Above average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
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 Inland Christian Home during CMS and state inspections, most recent first.
A resident's barrier cream was found left open and unsanitarily on a bedside table, contrary to facility policy requiring clean and safe medication storage. Additionally, expired hydrogel gauze packets were discovered in a treatment cart, with staff confirming these items should have been removed according to policy.
Surveyors found that food items in the kitchen, including BBQ sauce and shredded Parmesan cheese, were stored without required labels or dates, and a tray of tomatoes was kept past its expiration date. Review of cooling logs showed improper cooling practices, with food not reaching required temperatures within policy timeframes and temperature checks performed too early. The Director of Kitchen acknowledged these lapses and confirmed that facility policies for food storage, labeling, and cooling were not followed.
Essential kitchen equipment, including a stove, griddle, and grill, were found with significant accumulations of grease, burnt food, and grime during a survey. The Director of Kitchen confirmed that cleaning had not been performed according to facility policy, leading to unsanitary conditions.
Two residents with complex medical conditions did not have their required RAI/MDS assessments completed within the mandated timeframes. The DON confirmed that both annual and quarterly assessments were significantly overdue, and facility policy regarding timely assessments was not followed.
Two residents did not have their required MDS assessments completed and transmitted within the mandated timeframes, resulting in significant delays. One resident with multiple chronic conditions had an annual comprehensive assessment completed over four months late, while another with diabetes and kidney disease had a quarterly assessment completed more than three months late. The DON confirmed that facility policy requiring timely assessments was not followed, leading to inadequate monitoring and delayed reporting to CMS.
A resident with severe cognitive impairment and multiple diagnoses, including dementia, was allowed to sign a POLST form instead of the legally recognized decisionmaker, despite facility policy requiring the representative's signature when the resident lacks capacity. The DON and Social Services Director confirmed the error during interviews and record review.
A resident with multiple medical conditions was found with an uncovered and undated yankauer suction device and suction canister in their room. Staff interviews revealed inconsistent knowledge about proper infection control practices, and the facility could not provide a policy for handling this equipment.
A resident with dementia, Type 2 diabetes, and dysphagia did not receive the influenza vaccine despite providing consent, as there was no documented evidence of administration. The facility's policy and CDC guidelines required vaccination, but the process was not followed after the resident's request.
The facility failed to store food properly, with uncovered and undated items like pudding, cut melon, hot dogs with mold, and leftover pork found in the refrigerator. Interviews confirmed that these items should have been discarded or properly stored, as per facility policy.
The facility failed to maintain a sanitary kitchen environment, with grease and food crumbs behind the cooking line and under dry storage shelves. Thawing meat in the walk-in refrigerator was unlabeled and undated, and the ice machine had a brown slime build-up. These issues were acknowledged by the Nutrition Care Manager and Dining Services Director, indicating lapses in routine maintenance and adherence to facility policies.
The facility failed to maintain an effective pest control program when a roll-up door in the paper goods storage closet had a gap where light could be seen coming through. The Dining Service Director acknowledged the issue, and the facility's policy indicated that such gaps should be repaired or sealed to prevent pest entry.
The facility failed to administer the correct amount of enteral feeding nutrition as ordered for two residents. Observations and interviews revealed that the feeding pumps were not on, and significant amounts of the formula remained in the bottles. The DON confirmed that the facility's policy on enteral nutrition was not followed, and there was no documentation explaining the deviations.
The facility did not follow the menu when residents on a CCHO diet received a 1/4 cup serving of Yukon whipped potatoes instead of the prescribed 1/2 cup, and residents on a regular diet received 2.6 ounces of baked ham instead of 3 ounces. This affected 29 of 52 medically compromised residents. The Dining Service Director and Registered Dietitian confirmed the discrepancy.
A resident was administered Tramadol 50 mg by mouth instead of through their G-tube as prescribed, resulting in a medication error. Interviews with the DON and DD confirmed that staff are required to follow physician's orders for medication administration routes.
The facility failed to ensure that pharmacist recommendations made during monthly Medication Regimen Reviews (MRR) were communicated to the physician for two residents. For one resident, recommendations included assessing the risk versus benefits of antipsychotic therapy, evaluating dual antipsychotic therapy, and considering an antidepressant. For another resident, the recommendation was to request laboratory testing of her Thyroid Stimulating Hormone (TSH). The Director of Nursing (DON) acknowledged that there was no documented evidence indicating the physician was made aware of these recommendations.
An expired bottle of [brand name] docusate sodium was found in the medication supply room during an observation with the Director of Staff Development. The Director of Nursing confirmed that nursing staff are responsible for removing expired medications, as per the facility's policy.
The facility failed to ensure a resident's medical record was complete and accurate when an LVN did not document a physician's telephone order regarding a change in the route of medication. This resulted in an incomplete medical record, potentially affecting the resident's care.
A used syringe was left on a resident's bedside table, contrary to the facility's policy on sharps disposal. The LVN was uncertain about the syringe's use, and the DON confirmed that the policy was not followed.
The facility failed to maintain the walk-in refrigerator in safe operating condition, resulting in ice build-up on the bottom portion of one wall. The Nutrition Care Manager acknowledged the issue but stated that no work order had been submitted. The Dining Service Director confirmed that ice build-up should not occur. According to the FDA Federal Food Code, equipment must be properly maintained to ensure safe food temperatures.
The facility failed to provide three residents with the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN: CMS-10055) when their Medicare Part A benefits were ending. The Social Services Director was unaware of the requirement, and the Director of Nursing confirmed that the facility's policy was not followed, resulting in residents not being informed of their financial responsibility and right to appeal.
The facility failed to post Direct Care Service Hours Per Patient Day (DHPPD) in a prominent place readily accessible to residents and visitors. The staffing information was found to be outdated by five days, and the Director of Nursing (DON) and the Director of Staff Development (DD) acknowledged the lapse. The facility's policy required daily updates, but the information had not been updated due to the DD's absence and the DON's oversight.
Improper Storage of Barrier Cream and Expired Wound Care Supplies
Penalty
Summary
The facility failed to ensure proper storage and handling of medications and biologicals in two separate instances. For one resident with a history of multi-system degeneration of the autonomic nervous system, neuromuscular dysfunction of the bladder, and muscle weakness, a medication cup containing barrier cream and opened packets of zinc oxide barrier cream were found left open and unsanitarily on the bedside table. The resident had physician orders for daily wound care involving the application of barrier cream to areas of moisture-associated skin damage. Interviews with nursing staff and the infection preventionist confirmed that leaving medication cups with barrier cream at the bedside was not acceptable and not in accordance with facility policy, which requires medication storage and preparation areas to be maintained in a clean, safe, and sanitary manner. In a separate incident, five expired packets of hydrogel saturated gauze were found in the treatment cart in front of the nurse's station. The gauze had expired over a month prior to the observation. Facility policy requires that all expired medications be removed from active supply and destroyed. Interviews with nursing staff and the DON confirmed that the expired items should have been removed and that the policy was not followed. A nurse acknowledged responsibility for checking the treatment cart weekly to ensure all items were within expiration dates.
Failure to Follow Food Storage, Labeling, and Cooling Procedures
Penalty
Summary
The facility failed to adhere to proper food storage and handling practices as observed during a kitchen inspection. Two food items, a bottle of BBQ sauce and a bag of shredded Parmesan cheese, were found in the refrigerator without labels or dates indicating when they were placed there. Additionally, a tray of tomatoes was discovered in the refrigerator past its labeled expiration date, with the label indicating they should have been discarded the previous day. The Director of Kitchen (DOK) acknowledged that these items should have been labeled, dated, and discarded according to the facility's policy and procedure, but was unsure why this was not done. A review of the facility's cooling logs for May and June revealed improper cooling practices. Several entries showed that food items, such as chicken and pork, were not cooled to the required temperature of 70°F within two hours, as stipulated by the facility's policy. In some cases, temperature checks were performed before the two-hour mark, resulting in inaccurate documentation of the cooling process. The DOK admitted to checking temperatures too early and not following the policy's requirements for cooling and documentation. The facility's policies and procedures, which were reviewed with the DOK, clearly state that all food items must be labeled, dated, and discarded when expired, and that proper cooling techniques must be followed and documented. The DOK confirmed that these policies were not followed in the instances identified during the survey.
Failure to Maintain Kitchen Equipment in Sanitary Condition
Penalty
Summary
During an inspection of the facility's kitchen, surveyors observed that essential cooking equipment, including a 4-burner stove, flat top griddle, and grill, were not maintained in a sanitary condition. The stove had a buildup of oil, burnt food particles, and grime on, around, and underneath the burners. The flat top griddle displayed visible layers of grease stains and dark discoloration across its cooking surface, while the grill had old burnt food particles sticking to it. These observations were made during the initial kitchen tour. Interviews with the Director of Kitchen (DOK) and a review of the facility's cleaning logs and policy revealed that the equipment had last been cleaned four days prior, and that deep cleaning was scheduled weekly. The facility's policy required that food contact surfaces be kept free of encrusted grease and accumulated soil, and that non-food contact surfaces be cleaned as often as necessary to prevent buildup. The DOK acknowledged that the policy was not followed, resulting in the unsanitary conditions found during the inspection.
Failure to Complete Timely Resident Assessments
Penalty
Summary
The facility failed to ensure that the required Resident Assessment Instrument/Minimum Data Set (RAI/MDS) assessments were completed within the federally mandated timeframes for two residents. For one resident with chronic obstructive pulmonary disease, heart failure, mild cognitive impairment, and acute on chronic respiratory failure, the annual comprehensive assessment was completed 146 days late. The Director of Nursing (DON) confirmed that the last quarterly assessment for this resident was completed on January 23, 2025, and the annual comprehensive assessment, which was due on April 26, 2025, was not completed until June 18, 2025. For another resident with type 2 diabetes mellitus, chronic kidney disease, hypertension, and anemia, the quarterly MDS assessment was not completed within the required 92-day interval. The last quarterly assessment was completed on February 16, 2025, and the subsequent assessment, due on May 19, 2025, was not completed until June 18, 2025, making it 122 days late. The DON acknowledged that the facility's policy and procedure, which requires timely completion of these assessments, was not followed.
Failure to Complete and Submit Timely MDS Assessments
Penalty
Summary
The facility failed to ensure that required Resident Assessment Instrument/Minimum Data Set (RAI/MDS) assessments were completed and transmitted to the State within the federally mandated timeframes for two residents. For one resident with chronic obstructive pulmonary disease, heart failure, mild cognitive impairment, and acute on chronic respiratory failure, the annual comprehensive MDS assessment was completed 146 days late. For another resident with type 2 diabetes mellitus, chronic kidney disease, hypertension, and anemia, the quarterly MDS assessment was completed 122 days late. These delays were confirmed through record review and interviews with the Director of Nursing (DON), who acknowledged responsibility for timely completion of MDS assessments and stated that the assessments were not completed within the required 92-day interval. Facility policy and procedure documents, reviewed during the survey, specified that the resident assessment coordinator and interdisciplinary team are responsible for ensuring timely and appropriate assessments, including quarterly and annual assessments as required by OBRA regulations. The DON confirmed that these policies were not followed, resulting in the late completion and submission of the assessments. The failure to adhere to these requirements led to inadequate monitoring of the residents' progress or decline and the lack of timely resident-specific information being submitted to CMS for payment and quality measure monitoring.
Failure to Ensure Proper Completion of POLST for Resident Lacking Capacity
Penalty
Summary
The facility failed to ensure that the Physician Orders for Life Sustaining Treatment (POLST) form was appropriately completed for a resident with severe cognitive impairment. The resident, who had a BIMS score of 00 indicating severe decision-making impairment, was admitted with diagnoses including dementia, diabetes type 2, and dysphagia. Despite the resident's lack of capacity, as documented in the Minimum Data Set (MDS), the POLST form was signed by the resident rather than the legally recognized decisionmaker, contrary to facility policy and professional standards. Interviews with the Director of Nursing (DON) and Social Services Director confirmed that the POLST should have been signed by the resident's legal representative, not the resident, due to the resident's incapacity. The facility's policy explicitly states that the form must be signed by the resident with capacity or by the resident representative when the resident lacks capacity. The DON acknowledged that the policy was not followed in this instance, and the documentation review supported this finding.
Failure to Maintain Proper Infection Control for Suction Equipment
Penalty
Summary
During an observation in a resident's room, a yankauer suction device was found uncovered and exposed to air, resting on top of the suction machine. Additionally, both the yankauer and the suction canister were not dated. The resident involved had a medical history including dementia, acute respiratory failure with hypoxia, and hemiplegia. These findings were based on direct observation, interview, and record review. Interviews with facility staff revealed inconsistent knowledge regarding the appropriate frequency for changing and covering the yankauer and suction canister. One LVN was unsure of the required change interval, while the Infection Preventionist Nurse stated the yankauer should be changed every seven days, covered, and labeled. The DON indicated the yankauer should be changed after each use and not left open to air. The facility was unable to provide a policy and procedure regarding infection control practices for the yankauer, indicating a lack of established protocol.
Failure to Administer Influenza Vaccine After Consent
Penalty
Summary
The facility failed to ensure that one of five sampled residents received the influenza vaccination, despite the resident having requested the vaccine and provided consent on November 14, 2024. Review of the resident's face sheet indicated diagnoses of dementia, Type 2 diabetes, and dysphagia. Examination of the immunization dashboard revealed no documented evidence that the influenza vaccine was administered to the resident in 2024. The Infection Preventionist confirmed that the facility should have followed up with the vaccination after consent was obtained. Further review of the facility's policy and procedure for influenza vaccination, as well as CDC guidelines, indicated that administration of the vaccine should occur in accordance with current recommendations. The Director of Nursing acknowledged that the policy was not followed, and the resident, who was in a high-risk environment, did not receive the required vaccination as per facility policy and CDC guidelines.
Improper Food Storage in Refrigerator
Penalty
Summary
The facility failed to store food by methods that conserve nutritive value, flavor, and appearance. During an observation, a tray of pudding and cut melon was found in the refrigerator uncovered and undated. Additionally, a bag of hot dogs with a mold-like substance, uncovered tortillas, and leftover pork from May 4 were stored in the refrigerator drawer, ready for use. These items were not properly stored, which could affect the palatability and safety of the food served to 52 of 53 vulnerable residents who receive food from the kitchen. Interviews with the Nutrition Care Manager and the Dining Service Director confirmed that the hot dogs and tortillas should have been discarded and that no food should be left uncovered in the refrigerator. The Dining Service Director also stated that leftovers should only be kept for three days. A review of the facility's policy on Production, Purchasing, Storage indicated that all food should be covered, labeled, and dated to prevent contamination and maintain safety and wholesomeness for human consumption.
Sanitary Deficiencies in Kitchen and Food Storage Areas
Penalty
Summary
The facility failed to maintain a sanitary kitchen environment, as observed by surveyors. The floor behind the cooking line had a significant build-up of grease and food crumbs, which the Nutrition Care Manager acknowledged should be kept clean. The Dining Services Director admitted that the area had been cleaned about two weeks prior but was not on the regular cleaning schedule, indicating a lapse in routine maintenance. Additionally, the floor under the shelves in the dry storage area also had a build-up of food crumbs, which the Dining Services Director confirmed should not be present in hard-to-reach areas. Both observations highlight a failure to adhere to the facility's policy on sanitation and infection prevention/control, which mandates that nonfood contact surfaces be cleaned as often as necessary to prevent the attraction of pests and the accumulation of pathogenic microorganisms. In the walk-in refrigerator, several pieces of meat, including steak, beef, ground beef, and chicken, were found unlabeled and undated while thawing. The AM Cook and the Dining Services Director both acknowledged that the meat should be labeled and dated when placed in the refrigerator to thaw, as per the facility's policy. This failure to properly label and date the meat poses a risk of foodborne illness due to improper tracking of the thawing process and potential for the meat to be used beyond its safe consumption period. The ice machine in the kitchen was found to have a brown slime build-up on the underside of the icemaker and a slimy substance on a stainless-steel plate inside the top portion of the ice bin. The Dining Services Director admitted to cleaning the ice machine but not the specific areas where the build-up and slime were found. This oversight contradicts the facility's policy, which requires routine cleaning of the ice machine to prevent the development of slime, mold, or soil residues that could contribute to an accumulation of microorganisms. The Infection Preventionist Nurse confirmed that there had been no documented cases of norovirus in the last six months, but the presence of slime and build-up in the ice machine still poses a potential risk for contamination.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program when a roll-up door in the paper goods storage closet had a gap where light could be seen coming through. This gap was observed on two separate occasions, and the floor was noted to be partially wet. During interviews, the Dining Service Director acknowledged that there should be no gap that could allow pest entry and that the gap needed to be closed. A review of the facility's policy indicated that all holes and cracks where pests could gain entry should be repaired or sealed, and exterior department doors should have less than a 1/4-inch gap to prevent pest entry.
Failure to Administer Correct Amount of Enteral Nutrition
Penalty
Summary
The facility failed to administer the correct amount of enteral feeding nutrition as ordered for two residents, Resident 45 and Resident 13. For Resident 45, the nursing staff did not administer the full 1000 milliliters of enteral nutrition as prescribed. Observations revealed that the feeding pump was not on, and 300 milliliters of the formula remained in the bottle. Interviews with the LVN and RD confirmed that Resident 45 did not receive the full amount of nutrition, which was her primary source of diet. The resident experienced a significant weight loss of 6 pounds within a week, and the facility's policy on enteral nutrition was not followed, as acknowledged by the DON. Similarly, Resident 13 did not receive the full prescribed dose of enteral nutrition. Observations showed that the feeding pump was not administering nutrition, and 400 milliliters of the formula remained in the bag, which should have contained only 160 milliliters after the prescribed dose. The DON confirmed that there was no documentation or evidence in Resident 13's medical record to explain why the full dose was not administered. The DON emphasized the importance of following physician orders and documenting any deviations. Both residents had specific medical conditions requiring enteral feeding, such as dysphagia and poor oral intake. The failure to administer the correct amount of enteral nutrition as ordered had the potential to negatively impact their nutritional status and overall health. The facility's policy and procedure on enteral nutrition were not adhered to, leading to these deficiencies.
Menu Portions Not Followed for CCHO and Regular Diets
Penalty
Summary
The facility did not follow the menu when residents on a Consistent Carbohydrate Order (CCHO) diet received a 1/4 cup serving of Yukon whipped potatoes instead of the prescribed 1/2 cup serving, and residents on a regular diet received 2.6 ounces of baked ham instead of the 3 ounces indicated by the menu for lunch on May 6, 2024. This discrepancy affected 29 of 52 medically compromised residents who received food from the kitchen. During an observation and interview with the Dining Service Director (DSD), it was confirmed that the portions served did not match the menu requirements. The Registered Dietitian (RD) also confirmed that residents should receive the correct portions according to the menu. A review of the lunch menu for May 6, 2024, indicated that the prescribed portions were not followed.
Medication Administration Error
Penalty
Summary
The facility failed to ensure that a resident received medications in the route prescribed by the physician. Specifically, a Licensed Vocational Nurse (LVN) administered Tramadol 50 mg by mouth to a resident instead of through the resident's gastrostomy tube (G-tube) as ordered by the physician. This incident was observed during a medication administration on May 8, 2024, and there was no documentation indicating physician approval to change the route of administration. The resident had been admitted with diagnoses including surgical aftercare following digestive system surgery, pancreatic cancer, chest pain, and difficulty swallowing. Interviews with the Director of Nursing (DON) and the Director of Staff Development (DD) confirmed that staff are required to administer medications as prescribed by the physician. A review of the facility's policy on medication administration, dated October 2012, also indicated that medications should be administered in a safe and effective manner, following the five rights of medication administration. The failure to follow these protocols resulted in a medication error, placing the resident at risk for adverse outcomes.
Failure to Communicate Pharmacist Recommendations to Physician
Penalty
Summary
The facility failed to ensure that pharmacist recommendations made during monthly Medication Regimen Reviews (MRR) were communicated to the physician for two residents. For Resident 41, there was no indication that a physician was notified regarding the pharmacist's MRR recommendations dated October 18, 2023. These recommendations included assessing the risk versus benefits of antipsychotic therapy, evaluating the continued use of dual antipsychotic therapy, and considering the adjunctive use of an antidepressant medication. The Director of Nursing (DON) acknowledged that the Physician/Prescriber Response section was blank and that there was no documented evidence indicating the physician was made aware of the pharmacist's recommendations. For Resident 43, there was no indication that a physician was notified regarding the pharmacist's MRR recommendations dated October 18, 2023, to request laboratory testing of her Thyroid Stimulating Hormone (TSH). The DON acknowledged that the follow-through section was left blank and that there was no documented evidence indicating the physician was made aware of the pharmacist's recommendation to obtain a TSH level. The DON also confirmed that there was no documented evidence that Resident 43's TSH level was assessed between the date of the pharmacist's recommendation and the current date of the interview. The facility's policy and procedure titled 'Consultant Pharmacist Reports' indicated that the consultant pharmacist's observations and recommendations regarding residents' medication therapy should be communicated to those with authority and/or responsibility to implement the recommendations and responded to in an appropriate and timely fashion. However, the facility failed to follow this policy, resulting in a delay of notification to the physician to evaluate residents' medication regimens, which had the potential to increase residents' risk of harm and injury without proper dosing adjustment and monitoring.
Expired Medication Found in Supply Room
Penalty
Summary
The facility failed to ensure expired medications were removed from the medication supply room. During an observation and interview with the Director of Staff Development (DD), an expired bottle of [brand name] docusate sodium was found in the medication cabinet. The expiration date on the bottle was September 2023, and the DD confirmed that expired medications were supposed to be removed and discarded. This observation took place on May 9, 2024, at 9:00 AM. In a subsequent interview with the Director of Nursing (DON), it was stated that it was the responsibility of the nursing staff to ensure expired medications were removed from the medication supply room. A review of the facility's policy and procedure on Medication Labeling and Storage, revised in February 2023, indicated that nursing staff are responsible for maintaining medication storage areas in a clean, safe, and sanitary manner, and that outdated medications should be returned or destroyed as per the dispensing pharmacy's instructions.
Failure to Document Physician's Telephone Order
Penalty
Summary
The facility failed to ensure the medical record for one resident was complete and accurate when staff did not document a physician's telephone order regarding a change in the route of medication in the resident's clinical record. This failure resulted in the resident's medical record being incomplete regarding physician's orders, which had the potential for staff to not provide care as specified by the physician. A review of the resident's admission record indicated the resident was initially admitted with diagnoses including surgical aftercare following surgery on the digestive system, pancreatic cancer, and difficulty swallowing. During an interview, an LVN stated he changed the route of multiple medications to be administered by gastrostomy tube instead of by mouth after receiving a telephone order from the physician but did not document the order. The Director of Nursing and the Director of Staff Development confirmed that nurses were supposed to document physician's orders in the resident's medical record, as per the facility's policies and procedures.
Used Syringe Left on Bedside Table
Penalty
Summary
The facility failed to provide a safe, sanitary, and comfortable environment when a used syringe was left on the bedside table of Resident 251. Resident 251 was admitted with diagnoses including a urinary tract infection, altered mental status, and hydronephrosis. During an observation, an unlabeled, unpackaged, used syringe containing approximately 2 milliliters of unknown fluid was found on the bedside table next to a pitcher of water and a box of tissues. This observation was made on May 6, 2024, at 11:18 AM. During a concurrent observation and interview with an LVN, the nurse was uncertain about the syringe's use and why it was on the bedside table. The LVN acknowledged that the syringe should not have been left there and should have been discarded in the sharps container immediately after use. A review of the facility's policy and procedure on sharps disposal confirmed that used syringes and needles must be discarded immediately. The Director of Nursing confirmed that the facility's policy was not followed in this instance.
Ice Build-Up in Walk-In Refrigerator
Penalty
Summary
The facility failed to ensure the walk-in refrigerator was in safe operating condition, as evidenced by ice build-up across the bottom portion of one wall. During an observation on May 6, 2024, ice build-up was noted on the bottom six inches of the wall behind the shelves. The Nutrition Care Manager (NCM) acknowledged the issue, stating that they try to undo the ice build-up occasionally, but it accumulates quickly. The Dining Service Director (DSD) confirmed that there should not be ice build-up in the walk-in refrigerator. Additionally, the NCM admitted that no work order had been previously submitted for the ice build-up. According to the FDA Federal Food Code, equipment must be maintained in a state of repair and condition that meets specified requirements, and failure to do so could compromise the equipment's ability to properly cool or hold time/temperature control for safety foods at safe temperatures.
Failure to Provide SNF ABN Forms to Residents
Penalty
Summary
The facility failed to provide three residents with the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN: CMS-10055) when their Medicare Part A benefits were ending. This document is essential as it informs residents about skilled services that may no longer be covered by Medicare Part A, their claim appeal rights, and their potential financial liability. During interviews and record reviews, it was found that Residents 8, 17, and 23 were not given the SNF ABN form prior to the termination of their Medicare Part A services. The Social Services Director (SSD) admitted to being unaware of the requirement to provide this form, indicating a gap in knowledge and adherence to the facility's policies and procedures. Further review with the Director of Nursing (DON) revealed that the facility's policy and procedure titled 'Advance Beneficiary Notices' was not followed. The policy clearly states that the facility must provide timely notices regarding Medicare eligibility and coverage, using the current CMS-approved version of the forms. The DON acknowledged that the facility failed to inform the residents of their financial responsibility and right to appeal, as mandated by the policy. This oversight resulted in the facility not meeting its obligation to notify the residents of their choices regarding their claim appeal rights and financial liability for services no longer covered by Medicare Part A.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post Direct Care Service Hours Per Patient Day (DHPPD) in a prominent place readily accessible to residents and visitors. During an observation and record review, it was found that the staffing information posted at the nursing station was dated five days prior to the current date. The Director of Nursing (DON) and the Director of Staff Development (DD) acknowledged that the DHPPD information had not been updated daily as required. The DD stated that the information had not been updated because she had been out of the facility, and the DON admitted that it was her responsibility to ensure the information was posted in the DD's absence. There was no other location in the facility where the DHPPD staffing information was posted. The facility's policy and procedure titled 'Staffing, Sufficient and Competent Nursing' indicated that direct care daily staffing numbers should be posted for every shift. Additionally, a review of the National Healthcare Safety Network (NHSN) document titled 'Nurse Staffing Hours Indicator' emphasized the importance of the Nursing Hours per Patient Day (NHPPD) as a tool to assess the value nursing staff provides around patient safety and care quality. The failure to update and post the DHPPD staffing information daily resulted in the facility's nurse staffing information not being readily available for review by residents and visitors as required by regulations.
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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
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Ontario
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ontario Healthcare Center | 1.2 mi | ★★★★★ | 12 | 0 |
| Trellis Chino | 1.4 mi | ★★★★★ | 27 | 0 |
| Montclair Manor Care Center | 2.2 mi | ★★★★★ | 0 | 0 |
| Community Extended Care Hospital Of Montclair | 3.1 mi | ★★★★★ | 10 | 0 |
| Las Colinas Post Acute | 3.5 mi | ★★★★★ | 24 | 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.