Above average — CMS composite of the measures below.
The next survey window likely opens around December 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 Jacob Healthcare Center during CMS and state inspections, most recent first.
Multiple residents with conditions including hemiplegia, quadriplegia, CHF, pressure ulcers, dementia, and cervical fracture reported that a CNA repeatedly failed to treat them with dignity and respect, using profanity, rude phrases such as “What do you want?”, and rough handling during care. Residents described being left in wet briefs, told not to use the call light after being changed once, refused assistance with simple tasks, and having a dirty washcloth used on the face after perineal care. Several residents stated they were scared or terrified of the CNA, cried due to fear, and felt disrespected or treated like animals. Staff interviews and text messages from a charge nurse to the DON and DSD corroborated that the CNA was perceived as rude, rough, lacking compassion, and dismissive of residents’ needs, while facility policy required that residents be treated with kindness, respect, dignity, and be free from abuse and neglect.
The facility failed to provide a written notice of bed hold rights for a resident who was transferred to the hospital for a change in condition. The resident had chronic respiratory failure with hypoxia, a trach, a feeding tube, and severely impaired cognitive skills. Record review and staff interviews showed the responsible party was not documented as having received written bed hold information, despite the facility policy requiring written notice to the resident or resident representative before transfer.
Failure to complete a significant change MDS assessment after a resident came off hospice. The resident had encephalopathy and a history of CVA, and the MDS still showed hospice services even after hospice discharge for extended prognosis. The MDS nurse and DON stated the MDS should have been updated because it affects the resident’s care plan and payment, and the RAI manual requires an SCSA when a resident comes off the hospice benefit.
A resident with dysphagia and hemiplegia had an MDS that incorrectly coded hospice care and services even though staff stated the resident had revoked hospice and requested more aggressive treatment. The record contained a physician order for hospice and no IDT or progress note documentation showing the revocation, and the MDSN acknowledged the coding error.
PASARR Level 2 screening was not completed for two residents whose PASARR Level 1 screens were positive and indicated further evaluation was required. One resident was admitted with paranoid schizophrenia and depression, and another was re-admitted with schizophrenia, major depressive disorder, and schizoaffective disorder. The MDS nurse stated she did not see the Level 2 screenings being conducted, and the DON stated both residents' Level 2 screenings should have been followed up to ensure proper placement to meet their care needs.
A facility failed to develop comprehensive, person-centered care plans for two residents. One resident with respiratory failure, a trach, and a feeding tube had no teeth and wanted dentures, but the care plan did not address oral status. Another resident with muscular dystrophy and a GT had discharge, redness, and possible infection at the site, but staff found no care plan addressing the GT discharge until after the change in condition was observed.
Failure to Document IDT Meeting After Hospice Revocation: A resident with dysphagia and hemiplegia was under hospice care, but the record did not show documented IDT meeting notes, progress notes, or a physician order when the resident revoked hospice and requested more aggressive treatment. LN and the DON stated the revocation occurred, while the SSD stated there was no formal IDT meeting documented to support updating the care plan and reflect the resident's wishes.
Failure to provide nail care and shaving assistance: A resident with respiratory failure and a tracheostomy, who required substantial/maximal assistance with personal hygiene and had intact cognition, was observed with black debris under the fingernails and initially unshaven. Staff gave inconsistent accounts of when nail care and shaving were provided, and a TN later stated the resident’s fingernails were dirty and should be cleaned. The DON stated shaving and nail care were part of personal care and skin care, and the facility policy required residents unable to perform ADLs independently to receive needed grooming and hygiene services.
A resident with respiratory failure, a trach, and a feeding tube did not receive needed social service follow-through for dental and hearing needs. The SSD said the resident was not on the dental referral log despite the daughter requesting dentures, the SSA missed adding the resident to the ENT referral list after a hearing concern was raised, and social service assessments incorrectly documented that the resident had teeth even though the SSD, LN, and DON confirmed the resident had no teeth.
Improper Labeling and Storage of Open Butter: Surveyors observed a torn-opened, used, unsealed crumpled plastic wrapper containing butter in the kitchen reach-in refrigerator. The DM stated the butter should have been labeled, dated, and stored properly, and the facility policy required newly opened food items to be closed and labeled with an open date.
A nurse and a CNA did not follow EBP during resident care. The nurse provided close-contact care to a resident with ESRD and EBP signage without consistently wearing a gown during vital signs, lung assessment, and incentive spirometer assistance. In a separate event, the CNA cared for a resident with an indwelling suprapubic catheter and EBP signage while wearing gloves but no gown during dressing, repositioning, catheter care, and a bed bath; both staff acknowledged the PPE was not used as required.
A facility failed to follow its policy for storing controlled medications, leading to a missing card of 60 Morphine tablets. The medication was signed in by a nurse but not found in the controlled drawer, with no count sheet for reconciliation. The issue was discovered when reordering, and despite a search, the medication was not located. The incident was reported to the pharmacy and law enforcement.
Two residents in an LTC facility did not receive timely assistance with activities of daily living. A resident with quadriplegia was left in a soiled state due to delayed incontinence care, while another resident with paraplegia had untrimmed toenails despite requesting assistance. The facility's policy requires providing necessary services for residents unable to perform ADLs independently.
The facility failed to implement non-pharmacological interventions (NPIs) before administering PRN pain medications to three residents, as ordered by physicians. Despite orders for NPIs like repositioning and dimming lights, the MAR showed no evidence of NPIs being attempted prior to administering medications such as Oxycodone and Tramadol. Interviews with staff confirmed the lack of consistent NPI implementation and documentation, contrary to the facility's policy and physician's plan of care.
The facility failed to provide sufficient staffing, resulting in delayed call light responses and unmet resident needs. Residents reported long wait times for assistance, particularly during evening shifts and weekends. Staffing shortages were exacerbated by call-offs without replacements, and the facility struggled to meet the required direct care service hours. Observations on subacute and subskilled units further highlighted the impact of inadequate staffing on resident care.
The facility failed to conduct PASARR II assessments for two residents, one with schizophrenia and another with a new diagnosis of schizoaffective disorder. The Minimum Data Set Nurse did not resubmit the assessment for a resident returning from the hospital and was not informed of a new diagnosis for another resident, leading to missed evaluations. This oversight potentially affected the residents' care and placement.
A facility failed to develop a resident-centered care plan for a resident with dementia. Despite the resident's diagnosis, the care plan did not address dementia care, as confirmed by the DON. This omission was against the facility's policy, which requires comprehensive care plans to meet all resident needs.
A resident's care plan was not updated after their G-tube was discontinued, despite the resident being observed eating by mouth and having a physician's order for a soft diet. Interviews with the RD, LN, and DON confirmed the oversight, which could lead to staff confusion.
The facility failed to follow professional standards for three residents, leading to potential unnecessary medication side effects. Two residents were diagnosed with schizophrenia without meeting DSM criteria and were prescribed Seroquel without documented non-pharmacological interventions. Additionally, a nurse did not check a resident's heart rate before administering blood pressure medications, risking adverse effects.
A resident with functional quadriplegia and epilepsy was found without side rails on her bed, despite a physician's order and assessment indicating their necessity for safety and mobility assistance. The DON confirmed the oversight occurred during a room change, and the facility's policy required periodic safety checks for side rail use.
A resident with End Stage Renal Disease did not receive appropriate dialysis care as the facility failed to remove the pressure dressing from the dialysis access site within the required timeframe. The dressing, which should have been removed four hours post-dialysis, remained in place since the resident's last treatment, increasing the risk of infection and impaired blood flow. Both a licensed nurse and the DON confirmed the oversight, acknowledging the potential complications of not following the established care protocol.
Two residents were prescribed Seroquel for schizophrenia without clear indications, despite having diagnoses of anxiety and major depressive disorders. Interviews revealed no symptoms of schizophrenia, and non-pharmacological interventions were not attempted prior to medication use. The facility's policy requiring consistency with DSM and behavioral interventions before medication was not followed, and attempts to contact the prescribing physician for clarification were unsuccessful.
A resident did not receive prescribed cyanocobalamin and calcium due to unavailability during a medication pass. The nurse did not inform the physician or the resident about the missing medications, contrary to facility policy. The DON emphasized the importance of administering all medications and clarifying orders with the physician.
The QAPI committee failed to identify concerns about unnecessary antipsychotic medication use due to a lack of indications. The psychotropic committee focused on gradual dose reductions and medication reviews but did not discuss the appropriateness of these medications. The review should have included residents with continued psychotropic use after hospital discharge and new schizophrenia diagnoses.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a foley catheter, as observed when a nurse wore PPE without proper signage or availability of PPE outside the room. Interviews with the IPN and DON confirmed that EBP should have been applied immediately upon admission due to the resident's increased risk of MDROs, as per facility policy.
Failure to Ensure Dignified, Respectful Care by CNA During Resident Interactions
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were treated with dignity, respect, and kindness during care, particularly by one CNA (CNA 1). Multiple cognitively intact and cognitively impaired residents reported that CNA 1 was rude, rough, and used profanity when they requested assistance. One resident with hemiplegia and a BIMS score of 15 stated that when she called for a brief change, CNA 1 checked her brief and told her, “Don’t fucking call if you’re not wet,” and that CNA 1 entered her room saying, “What do you want? your light is on,” without greeting her or explaining procedures. This resident also reported that CNA 1 threw soiled linens and towels on the floor, leaving stains on the wall, and that CNA 1 wiped her face with a washcloth that had previously been used to clean her bottom, which she found appalling. Another resident with hemiplegia, hemiparesis, and moderate dementia, with a BIMS score of 3, stated that CNA 1 was rude, uncaring, and had an attitude, and that CNA 1 would say, “What do you want?” upon entering the room, making her feel disrespected. This resident reported that CNA 1 refused to assist with turning the TV, telling her to “just turn it a little bit” and then leaving the room, and that she felt she could not reach CNA 1 when she needed help. A resident with congestive heart failure and muscle weakness, with a BIMS score of 12, reported that CNA 1 would leave him in a wet brief all night and that he could not get CNA 1 to change him, and he refused to have CNA 1 assigned to his care. A resident with quadriplegia and pressure ulcers, with a BIMS score of 10, reported that CNA 1 was rude and rough, did not seem to care about patient care, did not return to assist with turning every two hours, and would say, “What the fuck do you want?” when called for help. A resident with hemiplegia and a BIMS score of 13 reported being scared to death of CNA 1, was observed crying, and stated that CNA 1 glared at her when she asked for anything. Another cognitively intact resident with pressure ulcers and a cervical fracture reported that CNA 1 was really rough when turning her, pushed her side-to-side in a hurry, did not explain the process of care, and treated her like an animal. Staff interviews corroborated concerns about CNA 1’s behavior: one licensed nurse described the resident who complained as quiet, sweet, and not known to make false accusations, and stated she did not want to work with CNA 1 due to inconsistent work performance and uncomfortable communication. Another CNA described CNA 1 as careless in performing resident care. The charge nurse reported hearing CNA 1 say “what do you want” to residents, observing that CNA 1 showed no compassion or empathy, became defensive when given feedback, wore a hood that scared at least one resident, and told a resident, “Don’t turn on the call light if you can do it yourself.” Text messages from the charge nurse to the DON and DSD documented that several named residents feared CNA 1, reported rough and rude care, being told not to use the call light after being changed once, being left wet, and being terrified and crying due to CNA 1’s demeanor. The DON later acknowledged that resident rights were not protected when CNA 1 did not treat residents with respect and dignity, and facility policy required employees to treat all residents with kindness, respect, and dignity and to ensure residents were free from abuse and neglect.
Failure to Provide Written Bed Hold Notice
Penalty
Summary
The facility failed to provide a written notice of bed hold rights for one of two residents reviewed for hospitalization, Resident 26. Resident 26 was re-admitted with diagnoses including chronic respiratory failure with hypoxia, and during observation was in bed with eyes closed, with a tracheostomy and feeding tube. The Minimum Data Set dated 11/18/25 indicated the resident’s cognitive skills for daily decision making were severely impaired. Record review showed Resident 26 had fever and abnormal vital signs on 11/18/25, and the physician ordered transfer to the emergency room. The documentation did not indicate that the resident’s responsible party was provided with a written notice of bed hold rights. Interviews with LN 2, the SSA, and the DON confirmed uncertainty or lack of documentation about whether a written bed hold notice was sent, and the facility policy stated residents or resident representatives will be informed in writing of the bed-hold and return policy prior to transfers and therapeutic leaves.
Failure to Complete Significant Change MDS After Hospice Discharge
Penalty
Summary
The facility failed to complete a significant change MDS assessment for one resident after a change in hospice status. The resident was admitted with a diagnosis of other encephalopathy and later admitted to hospice with a diagnosis of late effect of CVA. The paper medical record showed the resident was discharged from hospice on 11/2/25 for extended prognosis, but the MDS assessment still indicated in Section O that the resident was receiving hospice services while residing at the facility. During interview, the MDS nurse stated the MDS assessment was used to establish care plans and reimbursement rates and said an MDS assessment should have been completed when the resident was discharged from hospice services. The MDS nurse also stated there should have been a change in condition assessment and that the resident could miss care because staff thought hospice was coming. The DON stated the MDS was the picture of the resident and affects payment and the resident's plan of care, and that CMS and insurance would think the resident was still on hospice because the MDS nurse should have checked No. The LTC Facility Resident Assessment Instrument 3.0 User's Manual stated the nursing home is required to complete an SCSA when the resident comes off the hospice benefit.
MDS Hospice Status Was Coded Incorrectly
Penalty
Summary
The facility failed to ensure an accurate MDS assessment for one resident whose hospice status was not coded correctly. Resident 9 was admitted with diagnoses including dysphagia and hemiplegia. The clinical record showed an MDS assessment dated 11/23/25 that indicated the resident was under hospice care and services, and a physician order dated 6/25/25 also indicated hospice care and services. A review of the record found no documentation in IDT notes or progress notes showing that Resident 9 revoked hospice care and services. During interviews, an LN stated the resident had been discharged from hospice two months earlier because the resident requested more aggressive treatment, while the DON stated the resident revoked hospice on 11/13/25 but there was no physician order documenting the physician's awareness of the revocation. The MDSN acknowledged she knew the resident revoked hospice care and services on 11/13/25 but incorrectly coded the 11/23/25 MDS assessment as if the resident were still under hospice care and services.
PASARR Level 2 Screening Not Completed for Two Residents
Penalty
Summary
The facility failed to follow the PASARR Level 2 evaluation and determination screening process for two residents reviewed for PASARR. Resident 5 was admitted with diagnoses including paranoid schizophrenia and depression. Her PASARR Level 1, dated 12/18/25, was positive and indicated that a Level 2 screening should have been submitted for evaluation and proper placement, but the MDS nurse stated she did not see a PASARR Level 2 being conducted for this resident. The MDS nurse also stated she did not know what happened and that she should have followed up to make sure Resident 5 was getting the right services at the facility. Resident 114 was re-admitted with diagnoses including schizophrenia, major depressive disorder, and schizoaffective disorder. Her PASARR Level 1, dated 5/21/24, was also positive and indicated that a Level 2 screening should have been submitted for evaluation and proper placement, but the MDS nurse stated she did not see a PASARR Level 2 being conducted for this resident. The MDS nurse stated Resident 114's PASARR Level 1 indicated a Level 2 was required and that she should have followed up to make sure Resident 114 was getting the right services at the facility. The DON stated that both residents' PASARR Level 2 screenings should have been followed up to ensure proper placement to meet their care needs.
Failure to Develop Person-Centered Care Plans for Oral Status and GT Site Discharge
Penalty
Summary
The facility did not develop comprehensive, person-centered care plans for two residents reviewed for care planning. One resident was admitted with respiratory failure with hypoxia and was observed in bed with a tracheostomy and feeding tube; the resident had a beard and long moustache covering part of the mouth, could not speak normally, and later whispered that he had no teeth and wanted dentures. The resident’s daughter, who was the responsible party, stated she had told staff during a care conference that the resident needed dentures, but had not heard back. Review of the resident’s care plans showed no indication of the resident’s oral status, and staff interviews confirmed there was no care plan addressing the resident not having teeth. A second resident was admitted with other specified muscular dystrophies and a gastrostomy tube. During observation, the GT dressing had grayish/tan discharge, later grayish/green discharge with a small amount of blood, and the surrounding site was pink then reddened. Staff stated the discharge could be pus and that the site required monitoring for signs of infection. Review of the care plans showed there was no care plan to address the GT discharge, and staff stated the care plan had only been developed the day before the second observation. The facility policy stated that a comprehensive, person-centered care plan with measurable objectives and timetables is developed and implemented for each resident.
Failure to Document IDT Meeting After Hospice Revocation
Penalty
Summary
The facility failed to ensure that an Interdisciplinary Team (IDT) meeting was documented for Resident 9 when the resident decided to revoke hospice services. Resident 9 was admitted with diagnoses including dysphagia and hemiplegia. The clinical record showed the resident was under hospice care per the MDS assessment and a physician order dated 6/25/25, and the resident was observed in bed with eyes closed and wearing a hospital gown on 1/12/26 at 9:10 A.M. Review of the record found no documented evidence in IDT meeting notes or progress notes showing that Resident 9 revoked hospice care, and there was no physician order documenting that hospice services were discontinued. During interviews, LN 6 stated the resident had been discharged from hospice about two months earlier because the resident requested more aggressive treatment, and the DON stated Resident 9 revoked hospice on 11/13/25. The DON also stated there was no physician order documenting the physician's awareness of the revocation, and the SSD stated there was no formal IDT meeting when Resident 9 revoked hospice care and services, although such documentation should have been present to assess and update the care plan and align care with the resident's wishes.
Failure to Provide Nail Care and Shaving Assistance
Penalty
Summary
The facility failed to ensure that Resident 128, who required substantial to maximal assistance with personal hygiene, received assistance with nail care and shaving. Resident 128 was admitted with diagnoses including respiratory failure and need for assistance with personal care, and had a tracheostomy. During observation, Resident 128 was eating breakfast with black debris under the fingernails and was unshaven; the resident nodded when indicating a desire to be shaved. On a later observation, Resident 128 was shaved with a moustache, but the fingernails were still short with black debris underneath. The resident’s MDS dated 1/13/26 showed a BIMS score of 15, indicating intact cognition, and section GG0130I indicated substantial/maximal assistance was required with personal hygiene. LN 2 stated nail care was provided by the assigned CNA on Saturdays and that the treatment nurse was responsible for checking, while shaving was provided during showers. TN 2 stated nail care was provided on Tuesdays and Thursdays and as needed, and shaving was provided as needed; when shown the resident’s fingernails, TN 2 stated they were dirty and should be cleaned. The DON stated shaving and nail care were part of personal care and skin care, and that shaving should be done daily if needed. The facility policy stated residents unable to perform ADLs independently would receive services necessary to maintain good nutrition, grooming, and personal and oral hygiene.
Missed Dental and Hearing Referrals With Inaccurate Social Service Assessments
Penalty
Summary
Medically-related social services were not fully provided for one resident who was admitted with respiratory failure with hypoxia and had a tracheostomy and feeding tube. During observation, the resident was seen in bed with a beard and long moustache covering part of the mouth, and the resident had no voice. The resident's daughter stated she had told facility staff during care conference that the resident needed dentures but had not heard back from the facility. The resident later indicated a desire to keep the moustache and wanted dentures, and the SSD stated the resident was not in the dental referral log. The facility also missed a hearing-related consultation requested by the resident's daughter. The SSA stated the daughter had requested an ENT consultation because of the resident's difficulty hearing, but the resident's name was not on the referral list because the SSA missed checking the log to ensure the resident was added. In addition, the social service assessments dated 7/24/25 and 10/23/25 inaccurately documented that the resident had own teeth, even though the SSD and LN confirmed the resident had no teeth. The DON also confirmed the assessments were inaccurate and stated resident referrals should be followed and dental assessments should be accurate to ensure a dental referral would be made if needed.
Improper Labeling and Storage of Open Butter
Penalty
Summary
The facility failed to ensure that an open food item was labeled with an open date and stored properly in the reach-in refrigerator in the kitchen. During a joint observation of the kitchen area with the Dietary Manager, surveyors found a torn-opened, used, unsealed crumpled plastic wrapper containing butter inside the reach-in refrigerator. The Dietary Manager disposed of the butter and stated that the butter should have been labeled, dated, and stored properly for resident safety. The facility's policy and procedure titled "Labeling and Dating of Foods" stated that newly opened food items will be closed and labeled with an open date and used by the date that follows the various storage guidelines.
Failure to Follow Enhanced Barrier Precautions During Resident Care
Penalty
Summary
Infection control procedures were not followed when a Licensed Nurse provided care to a resident on enhanced barrier precautions without consistently wearing a gown. The resident was admitted with end stage renal disease and had an EBP sign posted on the door. During medication pass, the nurse checked vital signs without donning a gown, then later returned to the room and listened to lung sounds and assisted with an incentive spirometer without putting on a gown. The nurse stated she should have worn PPE and forgot again when she assessed the resident. The DON stated staff were expected to follow EBP procedures consistently to prevent spread of infection, especially during close contact. In a separate event, a CNA failed to use proper PPE while providing care to another resident on EBP who had an indwelling suprapubic catheter and a history of infection. The resident’s door had EBP signage posted, and the CNA was observed assisting with dressing, repositioning, and moving the catheter while wearing gloves but no gown. The CNA later stated she emptied the catheter and provided a bed bath without proper PPE because the resident was in a hurry to get up, and acknowledged she should have used PPE to prevent spread of infection. The IPN stated staff should wear gown and gloves during high-contact care because PPE serves as a barrier to protect staff and others and avoid spread of germs.
Failure to Properly Store and Account for Controlled Medications
Penalty
Summary
The facility failed to adhere to its policy regarding the receipt and storage of controlled medications, resulting in a medication card containing 60 tablets of Morphine being unaccounted for. The issue was discovered when the facility attempted to reorder the medication for a resident, only to be informed by the pharmacy that it had already been delivered. The delivery log confirmed the medication was signed in by a licensed nurse, but the medication was not found in the controlled medication drawer, and there was no accompanying count sheet to verify its reconciliation. Interviews with the Assistant Director of Nursing, licensed nurses, and the Director of Nursing revealed that the medication was supposed to be placed in a locked drawer and reconciled at each shift change. However, since there was no count sheet for the missing Morphine, the reconciliation process could not be verified. The Director of Nursing was notified of the missing medication, and despite a search of the facility, it was not located. The incident was reported to the pharmacy and law enforcement, as per the facility's policy on controlled substances.
Deficiencies in ADL Assistance for Two Residents
Penalty
Summary
The facility failed to provide timely assistance with activities of daily living (ADL) for two residents, leading to deficiencies in care. Resident 28, who was admitted with quadriplegia and a history of urinary tract infections, was found in bed on a foul-smelling, dark brown substance with a visibly wet brief. The CNA assigned to Resident 28 admitted to noticing the need for incontinence care during rounds but delayed attending to it due to other tasks. The Director of Nursing acknowledged that the delay in providing incontinence care placed Resident 28 at risk for skin breakdown, wounds, or infection. Resident 30, admitted with paraplegia and muscle weakness, was observed with long, jagged toenails, which she expressed embarrassment about and had requested staff assistance to trim. The CNA was unsure if she could trim the resident's nails, although nail clippers and files were available. The Director of Nursing stated that CNAs could trim nails depending on the resident's preference, but preferred a licensed nurse to perform the task. The facility's policy indicated that residents unable to perform ADLs independently should receive necessary services, including grooming and personal hygiene.
Failure to Implement Non-Pharmacological Interventions Before PRN Pain Medication
Penalty
Summary
The facility failed to implement non-pharmacological interventions (NPIs) as ordered by the physician before administering PRN pain medications to three residents. Resident 22, who was admitted with chronic pain syndrome, had a cognitive score indicating intact cognition. Despite physician orders requiring NPIs such as repositioning and dimming lights before administering Oxycodone, the Medication Administration Record (MAR) showed no evidence of NPIs being attempted prior to medication administration. Resident 99, admitted with orthopedic aftercare following surgical amputation, had a moderately impaired cognitive score. The physician's orders specified NPIs before administering Tramadol for severe pain. However, the MAR indicated that Tramadol was administered 17 times, with no documentation of NPIs being attempted, even when the recorded pain level was below the threshold for severe pain. Additionally, the pain assessment interview for Resident 99 was incomplete, lacking details on pain triggers and location. Resident 312, diagnosed with rectal cancer, also did not receive NPIs before the administration of Oxycodone for breakthrough pain, as per physician orders. The MAR showed multiple administrations of Oxycodone without documented NPIs. Interviews with staff, including a CNA, LN, DSD, and DON, confirmed that NPIs were not consistently attempted or documented, despite being part of the physician's plan of care and facility policy. The facility's policy emphasized the importance of NPIs in pain management, yet these were not implemented as required.
Staffing Deficiencies Lead to Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient staffing to meet the care needs of residents, as evidenced by delayed responses to call lights. Interviews and record reviews revealed that call lights were not answered timely for three of six confidential residents interviewed. Specifically, one resident with a left heel wound and vision impairment reported that staff ignored his call light, and it took a long time for it to be answered, especially during the evening shift. Another resident stated that while staff assisted with bathroom needs, they were made to wait for other assistance. The Resident Council minutes from June to August 2024 repeatedly identified issues with call light response and insufficient staffing. The facility's staffing issues were particularly pronounced on weekends, with several instances of staff calling off without replacements. Interviews with the Staffing Coordinator and Director of Nursing confirmed awareness of these issues, and attempts were made to call in off-duty staff. However, the facility struggled to maintain adequate staffing levels, particularly on weekends, due to staff preferences for time off and infrequent use of registry staff. The facility's policy required a minimum of 3.5 direct care service hours per patient per day, but there were instances where this was not met, leading to licensed nurses performing CNA duties. Additional observations on the subacute and subskilled units highlighted further staffing challenges. A resident's call light went unanswered while respiratory therapists engaged in conversation nearby, and a CNA reported difficulties in timely call light responses due to the high acuity of residents and the need for additional staff. The subskilled unit was under the supervision of a nurse from another unit, complicating communication and assistance requests. These staffing deficiencies were documented in the facility's policy, which mandated 24-hour availability of licensed nurses and CNAs to provide direct resident care services.
Failure to Conduct PASARR II Assessments for Residents
Penalty
Summary
The facility failed to ensure that Preadmission Screening and Resident Review II (PASARR II) assessments were conducted for two residents, which is a federal requirement to prevent inappropriate placement of individuals with mental disorders in nursing homes. Resident 6, who was diagnosed with schizophrenia, was admitted to the facility and had a positive PASARR I screening, indicating the need for a Level II Mental Health Evaluation. However, the PASARR II assessment was not conducted after Resident 6 returned from a hospital stay, as the Minimum Data Set Nurse (MDSN) did not resubmit the assessment to the state. Resident 99 was admitted with a diagnosis of unspecified psychosis and initially had a negative PASARR I screening, indicating no need for a Level II evaluation. However, after a new diagnosis of schizoaffective disorder was made, which would have triggered a PASARR II assessment, no reassessment was conducted. The MDSN stated that she was not informed of the new diagnosis, which led to the oversight. As a result, it was undetermined if Resident 99 qualified for additional services or if the placement was appropriate. The facility's policy requires all new admissions and readmissions to be screened for mental disorders through the PASARR process. The policy mandates a Level I PASARR screen for all potential admissions and a referral to the state PASARR representative for a Level II evaluation if the criteria for a mental disorder are met. The failure to conduct the necessary PASARR II assessments for Residents 6 and 99 indicates a lapse in following these procedures, potentially affecting the residents' care and placement.
Failure to Develop Dementia Care Plan for Resident
Penalty
Summary
The facility failed to develop a resident-centered care plan for a resident diagnosed with dementia. Despite the resident's admission records indicating diagnoses of major depressive disorder and anxiety disorder, a subsequent History and Physical examination revealed the resident also had dementia and lacked the capacity to understand and make decisions. This critical information was not incorporated into the resident's care plan, which is a requirement to ensure all care needs are addressed. During a joint interview and record review with the Director of Nursing, it was acknowledged that the care plan for the resident did not include provisions for dementia care. This omission was contrary to the facility's own policy, which mandates the development of a comprehensive, person-centered care plan that includes objectives to meet the resident's physical, psychosocial, and functional needs. The failure to include dementia care in the resident's care plan had the potential for the resident's needs to be unmet.
Failure to Revise Care Plan After Discontinuation of G-tube
Penalty
Summary
The facility failed to revise the care plan for a resident when their gastrostomy tube (G-tube) was discontinued. The resident, who was admitted with a diagnosis of traumatic subdural hemorrhage, was observed feeding himself in the dining hall, indicating a change in his nutritional intake method. Despite a physician's order for a soft textured diet, the care plan still included instructions for managing tube feeding, such as checking residuals every shift and holding feedings if residuals exceeded 250 milliliters. Interviews with the Registered Dietitian and a Licensed Nurse confirmed that the resident was no longer receiving tube feedings and was exclusively eating by mouth. The Director of Nursing acknowledged that the care plan interventions were outdated and could lead to confusion among staff. The facility's policy on care plans emphasized the need for ongoing assessments and revisions as residents' conditions change, highlighting the oversight in updating the resident's care plan.
Failure to Follow Professional Standards in Diagnosing and Medication Administration
Penalty
Summary
The facility failed to adhere to professional standards of practice for three residents, leading to potential unnecessary medication side effects. Resident 5 was diagnosed with schizophrenia at the facility without meeting the criteria outlined in the DSM. Despite being admitted with anxiety and major depressive disorder, Resident 5 was prescribed Seroquel for schizophrenia based on behavior such as pulling at life-sustaining devices. Interviews with staff and the responsible party revealed no history or symptoms of schizophrenia, and the diagnosis did not align with DSM guidelines. Additionally, there were no documented non-pharmacological interventions attempted before administering Seroquel. Similarly, Resident 6 was diagnosed with schizophrenia without meeting DSM criteria. The resident, admitted with anxiety and major depressive disorder, was prescribed Seroquel for unprovoked agitation. Interviews indicated that Resident 6 was alert and oriented, with no hallucinations or paranoia documented in the medical record. The facility's DON acknowledged the lack of documentation supporting the schizophrenia diagnosis and the absence of non-pharmacological interventions prior to medication use. For Resident 18, a licensed nurse failed to obtain the heart rate before administering blood pressure medications, contrary to the facility's policy. The nurse acknowledged the oversight, which could have put the resident at risk for adverse effects due to the medications' potential to lower heart rate. The DON confirmed the expectation for nurses to check all pertinent vital signs before medication administration, highlighting a lapse in following established procedures.
Failure to Install Side Rails for Resident with Epilepsy
Penalty
Summary
The facility failed to maintain a safe environment for Resident 28, who was diagnosed with functional quadriplegia and epilepsy, by not installing side rails on her bed. The resident was admitted with a severe mental impairment, as indicated by a BIMS score of 3. Observations on 09/09/24 revealed that Resident 28's bed was pushed against the wall without side rails, despite a physician's order and a side rail assessment indicating the need for 1/2 bilateral side rails for safety and assistance with bed mobility and transfers. The Director of Nursing (DON) acknowledged that Resident 28 was moved to a different room without her side rails, which were intended for her safety, particularly in the event of a seizure. The DON stated that the licensed nurse should have ensured the side rails were installed according to the physician's order. The facility's policy on the proper use of side rails, revised in December 2016, required periodic safety checks relative to side rail use, which were not adhered to in this instance.
Failure to Remove Dialysis Pressure Dressing
Penalty
Summary
The facility failed to provide appropriate dialysis care for a resident with End Stage Renal Disease who was dependent on dialysis. The resident, identified as Resident 71, had a dialysis access site on the left upper arm, which was covered with a pressure dressing. According to the facility's policy and the resident's physician's orders, the pressure dressing should have been removed four hours after the resident returned from dialysis to allow for proper assessment of the site for any signs of redness or bleeding. However, during an observation and interview conducted on 9/9/24, it was found that the pressure dressing had not been removed since the resident's last dialysis treatment on 9/7/24. Licensed Nurse 35 confirmed that the pressure dressing should have been removed to prevent potential complications such as infection or impaired blood flow to the fistula. The Director of Nursing also acknowledged that the pressure dressing should have been removed by a licensed nurse within the specified timeframe to avoid risks of bleeding or infection. The facility's failure to adhere to the established protocol for post-dialysis care resulted in a deficiency in providing safe and appropriate dialysis services to the resident.
Unnecessary Antipsychotic Medication Use Without Clear Indications
Penalty
Summary
The facility failed to ensure that two residents, Resident 5 and Resident 6, were free from unnecessary medications, specifically antipsychotic medications, without clear indications. Resident 6 was admitted with anxiety disorder and major depressive disorder but was prescribed Seroquel for schizophrenia based on unprovoked agitation. Interviews with staff and the resident revealed that Resident 6 was alert, oriented, and did not exhibit symptoms of schizophrenia such as hallucinations or paranoia. The Director of Nursing (DON) confirmed that there was no documentation supporting the use of Seroquel for schizophrenia and that non-pharmacological interventions were not attempted prior to medication use. Similarly, Resident 5 was admitted with anxiety disorder and major depressive disorder and was also prescribed Seroquel for schizophrenia, allegedly due to indifference to surroundings and pulling at life-sustaining devices. Interviews with staff and the resident's responsible party indicated that Resident 5 had no history of schizophrenia or hallucinations. The DON and Social Worker (SW) confirmed that there was no appropriate diagnosis of schizophrenia and that the behavior of pulling tubes was not a valid indication for the use of Seroquel. Non-pharmacological interventions were not documented as attempted before resorting to medication. The facility's policy on antipsychotic medication use, which requires consistency with the Diagnostic and Statistical Manual of Mental Disorders (DSM) and the attempt of behavioral interventions before medication, was not followed. Attempts to contact the prescribing physician, MD 1, for clarification on the schizophrenia diagnoses were unsuccessful. The lack of appropriate documentation and adherence to policy resulted in the unnecessary administration of antipsychotic medications to Residents 5 and 6.
Medication Error Due to Unavailable Medications
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as evidenced by the unavailability of two routine medications for a resident during a medication administration observation. The resident, who was admitted with diagnoses including nutritional anemia and muscle weakness, was supposed to receive cyanocobalamin 5000 micrograms and Calcium 500 milligrams every morning at 9 A.M. However, these medications were omitted during the medication pass conducted by a licensed nurse. The nurse acknowledged the absence of the medications, stating that only Oyster Shell Calcium and cyanocobalamin 1000 micrograms were available, and did not inform the physician or the resident about the unavailability. The Director of Nursing confirmed the importance of administering all prescribed medications and stated that staff should have clarified the orders with the physician. The facility's policy on administering medications requires contacting the prescriber or attending physician if a dosage is believed to be inappropriate. However, this protocol was not followed, as the nurse did not seek guidance from the physician regarding the medication unavailability, leading to the deficiency.
QAPI Committee Fails to Address Unnecessary Antipsychotic Use
Penalty
Summary
The facility's Quality Assurance and Performance Improvement (QAPI) committee failed to identify concerns related to the unnecessary use of antipsychotic medications due to a lack of indications. During an interview with the Administrator, Director of Nursing (DON), and Administrator in Training (AIT), it was revealed that the psychotropic committee focused primarily on gradual dose reductions (GDR) and Medication Review Regimen (MRR) for residents on psychotropic medications. However, the committee did not discuss the indications for use or the appropriateness of these medications, which are crucial aspects of psychotropic review. The DON acknowledged that the review should have included residents who continued psychotropic medications after hospital discharge and those with new diagnoses of schizophrenia. The facility's policy on QAPI, revised in February 2020, aimed to establish and implement performance improvement projects to correct identified negative indicators. Despite this, the QAPI committee did not expand its review to thoroughly assess the necessity of psychotropic medication use, potentially leaving deficiencies uncorrected and exposing residents to unnecessary medication side effects.
Failure to Implement Enhanced Barrier Precautions for Resident with Foley Catheter
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with an indwelling foley catheter, which is necessary to prevent the transmission of multi-drug resistant organisms (MDROs). During an observation, a Licensed Nurse (LN) was seen wearing full Personal Protective Equipment (PPE) while providing care to the resident, but there was no signage indicating the need for PPE, nor was PPE available outside the resident's room. The LN stated that she wore PPE to avoid urine splashing on her scrubs while emptying the resident's catheter bag. Interviews with the Infection Prevention Nurse (IPN) and the Director of Nursing (DON) revealed that residents with foley catheters should be placed on EBP immediately upon admission due to their higher risk of acquiring MDROs. The facility's policy on Enhanced Barrier Precautions, revised in June 2024, indicates that EBP should be applied to residents with wounds and/or indwelling medical devices, regardless of MDRO colonization, for the duration of their stay or until the discontinuation of the device. The failure to implement these precautions for the resident upon admission was a deficiency in infection control practices.
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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.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near San Diego
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| University Care Center | 0.2 mi | ★★★★★ | 0 | 0 |
| Arroyo Vista Nursing Center | 1.5 mi | ★★★★★ | 7 | 0 |
| Brighton Place San Diego | 2.1 mi | ★★★★★ | 3 | 0 |
| La Mesa Healthcare Center | 2.3 mi | ★★★★★ | 3 | 0 |
| Bella Vista Health Center | 3.1 mi | ★★★★★ | 11 | 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.