Below average — CMS composite of the measures below.
A standard survey is most likely before around February 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Inspire Behavioral Health during CMS and state inspections, most recent first.
Inadequate elopement supervision and inaccurate risk assessment. A resident with schizoaffective disorder, a conservatorship, and a history of AWOL behavior was able to leave after a housekeeper lost her keys, and the resident was later found at a family member’s home. Two other residents were also assessed as low elopement risk despite mental illness and psychotropic use being present; one later went AWOL and another ran away during a supervised community walk.
A resident with multiple diagnoses and on psychotropic medications was not accurately assessed for fall risk, resulting in a lower-than-appropriate risk score. After an initial fall, a care plan intervention to encourage the resident to wait in her room for meals was not implemented or monitored, leading to a second fall that caused a femur fracture. Additionally, required orthostatic blood pressure measurements were not completed or documented after the second fall, contrary to facility policy.
Medication administration was carried out through a pre-pour process for multiple residents at the nursing station, but the cups were not labeled and staff did not verify the cup contents against the MAR before giving them to residents. Nurses prepared doses ahead of time for the next pass, relied on residents to recognize their own meds, and in one instance gave later-scheduled meds during an earlier pass because the resident wanted them all together. Facility guidance allowed pre-pouring but did not include specific safeguards, and the CP records showed no documented oversight of the medication pass process.
Food service staff failed to label opened eggs and prepared gelatin desserts in the walk-in refrigerator, and kitchen staff did not perform hand hygiene after handling trash or dirty equipment before returning to food prep. A CNA also distributed meal trays and handled food items, plates, and utensils for multiple residents without sanitizing hands between residents, contrary to facility policy and the IP's stated expectations.
The facility had a 13.11% med error rate, with staff giving some meds hours early instead of at the ordered bedtime time and RN insulin pen administration errors involving improper priming and not holding the pen in place long enough. An LVN gave bedtime meds during an earlier pass because the resident wanted them together, and an RN failed to follow manufacturer instructions for insulin pen use, including the required safety test and injection hold time.
A loose handrail was observed in Hallway B across from a resident room. Surveyors noted an indent in the dry wall where the handrail should have been attached, and the handrail was still loose on a later observation. An MNT staff member confirmed the handrail was not supposed to be loose.
Failure to timely notify the Ombudsman of a planned discharge: A resident with schizoaffective disorder, stimulant dependence, depression, and anxiety was discharged to a board and care/assisted living/group home, but the faxed discharge notice to the Ombudsman did not go through and was not verified. The SSD acknowledged the missed notification, and the notice was not successfully sent until the survey period.
Failure to assess and document transfer pole use for two residents was identified. One resident had diagnoses including schizoaffective disorder, conversion disorder with seizures or convulsions, neuroleptic induced Parkinsonism, and a history of falling, while the other had schizoaffective disorder, prediabetes, and hyperlipidemia. Both residents used wheelchairs, a transfer pole was observed beside each bed, and the DON confirmed there was no documentation for the transfer poles or a current form in PCC to record their use.
Therapeutic diets were not provided as ordered for three residents during lunch tray line service. Each resident's tray ticket indicated a fortified diet, but staff plated the trays without the fortified item, and the CDM confirmed the trays were missing the ordered item. The RD stated that all residents are expected to receive the diet ordered for each meal.
Open Toilet Paper Holder in Resident Bathroom A A toilet paper holder in a resident bathroom was observed open with the toilet paper exposed during two separate observations. The MAIN later confirmed the holder was open and was supposed to be closed.
A maintenance director entered the kitchen, handled grease trap lids outside, and touched kitchen surfaces before washing his hands, contrary to facility policy and staff expectations for hand hygiene upon kitchen entry.
A resident at high risk for elopement due to mental illness and substance abuse successfully left the facility without authorization. The staff failed to follow the conservator's instructions to restrict visitation from friends and did not update the care plan with necessary interventions. During a visit, the resident was able to exit the facility when a CNA did not monitor her proximity to the exit door, leading to her elopement with the assistance of visitors.
A resident with a history of schizoaffective disorder and bipolar type eloped from the facility but was returned safely. The resident's elopement risk assessment was inaccurately coded by an RN, who failed to review the Psychiatry Discharge Summary indicating a history of elopement attempts. The DON confirmed the oversight, which contradicted the facility's policy on admission assessments.
Two residents with schizoaffective disorder eloped from the facility due to staff and visitors failing to ensure the area was clear before opening locked exit doors. Despite being identified as high risk for elopement, one resident managed to leave the facility on three occasions, engaging in unsafe behaviors. Another resident eloped when nursing students entered the unit, despite prior orientation on elopement risks. The facility's policy to prevent such incidents was not adhered to.
The facility did not conduct annual performance reviews for three CNAs, leading to unaddressed training needs. CNA A, hired in 2020, missed reviews in 2021, 2022, and 2023, while CNA B and CNA C, hired in 2013 and 2012, respectively, missed reviews in 2021 and 2022. The DSD confirmed these omissions, which are contrary to the facility's Employee Handbook guidelines.
A resident with schizophrenia and moderate cognitive impairment left the facility without permission, walking towards the parking lot. Staff failed to follow the facility's elopement prevention policy, which requires ensuring exit doors are locked and no residents are nearby when opened. The resident was safely redirected back without injury.
A facility failed to report a sexual allegation within the required timeframe and did not prevent further incidents involving a resident with a history of inappropriate behavior. A resident reported being inappropriately touched by another resident, but the incident was not reported to authorities within the required two hours. The resident involved in the incident had a history of similar behavior, yet the facility's interventions were ineffective in preventing further occurrences.
The facility failed to notify the Ombudsman of resident transfers or discharges to a hospital, as required by policy. This deficiency involved three residents who were hospitalized. The facility's administrator admitted that documentation of notifications was missing due to the previous Social Services Director's disorganized departure. The DON was not involved in the notification process but expected timely notifications. The Ombudsman confirmed not receiving the required notifications.
A facility failed to ensure staff washed their hands before applying gloves during food preparation. A Dining Services Aide was observed applying new gloves without handwashing after answering the kitchen door, contrary to the facility's Glove Use Policy. Interviews with staff confirmed the expectation of handwashing after touching high-contact surfaces and before handling food.
The facility's Station 2 dining room was insufficient to accommodate all residents wishing to dine, leading to wait times of 5-15 minutes. Observations and interviews confirmed the room's capacity was limited to 24 residents, while the facility housed 116. Residents with intact cognition expressed dissatisfaction, and staff acknowledged the issue. Attempts to adjust meal settings were unsuccessful, resulting in a first-come, first-served system that did not meet residents' needs.
A facility failed to accurately document a resident's use of oxygen therapy in the MDS assessment. The resident, with a history of COPD and other respiratory issues, was observed using supplemental oxygen, which was not reflected in the MDS. Staff interviews confirmed the oversight, acknowledging the resident's ongoing oxygen therapy since 2018.
A resident with PTSD did not receive trauma-informed care at the facility. Despite having a care plan, the resident's PTSD and triggers were not addressed, and staff were unaware of the diagnosis. The facility lacked a trauma-informed care policy, and no trauma assessments were conducted, leading to a deficiency in care.
A registered nurse failed to document the administration of benztropine mesylate to a resident, as required by facility policy. The resident had intact cognition and an active order for the medication. Attempts to interview the nurse were unsuccessful, but other staff confirmed the importance of immediate documentation to prevent errors.
The facility did not follow its policy for handling soiled linen, as observed when a resident's heavily soiled clothing was left soaking in buckets outside the laundry exit. The policy required soaking in a machine or sink with a degreasing presoak or detergent for at least an hour before washing. Interviews with staff, including the Laundry Aid, interim Laundry Manager, Administrator, and DON, confirmed the policy was not followed.
Inadequate elopement supervision and inaccurate risk assessment
Penalty
Summary
The facility failed to ensure adequate supervision and accurate elopement risk assessment for residents who were at risk for unauthorized departure from the facility. Resident 48, who had schizoaffective disorder, bipolar type, a conservatorship, and a documented history of AWOL behavior and substance use, was found missing during the morning shift. Facility records and staff interviews indicated that a housekeeper had lost her keys, and the keys were later found outside the Station 1 exit door near the dining room. A resident reported seeing Resident 48 with a set of keys that were not his, and the resident was later found at a family member’s home after being missing for approximately three days. The record also showed that Resident 48 had been identified as an elopement risk in the care plan, with interventions for redirection away from exit doors and staff observation for exit-seeking behavior. Staff interviews described that the housekeeper had been cleaning and keeping her keys in her apron pocket, then realized they were missing. The housekeeping supervisor stated it was her expectation that housekeepers keep keys around their necks and know where they are at all times. The facility administrator stated that the missing keys were found outside the exit door and that it was possible the resident took the keys and used them to leave the locked facility. The facility also failed to accurately assess elopement risk for Resident 98 and Resident 36. Resident 98’s baseline care plan marked psychotropic medications and mental illness as absent, resulting in a low elopement risk score, even though the DON later stated the resident was taking psychotropic medications and had schizoaffective disorder. Resident 98 later went AWOL from the facility. Resident 36, who had schizoaffective disorder, anxiety disorder, epilepsy, PTSD, and a BIMS score of 15, was also assessed as low risk because mental illness was not selected on the baseline elopement assessment. Resident 36 later ran away from a staff-supervised neighborhood walk, and the incident report stated staff followed the resident on foot and in cars while attempting to get her to return.
Failure to Accurately Assess Fall Risk and Implement Care Plan Interventions
Penalty
Summary
The facility failed to provide resident-centered care and services for a resident by not accurately assessing the resident's fall risk prior to two fall events. The resident, who had diagnoses including schizophrenia, anxiety disorder, and type 2 diabetes mellitus, was marked as low fall risk in the facility's assessments, despite being prescribed multiple psychotropic medications and using a wheelchair. The assessments did not reflect the resident's actual medication regimen or mobility status, resulting in a fall risk score that was lower than appropriate. The DON confirmed that the assessments were inaccurate and that all residents on psychotropic medications should be considered high fall risk. After the resident experienced a fall, the interdisciplinary team recommended an intervention for staff to encourage the resident to wait in her room for her meal tray, which was added to the care plan. However, there was no documented evidence that this intervention was implemented or monitored by staff between the first and second fall events. The resident subsequently fell again while attempting to get her breakfast tray, resulting in a left femur fracture and transfer to an acute care hospital. The facility's policy required staff to monitor and document the resident's response to fall interventions, but this was not done. Additionally, following the second fall, the facility failed to complete and document orthostatic blood pressure measurements as indicated in the post-fall SBAR and required by facility policy. There were no recorded orthostatic blood pressure readings for the resident between the time of the fall and her transfer to the hospital. The DON confirmed that the required measurements were not documented, and the SBAR response was not accurate. Facility policy required documentation of blood pressure measurements, including date, time, and the name of the person recording the data, but this was not followed.
Medication Pass Process Lacked Safeguards
Penalty
Summary
The facility failed to ensure safe and effective medication administration by allowing medications to be pre-poured 1 to 2 hours before administration for all residents at the same time without adequate safeguards. During observations, nursing staff prepared medications for multiple residents in advance, placed the doses into small cups inside medication cart bins, and did not label the cups with resident identifiers. Staff also did not verify the contents of the pre-poured cups against the MAR at the time of administration before handing the medications to residents. On the nursing stations observed, RN C, RN D, LVN A, LVN F, and RN D were seen preparing and administering medications in a communal process for residents waiting in line at the nursing station. The medication carts contained bins for individual residents, but the cups themselves were unlabeled. Staff stated they prepared medications ahead of time to reduce delays and avoid resident agitation, and some staff relied on residents to recognize their own medications by color or count. During one observation, LVN A administered medications to two residents that were scheduled for a later time, including atorvastatin and olanzapine for one resident and lithium, haloperidol, Risperdal, and benztropine for another resident, because the residents wanted them all at the same time. The facility’s written guidance allowed pre-pouring for the next medication pass but did not include specific safeguards such as labeling the cups or a process to prevent mix-ups. The DON stated the nurses were expected to verify the number of pre-poured medications against the MAR before giving them, but the observed practice did not reflect that. The resident roster also showed multiple residents with the same last name, including two residents with look-alike and sound-alike first names. In addition, the consultant pharmacist records reviewed by the surveyor showed medication regimen reviews and quarterly reports, but there was no documented evidence that the consultant pharmacist observed the medication pass or identified and addressed the medication administration process concerns.
Food Storage Labeling and Hand Hygiene Failures During Meal Service
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards and its own food service safety policies. In the kitchen walk-in refrigerator, an opened tray of eggs was observed without an open date or use-by date, and nine trays of prepared gelatin desserts were observed without labels identifying the type of dessert or the date prepared. The Certified Dietary Manager stated the eggs should have been labeled and identified the desserts as being for lunch, with yellow desserts for the CCHO diet and green desserts for the regular diet. The facility policy titled "Labeling and Dating of Foods" required all food items in storage areas to be labeled and dated, and prepared foods to be covered, labeled, and dated. The policy titled "Procedure for Refrigerated Storage" stated eggs need to be dated to assure proper rotation. The facility also failed to ensure hand hygiene was performed by kitchen staff and a CNA during food service activities. One kitchen staff member picked up trash from the floor, touched the trash can lid, and returned to operating the dishwasher without performing hand hygiene; the CDM observed this and instructed the staff member to wash hands. Another kitchen staff member wore gloves while operating the dishwasher, handled dirty and clean items, and then returned to food preparation without hand hygiene. In the dining room, a CNA distributed meal trays and handled food items, plates, and utensils for seven residents without performing hand hygiene between residents. The CNA later confirmed she did not sanitize her hands between serving residents, and the IP stated staff are required to perform hand sanitization prior to handling food plates and utensils between tasks for each resident to prevent transmission of diseases from one resident to another.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure its medication error rate remained below 5%, with an observed error rate of 13.11% based on 8 medication errors out of 61 opportunities during medication administration observations for 4 sampled residents. The errors involved medications being given outside the ordered time frame and insulin pen administration errors, including incorrect priming and failure to follow the required injection technique. For one resident, an LVN prepared medications for residents scheduled at 5 PM and later gave additional medications that were ordered for 9 PM at the earlier medication pass because the resident wanted them all at the same time. The medications given early included atorvastatin 20 mg and olanzapine 20 mg, both ordered for bedtime administration. For another resident, the LVN handed the resident a cup containing 5 medications even though only 1 medication was due at 5 PM; the other 4 medications, including lithium, haloperidol, risperidone, and benztropine, were ordered for 9 PM. The DON stated routine medications are to be administered within 1 hour before or after the scheduled time and that nurses are to prepare medications for one administration at a time. During insulin administration observations, RN B administered NovoLOG FlexPen to one resident after priming the pen with 2 units, then removing the priming needle and replacing it with a new needle before giving the dose. RN B also did not hold the pen in the skin for the required time after injection. For another resident, RN B administered Admelog SoloStar without priming the pen and held it in the skin only about 1 to 2 seconds. RN B acknowledged both the lack of priming and the short hold time. The resident records showed orders for rapid-acting insulin before meals or based on sliding scale, and the manufacturer instructions reviewed during the observation required a safety test before each injection and holding the injection button in place long enough to ensure the full dose was delivered.
Loose Hallway Handrail
Penalty
Summary
The facility failed to equip the corridors with firmly secured handrails when the handrail in the hallway across from a resident room in Hallway B was loose. During an observation on 10/27/25 at 12:19 PM, the handrail in Hallway B was observed to be loose, and an indent in the dry wall was seen where the handrail was supposed to be attached to the wall. During a second observation on 10/29/25 at 12:19 PM, the handrail in Hallway B was still observed to be loose. During an interview on 10/29/25 at 1:13 PM, the maintenance person confirmed the handrail in Hallway B was not supposed to be loose and stated he would repair it right away.
Failure to Timely Notify Ombudsman of Planned Discharge
Penalty
Summary
The facility failed to timely notify a representative of the Office of the State Long-Term Care Ombudsman regarding the discharge of one sampled resident, Resident 121. Resident 121 was admitted with diagnoses including schizoaffective disorders, other stimulant dependence, depression, and anxiety disorder, and progress notes showed the resident was discharged to a board and care/assisted living/group home on 8/6/25. The resident’s Notice of Proposed Transfer/Discharge showed the discharge notice was provided on 7/30/25 with an effective discharge date of 8/6/25. A fax transmission document sent to the Office of the State LTC Ombudsman dated 8/7/25 indicated the data could not be sent and instructed that the transaction report be given to the sender. During interview and record review, the SSD verified that the discharge notice was dated 8/6/25 and that the copy of the notice faxed to the Ombudsman on 8/7/25 did not go through, stating she forgot to verify that the notification was not sent. The facility later faxed the Notice of Proposed Transfer and Discharge to the Ombudsman’s office during the annual recertification survey on 11/3/25. The DON stated the facility needed to follow Federal/State regulation for notifying the Ombudsman regarding discharge, and the ADM stated that for planned discharge social services would notify the MD, RP, and Ombudsman and would usually follow up the next morning to confirm the notice was sent.
Failure to Assess and Document Transfer Pole Use
Penalty
Summary
The facility failed to assess the need for a transfer pole for two residents, Resident 9 and Resident 81. Resident 9 was admitted with diagnoses including schizoaffective disorder, conversion disorder with seizures or convulsions, neuroleptic induced Parkinsonism, and a history of falling. Resident 9's MDS Section GG showed use of a wheelchair with partial/moderate assistance needed for function. Resident 81 was admitted with diagnoses including schizoaffective disorder, prediabetes, and other hyperlipidemia. Resident 81's MDS Section GG showed use of a wheelchair with independent function. For both residents, the clinical record contained no documentation on the use of a transfer pole. During observation, a transfer pole was seen on the left side of each resident's bed, with Resident 81 sitting in a wheelchair near the bed and Resident 9 sitting up in bed. A CNA stated both residents had the transfer poles in their rooms for as long as he could remember. The DON confirmed there was no documentation on the use of the transfer poles for either resident and stated the facility did not currently have a document to record transfer pole use. Facility policy titled Proper Use of Side Rails stated an assessment would be made to determine the resident's symptoms or reason for using side rails and, when used for mobility or transfer, the assessment would include review of bed mobility and ability to change positions, transfer to and from bed or chair, and stand and toilet.
Therapeutic Diets Not Provided as Ordered During Lunch Service
Penalty
Summary
The facility failed to ensure therapeutic diets were provided as ordered for three residents during lunch tray line service. The report states that Resident 52, Resident 83, and Resident 95 each had meal tray tickets marked "Fortified," and the facility's Fortified Lunch Menu for 10/29/25 listed the fortified item as 1.2 ounce melted margarine. During observation of the lunch tray line in the kitchen, staff plated Resident 52's tray and placed it on the cart without adding the fortified item, and the Certified Dietary Manager confirmed the tray did not have the fortified item and said she would add it. The same occurred for Resident 83, whose tray was plated and placed on the cart without the fortified item, and the CDM again stated the tray did not have the fortified item and that she would add it. For Resident 95, the tray ticket also indicated "Fortified," but during observation staff plated the tray and began serving it in the dining room without adding the fortified item. The CDM stated Resident 95's tray did not have the fortified item and said she would add it. The Registered Dietician stated that it was his expectation that all residents receive the diet ordered to them for each meal.
Open Toilet Paper Holder in Resident Bathroom
Penalty
Summary
The facility failed to maintain equipment and the environment in a safe operating and sanitary condition when the toilet paper holder in Resident Bathroom A was left open with the toilet paper exposed. During an observation on 10/27/25 at 8:59 AM, the toilet paper holder in Resident Bathroom A was seen open. A second observation on 10/29/25 at 10:58 AM showed the toilet paper holder in the same bathroom was still open. During an interview on 10/29/25 at 1:13 PM, the maintenance person confirmed that the toilet paper holder in Resident Bathroom A was open and was supposed to be closed.
Failure to Follow Hand Hygiene Protocol Upon Kitchen Entry
Penalty
Summary
The facility failed to implement proper infection control practices when the maintenance director (MD) entered the kitchen without washing his hands. Observation showed that the MD put on a hair net and entered the kitchen, then handled the lids of the grease trap outside the kitchen with his bare hands. Upon returning inside, the MD touched the front and top edge of the two-compartment sink before proceeding to the hand washing sink to wash his hands. During interviews, the MD confirmed he did not wash his hands upon entering the kitchen and acknowledged the requirement to do so. The certified dietary manager (CDM) also stated that staff are expected to put on a hair net and wash their hands when entering the kitchen. Review of the facility's handwashing policy indicated that hand washing is required before starting work in the kitchen.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to implement effective safety measures to prevent the elopement of a high-risk resident. The staff was aware of the resident's desire to leave the facility, as she had expressed a wish to go home prior to a friend's visit. Despite this knowledge, the facility did not follow the conservator's instructions to restrict visitation from friends, which was crucial given the resident's history of mental illness and substance abuse. The care plan for elopement was not updated to include necessary interventions such as checking visitor IDs and restricting visits from friends. On the day of the incident, a Certified Nursing Assistant (CNA) did not ensure the resident was kept away from the exit door during a visitor's departure. This lapse allowed the resident to exit the facility and run outside when the door was opened for the visitor. The staff's failure to monitor the resident's proximity to the exit and to follow the conservator's visitation restrictions contributed to the resident's successful elopement. The facility's policies and procedures for preventing elopement were not adequately followed. The staff did not check the identification of the resident's visitors on multiple occasions, and the interdisciplinary team was not informed of the conservator's instructions. As a result, the resident was able to leave the facility with the assistance of visitors, and her whereabouts remained unknown, posing a significant risk to her health and safety.
Inaccurate Elopement Risk Assessment
Penalty
Summary
The facility failed to accurately code the elopement risk assessment for a resident, which had the potential to compromise the resident's health and safety. The resident, who had a history of schizoaffective disorder and bipolar type, was involved in an elopement incident where he left the facility unsupervised and was later returned safely. Despite this incident, the resident's readmission initial elopement risk assessment was incorrectly coded by a registered nurse, who failed to acknowledge the resident's history of elopement attempts as documented in the Psychiatry Discharge Summary from a previous hospital stay. The registered nurse admitted to not reviewing the Psychiatry Discharge Summary, which clearly indicated the resident's history of leaving unlocked residential facilities to use drugs. This oversight was confirmed during an interview with the Director of Nursing, who acknowledged that the nurse should have read the discharge summary and accurately coded the resident's elopement risk. The facility's policy and procedure for admission assessment emphasize the importance of reviewing an individual's recent medical history, including hospitalizations and relevant medical history, which was not adhered to in this case.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to prevent two residents from eloping due to inadequate supervision and failure to adhere to established protocols. Resident 1, diagnosed with schizoaffective disorder, was identified as high risk for elopement. Despite this, she managed to elope on three separate occasions. On each occasion, Resident 1 took advantage of moments when the exit door was opened by staff or visitors, allowing her to leave the facility unsupervised. These incidents occurred on 12/20/23, 1/7/24, and 1/27/24, during which Resident 1 engaged in unsafe behaviors such as walking on the street and attempting to board a bus. Law enforcement was involved in returning her to the facility. Similarly, Resident 2, also diagnosed with schizoaffective disorder, eloped on 5/24/24 when nursing students entered the unit and inadvertently allowed her to exit through the open door. Despite prior orientation about the risk of elopement, the nursing instructor and students failed to ensure the area was clear of residents before opening the door. Resident 2 was found walking unsafely on the street and attempting to acquire matches and cigarettes from a store. The facility's policy clearly stated that staff should not open exit doors if residents are nearby, and they should check through the glass window before entering, which was not followed in these instances.
Failure to Conduct Annual CNA Performance Reviews
Penalty
Summary
The facility failed to conduct annual performance reviews for three certified nursing assistants (CNAs), identified as CNA A, CNA B, and CNA C. CNA A, hired on August 14, 2020, did not receive performance reviews in 2021, 2022, and 2023. Similarly, CNA B and CNA C, hired on April 15, 2013, and August 22, 2012, respectively, did not have performance reviews in 2021 and 2022. This lack of performance evaluations resulted in the facility's inability to identify and address the training needs of these CNAs to enhance their skills in resident care. The Director of Staff Development (DSD) confirmed these omissions during interviews conducted on September 23 and 24, 2024. The facility's Employee Handbook, dated February 2024, stipulates that performance evaluations should occur annually around the anniversary date of employment.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent a resident from leaving the premises without staff's knowledge and permission. The resident, who was admitted with unspecified schizophrenia and had a moderate cognitive impairment, was observed walking towards the parking lot outside the facility. This incident occurred despite the facility's policy that requires staff to ensure exit doors are locked and no residents are nearby when doors are opened. Interviews with the Program Consultant and the Social Service Director confirmed that the resident did not have permission to leave and should not have been able to exit the facility. The facility's policy on preventing elopement was not followed, as staff did not ensure the door was locked and that no resident was in proximity when the door was opened. The resident was safely redirected back to the facility without injury.
Failure to Timely Report and Prevent Recurrence of Sexual Allegations
Penalty
Summary
The facility failed to adhere to its policies and procedures regarding the timely reporting of a sexual allegation involving two residents. Resident 1 reported that Resident 2 had inappropriately touched her breast while she was playing poker near the nursing station. Despite Resident 1's immediate report to staff, including certified nursing assistants and a licensed vocational nurse, the incident was not reported to the appropriate authorities within the required two-hour timeframe. The delay in reporting was confirmed by the registered nurse supervisor, who acknowledged the late reporting and the lack of specific details provided by the staff. Additionally, Resident 2 had a history of inappropriate behavior, having been involved in two other incidents of sexual assault within a week. Despite these incidents, the facility did not implement effective interventions to prevent further occurrences. The care plan for Resident 2, which included monitoring and notification to various authorities, was deemed ineffective by the program director, who admitted that the current plan did not prevent further incidents of sexual abuse. The facility's policy on preventing, investigating, and reporting alleged sexual assault and abuse violations clearly states that all employees are responsible for immediately reporting any reasonable suspicion of a crime or abuse. However, the failure to report the incident involving Resident 1 within the stipulated timeframe and the lack of preventive measures for Resident 2's recurring behavior highlight significant lapses in the facility's adherence to its own policies.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to notify the Ombudsman when residents were transferred or discharged to a hospital, as required by their policy. This deficiency was identified for three residents who were hospitalized. The facility's policy, revised in September 2012, outlines the procedures for emergency transfers or discharges, including notifying the resident's attending physician, the receiving facility, and the resident's representative or family member. However, the policy also requires notifying the Ombudsman, which was not done in these cases. The deficiency was discovered during interviews and record reviews. The facility's administrator acknowledged that the previous Social Services Director, who was terminated in May 2024, did not leave the office in good order, resulting in the inability to locate documentation of Ombudsman notifications for transfers or discharges from January to May 2024. The Director of Nursing stated he was not involved in the notification process but expected the Ombudsman to be notified timely. The Ombudsman confirmed that their office did not receive notifications for the transfers or discharges of the three residents in question.
Failure to Wash Hands Before Glove Use in Food Preparation
Penalty
Summary
The facility failed to ensure that staff washed their hands before applying gloves during food preparation, as observed during a survey. A Specialist Dining Services Aide (SDSA) was seen applying a new pair of gloves without washing his hands after answering the kitchen door, while in the process of making peanut butter and jelly sandwiches. This action was contrary to the facility's Glove Use Policy, which mandates handwashing when changing to a fresh pair of gloves and specifies that gloves should not replace handwashing. Interviews with the SDSA, Dining Services Manager, Director of Nursing, and the Administrator confirmed the expectation that staff should wash their hands after touching high-contact surfaces and before handling food. The SDSA acknowledged the importance of handwashing to prevent contamination, and the Dining Services Manager, Director of Nursing, and Administrator reiterated the requirement for staff to follow infection control procedures, including handwashing after touching surfaces like doors or trashcans and before food preparation.
Inadequate Dining Space for Residents
Penalty
Summary
The facility was found to have a deficiency in providing adequate dining space for residents, as observed during a survey. The Station 2 dining room was not large enough to accommodate all residents who wished to eat their meals there, leading to a queue of residents waiting outside the dining room. Observations and interviews with staff and residents confirmed that the dining room could only accommodate 24 residents, while the facility housed 116 residents. This resulted in residents having to wait between five to fifteen minutes to be seated for meals, which was not in line with the facility's policy of providing a structured environment for social dining. Interviews with multiple residents, all of whom had intact cognition as indicated by their BIMS scores, revealed dissatisfaction with the waiting times and the lack of space in the dining room. Staff members, including CNAs and the Dining Services Manager, acknowledged the limited capacity of the dining room. The Director of Nursing expressed the expectation that all residents should be able to eat when they are hungry or ready, but the current first-come, first-served system was not meeting this expectation. The Administrator noted that previous attempts to adjust meal settings had failed, leading to the current system that inadequately addressed the residents' needs for dining space.
Inaccurate MDS Assessment for Resident on Oxygen Therapy
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for a resident who was receiving respiratory care. The resident, admitted on 07/21/2017, had a medical history of chronic obstructive pulmonary disease (COPD) and was on oxygen therapy due to decreased oxygen levels, acute respiratory failure, and a history of COVID-19 and pneumonia. Despite these conditions, the quarterly MDS assessment dated 06/27/2024 did not reflect that the resident was receiving oxygen therapy, which was a significant oversight given the resident's ongoing treatment. Observations and interviews confirmed the deficiency. On 07/09/2024, the surveyor observed the resident using a nasal cannula with supplemental oxygen. Interviews with Registered Nurse #18 and the Director of Nursing revealed that the resident had been receiving supplemental oxygen therapy since 11/29/2018, and both acknowledged that the MDS should have indicated the resident's use of oxygen therapy. The Administrator also confirmed awareness of the resident's oxygen use and expected the MDS to be accurate, highlighting a lapse in the facility's documentation process.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care to a resident diagnosed with post-traumatic stress disorder (PTSD). The resident, admitted on June 1, 2022, had a medical history including schizoaffective disorder, mood disorder, and depression, alongside PTSD. Despite these diagnoses, the resident's care plan and psychosocial assessments did not address trauma-informed care or identify triggers related to PTSD. Interviews with the resident revealed that their trauma and PTSD were not discussed upon admission, and no trauma interview was conducted. The resident expressed that interactions with people of the opposite sex and crowded spaces triggered their PTSD anxiety, yet these concerns were not addressed by the facility. Interviews with various staff members, including CNAs, nurses, and mental health workers, indicated a lack of awareness regarding the resident's PTSD diagnosis and the necessary care to avoid re-traumatization. The Director of Nursing and the Administrator acknowledged the absence of a trauma-informed care policy and assessments for the resident's PTSD. The Administrator expected social services to conduct trauma assessments, but this was not done, leading to a deficiency in providing appropriate care for the resident's condition.
Failure to Document Medication Administration
Penalty
Summary
The facility failed to ensure proper documentation of medication administration for a resident, as observed during a survey. The facility's policy required that the licensed nurse who prepared the medication should administer and document the administration accordingly. However, during an observation, a registered nurse administered benztropine mesylate to a resident but did not sign the medication administration record (MAR) to indicate that the medication had been given. The resident, who had intact cognition, was admitted to the facility in October 2023 and had an active order for benztropine mesylate since January 2021. Attempts to interview the registered nurse responsible for the medication administration were unsuccessful, as the nurse was not available during the surveyor's visits. The Director of Nursing and other staff members acknowledged that the nurse should have documented the administration immediately after the medication was given. Licensed Vocational Nurses interviewed during the survey confirmed that immediate documentation is necessary to prevent errors in medication administration records.
Failure to Follow Linen Soaking Policy
Penalty
Summary
The facility failed to adhere to its infection prevention and control program by not following the established policy for handling soiled linen. The policy required that kitchen linen, towels, aprons, and similar items be soaked in a machine or sink using a degreasing presoak or detergent for at least an hour before washing to remove grease and stains. However, during an observation and interview, it was found that two buckets filled with liquid and clothing, covered with a trash bag, were left outside the laundry exit. These clothes belonged to a resident who had heavily soiled their pants, and the staff allowed the items to soak from the previous day, contrary to the policy. Interviews with the Laundry Aid, interim Laundry Manager, Administrator, and Director of Nursing confirmed that the soiled items should have been washed according to the policy. The Laundry Aid admitted to allowing the items to soak, while the interim Laundry Manager and Director of Nursing stated that staff should follow the policy. The Administrator also expressed the expectation that staff adhere to the policy.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 338 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near San Jose
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Canyon Springs Post-acute | 1.5 mi | ★★★★★ | 1 | 0 |
| Vista Manor Nursing Center | 1.7 mi | ★★★★★ | 0 | 0 |
| The Ridge Post Acute | 1.8 mi | ★★★★★ | 26 | 0 |
| San Jose Healthcare & Wellness Center | 3.6 mi | ★★★★★ | 0 | 0 |
| Mission De La Casa | 4 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.