigned on some days.
A resident with full-code status was found on the floor unresponsive, pulseless, and not breathing. Nursing staff with documented BLS/CPR competencies initiated CPR, with one LVN performing chest compressions and an RN providing ventilations via Ambu bag. After approximately 18–20 minutes, staff believed a carotid pulse had returned and stopped compressions, even though the resident remained unconscious, was barely breathing, and had no blood pressure while they waited several minutes for paramedics. When the fire department arrived, they found the resident pulseless, apneic, and without compressions in progress, and they restarted manual compressions and advanced resuscitative measures. This conduct did not follow the facility’s CPR policy or BLS standards requiring continuous CPR for an unresponsive, non-breathing person until help takes over.
A resident was transferred from the facility to an acute care hospital, but staff did not complete the required Notification of Transfer/Discharge or send a copy to the State LTC Ombudsman. During record review, an RN confirmed that the electronic medical record lacked the notice and any documentation of Ombudsman notification, despite acknowledging that a change of condition form, transfer form, and notice of transfer are required for resident transfers. The interim DON later acknowledged that staff should have completed the transfer notice and provided it to the LTC Ombudsman.
A resident with no capacity for medical decisions and a history of confusion was allowed to leave for an outpatient appointment without being accompanied by a responsible person, as required by the care plan for elopement risk. The resident did not return directly to the facility and the responsible party was not informed or present, which was verified by the DON and confirmed by the responsible party.
A resident did not receive and have documented intravenous fluids (IVF) as ordered by a physician. Nursing staff failed to document the administration, monitoring, and removal of normal saline IVF from the emergency kit, and there was no evidence that the physician was notified if the IVF was not given. The required documentation was missing from the medical record, and both the administrator and DON confirmed these findings.
A resident who lacked decision-making capacity was found with an expired tube of diclofenac sodium 1% topical gel stored at the bedside, without a physician's order, care plan, or authorization for self-administration. Facility staff confirmed the medication was not permitted to be stored at the bedside and that required procedures for unauthorized medications were not followed.
A resident did not receive stat CBC and CMP laboratory tests as ordered by the physician, with no evidence in the medical record that the tests were completed. Nursing staff and laboratory interviews confirmed that the stat order was not processed or communicated as required, and there was no documentation of follow-up or notification to the physician regarding the delay. The DON and Administrator acknowledged the deficiency.
A resident with an indwelling urinary catheter did not have required monitoring of urine characteristics documented on two shifts, despite physician orders and facility policy. LVNs confirmed the lack of documentation in the TAR, and the DON acknowledged that licensed nurses are expected to follow physician orders.
Surveyors found that POLST forms for three residents were incomplete or inaccurate, missing required signatures, contact information, and documentation of consent. In some cases, verbal consents were not properly witnessed, and sections regarding artificially administered nutrition were left blank. These deficiencies were confirmed by nursing staff and the DON.
Surveyors found multiple sanitation and equipment failures in the kitchen, including a greasy stove hood, chipped and melted utensils, dirty and improperly dried kitchenware, heavily marred cutting boards, and rusted equipment such as a can opener and microwave. The Dietary Services Supervisor confirmed these deficiencies and acknowledged that items were not maintained or cleaned according to policy.
Surveyors identified multiple failures in infection prevention and control, including inaccurate infection surveillance logs, lack of Enhanced Barrier Precautions for a resident with a central line, and repeated lapses in hand hygiene by staff during resident care activities such as feeding, medication administration, and wound care. These deficiencies were confirmed by staff and leadership, and involved both direct care and documentation practices.
A resident was found self-administering Systane eye drops without being assessed as able or willing to do so, and without a physician's order or care plan documentation. Facility staff confirmed the resident should not have had the medication at the bedside, and required assessments and documentation were missing.
The facility did not maintain copies of executed advance directives in the medical records for two residents and failed to provide written information or assistance on formulating advance directives to two other residents or their responsible parties, as confirmed by staff interviews and record reviews.
A nurse administered insulin to a resident without allowing the alcohol at the injection site to air dry, contrary to facility policy and manufacturer guidelines. The nurse and DSD confirmed that proper training was provided, and both acknowledged the importance of letting the site dry before injection.
A resident with limited ROM had a physician's order for a left knee extension splint, but staff failed to document the times of application and removal, and did not perform or record required skin assessments during splint use. This omission was confirmed by staff interviews and review of the care plan and medical record.
A resident with an indwelling urinary catheter was repeatedly observed with cloudy urine and sediments in the catheter tubing, but nursing staff did not complete required change of condition documentation, progress notes, or care planning in the EHR, despite facility policy and physician orders. Staff interviews confirmed the lack of follow-up and documentation for the resident's condition.
Two residents receiving enteral feeding did not receive proper care as required by facility policy: one resident's intake and output were not monitored or documented, and another resident's enteral feeding formula and water bag were not changed or labeled according to protocol. Staff interviews and record reviews confirmed these lapses in care and documentation.
The facility did not ensure proper respiratory care for four residents, including failure to administer oxygen as ordered, improper storage of nasal cannula tubing, lack of care planning and maintenance for a CPAP device, and oxygen tubing left on the floor. Staff did not consistently follow physician orders or infection control policies, and there was no documentation of communication with physicians regarding changes in respiratory care.
A resident did not receive appropriate pain management when staff failed to accurately document pain assessments and administered oxycodone outside of the prescribed pain level parameters. Non-pharmacological interventions were not consistently implemented or documented prior to medication administration, and staff interviews confirmed these lapses in following physician orders and facility policy.
Two residents with ESRD did not receive appropriate dialysis care, as the facility failed to complete dialysis communication records, maintain an emergency dialysis kit at the bedside, and ensure licensed nurses assessed and documented dialysis access sites or maintained transparent dressings. These deficiencies were confirmed by both nursing staff and the DON.
A resident with severe cognitive impairment and a diagnosis of dementia did not receive the required monitoring and documentation of mood and behavioral symptoms as outlined in their care plan. Staff interviews and medical record reviews confirmed that assessments for altered mood and related dementia symptoms were not performed or documented, despite facility policy and care plan directives.
Two residents received controlled medications that were dispensed and signed out, but the administration was not documented on the EMAR as required by facility policy. This lack of documentation was confirmed through medical record review and staff interviews, and involved both pain and anxiety medications.
A resident with hypertension and congestive heart failure was given amlodipine and two diuretics despite physician orders to hold these medications when blood pressure was below specific thresholds. The MAR showed the medications were administered outside of the prescribed parameters, and staff confirmed that reminders about these parameters were present in the MAR.
Surveyors found that medications were not properly stored or labeled, with oral and external medications mixed in medication carts, a topical antibiotic missing an open date, and two residents' creams stored at the bedside without proper orders or documentation. Staff confirmed these practices did not follow facility policy.
Respiratory Care and Oxygen Therapy Deficiencies
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for multiple residents receiving oxygen therapy. During the initial tour and subsequent record review, surveyors observed that Resident 2’s nasal cannula tubing was unlabeled and undated while the resident was receiving oxygen at 2 LPM, and Resident 5’s oxygen tubing was also unlabeled and undated, coiled, and hanging on the oxygen machine rather than being inside a bag when not in use. The facility’s records showed both residents had physician’s orders for oxygen therapy and for routine tubing changes, and staff confirmed the tubing should have been labeled and dated after changes. Resident 29 was observed receiving continuous oxygen at 2 LPM via nasal cannula, but the medical record review failed to show a physician’s order for that continuous oxygen therapy. Staff verified the resident was receiving oxygen and confirmed that an order should have been present. Resident 74 had a physician’s order for continuous oxygen at 2 LPM via nasal cannula, but surveyors observed the resident receiving oxygen at 3 LPM. The resident stated the nurses adjusted the oxygen rate, and a nurse confirmed the resident was receiving 3 LPM throughout the day shift despite the order for 2 LPM. Resident 92 was observed receiving oxygen via nasal cannula with the tubing not on the nares, unlabeled, undated, and without oxygen signage posted on the room door. Resident 137 was observed receiving continuous oxygen at 2 LPM via nasal cannula and using a CPAP machine at night, but there was no oxygen sign outside the room. The CPAP water chamber cleaning instructions in the manufacturer’s guide called for daily cleaning, yet the physician’s orders did not show how often the chamber should be cleaned, and the resident’s care plan did not include the CPAP machine or continuous oxygen therapy. Staff and the DON verified the missing signage, the lack of a care plan for CPAP and oxygen therapy, and the absence of orders addressing CPAP water chamber cleaning.
Incomplete dialysis monitoring and inaccurate communication records
Penalty
Summary
The facility failed to provide complete and accurate hemodialysis care and communication for two residents receiving dialysis services. The facility’s dialysis services policy required ongoing assessment before and after dialysis, monitoring for complications, and ongoing communication with the dialysis facility. The facility also had a policy for residents with ESRD requiring staff training in the care and special needs of these residents, including the type of assessment data to gather on a daily or per-shift basis and care of grafts and fistulas. For one resident with ESRD and a left arm AV fistula, the medical record showed physician orders to monitor for bruit and thrill every shift and to document whether each was present or absent, and to notify the physician if either could not be auscultated or palpated. The hemodialysis communication records contained multiple missing or inaccurate entries, including blank access-site assessments, missing post-dialysis weights, incorrect documentation of the access being in the right arm, and blank vital signs and signature fields. The MAR also showed several shifts where the licensed nurse documented the absence of thrill, but the record did not show that the physician was notified of those findings. During interview, staff confirmed the access was to be monitored every shift and that the hemodialysis communication record should be reviewed for completeness upon the resident’s return from dialysis. For another resident with ESRD and a right forearm AV fistula, the physician ordered bruit and thrill checks every shift, monitoring for bleeding, drainage, warmth, pain, redness, numbness, tenderness, or swelling, and a fluid restriction of 1500 ml per day. The care plan addressed dialysis treatment and access-site monitoring, but the fluid restriction interventions did not include monitoring intake and output. The medical record did not show that fluid intake was monitored and documented. The hemodialysis communication records for multiple dialysis dates contained blank or conflicting documentation for access-site assessment, bruit, and thrill, including entries marked both present and absent or left blank. Staff interviewed verified that the dialysis communication forms should have been completed accurately and that the fluid intakes were not recorded.
Failure to Follow Up on Consultant Pharmacist Medication Review Recommendations
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist’s monthly medication regimen review recommendations were followed up for four residents reviewed for unnecessary medications and related medication monitoring concerns. The report states that the facility did not act on recommendations for Resident 3, Resident 4, Resident 7, and Resident 60, and that the medical records did not show documentation of physician follow-up or physician responses to those recommendations. Resident 7 was cognitively intact with a BIMS score of 13 and had an order for pantoprazole 40 mg twice daily for gastrointestinal protection. The Consultant Pharmacist reviewed the regimen and documented that pantoprazole is typically given once daily, recommending consideration of a reduction from twice daily to once daily and possible duration of therapy for the higher dose. Facility staff, including the ADON and DON, verified that the recommendation was not followed up with the physician. Resident 3 had moderately impaired cognition and orders for metoclopramide before meals, pantoprazole twice daily, and sucralfate before meals and at bedtime for GERD. The Consultant Pharmacist recommended considering discontinuation of one of the pantoprazole and metoclopramide orders because the combination may be duplicate therapy, and questioned whether sucralfate could be reduced from four times daily to twice daily. RN staff reviewed the record and could not find documentation showing the recommendations were followed up or that the physician responded. Resident 4 had severely impaired cognition with a BIMS score of 5 and was ordered enoxaparin for DVT prophylaxis and prednisone for inflammation. The Consultant Pharmacist asked for a duration of therapy for enoxaparin and requested clarification of the prednisone indication because inflammation was considered too vague. RN staff and the ADON verified that the record did not show documentation that the pharmacy recommendations were addressed. Resident 60 had a BIMS score of 13 and was receiving phenobarbital twice daily for seizures. The Consultant Pharmacist requested phenobarbital recheck lab monitoring, with the recommendation marked pending and sent to the NP/MD, but the record did not show that the recommendation was followed up or that the physician responded sooner.
Kitchen sanitation and equipment maintenance deficiencies
Penalty
Summary
The kitchen was found to have multiple sanitation and equipment issues during surveyor observation and interview with the DSS. The hood over the stove had black, dirty grease residue. The DSS acknowledged the condition and stated the dietary staff cleaned the hood once a week on Thursdays and that an outside company serviced it every six months; the hood sticker showed it was last serviced on 2/19/26. The facility’s policy required the hood to be cleaned every two weeks and free of dust and grease. Surveyors also observed several kitchen utensils that were damaged or not in good repair. These included a stainless steel slotted spatula with a partially melted black handle, a stainless steel scoop with a partially chipped and broken blue handle, a rubber spatula with chipped and cracked edges, and a stainless steel dough cutter with a partially melted black handle. The DSS verified these findings and stated the utensils and equipment should have been discarded and replaced. The facility’s policy required utensils and equipment to be kept clean, maintained in good repair, and free from breaks, corrosion, open seams, cracks, and chipped areas. In addition, multiple kitchen utensils and food-contact items were observed with visible soil and residue, including fuzzy films, watermarks, and dry crusted residue. Cutting boards in green, yellow, blue, red, brown, and white were observed to be fuzzy, heavily marred, and deeply grooved. Surveyors also observed one heavy-duty blender and five clear rectangular food-storage containers still wet with visible water inside when stored. The DSS verified these findings and stated the utensils should have been washed properly, the cutting boards were replaced every three months, and the equipment should have been air dried to prevent bacteria growth. The DON and ADON were later informed and acknowledged the findings.
Inaccurate medical record documentation for advance directives and AV access-site blood pressures
Penalty
Summary
The facility failed to ensure medical records were complete and accurately documented for five sampled residents. The deficiencies involved inaccurate documentation of advance directive status for one resident and incorrect blood pressure access-site documentation for four residents with hemodialysis access sites. The report states that these residents had ESRD and were receiving hemodialysis, and that the facility had policies requiring accurate charting and protection of AV access sites. For Resident 4, the POLST dated 4/27/26 indicated no advance directive in Section D, but the medical record also contained an advance directive and a copy of that document dated 5/8/25. The facility’s advance directive policy stated that copies of executed advance directives are to be obtained and maintained in the medical record. The SSD acknowledged the inconsistency and stated the POLST would be revised to reflect that the resident had an advance directive. For Residents 7, 29, 60, and 73, the medical record documented blood pressure readings on arms that had physician orders to avoid BP measurements because of AV access sites. Resident 7 had a right upper arm AV shunt and an order to avoid BP, venipuncture, injections, strenuous activity, and restrictive clothing on the right upper extremity AV site, yet multiple BP readings were charted on the right arm. Resident 60 had a right upper extremity AVF and a similar order, yet BP readings were documented on the right arm. Resident 73 had a left upper extremity AV site and an order to avoid BP on the left arm, yet BP readings were documented on the left arm. Resident 29 had a left arm hemodialysis access and an order to avoid BP on the left arm, yet multiple BP readings were documented on the left arm. Staff interviews confirmed the charted arm locations and acknowledged that the access sites should not have been used for BP measurements.
Infection surveillance program not fully implemented
Penalty
Summary
The facility failed to implement its infection control surveillance program in accordance with its Infection Prevention and Control Program policy. The policy stated that outcome surveillance is used to measure the effectiveness of the IPCP, and that surveillance tools are used to recognize infections, record their number and frequency, detect outbreaks and epidemics, monitor adherence to infection prevention and control practices, and detect unusual pathogens with infection control implications. During interview and record review, the Infection Preventionist stated the facility’s surveillance process was based on residents being prescribed antimicrobial medications before determining whether they met McGeer’s Criteria. Review of the monthly Infection Prevention and Control Surveillance Logs from May 2025 through March 2026 showed entries for HAI, CAI, and DNMC, but the documentation reflected only residents who were prescribed antimicrobial medications. There was no documentation showing whether residents who had signs and/or symptoms of infection but were not prescribed antimicrobial medications were evaluated to determine if they met McGeer’s Criteria. The Infection Preventionist stated the facility did not determine whether those residents met McGeer’s Criteria unless they were prescribed an antimicrobial medication, and she was uncertain how many such residents existed during that period.
Incomplete Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident or the resident’s representative was fully informed in advance of the proposed use of a psychotropic medication, valproic acid, because the informed consent form did not include the resident’s manifested behaviors for the medication. Resident 3 had moderately impaired cognition and was admitted with a physician’s order for valproic acid 250 mg/5 ml, given 5 ml by mouth twice daily for an unspecified mood disorder manifested by sudden mood swings from calm/pleasant to angry/frustrated and for seizure disorder. Review of the resident’s Psychotherapeutic Drug Informed Consent Form showed the responsible party was informed for the valproic acid medication, but the form did not document the specific behavior manifestations for its use. During a concurrent interview and record review, RN 4 verified that the informed consent did not include the specific manifested behaviors for the medication. The DON stated that informed consent for psychotropic medications should include the type of medication, name, dose, route, frequency, indications, and manifested behaviors, and the Administrator, ADON, and DON were informed of the findings.
Failure to Assess Safe Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that Resident 54 was assessed for safe self-administration of medications. During an observation on 5/19/26, Resident 54 was sitting in a wheelchair with an Equate nasal spray medication on the overbed table at the bedside. Resident 54 stated the nasal spray was his medication and that he used it to spray in his nose. LVN 3 stated that Resident 54 should have no medication at the bedside and that other residents could get and use the medication. Review of the medical record showed no physician order for the nasal spray or for self-administration of medication, no self-administration assessment, and no care plan addressing the use of the nasal spray. Resident 54's H&P dated 4/2/26 showed he had the capacity to understand and make decisions. The Order Summary Report for 5/2026 did not show a physician order for nasal spray medications, and the Plan of Care dated 5/20/26 did not show a care plan problem related to safe self-administration of medications. The DON later verified that Resident 54 had no physician order, assessment, or care plan for self-administration of any medications.
Advance Directive Information Not Documented
Penalty
Summary
The facility failed to inquire about the existence of an advance directive and failed to inform, provide, and document written information regarding the right to formulate an advance directive for one resident reviewed for advance directives. The resident’s record showed a POLST dated 4/18/26 indicating the resident had capacity and had no advance directive, but the Resident Centered Social History and Discharge Planning assessment did not document whether advance directive formulation was offered to the resident or the responsible party. Review of the resident’s admission MDS showed a BIMS score of 12, indicating moderate cognitive impairment. Further review of the medical record did not show an Advance Directive Acknowledgement form. During interview and record review, the SSD acknowledged that if a resident did not have an advance directive, information on advance directive formulation was provided, and verified that no Advance Directive Acknowledgement form was present for the resident, stating the advance directive formulation should have been offered sooner. The ADON and DON were also informed and acknowledged the findings.
Incomplete Orthostatic BP Monitoring for Quetiapine Use
Penalty
Summary
The facility failed to ensure that one of five sampled residents reviewed for unnecessary medications, Resident 3, was free from unnecessary psychotropic medication management concerns. Resident 3 was admitted to the facility and had moderately impaired cognition on the MDS assessment. The physician ordered quetiapine 25 mg by mouth three times a day for unspecified mood disorder manifested by angry outbursts, and also ordered weekly orthostatic blood pressure monitoring while the resident was receiving quetiapine, including readings in the lying and sitting positions during the day shift. Review of the resident’s MARs for April and May 2026 showed the orthostatic blood pressure documentation was not completed as ordered. On multiple dates, the lying and sitting blood pressure readings were documented as NA or were recorded as the same value for both positions. During interview and record review, RN 4 verified these findings and stated the readings should not be the same and that NA should not have been documented. RN 4 also stated the nurse should have reattempted to obtain the readings and/or documented the issue in the nurse’s progress notes, but no such progress note documentation was found for the dates in question. The DON, ADON, and Administrator were informed of and acknowledged the findings.
Failure to Provide Transfer and Bed-Hold Notifications
Penalty
Summary
The facility failed to follow its protocol for written notification of transfer or discharge for two residents who were sent to acute care hospitals. Review of the facility policy showed that residents or their representatives are to be notified in writing of transfer or discharge, that a copy of the notice is to be sent to the Office of the State Long-Term Care Ombudsman, and that bed-hold and return policies are to be provided within 24 hours of an emergency transfer. For Resident 29, the record showed a physician order to transfer the resident to an acute hospital emergency room for weakness, diaphoresis, shaking, and malaise, with a bed hold for seven days if admitted. The resident’s H&P showed the resident had the capacity to understand and make decisions. The Bed Hold Policy and Notification form dated 4/1/26 was blank in the section to be completed upon transfer, and the medical record did not show documentation that the resident was provided information on bed-hold options or that the Ombudsman was notified of the transfer. For Resident 138, the record showed a physician order to transfer the resident to an acute care hospital emergency room for further evaluation due to an episode of blackish stool, with a bed hold for seven days if admitted. The medical record did not show proof that the Ombudsman was notified of the transfer. Interviews with the SSD and DON confirmed that the bed-hold notification for Resident 29 was not completed and that notification to the Ombudsman for Resident 138 was missed.
Inaccurate MDS Coding for Psychiatric Diagnoses
Penalty
Summary
The facility failed to ensure the MDS assessment was accurate for two residents reviewed for MDS coding. For one resident, the MDS dated [DATE] showed an active diagnosis of schizophrenia, but the psychiatric initial evaluation dated 3/9/26 documented that the resident was not diagnosed with schizophrenia while in the facility and stated he had no prior diagnosis of schizophrenia. During interview and record review, the MDS Coordinator stated that coding the resident with schizophrenia was an error and confirmed the physician had assessed the resident and that he did not have schizophrenia; she also stated the resident had not exhibited signs or symptoms of schizophrenia while in the facility. For another resident, the record showed a physician's order for lamotrigine 200 mg at bedtime for Bipolar disorder, and the resident's order summary identified the medication as being for Bipolar disorder manifested by verbalization of helplessness. However, the quarterly MDS assessment dated [DATE] coded the anticonvulsant medication but did not code the diagnosis of Bipolar disorder. During interview and concurrent record review, an LVN stated the resident was administered lamotrigine for Bipolar disorder and verified the MDS findings. The Administrator, ADON, and DON were informed of and acknowledged the findings.
Inaccurate PASRR Level I Screening for Mental Illness
Penalty
Summary
PASRR Level I screening for Resident 11 contained inaccurate information related to mental illness. Resident 11 had a diagnosis of Bipolar disorder and was prescribed divalproex sodium 1500 mg orally at bedtime for that condition, but the PASRR Level I screening dated 5/4/26 indicated the resident had no diagnosed serious mental illness and was not prescribed psychotropic medications. During an interview and concurrent record review on 5/19/26, the MDS Coordinator reviewed the record and verified that the PASRR Level I screening was incorrect because it did not reflect the Bipolar diagnosis or the divalproex sodium order. The MDS Coordinator stated the PASRR Level I screening is used to screen and evaluate residents for serious mental illness and may lead to a Level II mental health evaluation.
Oxygen Therapy Not Provided as Ordered
Penalty
Summary
The facility failed to ensure the comprehensive care plan was implemented for Resident 74, specifically related to oxygen administration. Resident 74 had a care plan focus initiated on 2/10/26 for being at risk for an ineffective breathing pattern related to chronic pulmonary edema, and the interventions included administering oxygen as ordered. The physician's order dated 4/9/26 directed that oxygen be administered continuously at 2 LPM via nasal cannula. On 5/18/26 at 1010 hours, Resident 74 was observed lying in bed receiving continuous oxygen via an oxygen concentrator and nasal cannula at 3 LPM. During a concurrent interview, the resident stated he required continuous oxygen therapy and that he received oxygen at 3 LPM. At 1015 hours, LVN 3 confirmed the resident was receiving oxygen at 3 LPM throughout the day shift, while the physician's order specified 2 LPM. LVN 3 verified that Resident 74's oxygen was not administered in accordance with his care plan.
Care plans not updated to reflect current treatments and conditions
Penalty
Summary
The facility failed to revise comprehensive care plans to reflect residents’ current care needs and interventions for four sampled residents. The report states that the comprehensive plan of care was not updated within the required timeframe and was not revised when residents’ conditions or treatments changed, despite the facility policy requiring ongoing assessment and care plan updates when there is a significant change in condition. For Resident 31, the care plan addressed impaired skin integrity and a coccyx pressure injury, but it was not revised to include the Wound Consultant’s recommendation to avoid sitting for longer than two-hour periods at a time. The resident had a Stage 4 pressure ulcer to the coccyx, and the Preliminary Wound Reports documented the recommendation on more than one occasion. For Resident 50, the care plan addressed anticoagulant therapy and the black box warning for enoxaparin, but the medical record showed the resident was receiving Eliquis 2.5 mg twice daily for DVT prophylaxis, and the care plan was not updated to reflect the current anticoagulant medication. For Resident 63, the care plan for dehydration related to enteral nutrition listed Promote with Fiber at 72 ml/hr and water flushes at 18 ml/hr, but the physician’s orders showed Jevity 1.2 at 75 ml/hr and water flushes at 40 ml/hr. For Resident 84, the enteral feeding/medication care plan still listed PEG tube feeding interventions, including Jevity 1.2 at 35 ml/hr, even though the order summary no longer showed the resident receiving enteral feeding. The MDS Assistant verified that the care plan did not reflect Resident 84’s current condition and that the resident was no longer receiving enteral feeding through the PEG tube.
Insulin Injection Sites Not Rotated
Penalty
Summary
The facility failed to ensure that insulin injection sites were rotated for one resident with Type 2 diabetes mellitus with hyperglycemia. The resident had a physician order dated 1/23/26 for regular insulin to be administered subcutaneously before meals and at bedtime per sliding scale, with instructions to rotate the injection sites. The facility’s policy on insulin administration, revised 3/2025, stated that insulin may be injected into the upper arm, anterior or lateral thighs, and abdomen, and that injection sites should be rotated, preferably within the same general area. Review of the resident’s MARs for April and May 2026 showed repeated insulin administration at the same abdominal locations rather than rotated sites. The right upper quadrant of the abdomen was used multiple times on 4/4/26 and 4/5/26, and the left lower quadrant of the abdomen was used repeatedly on numerous dates in April and May 2026. During an interview and concurrent record review, the RN verified that the injection sites were not rotated and stated that sites should be rotated to prevent skin complications if insulin is injected at the same site repeatedly. The Administrator, ADON, and DON were informed of and acknowledged the findings.
LAL Mattress Setting Not Consistent With Resident Weight
Penalty
Summary
The facility failed to ensure appropriate pressure ulcer care for Resident 17 by not keeping the low air loss mattress setting consistent with the resident’s weight. During the initial tour on 5/18/26, Resident 17 was observed lying on a LAL mattress with the Select Air MAX plus pump set at comfort pressure level 6, which the device indicated was for a 200-lb weight. Later the same day, the resident was again observed on the same mattress with the pump set at comfort pressure level 12, which the device indicated was for a 700-lb weight. Resident 17 was admitted and later readmitted to the facility, had a care plan identifying risk for skin breakdown with a pressure reduction mattress intervention, and had no capacity to make medical decisions per the H&P. The annual MDS showed a BIMS score of 2, indicating severely impaired cognition and functional challenges. The physician’s order for an air mattress for skin management directed that it be set according to the resident’s weight, and the resident’s weight was documented as 111.4 lbs. The facility’s treatment nurse and leadership were informed of the findings and acknowledged them.
Failure to Follow RD Nutrition Recommendations
Penalty
Summary
Failure to ensure the RD’s nutritional recommendations were followed occurred for Resident 29, who had ESRD/HD, was on a regular CCHO diet, and had documented weight loss after readmission. The resident’s weights decreased from 179.6 lbs. to 176.6 lbs., then to 170.6 lbs. and 169.8 lbs., reflecting a 5% loss and a 9 to 9.8 lb. decrease from the earlier weight. The RD documented that the resident had lost 6 lbs. in one week and recommended 30 cc of sugar-free liquid protein and a diet change to Renal-CCHO because of the risk for further weight changes with ESRD/HD and continued antibiotic use. The IDT weight variance assessments also documented the weight loss and listed interventions to change the diet to Renal-CCHO and administer 30 ml of sugar-free liquid protein twice daily. However, the Order Summary Report did not show a documented diet change to Renal-CCHO or a physician’s order for the liquid protein supplement. RN 3 verified the RD and IDT recommendations, but there was no documentation that the physician was notified of the recommendations or that an order for the supplement was obtained. The DON later stated the recommendations should have been followed up and documented, and confirmed the resident remained on the CCHO diet without a physician’s order for protein supplements.
IV access and medication labeling deficiencies
Penalty
Summary
The facility failed to provide the necessary care and services to maintain intravenous access for Resident 23, who had a right upper arm single lumen PICC line and a BIMS score of 12 on admission. The resident’s medical record showed a physician’s order to measure the external catheter length of the PICC and midlines upon admission and with each dressing change, and to include arm circumference for the midline device every seven days and as needed. However, the Nursing Admission/readmission Evaluation/assessment did not document the measurement and assessment of the PICC line, and the record did not show evidence that the length of the catheter above the insertion site or arm circumference were obtained upon admission. The facility also failed to ensure Resident 123’s IV tubing was labeled. During an initial tour, Resident 123 was observed with a peripheral IV in the left hand and a one-liter bag of 0.9% Sodium Chloride infusing at 75 mL per hour. The IV tubing was not labeled with the date, time, and nurse’s initials. The resident’s order summary showed an order to change IV tubing every 24 hours for intermittent IV infusion and TPN and every 72 hours for continuous IV infusion. In addition, the facility failed to ensure Resident 9’s IV medication was correctly labeled. During medication administration observation, Resident 9 was observed with a right upper arm three lumen PICC line and meropenem 1 gram was prepared and administered through the PICC line. The IV tubing was labeled by the RN, but the meropenem medication bag was not labeled with the date, time, and initials of the RN who administered the medication. Facility policy stated that the nurse hanging IV solutions will label the bag with the date, time, and initials.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure the medication error rate remained below 5%, with a reported error rate of 8% based on observation, interview, medical record review, facility document review, and policy review. Two of five licensed nurses observed during medication administration were found to have errors: LVN 2 and LVN 4. The facility policy titled Administering Medication stated medications are to be administered safely, timely, and in accordance with prescriber orders, including required time frames. During observation of Resident 92, LVN 4 took the resident’s blood pressure at 112/66 mmHg and administered midodrine via GT, but did not administer the ordered diltiazem 30 mg via GT. The physician’s order required diltiazem four times daily for hypertension and to hold it only if systolic blood pressure was below 100 mmHg or heart rate was below 60 beats per minute. LVN 4 later stated she withheld the diltiazem because the blood pressure was low, and verified she should have given it. During observation of Resident 85, LVN 2 administered metformin 1000 mg, Eliquis, and insulin lispro, but there was no dinner tray on the overbed table and LVN 2 later verified the metformin was not given with meals or food. Resident 85’s record showed metformin was ordered twice daily with meals, and the resident’s H&P stated the resident did not have the capacity to understand and make decisions.
Expired and Improperly Stored Medications in Medication Room and Cart
Penalty
Summary
The facility failed to ensure drugs and biologicals were stored, labeled, and disposed properly in the medication room and Medication Cart A. During an inspection of the medication room, surveyors found one bottle of nystatin suspension for Resident 37 with an opened date of 3/24/26 even though the resident was no longer on the medication, one Humalog KwikPen for Resident 29 that had been opened on 4/2/26 and was labeled with an expiration date of 4/30/26 while still stored in the refrigerator, and 12 culture swabs with an expiration date of 4/23/26. LVN 10 verified these findings and stated the insulin pen should not remain in the refrigerator once removed and opened. During inspection of Medication Cart A, surveyors observed one opened box of levalbuterol for Resident 10 with an opened date of 2/26/26 and an expiration date of 3/26/26, along with several oral medications and a supplement stored together with bisacodyl suppositories. The cart contained furosemide, alendronate, naloxone nasal spray, glucosamine sulfate, and bisacodyl suppositories stored together rather than separating internal and external medications. LVN 10 verified the findings and stated internal and external medications should be stored separately. The DON stated the licensed nurses assigned to the carts were responsible for dating, labeling, separating medications by route, and discarding expired medications, and the IP nurse and night shift nurses were responsible for removing expired medications and supplies from the medication rooms.
Therapeutic Menu Not Followed for Resident on Soft and Bite Sized Diet
Penalty
Summary
The facility failed to ensure the menu was followed for one resident receiving a therapeutic diet. Resident 120 was admitted to the facility and had severely impaired cognition. The resident’s MDS showed the resident was coded for receiving a mechanically altered and therapeutic diet, and the physician’s order specified an IDDSI Level 6 soft and bite sized texture with thin liquids, with soft bread allowed for feeding assistance. The facility’s therapeutic menu for the lunch meal on 5/18/26 listed tender, chopped baked hamburger with puree brown sauce, boiled potatoes, chopped capri-blend vegetables, and chopped, moist spring fruit crisp for the soft and bite sized diet. During the meal observation, Resident 120 was served chopped baked hamburger with brown sauce, chopped vegetable blend, rice, a wheat roll, and fruit crisp dessert, but was not served the boiled potatoes listed on the therapeutic menu. The DSS verified the finding and stated residents on the soft and bite sized diet should have had the boiled potatoes as per the menu.
Missed Resident Food Preference on Meal Tray
Penalty
Summary
The facility failed to ensure that one of 27 sampled residents, Resident 31, received food that accommodated the resident’s preferences. During the lunch meal observation on 5/18/26, Resident 31 was observed eating in her room with a tray that included a baked hamburger with brown sauce, capri blend vegetables, fried diced potatoes, a wheat roll, and a fruit crisp dessert. Review of the resident’s lunch meal ticket showed a note to add a fresh fruit cup, but the fruit cup was not present on the tray. When asked, Resident 31 stated she would like to have her fruit cup for her lunch meal. Resident 31 had been admitted to the facility and later readmitted. During the concurrent observation and interview, LVN 7 reviewed the meal ticket and verified that the fresh fruit cup should have been included. The DSS stated that items listed in the Notes section of the meal ticket were resident preferences for the meal and that if listed, the resident should have that item in addition to the menu items. The Administrator, ADON, and DON were informed of and acknowledged the findings.
Improperly Stored Garbage in Outside Dumpsters
Penalty
Summary
The facility failed to ensure garbage was properly stored in two of four outside garbage dumpsters. During observation, two dumpsters were seen with lids partially propped open by garbage bags, which prevented the lids from fully closing. The report states this condition was observed during a surveyor review with the DSS, and the Maintenance Director later verified the finding and stated the dumpster lids should be fully closed for pest control and infection control purposes. The deficiency was identified after review of the facility’s policies and procedures for Dumpster Management, Miscellaneous Areas: Garbage and Trash, and Sanitization, all of which required garbage and refuse to be stored in covered, secured, and vermin-proof containers. The report also cites USDA Food Code requirements stating refuse must be stored so it is inaccessible to insects and rodents and that outside receptacles used with food residue must have tight-fitting lids, doors, or covers. The DON and ADON were informed and acknowledged the findings.
Hospice Care Plan Not Integrated With Facility IDT Process
Penalty
Summary
The facility failed to provide necessary care and services for one of two final sampled residents, Resident 63, who was receiving hospice services for a CVA (stroke). The deficiency involved the facility not ensuring hospice staff were included in Resident 63's interdisciplinary team meetings to discuss the resident's plan of care, and not ensuring the hospice plan of care was integrated into the facility's care plan with the frequency of visits and provisions of care from each hospice discipline. Resident 63 had a physician's order dated 10/4/25 to admit the resident to Hospice Provider A under routine care. The hospice plan of care dated 10/8/25 listed visit frequencies for the hospice aide, skilled nurse, and spiritual counselor. However, the facility's care plan for end of life and hospice admission did not include the frequency of visits by each hospice staff member or the services provided by each discipline. The document titled Hospice Provider A- Integrated Hospice and Facility Plan of Care was also not completed to include the frequency of hospice nurse and hospice aide visits and was not signed by the hospice RN or the facility RN. Review of the IDT Conference Notes dated 1/1/26 and 4/3/26 showed Resident 63 continued with hospice services and that care was to be integrated with the hospice team, but the notes did not show hospice staff participated in the IDT meetings. During interview and record review, the SSD stated he was responsible for coordinating hospice resident care and verified the IDT meetings for Resident 63 did not include Hospice Provider A staff and that he could not find documentation that hospice was informed or contacted to attend. The SSD also verified that an IDT meeting was not conducted to discuss Resident 63's hospice plan of care and that the facility care plan was not updated to incorporate the hospice plan of care. The DON, ADON, and Administrator were informed and acknowledged the findings.
Glucometer Quality Control Documentation Was Incomplete and Mismatched
Penalty
Summary
The facility failed to ensure Medication Cart A’s glucometer was maintained in a safe operating condition. During inspection and interview, LVN 3 verified that the serial number for the glucometer currently in use on Medication Cart A was not documented on the cart’s Quality Control Record. LVN 3 also verified that the test strip bottle currently in use was dated 5/18/26 and that its lot number did not match the lot number recorded on the Quality Control Record for the cart. Review of the Quality Control Record for May 2026 showed documented control test results for Medication Cart A on 5/16/26, 5/17/26, 5/18/26, and 5/19/26, including normal and high control values. However, concurrent review of the glucometer’s stored result history did not show the documented control results. The Assure Platinum Blood Glucose Monitoring System manual stated that control solution testing should be performed before using a new glucometer or a new bottle of test strips, and that control solution results would not be valid unless the meter was set in control solution mode. The DON stated the purpose of the quality control testing was to ensure the glucometers were working properly and to ensure accurate blood glucose measurements.
Failure to Provide Ordered CPR, Diagnostic Follow-Up, Lab Response, and Wound Care
Penalty
Summary
The deficiency involves multiple failures to provide treatment and care according to physician orders, facility policies, and residents’ needs and conditions. For one resident with a documented full code status and POLST indicating CPR and full treatment, staff initiated CPR after the resident was found unresponsive, pulseless, and not breathing. Staff reported that after approximately 18–20 minutes of CPR, a carotid pulse was obtained, but the resident remained unconscious, barely breathing, and without a blood pressure reading. Despite this, staff stopped chest compressions and rescue breathing while waiting approximately 5–7 minutes for paramedics to arrive. When the fire department arrived, they found the resident pulseless, apneic, and without compressions being performed, and they restarted manual compressions and advanced resuscitation efforts. The facility’s DON stated the expectation was that licensed nurses continue CPR until the fire department arrives and takes over. Another deficiency concerns a resident with severe cognitive impairment who experienced a fall and developed consistent right hip pain with a positive test noted by PT. The PT documented a recommendation for right hip/femur and knee x-rays, but the medical record did not show that nursing staff notified the physician of this recommendation at that time. A later physician order was written for bilateral hip/femur to knee x-rays, but the record only contained results for bilateral hip x-rays and no results for femur-to-knee imaging as ordered. The resident was later found at the hospital to have markedly displaced fractures of the distal femur requiring ORIF surgery. For the same resident, a STAT BMP, CBC, and magnesium were ordered, and lab results showed a hemoglobin of 6.3 g/dL, but the record did not show timely physician or family notification of this abnormal result. The resident was transferred to the ER later with low hemoglobin and received a blood transfusion. The resident’s family member reported not being notified of the low hemoglobin until the following day and that transfer to the hospital occurred two days after the low result. Additional deficiencies for this resident involved failure to follow through on a physician recommendation to obtain a urine sample after a change in condition. The family reported lethargy and sediment in the urine, and the physician recommended collecting a urine sample, but the record contained no physician order, no lab requisition, and no urine test result. The resident, who had a suprapubic catheter and was care planned as at risk for catheter-related complications, was later transferred to the hospital and diagnosed with acute kidney injury and catheter-associated UTI. The family member stated the facility resisted transferring the resident to the hospital until the resident was eventually sent. The facility also failed to provide ordered wound and skin treatments for several residents. For one resident with multiple treatment orders for bilateral upper and lower extremity discoloration, a left thumb lesion, MASD with excoriation to the buttocks, and suprapubic catheter site care and monitoring, the Treatment Administration Record and MAR for specific days lacked nurse initials, indicating treatments and monitoring were not completed. The resident’s family member reported the catheter was visibly cloudy and the split gauze dressing was filthy. For another resident with a gastrostomy tube, the TAR showed no nurse initials on a day when the daily order to cleanse the G-tube site and apply dressing should have been completed. For a third resident with mild cognitive impairment and multiple skin and wound treatment orders, including monitoring lower extremity discoloration, treating facial and shin scabs, managing MASD, and caring for surgical incisions and pressure injuries, the TAR lacked nurse initials for several ordered treatments on a specific day. Staffing assignment records showed that on some days there was no signed or assigned treatment nurse for certain stations, and LVN staff confirmed that missing initials indicated treatments were not completed.
Failure to Continue CPR for Full-Code Resident Until EMS Arrival
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing staff with documented BLS/CPR competencies provided appropriate and continued emergency care to a full-code resident. Facility policies required that all nursing staff meet competency requirements per state law and that staff certified in CPR/BLS initiate and continue CPR for unresponsive individuals without normal breathing unless a DNR order exists or there are obvious signs of irreversible death. The facility’s CPR policy and cited clinical references emphasized that chest compressions are the cornerstone of CPR, that compressions and ventilations should continue in cycles until an AED is available or additional help arrives, and that compressions should only be stopped when the person speaks, moves, or breathes normally or when help takes over. Resident 7 was admitted with orders indicating full code status, including a POLST specifying “Attempt Resuscitation/CPR” and “Full Treatment” as the primary goal. On the date of the event, documentation in the resident’s eInteract SBAR and progress notes showed the resident was found on the floor next to the bed, unresponsive to verbal and tactile stimuli, with asystole and absence of respirations. CPR was initiated and 911 was called. The notes indicated that after approximately 20 minutes of CPR, return of spontaneous circulation was achieved and care was assumed, and that the fire department arrived and continued CPR and lifesaving measures for another 20 minutes. The resident’s medical record did not contain documentation of vital signs at the time staff believed spontaneous circulation had been achieved. The fire department’s electronic patient care report documented that responders arrived to find the resident on the ground, pulseless, apneic, and without compressions being performed, and that manual compressions were then initiated, BVM with high-flow oxygen was administered, and defibrillation pads were applied, with the rhythm noted as PEA. The emergency department record later documented that the resident died in the ED. In interviews, the Fire Captain stated that staff reported they had provided CPR for about 20 minutes, believed the heart rate had returned, and stopped compressions while waiting for paramedics. In interviews with facility staff, LVN 4 stated the resident was unresponsive with no pulse, and that CPR was started immediately, with LVN 5 performing compressions and RN 3 providing ventilations via Ambu bag. LVN 4 reported that after about 20 minutes of CPR, the resident’s pulse returned and RN 3 instructed staff to stop CPR while waiting for paramedics. RN 3 stated that she and LVN 5 initiated CPR when they found the resident unresponsive and pulseless, with LVN 5 doing compressions and RN 3 providing breaths, and that a pulse was achieved before the fire department arrived; however, she also stated the resident had no blood pressure and remained unconscious. LVN 5 reported finding the resident on the floor, with no pulse oximeter reading, and that RN 3 confirmed no pulse or respirations; he described performing compressions while RN 3 provided breaths, then stopping compressions after 18–20 minutes when a carotid pulse was obtained, even though the resident remained unconscious, was barely breathing, and had no blood pressure for approximately 5–7 minutes while they waited for paramedics. Review of staff records showed that LVN 4 and LVN 5 had documented competencies for emergency equipment and current BLS Provider certification, and RN 3 had documented competencies in emergency equipment, emergency responses, and CPR, along with an RQI Healthcare Provider BLS certificate demonstrating competence in high-quality CPR skills. Despite these documented competencies and the facility’s CPR policy, LVNs 4 and 5 and RN 3 did not continue life-saving measures for the resident, as they stopped chest compressions while the resident remained unconscious, barely breathing, and without a blood pressure reading, and before EMS personnel arrived and took over resuscitation. The facility acknowledged through the DON’s interview that the expectation was for licensed nurses to continue CPR until the fire department arrived and assumed care.
Failure to Notify State LTC Ombudsman of Resident Transfer/Discharge
Penalty
Summary
The deficiency involves the facility’s failure to provide the Office of the State LTC Ombudsman with a copy of a required notice of transfer/discharge for one sampled resident. The resident was admitted to the facility and later transferred to an acute care hospital. During a closed medical record review initiated on 12/23/25, surveyors found no documented evidence that the LTC Ombudsman had been notified of this transfer. Review of the resident’s electronic medical record did not contain a completed Notification of Transfer/Discharge form or any documentation indicating that the Ombudsman had been informed of the transfer to the hospital. In an interview and concurrent record review on 1/8/26, RN 3 explained that a change of condition form, transfer form, and notice of transfer were required when transferring a resident and confirmed that all resident information was maintained in the electronic medical record. When asked to locate the Notification of Transfer/Discharge for this resident, RN 3 verified that no such notice had been completed and that there was no documentation of Ombudsman notification. In a subsequent interview on 1/12/26, RN 2, acting as interim DON, acknowledged that facility staff should have completed the resident’s notice of transfer and sent a copy to the LTC Ombudsman.
Failure to Follow Elopement Care Plan for Resident Lacking Capacity
Penalty
Summary
The facility failed to implement and follow the individualized care plan for a resident who lacked capacity to make medical decisions and had a history of mild, intermittent confusion. The resident's care plan, initiated due to elopement risk, specified that the resident was not to leave the facility without being accompanied by a responsible person. Despite this, the resident was allowed to leave the facility for an outpatient medical appointment without accompaniment from a responsible party or the resident's responsible person, as required by the care plan and physician orders. Medical records indicated that the resident left the facility under approved authorization for an appointment but did not return directly afterward, instead going to his apartment before eventually returning to the facility. Documentation did not show that the responsible party was informed or present, and the responsible party later confirmed she was not notified of the appointment or the need to accompany the resident. The DON verified that the care plan was not followed and that the responsible party was not informed, resulting in the resident leaving unaccompanied and eloping after the appointment.
Failure to Administer and Document IV Fluids per Policy
Penalty
Summary
The facility failed to provide necessary treatment and services related to the administration and documentation of intravenous fluids (IVF) for one resident. According to the facility's policy and procedure (P&P) for intravenous administration, staff are required to monitor residents receiving continuous fluids for signs of complications, document specific details of the infusion, and notify the provider of any issues. For the resident in question, a physician's order was received for STAT labs and normal saline IVF at a specified rate. Although a nurse documented that the orders were noted and carried out, there was no evidence in the resident's progress notes or medication administration record (MAR) that the IVF was actually administered or that the IV site was monitored as required. Additionally, there was no documentation that the physician was notified if the IVF was not given. Further review revealed that the required physician's order for the IVF was missing from the resident's order summary and MAR. Interviews with nursing staff confirmed the lack of documentation regarding the insertion of the IV, administration of fluids, and monitoring of the IV site. There was also no record of the removal of the normal saline IVF from the facility's emergency kit, as required by protocol. Both the facility's administrator and director of nursing acknowledged these findings, and the pharmacy supplying the IV fluids confirmed that no documentation was provided by facility staff to show the IVF was removed from the emergency kit for the resident.
Unauthorized Medication Storage at Bedside Without Physician Order
Penalty
Summary
A deficiency occurred when a tube of diclofenac sodium 1% topical gel, which had expired, was found stored at the bedside of a resident who lacked the capacity to understand and make decisions. The medication was not authorized for self-administration, and there was no physician's order, care plan, or documentation permitting the resident to store or self-administer the medication. The facility's policy required that any medications found at the bedside without authorization for self-administration be turned over to the nurse in charge, but this procedure was not followed in this instance. The resident's medical record indicated that the resident did not wish to self-administer medications and had no assessment or order allowing for self-administration. Facility staff, including an RN and the DON, confirmed that the medication should not have been left at the bedside and that it may have been brought in by the resident's family. The medication was accessible in the resident's room, and staff verified that there was no documentation or physician's order supporting its presence or use at the bedside.
Failure to Complete Stat Laboratory Orders as Prescribed
Penalty
Summary
The facility failed to ensure that a physician's order for stat laboratory tests, specifically a Complete Blood Count (CBC) and Comprehensive Metabolic Panel (CMP), was completed for one resident. The physician ordered these tests on 9/5/25 at 1315 hours due to the resident's decreased urine output and increased lethargy. However, a review of the resident's medical record did not show any documented evidence that the stat laboratory tests were performed as ordered. Interviews with nursing staff revealed that stat laboratory orders should be processed as soon as possible, typically within two to four hours, and require both entry into the facility's electronic system and direct communication with the laboratory. The laboratory's records confirmed that no stat order was received for the resident, and the last blood work on file was from a previous date. Further interviews with staff indicated that the expected protocol for stat laboratory orders includes notifying the laboratory by phone, documenting follow-up actions, and informing the physician if there are delays. In this case, the nurse who received the order did not see the laboratory technician arrive before the end of the shift, and there was no documentation of follow-up or communication regarding the delay. The Director of Nursing and Administrator acknowledged these findings during the survey.
Incomplete Documentation of Urine Monitoring for Catheterized Resident
Penalty
Summary
The facility failed to ensure that the medical record for one of six sampled residents was complete, specifically regarding documentation of urine characteristics for a resident with an indwelling urinary catheter. According to the facility's policy and procedure for catheter care, information such as urine color, clarity, and odor should be recorded in the resident's medical record to prevent catheter-associated complications. Medical record review revealed that the Treatment Administration Record (TAR) for August was incomplete, with missing documentation on two shifts where monitoring of urine characteristics was required by physician order. Interviews with two LVNs confirmed that the TAR entries for the specified dates and shifts were left blank, indicating that documentation was not completed. Both LVNs acknowledged that monitoring may have been performed but was not recorded as required. The Director of Nursing stated that the expectation was for licensed nurses to follow physician orders, and both the Administrator and DON acknowledged the findings during the survey.
Incomplete and Inaccurate POLST Documentation for Multiple Residents
Penalty
Summary
The facility failed to ensure that medical records, specifically the Physician Orders for Life-Sustaining Treatment (POLST) forms, were accurate and complete for three of eight sampled residents. For one resident with dementia and moderate cognitive impairment, the POLST form was missing the physician's phone number, license number, signature, and the responsible party's signature, address, and telephone number. The responsible party's signature was entered by a nurse without indicating it was a verbal consent, and the nurse practitioner’s name was incorrectly entered in the section for the supervising physician. These omissions were verified during a medical record review with a registered nurse. For another resident with moderate cognitive impairment, the POLST form lacked the nurse practitioner's phone number, license number, date signed, and the supervising physician's name. The form also did not indicate whether the information was discussed with the resident, and the resident's address, telephone number, and signature date were missing. A third resident, who was cognitively intact, had a POLST form that did not document a second nurse witnessing the verbal consent from the responsible party, omitted the resident's wishes regarding artificially administered nutrition, and left the responsible party's address and phone number blank. These findings were confirmed by both a registered nurse and the Director of Nursing.
Widespread Kitchen Sanitation and Equipment Failures
Penalty
Summary
Surveyors identified multiple failures in the facility's kitchen related to food safety and sanitation. The kitchen hood over the stove was found to have black, greasy residue, despite facility policy requiring it to be cleaned every two weeks and kept free of dust and grease. The Dietary Services Supervisor (DSS) confirmed that the hood was only cleaned once a week and acknowledged the presence of dirt and grease. Additionally, several kitchen utensils, including spatulas, ladles, whisks, and dough cutters, were observed to be chipped, cracked, melted, discolored, or otherwise worn out, contrary to facility policy and USDA Food Code requirements that utensils be maintained in good repair and have smooth, cleanable surfaces. Further observations revealed that numerous kitchen utensils and equipment were not properly cleaned. Items such as ladles, spoons, cake slicers, spatulas, scoops, measuring cups, and dough cutters were found with dry, crusted food residue, watermarks, and bristle-like debris. The DSS acknowledged that these items should have been cleaned and washed to prevent bacteria growth. Cutting boards used for food preparation were heavily marred, fuzzy, and had deep grooves, making them difficult to clean and sanitize. The DSS confirmed that these cutting boards should have been replaced. Additional deficiencies included improper drying and storage of kitchenware. A heavy-duty blender, several ladles, scoops, and clear plastic bins were stored while still wet, and some scoops were also dirty with food residue. The DSS acknowledged that all utensils and equipment should have been air dried before storage. The countertop-mounted can opener and the microwave were both found to have yellowish discoloration resembling rust, with the microwave also having white residue inside the door. The DSS confirmed that these items were old, unsanitary, and needed replacement. These findings were observed during an initial kitchen tour, and the DSS verified all deficiencies.
Infection Control Deficiencies and Failure to Follow Protocols
Penalty
Summary
The facility failed to implement and maintain effective infection prevention and control practices as outlined in its own policies and procedures. Surveyors found that the monthly Infection Prevention and Control Surveillance Logs for January and February did not accurately match the Infection Control Monthly Summary reports, resulting in inaccurate reporting of healthcare-associated infections (HAIs) and community-acquired infections (CAIs). The Infection Preventionist (IP) confirmed that the discrepancies were due to the volume of infections and acknowledged that the numbers should have matched to provide accurate information for infection control monitoring. Additionally, the facility did not follow Enhanced Barrier Precautions (EBP) for a resident with a central line, as there was no signage or personal protective equipment (PPE) available at the doorway, and no physician's order for EBP was documented. Staff also failed to adhere to hand hygiene protocols during resident care activities. For example, an occupational therapist did not perform hand hygiene between assisting multiple residents during mealtime, and a licensed vocational nurse (LVN) did not don a gown when providing enteral feeding care to a resident on EBP. Another LVN failed to perform hand hygiene and change gloves prior to administering insulin to a resident, despite facility policy requiring these steps to prevent infection. Furthermore, improper hand hygiene was observed during wound care treatment for a resident with stage 4 pressure injuries. The LVN performing the wound care did not sanitize hands immediately after removing gloves throughout the procedure, only washing hands at the end of the treatment. These failures were acknowledged by the staff involved and confirmed by the IP and Director of Nursing (DON) during interviews, demonstrating a lack of consistent adherence to infection control protocols designed to prevent the development and transmission of diseases and infections within the facility.
Failure to Ensure Safe Self-Administration of Medication
Penalty
Summary
A deficiency occurred when a resident was found to be self-administering Systane eye drops, despite not being assessed as able or willing to self-administer medications. During an observation, two bottles of Systane eye drops were found on the resident's bedside table, and the resident confirmed self-administration. A licensed vocational nurse (LVN) verified the presence of the medication at the bedside and stated that the resident was not able to self-administer the eye drops and should not have had them at the bedside. Review of the resident's medical record showed no physician's order for the Systane eye drops or for self-administration, and the care plan did not address the resident's eye condition or ability to self-administer medication. The facility's policy requires an assessment, physician's order, and care plan documentation for self-administration, none of which were present for this resident. The Director of Nursing (DON) confirmed that the necessary documentation and orders were missing.
Failure to Maintain and Provide Advance Directive Documentation and Information
Penalty
Summary
The facility failed to obtain and/or maintain copies of advance directives and provide written information regarding the formulation of advance directives for four residents. For two residents who had executed advance directives, the facility did not ensure that copies of these documents were available in their medical records or electronic health records. Interviews with nursing and social services staff confirmed that there was no documented follow-up to obtain these documents, despite facility policy requiring such actions and quarterly checks. For another resident who had not executed an advance directive, the facility did not provide written information or assistance on how to formulate one to the resident or their responsible party. Medical record review and staff interviews confirmed the absence of documentation showing that the required information and assistance were offered, as outlined in facility policy. The responsible staff acknowledged that this step was missed during the admission process and subsequent follow-up. A fourth resident, who lacked decision-making capacity, also did not have documentation in the medical record that the responsible party was provided with information on how to formulate an advance directive. The social services director and DON confirmed that, according to policy, this information should have been offered and documented, but there was no evidence of this in the resident's records. These failures were verified through interviews and concurrent record reviews with facility staff and administration.
Failure to Follow Proper Insulin Administration Procedure
Penalty
Summary
LVN 1 failed to follow the facility's policy and procedure for insulin administration for one resident. During a medication administration observation, LVN 1 was seen wiping the resident's left upper abdominal area with an alcohol wipe and immediately injecting Lantus insulin while the area was still visibly wet. The facility's policy, as well as the manufacturer's administration guide, require that the injection site be cleaned with alcohol and allowed to air dry before injection. LVN 1 did not wait for the alcohol to dry before administering the insulin. Interviews with LVN 1 and the Director of Staff Development (DSD) confirmed that LVN 1 had been trained to allow the injection site to air dry after cleaning with alcohol. Both LVN 1 and the DSD acknowledged that injecting insulin into a site that is still wet with alcohol could cause stinging and potentially alter the effect of the medication. The deficiency was identified through observation, interview, and review of facility policies and training records.
Failure to Document and Assess Skin During Splint Use for Resident with Limited ROM
Penalty
Summary
The facility failed to follow a physician's order for the application of a left knee extension splint for a resident with limited range of motion (ROM). The order specified that the splint should be applied to the resident's left knee five times a week for up to five hours a day or as tolerated. However, there was no documentation of the exact times when the splint was applied and removed. Additionally, the care plan and medical record did not include or document any skin assessments when the splint was in use, despite the resident having hardware (screws) in the leg and being at risk for skin issues. Interviews with staff confirmed that while the splint was applied as ordered, there was no record of skin assessments being performed or documented during its use. The facility's policy on restorative nursing services required care to promote safety and independence, but the lack of documentation and omission of skin assessments represented a failure to provide appropriate care to prevent a decline in ROM and potential skin complications. The Director of Nursing verified these findings during the survey.
Failure to Document and Respond to Change in Condition for Catheterized Resident
Penalty
Summary
A deficiency occurred when a resident with an indwelling urinary catheter did not receive appropriate care and services as required by facility policy and physician orders. The resident, who had moderate cognitive impairment, was observed on multiple occasions with cloudy urine and sediments in the catheter tubing. Despite these findings, which were recognized by nursing staff as a change in condition and potential sign of infection, there was no documentation of a change of condition (COC) assessment, progress notes, or care plan in the resident's electronic health record (EHR) for several days. Interviews with licensed nursing staff confirmed that the facility's policy required immediate reporting and documentation of unusual findings such as cloudy urine with sediments. However, staff acknowledged that no COC documentation, progress notes, or care plan had been completed for the resident's condition during the relevant period. One nurse stated that the change was reported to other staff, but those staff members did not follow up with the required documentation or care planning. The administrator was informed and acknowledged these findings.
Failure to Monitor and Document Enteral Feeding Care and Adherence to Protocols
Penalty
Summary
The facility failed to provide necessary gastrostomy tube (GT) care and services for two residents receiving enteral feeding. For one resident, staff did not monitor or document intake and output as required by both the resident's care plan and the facility's policy. The resident had a history of dysphagia and was receiving Glucerna via GT at a prescribed rate. Despite a care plan intervention to monitor intake and output, there was no evidence in the medical record that this was being done. Interviews with staff, including an LVN and the DON, confirmed that intake and output monitoring was not consistently performed or documented for residents on tube feeding, contrary to facility protocol and care plan requirements. For another resident, the facility did not ensure that the enteral feeding formula was changed within 24 hours, nor was the formula bottle properly labeled with the start time and nurse's initials. Additionally, the water bag used for enteral feeding was not labeled with the date and time it was prepared. This resident also had a history of dysphagia and was receiving Jevity 1.2 via feeding pump, along with scheduled water flushes. Observation and interviews confirmed that the labeling and timely changing of the formula and water bag were not performed as required by facility policy. These deficiencies were identified through observation, interviews, medical record review, and review of facility policies and procedures. Both the DON and Administrator acknowledged the findings related to the lack of intake and output monitoring, as well as the failure to follow protocols for changing and labeling enteral feeding supplies.
Failure to Provide Safe and Appropriate Respiratory Care and Maintain Infection Control
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for four residents who required oxygen therapy or CPAP support. For two residents, staff did not ensure oxygen was administered as per physician orders and failed to store nasal cannula tubing in a sanitary manner. One resident was observed with a nasal cannula left on the bed and not in a plastic bag, while another had the tubing wrapped around a bed rail. In both cases, the oxygen concentrator was running, but the residents were not using the oxygen as ordered, and there was no documentation of communication with the physician regarding changes in oxygen use or need. Another resident using a CPAP machine did not have a care plan addressing the use of the device, and there was no physician's order for the cleaning and maintenance of the CPAP as directed by the manufacturer's guidelines. The CPAP mask was left on top of a drawer, and the tubing was stored in a plastic bag, but staff could not provide the user guide for the device and confirmed that cleaning instructions were not being followed or documented. Additionally, a resident receiving continuous oxygen therapy was observed with oxygen tubing touching the floor, which was verified by the infection preventionist. The facility's policies required proper storage and regular changing of oxygen tubing and cannulas, as well as adherence to infection control practices, but these were not consistently followed for the residents reviewed.
Failure to Provide and Document Appropriate Pain Management
Penalty
Summary
The facility failed to provide appropriate pain management for one resident by not accurately documenting pain assessments and not administering pain medication according to the physician's orders. Specifically, the medical record review showed that the resident was given oxycodone, a narcotic opioid, even when the documented pain level was zero, which was outside the ordered parameters that required administration only for moderate to severe pain (pain levels 6-10). Additionally, pain assessments were not consistently documented each shift as required, and there were discrepancies between the administration of pain medication and the recorded pain levels. The facility also did not ensure that non-pharmacological interventions were implemented and documented prior to administering pain medication, as required by both physician orders and facility policy. On several occasions, the non-pharmacological interventions were either not documented or were marked as 'none' before the administration of oxycodone. This was confirmed through review of the Medication Administration Record (MAR) and interviews with both the LVN and the DON, who acknowledged that non-pharmacological interventions should have been attempted and documented prior to medication administration. Interviews with facility staff, including the LVN and DON, confirmed that the expected process was not followed. Both staff members verified that pain medication should not be administered when the pain level is documented as zero, and that non-pharmacological interventions should not be marked as 'none' if pain medication is given. The DON also stated that pain assessments should be accurately documented each shift and updated if the resident's pain status changes after initial documentation.
Failure to Provide Safe and Appropriate Dialysis Care and Documentation
Penalty
Summary
The facility failed to provide appropriate dialysis care for two residents with end-stage renal disease (ESRD) who required dialysis services. For one resident, the dialysis communication records, which serve as a communication tool between the dialysis center and the facility, contained multiple blank entries for the dialysis access site assessment on several dates. Both the LVN and the DON confirmed that these records should have been fully completed prior to the resident going to the dialysis center, as per facility policy. For another resident, the facility did not ensure that an emergency dialysis kit was kept at the bedside, as required by physician's order and facility policy. During an interview and observation, the LVN was unable to locate the emergency dialysis kit at the resident's bedside, despite acknowledging that it should be present even if the resident was no longer receiving dialysis treatments but still had a dialysis access in place. The DON also confirmed that the kit should have been readily available for any resident with a dialysis access. Additionally, the facility failed to ensure that licensed nurses assessed and documented the resident's dialysis access site and maintained a transparent dressing over the site. Medical record review showed no documentation of assessment of the dialysis catheter, and the resident's care plan did not address the care of the dialysis catheter. Observation confirmed that the resident's dialysis access site was not covered with a transparent dressing, and the DON was unable to find documentation of the last dressing change. These failures were verified by both the LVN and the DON during interviews and record reviews.
Failure to Implement and Document Dementia Care Interventions
Penalty
Summary
The facility failed to implement and document dementia care interventions for one resident diagnosed with dementia. According to the facility's own policy, staff and physicians are required to evaluate, monitor, and document the cognitive and behavioral status of residents with dementia, including signs of altered mood, loss of interest in activities, and other related symptoms. For the resident in question, the care plan specifically called for monitoring and reporting of mood changes and symptoms of depression or anxiety. However, medical record review revealed no documented evidence that these assessments or monitoring activities were being performed as required. Observations and interviews with staff confirmed that the resident exhibited severe cognitive impairment, was dependent for most ADLs, and displayed behaviors such as confusion, aggression, and lack of interaction. Despite these symptoms and the care plan directives, both CNAs and LVNs were unable to provide documentation of behavior or mood monitoring for the resident. The DON also verified that no such documentation existed, confirming that the required interventions and monitoring for dementia-related symptoms were not being carried out as outlined in the resident's plan of care.
Failure to Document Administration of Controlled Medications
Penalty
Summary
The facility failed to provide necessary pharmaceutical services in accordance with its policies and procedures for two residents. For one resident with the capacity to make decisions, a physician's order was in place for oxycodone-acetaminophen to be administered as needed for moderate to severe pain. The medication was dispensed and signed out, but there was no documentation of its administration on the Medication Administration Record (MAR) for the specified date and time. This omission was verified during a medical record review and interview with a registered nurse. Similarly, for another resident who was unable to make decisions, a physician's order was in place for lorazepam to be administered as needed for anxiety. The medication was dispensed and signed out, but again, there was no documentation of its administration on the MAR for the specified date and time. This finding was also confirmed through medical record review and staff interviews. The facility's policies require that the administration of controlled substances be documented on the MAR, including the date, time, dosage, route, and the signature of the administering nurse, which was not followed in these instances.
Failure to Adhere to Blood Pressure Parameters for Medication Administration
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary medications by not adhering to physician-prescribed blood pressure parameters for three medications: amlodipine, spironolactone, and ethacrynic acid. The physician’s orders specified that amlodipine should be held if the systolic blood pressure was less than 115 mmHg or the heart rate was less than 56 bpm, and that both diuretics should be held if the systolic blood pressure was less than 110 mmHg or the heart rate was less than 60 bpm. Despite these parameters, the resident was administered amlodipine when their systolic blood pressure was 113 mmHg and both diuretics when their systolic blood pressure was 104 mmHg, as documented in the Medication Administration Records (MAR) for January and March. The resident had a history of hypertension and congestive heart failure and was determined to have the capacity to understand and make decisions. During interviews, the LVN confirmed that reminders regarding medication parameters were present on the MAR prior to administration, and both the DON and Administrator acknowledged the findings. The facility’s policy required medications to be administered in accordance with prescribed orders, but this was not followed in the instances identified.
Deficiencies in Medication Storage, Labeling, and Documentation
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's medication management practices. During inspections of two medication carts, it was observed that orally administered medications were not stored separately from externally used medications, such as ointments, creams, and eye drops, contrary to facility policy. Staff, including the ADON and an RN, verified these findings. Additionally, a gentamicin ointment used for a resident's skin infection was found without an open date on its label, which was confirmed by both the LVN and the DON as a requirement for proper labeling. Further review revealed that a resident's Preparation H and Lidocaine creams were stored at the bedside without a physician's order or care plan authorizing bedside storage. The LVN responsible for administering these medications admitted to storing them at the bedside and failing to document their administration on the Treatment Administration Record (TAR) for several days. The DON and Administrator acknowledged these findings during interviews. The report also notes that the resident had the capacity to make decisions, as documented in their medical record.
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What surveyors actually found near you
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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
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Illustrative
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Nursing homes near Huntington Beach
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sea Cliff Healthcare Center | 1.3 mi | ★★★★★ | 24 | 0 |
| Beachside Nursing Center | 1.4 mi | ★★★★★ | 18 | 0 |
| Fountain Valley Post Acute | 3 mi | ★★★★★ | 34 | 0 |
| Extended Care Hospital Of Westminster | 4.1 mi | ★★★★★ | 1 | 0 |
| Mission Palms Healthcare Center | 4.3 mi | ★★★★★ | 23 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.