Below average — CMS composite of the measures below.
A standard survey is most likely before 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 Katherine Healthcare during CMS and state inspections, most recent first.
Failure to Complete Admission Nutritional Screening: The facility did not complete the NIS for seven of eight residents on admission. Affected residents had diagnoses including severe protein-calorie malnutrition, morbid obesity, gastric ulcer, type II DM, and obesity. The DM stated he usually started the NIS and the RD finished it, but records showed several screens were completed late and one resident had no NIS at all. The RD stated the NIS should be finished within seven days of admission and acknowledged some were not done by the prior RD.
A resident’s controlled medication, Lorazepam 0.5 mg, went missing from a medication cart, with the narcotic record showing 19 tablets remaining but the bubble pack unable to be located during a shift-change narcotic count by two RNs. The medication had been verified as present and correctly counted by two RNs on the prior shift, and a torn label from the missing Lorazepam bubble pack was later found in the bedside table of an empty room, but the tablets were not recovered. As a result, the resident missed two scheduled doses, and the incident constituted misappropriation of the resident’s property in violation of facility policies on controlled substances, resident rights, and investigation of theft/misappropriation.
A resident with a physician’s order for daily lorazepam 0.5 mg for anxiety did not receive two ordered doses when staff discovered the lorazepam bubble pack missing during a narcotic count. An RN and the night shift nurse searched multiple medication carts and resident rooms but could not locate the controlled medication, and the pharmacy reported a refill would be too early without DON authorization. The MAR reflected the missed administrations, the DON confirmed the medication had been missing since a prior night shift and that the resident missed two morning doses, and there was no lorazepam available in any of the E-kits, contrary to the facility’s controlled substances policy.
Missing oxygen orders, humidifier handling issues, and incomplete oxygen setup documentation were identified for two residents. One resident was observed wearing NC at 2 L without a documented MD order, and the humidifier bottle remained labeled from an earlier date despite being in use. Another resident had unlabeled NC tubing, a room air concentrator turned off, no oxygen in use sign posted, no documented oxygen order, and no care plan for oxygen use; the DON confirmed the missing order and care plan.
Unnecessary Medication Use and Improper Administration: A resident with ESRD received calcium acetate ordered as a supplement and scheduled away from meals, and the medication was repeatedly administered outside mealtimes despite being intended to bind phosphate in food. Another resident with ESRD had an PRN order for a magnesium-containing antacid/laxative product, which the CP stated is not recommended for residents with ESRD.
Infection control practices were not consistently followed when unlabeled resident care items were found in shared bathrooms, an uncovered BiPAP mask was left out in a resident room without a no smoking sign, and rooms on CP did not have a closed-lid receptacle for used PPE. Cloudy urine was observed in a resident's Foley catheter drain tube, and staff did not perform hand hygiene between resident care tasks during meal service when handling food and utensils.
Unsafe room equipment and environmental deficiencies were identified when a resident’s bedside commode was unsteady due to missing grip pads and a chest of drawers was broken, with the resident reporting the drawers would fall out when opened. Surveyors also found penetrating holes in a resident room and bathroom, along with rusted plumbing pipes and a missing bathroom light switch button; the MS confirmed these conditions and stated they were not safe or appropriate.
Incomplete POLST Forms for Two Residents: The facility failed to ensure POLST forms were completed for two residents. One resident’s advance directive section was left blank, and another resident’s section for artificially administered nutrition was left blank. The DON confirmed the omissions and stated nursing staff were responsible for reviewing and completing all POLST sections on admission, with the IDT also reviewing POLSTs during care plan meetings.
A resident with a mood disorder received PRN quetiapine, but the record lacked documentation of attempted non-pharmacological interventions before administration. The chart also had no documented behavior monitoring or side effect monitoring for the antipsychotic, and the DON confirmed the missing documentation during record review.
MDS Assessment Incorrectly Coded for Insulin Use: A resident with diabetes type 1 had orders for basal and sliding-scale insulin, and the EMAR showed insulin was administered daily. However, the MDS coded hypoglycemic medication use as No even though the MDSC confirmed it should have been coded Yes.
The facility failed to implement person-centered care plans for two residents. One resident had an order and care plan for heel boots while in bed, but during observation the boots were left on the bedside table and were not applied until later that day. Another resident had an order and care plan for a floor mat on the left side of the bed, but observation showed no mat in place while the resident was in bed. CNA D, the DON, and the DSD confirmed the missed interventions.
A resident with Parkinson disease, muscle weakness, and impaired ROM had ordered RNA services for BLE ROM and UE splinting/hand rolls, but weekly RNA documentation was missing for multiple weeks. The resident was observed in bed with bilateral hand contractures, and the RNA stated the resident’s extremities were stiffer than before and confirmed there were no written records showing the restorative services were provided during the missed weeks.
Failure to Administer Ordered Antibiotic for UTI: A resident with acute kidney failure, hepatorenal syndrome, spontaneous bacterial peritonitis, and cirrhosis was treated for a UTI after an ED visit and initially received cephalexin. The ED later documented that the urine culture grew ESBL E. coli resistant to cephalosporins and ordered Macrobid, but the facility had no documented Macrobid order or administration for the resident, and the DSD/IP confirmed the order was not followed.
Dialysis care was incomplete for two residents with ESRD and dialysis dependence. One resident had missing dialysis communication records, an inappropriate MOM order despite dialysis status, an antibiotic order that was not stopped as ordered, and no documented side effect monitoring for two antibiotics. Another resident’s dialysis care plan included intake/output monitoring and an emergency kit at bedside, but staff stated intake/output was not monitored and the RN was unfamiliar with the emergency kit location.
Controlled medication accountability was inaccurate when Norco was signed out of the CDR but not documented on the MAR for two residents. The DON stated PRN controlled meds must be assessed, removed from the cart, signed out, and recorded on the MAR, and the facility policy required the administering staff to initial the MAR and record the date and time. Review showed one resident had one omitted MAR entry and another resident had three omitted MAR entries, all confirmed by the DON and RN.
Medication administration errors exceeded the allowed rate when an RN gave calcium acetate without a meal, a LVN administered insulin lispro well before dinner, and an RN failed to give ordered metoprolol for a resident with HTN. The errors involved residents with end-stage kidney disease, diabetes, and elevated BP, and the report stated the medications were not given as prescribed or per manufacturer instructions.
Palatability and Texture of Vegetables Not Maintained: A resident with intact cognition and a regular texture diet complained that facility food was bland and that vegetables were soft, mushy, and overcooked. During meal observation, the vegetable dish was found to be soft and close to mushy, while dietary staff stated broccoli was cooked softer for residents on a bite size diet. The RD stated vegetables for a regular consistency diet should be served between al dente and soft, and facility policy required meals to be nourishing, palatable, and attractive.
Three shared resident rooms measured less than the required 80 square feet per resident. Staff, including CNAs, RNs, and maintenance, confirmed the room sizes, and observations noted no care or privacy issues, while the facility policy stated bedrooms must provide at least 80 square feet per resident.
The facility failed to ensure the proper use of bed rails for five residents, including not following manufacturers' recommendations, not offering alternatives, not completing entrapment risk assessments, not updating assessments, and not obtaining physician's orders.
The facility failed to maintain kitchen hygiene and food safety standards, with expired food, improper hair net use, unsanitized thermometers, and a rusty ice storage bin screw causing potential contamination. Staff acknowledged these lapses during interviews.
The facility failed to implement proper infection control practices, including hand hygiene and glove changes, and lacked a comprehensive water management program to prevent water-borne contaminants like Legionella. These deficiencies were confirmed through staff interviews and policy reviews.
The facility failed to accurately code the MDS for four residents, leading to discrepancies in their assessments. Issues included unrecorded hospice care, pressure injuries, nutritional interventions, and behaviors of rejecting care. These inaccuracies were confirmed by the MDS coordinator and social service director during record reviews.
The facility failed to ensure residents received necessary care and services as per medical orders. A resident's pacemaker information was missing, and routine check-ups were not scheduled. Multiple residents' medication refusals were not reported to physicians. LVNs did not follow physician orders for treatments and medication administration, leading to potential health risks.
The facility failed to ensure that the daily staffing information posted was current, with outdated postings observed on both the first and second floors. The Director of Staff Development, responsible for updating the postings, was on vacation, leading to the oversight. The Administrator confirmed the postings should reflect the current date.
The facility failed to conduct and act on drug regimen reviews for three residents. An iMRR was not performed for a resident after multiple falls, and the CP did not identify irregularities in monitoring heart rates and blood pressures for two residents. Additionally, the facility did not act on a CP's recommendation to administer Coreg with food for another resident.
The facility failed to accommodate a resident's needs by not placing his urinal within reach, despite his medical conditions and repeated complaints. Staff attempts to reposition the urinal were unsuccessful, and the care plan did not address the issue adequately.
The facility failed to complete and transmit the MDS discharge assessment in a timely manner for a resident. The MDS coordinator and DON confirmed the assessment was completed and transmitted beyond the required 14-day period after discharge, violating the RAI 3.0 User's Manual guidelines.
The facility failed to ensure accurate PASARR screenings for two residents, leading to potential inaccuracies in care. One resident with bipolar disorder and major depressive disorder exhibited disruptive behaviors, but no new PASARR was conducted. Another resident with anxiety, depression, and bipolar disorder was not marked for these conditions in the PASARR screening.
A resident with chronic respiratory conditions was found to be receiving oxygen at levels lower than the prescribed 3 LPM on two separate occasions. The facility's policy requires adherence to physician's orders for oxygen administration, but this was not followed, leading to a deficiency in the resident's care.
The facility failed to provide sufficient nursing staff on weekends, with CNA DHPPD falling below the required 2.4 hours per patient day on specific dates. The DSD confirmed that CNAs who called off were not replaced, leading to short staffing.
The facility failed to ensure proper handling of hazardous medications and prevent drug-drug interactions for two residents. Two nurses were observed preparing hazardous medications without gloves, and two residents received medications concurrently that could reduce the effectiveness of their treatments.
The facility failed to ensure that two residents were free from unnecessary medications. One resident's Carvedilol order lacked hold parameters for blood pressure and heart rate, and another resident's gabapentin order had an incorrect indication, while their amiodarone order lacked heart rate monitoring. These discrepancies were confirmed by the DON and CP, highlighting a failure to adhere to the facility's policies.
The facility failed to ensure a resident was free from unnecessary psychotropic medications by not considering a Gradual Dose Reduction (GDR) after multiple falls, not completing a baseline AIMS for aripiprazole use, and lacking specific target symptoms, interventions, and potential adverse effects in the care plan for bipolar disorder.
The facility had an 11.11% medication error rate when three medication errors were observed during a medication pass for two residents. Carvedilol and Metformin were administered without food, and magnesium oxide and ferrous sulfate were given simultaneously, contrary to manufacturer's specifications and facility policy.
The facility failed to ensure proper medication storage and labeling, as an opened multi-dose insulin vial and an insulin pre-filled pen were found without labeling for their open dates. Additionally, an expired insulin pen and four expired over-the-counter medications were identified. The facility's policy required proper labeling and disposal of outdated drugs, which was not followed.
The facility failed to maintain accurate documentation for a resident's death. The resident, with multiple serious medical conditions, passed away, but the pronouncement of death was not properly documented. The nurse's notes were inconsistent and lacked a detailed assessment, date, time, and the name of the nurse who pronounced the death. The facility's policy on documenting the death was not followed.
The facility failed to ensure that two residents were offered and/or received the pneumococcal conjugate vaccine 20 (PCV20). The infection preventionist confirmed that both residents had a history of receiving the pneumococcal polysaccharide vaccine (PPSV23) but were not offered the PCV20 as required by the facility's policy and CDC recommendations.
The facility failed to report allegations of verbal and financial abuse involving two residents to Adult Protective Services (APS) as required by their abuse policy. One resident alleged verbal abuse by a CNA, and another reported financial abuse by a caregiver prior to admission. Both incidents were not reported to APS, despite being documented and confirmed by staff.
Several multi-resident rooms in the facility provided less than the required 80 square feet per resident. Despite this, staff and residents were able to move freely, and residents received adequate care without expressing concerns about the room sizes.
A resident with major depressive disorder and bipolar disorder was observed by an LPN yelling and pushing another resident's wheelchair with force. The incident was not reported to the facility's abuse coordinator or relevant authorities, as required by the facility's policy.
Failure to Complete Admission Nutritional Screening
Penalty
Summary
The facility failed to complete the nutritional initial screener (NIS) for seven of eight residents upon admission. Residents 1, 2, 4, 5, 6, 7, and 8 were identified as not having the NIS completed in a timely manner or, in one case, not having one created at all. The residents had diagnoses including severe protein-calorie malnutrition, muscle weakness, chronic metabolic acidosis, morbid obesity, gastric ulcer, type II diabetes mellitus, obesity, and severe protein-calorie malnutrition with type II diabetes mellitus. During interview, the dietary manager stated he usually started the NIS on admission and the registered dietitian completed and locked it, but he did not see a nutritional assessment created and documented while he was on vacation from 12/26/25 through 1/26/26. Record review showed Resident 1's NIS was created on 1/27/26, Resident 2's on 1/28/26, Resident 4's on 2/6/26, Resident 6's on 1/27/26, and Resident 7's on 2/23/26. Resident 5 did not have a NIS created, only a Nutritional Quarterly/Annual Review created on 4/15/26. The administrator confirmed Resident 8 did not have a NIS. The registered dietitian stated the NIS should be finished within seven days of admission and acknowledged some NIS were not done by the previous registered dietitian.
Misappropriation of Resident’s Controlled Lorazepam and Resulting Missed Doses
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from misappropriation of property when a controlled medication, Lorazepam 0.5 mg, went missing from the medication cart, resulting in missed doses. During a narcotic count at shift change on 11/30/25, RN A and the night shift nurse (RN B) were unable to locate the resident’s Lorazepam bubble pack, which should have contained 19 tablets according to the narcotic record. RN A reported that three medication carts and 48 resident rooms were checked, but the medication could not be found, and confirmed that the resident missed two scheduled doses on 11/30/25 and 12/1/25. The facility’s controlled substances policy required controlled medications to be reconciled upon receipt, administration, disposition, and at the end of each shift, with incoming and outgoing nurses jointly determining the count. Interviews and record review established that the Lorazepam had been present and accounted for at the end of the prior shift. RN B stated that at the start of her night shift on 11/29/25 all narcotics were accounted for, and at the end of her shift RN A discovered the Lorazepam bubble pack was missing, despite the narcotic record book indicating 19 tablets remained. RN C, who worked the evening shift before RN B, confirmed that all narcotics, including the resident’s Lorazepam, were accounted for during the count with RN B, and both signed the narcotic book indicating no discrepancies. The MDS Coordinator later found a torn medication label from the missing Lorazepam bubble pack in the bottom drawer of a bedside table in an empty room, but the 19 tablets were not recovered. The DON confirmed that the medication had been accounted for on 11/29/25, was missing during RN B’s night shift, and that the torn label matched the missing Lorazepam, constituting misappropriation of the resident’s property in violation of the facility’s resident rights and misappropriation policies.
Failure to Account for and Provide Ordered Lorazepam Doses
Penalty
Summary
The facility failed to provide accurate accountability and timely availability of a controlled medication, lorazepam 0.5 mg, for one resident with an order for daily administration for anxiety. During a narcotic count on one shift, RN A and the night shift nurse (RN B) were unable to locate the resident’s lorazepam bubble pack in the Station 2 medication cart. RN A reported that three medication carts and 48 resident rooms were searched, but the medication could not be found. RN A contacted the pharmacy for a replacement, and the pharmacy indicated the refill was too early and would require DON authorization. As a result, the resident’s ordered lorazepam doses were not available for administration on two consecutive mornings. Review of the physician’s order dated 9/24/25 showed the resident was to receive lorazepam 0.5 mg by mouth once daily for anxiety, evidenced by repetitive questions and verbalizations. The MAR documented that lorazepam was not administered on two specified dates, and the DON confirmed that the medication had been missing since RN B’s night shift and that the resident missed those two morning doses. During an observation and interview, the DON also confirmed there was no lorazepam available in any of the five E-kits. The facility’s policy on controlled substances required compliance with all laws and regulations related to handling, storage, disposal, and documentation of controlled medications, but the missing lorazepam and resulting missed doses demonstrated a failure to meet this requirement for this resident.
Missing Oxygen Orders, Improper Humidifier Handling, and Incomplete Oxygen Setup Documentation
Penalty
Summary
Provide safe and appropriate respiratory care for residents when needed was not followed for two sampled residents. Resident 43 was admitted with dementia, ischemic cardiomyopathy, and acute on chronic systolic congestive heart failure. On two observations, she was seen sitting on the side of the bed wearing a nasal cannula with oxygen set at 2 L, but review of the physician orders showed no documented order for oxygen administration. The DSD/IP and DON both stated there needed to be a physician order for oxygen administration, and the DON confirmed there was no order for Resident 43. Resident 43 was also observed receiving oxygen through a nasal cannula connected to a humidifier bottle that was labeled 9/2/25. On a later observation, the humidifier bottle was still half full and remained labeled 9/2/25. The facility policy for respiratory therapy stated distilled water used in respiratory therapy must be dated and initialed when opened and discarded after 24 hours. The DSD/IP stated the humidifier bottle was changed whenever the bottle is empty. Resident 3 was admitted with chronic respiratory failure with hypoxia, congestive heart failure, and end stage renal disease, and had intact cognition on the MDS. During observation, Resident 3’s bedside nasal cannula was unlabeled and wrapped on a humidifier attached to a room air concentrator that was turned off, with the nasal cannula prongs open to air and no oxygen in use sign posted. Review of the order summary showed no documented order for oxygen administration, and review of the care plans showed no documented care plan for oxygen use. Resident 3 stated using oxygen on and off for shortness of breath, and RN A confirmed the tubing was not labeled, was uncovered, and there was no oxygen in use sign posted. The DON confirmed there was no documented order and no care plan for oxygen administration for Resident 3.
Unnecessary Medication Use and Improper Administration
Penalty
Summary
The facility failed to ensure that Resident 35’s drug regimen was free from unnecessary medication use when calcium acetate was ordered and administered in a manner inconsistent with its intended use. Resident 35 had ESRD and was receiving dialysis, yet the physician order listed calcium acetate 667 mg as a supplement and scheduled it for 9 a.m. and 7 p.m., rather than for administration with meals. During observation, RN A administered the medication around 10 a.m., and the resident reported eating breakfast around 7 a.m.; the CNA later stated breakfast had been served around 7:40 a.m. The DON and RN confirmed the medication was not written for ESRD and was not given with meals as required for its intended effect. Record review showed Resident 35’s calcium acetate was administered repeatedly outside of mealtimes over a 10-day period, with doses given in the morning and evening at times that did not align with breakfast or dinner. The consultant pharmacist stated calcium acetate binds phosphate in food and will not work to its capacity if not given with meals, and also stated it was for chronic kidney disease and not a supplement. Laboratory reports from the dialysis center showed elevated phosphorus levels during this period. The facility also failed to ensure Resident 53 was free from an unnecessary medication order when an as-needed order for aluminum and magnesium hydroxide-simethicone suspension was entered for indigestion, heartburn, gas, and nausea. Resident 53 had ESRD, along with acute respiratory failure with hypoxia, type 2 diabetes mellitus, and unspecified dementia. The consultant pharmacist stated Milk of Magnesia is not recommended for residents with ESRD and said he would recommend discontinuation on the next review. The DSD/IP also stated there should not be an order for Milk of Magnesia for residents who receive dialysis and that the order for Resident 53 would be discontinued.
Infection Control Practices Not Followed
Penalty
Summary
Infection prevention and control practices were not consistently followed when unlabeled personal care items were found in shared bathrooms. During room rounds, an unlabeled gray plastic wash basin was observed in one bathroom, and an unlabeled gray kidney-shaped basin with a toothbrush and toothpaste inside was observed in another bathroom. A CNA confirmed that the care items had been in use and that both bathrooms were shared by multiple residents. The CNA stated that resident care items should have been labeled because, without labels, the items could potentially be used by unassigned residents and create infection control concerns. In another observation, an uncovered BiPAP face mask was left on a tray table when not in use in a resident room. The room also did not have a no smoking sign posted. A RN confirmed the uncovered BiPAP mask and stated it should have been in a bag when not in use. The DON later stated that the smoking sign should have been posted when using the BiPAP machine and that the BiPAP mask should be covered when not in use. The facility also did not have an appropriate closed-lid receptacle available in rooms with contact precautions, and cloudy urine was observed in the drain tube of Resident 8's Foley catheter. In addition, hand hygiene was not performed between resident care tasks during meal service. A restorative nursing assistant handled food for one resident after returning from taking another resident back to the room without performing hand hygiene, and a CNA used a resident's spoon twice to encourage eating without performing hand hygiene first. Resident 8 had a Foley catheter and a diagnosis of obstructive and reflux uropathy, and the RN confirmed the urine in the catheter drain tube was cloudy rather than clear and amber.
Unsafe Room Equipment and Environmental Deficiencies
Penalty
Summary
Keep all essential equipment working safely was not maintained when a bedside commode in Resident 40’s room was observed to be unsteady because the floor grip pads were missing from both back legs, and a chest of drawers in the room was broken. Resident 40 was admitted to the facility on 8/20/2025, and the MDS dated 8/26/2025 indicated a BIMS score of 13, reflecting intact cognition. During interview, the resident stated the bedside commode was unsteady and the chest of drawers doors were not opening and closing appropriately, with both bottom drawers falling to the floor when opened. The maintenance supervisor later confirmed the commode and chest of drawers were not safe to use for the resident. The facility also had penetrating holes in room [ROOM NUMBER] and bathroom [ROOM NUMBER], including a hole approximately 6 inches long on one side and 3 inches long on another side of the light switch plate in the bathroom, five small penetrating holes at the head of the bed, and a penetrating hole behind the metal cover for the heater near the room door. In addition, three metal plumbing pipes in bathroom [ROOM NUMBER] were observed to be red to dark brown in color, and the on/off button for the bathroom light switch was missing. The maintenance supervisor confirmed these conditions and stated the rusted pipes and broken light switch button were not appropriate for a resident bathroom and that the wall and equipment concerns should have been fixed as soon as possible.
Incomplete POLST Forms for Two Residents
Penalty
Summary
The facility failed to follow its policy and procedure for physician orders for life-sustaining treatment (POLST) for two sampled residents. Resident 3 was admitted on 8/8/2025, and review of the POLST form prepared the same day showed section D for advance directive was not completed, with all three available options left blank. Resident 8 was admitted on 7/2/2022, and review of the POLST form prepared on 8/1/2022 showed section C for artificially administered nutrition was not completed, with all three available options left blank. During a concurrent record review and interview on 9/4/2025 at 12:12 p.m., the DON confirmed that section D for Resident 3 and section C for Resident 8 were not completed and left blank. The DON stated nursing staff were responsible for reviewing and completing all sections of the POLST upon admission, and also stated the nursing staff should have completed all sections of the POLST form for both residents. The DON further stated the IDT reviews and completes the POLST form as needed during care plan meetings for each resident. The facility policy titled, Physician Orders For Life-Sustaining Treatment (Or POLST), updated 4/8/2022, stated a qualified healthcare provider, preferably an RN or social worker, will review the POLST form for completeness and the POLST will be reviewed by the facility IDT.
Unnecessary Psychotropic Medication Use Not Properly Documented
Penalty
Summary
The facility failed to ensure free from unnecessary psychotropic medication for one sampled resident, who was admitted on 8/1/2025 and discharged on 8/3/2025. The resident’s diagnoses included mood disorder, and the order summary showed quetiapine fumarate 25 mg every 12 hours as needed for mood disorder for 14 days. The EMAR indicated the resident received one dose of quetiapine on 8/2/2025 at 7:11 p.m. Record review showed no documented evidence that non-pharmacological approaches were attempted before quetiapine was administered. There was also no documented evidence of episodes of appropriate behavior being monitored for quetiapine use and no documented evidence of side effects being monitored. During a concurrent record review and interview, the DON confirmed the lack of documentation for non-drug interventions, behavior monitoring, and side effect monitoring. The facility policy stated that psychoactive medication must have an appropriate indication, that non-pharmacological interventions must be attempted first and clearly documented when prescribed after admission, and that side effect monitoring should be mentioned and documented.
MDS Assessment Incorrectly Coded for Insulin Use
Penalty
Summary
The facility failed to accurately code the MDS assessment for one resident when section N0415 for high-risk drug classes did not reflect the resident’s actual medication status. Resident 3 was admitted with a diagnosis of diabetes type 1 and had orders for insulin glargine 5 units subcutaneously at bedtime and insulin lispro by sliding scale at bedtime and before meals. Review of the resident’s EMAR for August and September 2025 showed the resident received insulin every day after admission, but the MDS assessment dated [DATE] coded hypoglycemic medication use as No. During concurrent record review and interview with the facility’s MDS coordinator on 9/5/2025 at 1:18 p.m., the MDS coordinator confirmed that Resident 3 received insulin every day after admission and that the MDS assessment was not coded accurately. The MDS coordinator stated that hypoglycemic medication should have been coded Yes for Resident 3 and stated she would modify the assessment to correct the concern. The facility policy titled Resident Assessments states the Resident Assessment Coordinator is responsible for ensuring the IDT conducts timely and appropriate resident assessment and reviews.
Failure to Implement Ordered Heel Boots and Floor Mat
Penalty
Summary
The facility failed to implement comprehensive person-centered care plans for two residents. One resident had a physician order dated 4/29/25 to keep weight off the heels by using a heel boot on the right foot while in bed and to check placement every shift, and the care plan revised on 8/6/25 stated that boots were to be used on the heels when in bed as a preventative measure. During an observation on 09/02/2025 at 10:19 a.m., the resident was in bed with bilateral boots left on the bedside table and no pillow under the feet for offloading pressure on both feet. During an interview later that day, CNA D confirmed the boots had not been applied until the afternoon. A second resident had a physician order dated 2/14/23 for a floor mat on the left side of the bed to decrease the risk for injury, and the care plan dated 4/10/23 identified a goal of being free from injury from device usage. During an observation on 09/02/2025 at 10:45 a.m., the resident was in bed watching television, the bed was against the wall on the right side, and there was no floor mat on the left side of the bed. CNA D later confirmed there was no floor mat on the left side and stated it should have been placed there to prevent injury. The DON and DSD also confirmed the findings and stated nursing staff should have followed the orders and implemented the care plans for both residents.
Missing Restorative ROM Services and Documentation
Penalty
Summary
The facility failed to ensure a restorative nurse assistant (RNA) program was provided for a resident with Parkinson disease, muscle weakness, and impaired range of motion in both upper and lower extremities. The resident’s MDS showed she was totally dependent for ADLs and had impaired ROM on both sides of her upper and lower extremities. Her orders included an RNA program for active assisted ROM to passive ROM of both lower extremities 10 repetitions x 3 sets, 3 times per week to maintain mobility, and a separate RNA program for a right upper extremity resting hand splint and left upper extremity hand roll 5 times per week for 4 to 6 hours to prevent further wrist and digit contracture. The resident’s RNA monthly summary dated 7/31/25 stated she was provided ROM to maintain strength and mobility, but there was no improvement and both hands and legs were stiff; it also noted she screamed when staff attempted to apply the hand roll and splint. The RNA weekly summary from 5/2025 to 8/5/25 showed no documented evidence for six weeks, including weeks in May and July/August. During observation on 9/2/25, the resident was lying in bed with bilateral hand contractures. The RNA stated the resident’s bilateral extremities were stiffer than before and confirmed she had been on vacation during the weeks with missing documentation, that CNA coverage should have occurred, and that there were no written documents showing RNA services were provided during those weeks.
Failure to Administer Ordered Antibiotic for UTI
Penalty
Summary
The facility failed to ensure that one resident with diagnoses including acute kidney failure, hepatorenal syndrome, spontaneous bacterial peritonitis, and cirrhosis was appropriately treated for a UTI with the medication ordered by the physician. The resident was sent to an acute care hospital ED for abdominal discomfort and was diagnosed with a UTI, then returned to the facility the same day with an order for cephalexin 500 mg every six hours for seven days, which was administered from 8/10/25 through 8/16/25. An ED addendum dated 8/11/25 documented that the resident's urine culture grew ESBL E. coli resistant to cephalosporins, with sensitivity to Macrobid, and the ED physician entered an order for Macrobid 100 mg every 12 hours for seven days. During interview and record review, the DSD/IP confirmed there was no documented evidence of a Macrobid order or administration for the resident, and stated she had received the ED documentation on 8/18/25 but did not follow up on the Macrobid order. Facility policy required antibiotic orders to be recorded in the resident's chart, and the antibiotic stewardship policy stated the admitting nurse would review discharge and transfer paperwork for current antibiotic orders.
Dialysis Care Deficiencies
Penalty
Summary
Safe, appropriate dialysis care/services were not provided for two residents receiving dialysis. Resident 3 was admitted with end stage renal disease, dependence on renal dialysis, and cellulitis of the left lower limb. The dialysis communication record for this resident was incomplete on multiple dialysis visits, with the dialysis center leaving the treatment information section blank on two dates and only partially completing it on another date. A registered nurse confirmed the missing dialysis communication information and stated the dialysis center should have completed the required information to communicate and coordinate care with the facility. Resident 3 also had a physician order for milk of magnesia 30 mL as needed for constipation despite dialysis status. The consultant pharmacist stated milk of magnesia would not be recommended for residents who depend on dialysis because impaired kidneys cannot remove excess magnesium from the body, and the DON confirmed the order was contraindicated for a resident with impaired kidney function and dialysis status. In addition, Resident 3 had a cefazolin order from the hospital with a stop date of August 26, 2025, but the order was not discontinued as ordered. The DSD/IP confirmed the cefazolin order continued beyond the stop date. The record also showed no documented evidence of side effect monitoring for two antibiotic medications, cefazolin and cephalexin, and the DSD/IP, consultant pharmacist, and DON each confirmed that monitoring and documentation were missing. Resident 35 was admitted with end stage renal disease and dependence on renal dialysis and was scheduled for dialysis three times weekly. Observation showed a permacath dressing on the right chest. Although the care plan included dialysis interventions, the MDS coordinator stated the facility did not monitor intake and output as an intervention for the resident with dialysis status. The care plan also included an emergency kit at bedside, but the RN stated he was not familiar with where the emergency kit was stored at the beginning of the interview and said that if the resident had bleeding at the dialysis access site, he would call 911. The facility policy stated the dialysis emergency kit should be available at bedside at all times.
Controlled Medication Sign-Out Not Documented on MAR
Penalty
Summary
The facility failed to ensure accurate accountability of controlled substances when hydrocodone/acetaminophen (Norco) was signed out of the controlled drug record (CDR) but not documented on the medication administration record (MAR) for two residents. During interview and record review, the DON stated that when an as-needed controlled medication is requested, nursing staff must assess the resident, remove the medication from the cart, sign it out of the CDR, and document the administration on the MAR. The facility’s policy also stated that the person administering the medication initials the MAR after giving each medication and records the date and time the medication was administered. Resident 54 had an order for Norco 5/325 mg, 1 tablet by mouth every 4 hours as needed for severe pain. Review of the CDR and July 2025 MAR showed that 1 tablet was signed out on 7/16/25 at 10:30 p.m., but the administration was not documented on the MAR, which the DON and RN A confirmed. Resident 55 had an order for Norco 5/325 mg, 1 tablet by mouth every 4 hours as needed for moderate to severe pain. Review of the CDR and July 2025 MAR showed Norco was signed out without MAR documentation on 7/1/25 at 11:06 p.m., 7/5/25 at 2:18 a.m., and 7/6/25 at 0:13 a.m., and both the DON and RN A confirmed these omissions.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility had a medication error rate of 7.89%, with three medication errors occurring out of 38 opportunities during medication administration for three residents. The errors involved a resident with end-stage kidney disease who did not receive calcium acetate in accordance with the manufacturer's specifications, a resident who received insulin lispro not in accordance with the manufacturer's specifications, and a resident with hypertension who did not receive metoprolol as ordered. The report stated these failures resulted in the residents not receiving medications as prescribed or per manufacturer's specifications. During medication administration observation, an RN gave a resident 2 tablets of calcium acetate (Phoslo) 667 mg around 10 a.m. The resident stated he ate breakfast around 7 a.m., and a CNA stated breakfast was around 7:40 a.m., indicating the medication was not given with a meal. The resident's record showed an order for calcium acetate 2 tablets by mouth twice daily, and the prescribing information stated it should be taken with each meal. The DON stated calcium acetate should be given with meals, and the RN confirmed it was administered around 10 a.m. and not with a meal. A LVN administered 3 units of insulin lispro to another resident before dinner, but the resident had not yet received dinner and the dinner cart had not reached the room nearly an hour later. The resident's order was for insulin lispro before meals and at bedtime, scheduled daily at 4:30 p.m., and the prescribing information stated it should be administered within 15 minutes before a meal or immediately after a meal. In a separate observation, an RN assessed a resident's BP at 179/98 and then administered medications that did not include ordered metoprolol succinate ER 100 mg scheduled for 9 a.m. The RN documented waiting for pharmacy delivery and later stated the medication was not available that morning.
Palatability and Texture of Vegetables Not Maintained
Penalty
Summary
The facility failed to ensure food was palatable and served at an appropriate texture for one sampled resident, Resident 47, who had a regular texture diet with thin liquids and chopped meats and was cognitively intact with a BIMS score of 13. During an initial room round, Resident 47 stated the food in the facility was horrible, bland, had no taste, and that vegetables were served soft, mushy, and overcooked. The resident’s concerns were consistent with the meal observation and record review showing the lunch menu included cheesy broccoli rice as the vegetable dish. During a concurrent test tray observation, the cheesy broccoli rice was noted to be soft and close to mushy. The certified dietary manager stated the broccoli was soft but not mushy and explained that cooking broccoli with rice made it softer. During a separate observation, dietary staff were seen preparing broccoli in boiling water and stated they made the broccoli softer for residents on a bite size diet. The registered dietitian stated vegetables for residents on a regular consistency diet should be cooked and served not hard and not soft, and should be between al dente and soft. The facility policy required nourishing, palatable, well-balanced meals and tray inspection to ensure food appeared palatable and attractive.
Resident Rooms Did Not Meet Required Square Footage
Penalty
Summary
Rooms 3, 10, and 23 were identified as multi-resident rooms that measured less than the required 80 square feet per resident. The report listed Room 3 at 148.5 square feet total for 2 beds, Room 10 at 156.96 square feet total for 2 beds, and Room 23 at 152.6 square feet total for 2 beds, resulting in 74.25, 78.48, and 76.30 square feet per resident, respectively. Facility staff, including CNA D, RN A, CNA B, and RN G, were interviewed and stated they had no concerns with providing care or safety in the rooms despite the reduced space, and observations noted no care or privacy issues related to room size. The facility’s maintenance supervisor confirmed that the three rooms were each shared by two residents and were less than 80 square feet per resident. The residents were observed in their rooms throughout the survey, and the report stated that nursing care and services were not impacted by the shortage of space. Review of the facility policy titled Bedrooms, revised May 2017, showed that bedrooms are to measure at least 80 square feet of space per resident, and the facility’s room variance reports recommended the waiver.
Improper Use of Bed Rails
Penalty
Summary
The facility failed to ensure the proper use of bed or side rails for five residents. There was no documentation indicating that the facility followed the manufacturers' recommendations and specifications for installation and maintenance of the beds and side rails for all five residents. Additionally, there was no documentation that alternatives were offered or attempted prior to the use of bed or side rails for three of the residents. Furthermore, there was no entrapment risk assessment completed prior to the use of bed or side rails for two residents, and one resident did not have an updated bed or side rail assessment form completed. Lastly, one resident did not have a physician's order indicating the use of bed or side rails. During observations and interviews, it was confirmed that the bed rails were in the upright position for all five residents. The maintenance supervisor admitted that bed rails were installed without following the manufacturers' specifications and without proper documentation. The director of nursing confirmed that the facility's beds were old and lacked the manufacturer's handbook. The facility's policy and procedure indicated that manufacturer instructions should be adhered to and that residents should be periodically checked for safety relative to side rail use. The minimum data set coordinator and the director of nursing confirmed that there was no documentation indicating that alternatives were offered or attempted prior to the use of bed rails for three residents. Additionally, there was no entrapment risk assessment completed for two residents, and one resident's bed rail assessment was not updated quarterly. The director of nursing also confirmed that a physician's order should be obtained prior to the installation of bed rails, which was not done for one resident.
Hygiene and Food Safety Violations in Kitchen
Penalty
Summary
The facility failed to maintain hygiene in the kitchen and ensure food was stored in accordance with professional standards for food safety. Observations revealed past use-by date food, rotten bananas, and dented cans in the freezer and on the shelves. Specifically, a container of Blue Bunny sherbet, frozen cookie dough, and cans of lemon pudding were found to be expired or damaged. Additionally, seven bananas had black spots. During interviews, the Dietary Director acknowledged these issues and stated that the food items would be discarded. The facility's policies on washing and handling produce and dented cans were not followed as required. Further observations in the kitchen showed that staff did not adhere to personal hygiene standards. Cook K and dietary aid L had hair out of their hair nets, and the maintenance director did not wash his hands before handling the ice machine. The dietary director also failed to sanitize thermometers before checking food temperatures. Additionally, a rusty screw in the ice storage bin caused rusty water to drip onto the ice, and the ice machine lacked an air gap, leading to potential contamination. These observations were confirmed through interviews with the staff involved, who acknowledged the lapses in following the facility's policies on personal hygiene and equipment maintenance.
Infection Control and Water Management Deficiencies
Penalty
Summary
The facility failed to implement proper infection control practices in several instances. Licensed vocational nurse A (LVN A) contaminated clean gauzes and Silver Alginate dressing by handling them with gloved hands that had touched a ring of keys and the treatment cart. Additionally, LVN A wore the same gloves while moving between residents' rooms, further risking cross-contamination. Certified nursing assistant H (CNA H) did not sanitize her hands before serving a lunch tray to a resident, and a restorative nurse assistant (RNA) failed to perform hand hygiene between assisting multiple residents during meal times. Licensed vocational nurse C (LVN C) also did not change gloves after touching a privacy curtain and continued to use the contaminated gloves for wound treatment. The facility also lacked a comprehensive water management program to prevent water-borne contaminants such as Legionella. The maintenance supervisor (MS) was unaware of the necessary steps to prevent the spread of water-borne contaminants and did not conduct a Legionella Risk Assessment for the current year. The outside water contractor confirmed that their monthly checks did not include testing for Legionella or potable water quality. These deficiencies were confirmed through interviews with the involved staff and the infection preventionist (IP G), as well as a review of the facility's policies. The facility's failure to adhere to proper infection control practices and maintain a water management program had the potential to spread infections within the facility.
Inaccurate MDS Coding for Multiple Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for four residents, leading to discrepancies in their assessments. For Resident 34, two different MDS assessments did not reflect hospice care, a facility-acquired pressure injury, nutritional intervention, and the physician orders for life-sustaining treatment (POLST). The MDS coordinator confirmed these omissions during a review of the resident's records. Additionally, Resident 27's behavior of rejecting care was not accurately coded in the MDS, as confirmed by the social service director who did not review the medication administration record (MAR) before completing the assessment. Resident 17's left-sided weakness was not reflected in the MDS assessment, despite being observed by the MDS coordinator during a review. The coordinator acknowledged that the limitation of the resident's upper and lower extremities should have been coded. Similarly, Resident 7's behavior of rejecting care, such as refusing medications, was not accurately coded in the MDS. The social service director confirmed that the MDS should have indicated the resident's refusal of care during the observation period. These inaccuracies in the MDS assessments resulted in potential impacts on the residents' care. The Long-Term Care Facility Resident Assessment Instrument (RAI) manual emphasizes the importance of validating information for accuracy during the observation period. The facility's interdisciplinary team is responsible for ensuring that all participants in the assessment process have the requisite knowledge to complete accurate assessments.
Failure to Follow Physician Orders and Document Care
Penalty
Summary
The facility failed to ensure that residents received the necessary care and services as per their medical orders and preferences. For Resident 1, the facility did not have information on the resident's cardiologist and pacemaker, and did not schedule routine check-ups for the pacemaker. LVN A, who worked with Resident 1 for a year, was unaware of the resident's pacemaker, indicating a lack of proper documentation and communication within the facility. The Director of Nursing (DON) confirmed that the necessary information was missing from Resident 1's medical record and acknowledged the oversight in scheduling routine check-ups for the pacemaker. Resident 7 repeatedly refused her prescribed medications, including vitamin D3, cyanocobalamin, and levothyroxine, over several months. However, there was no documentation indicating that the physician was notified about these refusals. The DON confirmed that the licensed nurses should have informed the physician about Resident 7's medication refusals, as per the facility's policy. Similarly, Resident 27 also refused multiple routine medications, and the nurses failed to notify the physician about these refusals. The DON and other staff members acknowledged that the physician should have been informed about the refusals. For Resident 9, LVN A did not follow the physician's order for treating a suspected deep tissue injury on the resident's toes, applying povidone iodine instead of the prescribed skin prep. Additionally, LVN B administered Cyclosporine 0.05% eyedrops to Resident 145 without a physician's order indicating the strength of the medication. Lastly, LVN B administered Amlodipine to Resident 22 without adhering to the blood pressure parameters set by the physician, resulting in multiple instances where the medication was given despite the blood pressure being below the specified threshold. These actions and inactions highlight significant lapses in following physician orders and proper documentation, potentially jeopardizing the residents' health and well-being.
Failure to Post Current Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the daily staffing information posted was current, which could result in nurse staffing misinformation to residents, families, and visitors. During facility rounds on 4/22/2024, it was observed that the Census and Direct Care Service Hours Per Patient Day (DHPPD) forms posted on the first and second floors were outdated by 17 and 20 days, respectively. The Director of Staff Development (DSD) confirmed that she was responsible for updating the DHPPD postings but had been on vacation, leading to the outdated postings. The Administrator (ADM) also confirmed the outdated postings and acknowledged that the DHPPD should reflect the current date. The facility's policy, dated 7/2016, requires daily posting of the number of nursing personnel responsible for providing direct care to residents. Additionally, the Centers for Medicare and Medicaid Services Compliance Group document, dated 4/30/2021, mandates that the posted nurse staffing information must include the facility name and current date, and be placed in a prominent location accessible to residents and visitors. The failure to update the DHPPD postings as required was confirmed by both the DSD and ADM during interviews conducted on 4/24/2024.
Failure to Conduct and Act on Drug Regimen Reviews
Penalty
Summary
The facility failed to ensure that drug regimen reviews were conducted and acted upon for three residents. For Resident 11, an Interim Medication Regimen Review (iMRR) was not performed after multiple falls, despite the facility's policy requiring such reviews after significant changes. Additionally, the Consultant Pharmacist (CP) did not identify and report irregularities related to the lack of consistent monitoring of Resident 11's heart rate, which was necessary due to the resident's atrial fibrillation and use of Amiodarone. The heart rate was monitored inconsistently, with significant gaps in the monitoring schedule, which was verified by both the Licensed Vocational Nurse (LVN) and the Director of Nursing (DON). The CP confirmed that the iMRR should have been done and that the heart rate monitoring was inadequate. For Resident 15, the CP also failed to identify and report irregularities related to the lack of blood pressure and heart rate monitoring. For Resident 31, the facility did not act on the CP's recommendation to administer Coreg with food to minimize the risk of orthostatic hypotension. The CP had recommended changing the administration time to align with the resident's breakfast time, but this recommendation was not implemented. The DON confirmed that the recommendation was not acted upon. These failures indicate a lack of adherence to the facility's policies and procedures for medication regimen reviews, potentially compromising the residents' health outcomes.
Failure to Accommodate Resident's Needs for Urinal Placement
Penalty
Summary
The facility failed to ensure that Resident 17's needs were accommodated when his urinal was not placed within reach. Resident 17, who has a history of urinary tract infection, major depressive disorder, hemiplegia affecting the nondominant side, and cerebral infarction, was observed multiple times struggling to reach his urinal. Despite being cognitively intact, as indicated by a BIMS score of 14, Resident 17 was unable to access the urinal due to its placement on the transfer pole, which was confirmed by both a CNA and an LVN. The resident repeatedly complained about the issue, but the staff's attempts to reposition the urinal were unsuccessful. The Director of Nursing (DON) acknowledged awareness of the problem but had not yet checked with Resident 17. The DON mentioned that the urinal should be placed on the bed frame within the resident's reach, but it was not done due to infection control concerns. The care plan for Resident 17 noted non-compliance with urinal use but did not address the contributing factors or provide interventions to resolve the issue. The facility's policy on accommodating needs emphasizes maintaining residents' independence and dignity, but this was not achieved in Resident 17's case.
Late Submission of MDS Discharge Assessment
Penalty
Summary
The facility failed to complete and transmit the Minimum Data Set (MDS) discharge assessment in a timely manner for one resident. Resident 12 was admitted to the facility and later discharged. The MDS coordinator confirmed that the discharge assessment for Resident 12 was completed and transmitted late, beyond the required 14-day period after discharge. The Director of Nursing (DON) also confirmed the delay, noting that the MDS coordinator requested her to sign the discharge assessment after the deadline had passed. The Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual specifies that discharge assessments must be completed and submitted within 14 days of the discharge date, which was not adhered to in this case.
Failure to Accurately Complete PASARR Screenings
Penalty
Summary
The facility failed to ensure that the pre-admission screening and resident review (PASARR) was accurately completed for two residents, leading to potential inaccuracies in the care and services provided. Resident 27 was admitted with diagnoses including bipolar disorder, major depressive disorder, and other psychoactive substance abuse. However, the PASARR Level I Screening completed at the hospital indicated no mental illness. Despite exhibiting disruptive behaviors and refusing medications, the facility did not conduct a new PASARR screening. Both the Minimum Data Set Coordinator (MDSC) and the Director of Nursing (DON) acknowledged the oversight and confirmed that a new PASARR should have been completed to reflect Resident 27's mental health diagnoses and behaviors. Similarly, Resident 21 was admitted with diagnoses of anxiety, depression, and bipolar disorder, but the PASARR Level I Screening did not mark these mental disorders. The DON confirmed that Resident 21 should have been marked for having diagnosed mental disorders. The facility's policy mandates that all new admissions and readmissions are screened for mental disorders and intellectual disabilities, and that a new PASARR should be completed promptly after a significant change in a resident's mental or physical condition. The failure to accurately complete the PASARR screenings for these residents indicates a lapse in adherence to this policy.
Failure to Follow Physician's Order for Oxygen Administration
Penalty
Summary
The facility failed to ensure proper care and treatment services for oxygen use for a resident with chronic respiratory conditions. Resident 15, who was admitted with diagnoses including COPD, chronic respiratory failure with hypoxia, chronic diastolic heart failure, and dependence on supplemental oxygen, had a physician's order for oxygen administration at 3 LPM via nasal cannula as needed for shortness of breath. However, during observations on two separate days, the resident was found to be receiving oxygen at levels lower than the prescribed 3 LPM. On one occasion, the oxygen was set at 2.5 LPM, and on another, it was set at 2 LPM. These observations were confirmed by a registered nurse who reviewed the resident's order summary report and acknowledged that the oxygen levels did not comply with the physician's order. The facility's policy and procedure for oxygen administration, which was last revised in October 2010, requires verification of a physician's order for the procedure and adherence to the specified oxygen levels. Despite this policy, the licensed nurses did not follow the physician's order for Resident 15's oxygen administration, leading to a deficiency in the resident's care. The registered nurse confirmed that the oxygen should have been administered at the prescribed 3 LPM, highlighting a failure in following the established guidelines for safe oxygen administration.
Insufficient Nursing Staff on Weekends
Penalty
Summary
The facility failed to provide sufficient nursing staff on weekends, as evidenced by the review of the Census and Direct Care Service Hours Per Patient Day (DHPPD) from January through March 2024. On specific dates, the actual Certified Nursing Assistant (CNA) DHPPD fell below the required 2.4 hours per patient day. Specifically, on January 6 and 7, the CNA DHPPD were 2.28 and 2.39, respectively. Additionally, on February 17, the overall DHPPD was 3.35, below the required 3.5, and the CNA DHPPD was 2.0. These deficiencies were confirmed by the Director of Staff Development (DSD) during an interview, who stated that CNAs who called off on those dates were not replaced, leading to short staffing. The DSD confirmed that the Director of Nursing (DON) was responsible for the licensed nurses' schedule, while CNA J handled the CNA schedule, including weekends. The DSD acknowledged that the actual DHPPD and CNA DHPPD on the specified dates were below the required staffing levels. The short staffing was attributed to a CNA scheduled to work 12 hours who got sick and was not replaced. The All Facilities Letter (AFL) 21-11 mandates a minimum of 3.5 DHPPD, with 2.4 hours performed by CNAs, and the facility failed to meet these requirements on the mentioned dates.
Failure to Handle Hazardous Medications and Prevent Drug-Drug Interactions
Penalty
Summary
The facility failed to ensure the correct handling of hazardous medications and the safe and effective use of medications for two residents. Two licensed nurses were observed preparing hazardous medications without gloves, despite the medications being clearly labeled as hazardous and requiring gloves for handling. The nurses admitted to not knowing the proper procedures for handling these medications, which could lead to harmful exposure through skin absorption. The facility's policy indicated that staff should be trained and competent in handling hazardous drugs, but this was not followed in practice. Additionally, the facility failed to administer medications in a manner that would prevent drug-drug interactions for two residents. Resident 145 received ferrous sulfate and magnesium oxide at the same time, which could lead to decreased absorption of iron. Similarly, Resident 10 received ferrous sulfate and Calcium-Vitamin D at the same time, which could also reduce iron absorption. Both interactions were noted to have significant risk ratings and required therapy modification according to a nationally recognized drug information resource. The facility's policy on administering medications emphasized the importance of preventing potential medication interactions, but this was not adhered to in these cases.
Failure to Ensure Residents are Free from Unnecessary Medications
Penalty
Summary
The facility failed to ensure that two out of five residents were free from unnecessary medications. For Resident 15, an order for Carvedilol did not include hold parameters relevant to blood pressure and heart rate, and these vital signs were last monitored a month prior. Both the Director of Nursing (DON) and the Consultant Pharmacist (CP) confirmed the absence of hold parameters and inconsistent monitoring of blood pressure and heart rate, which are necessary due to the potential adverse effects of Carvedilol, such as bradycardia and hypotension. The facility's policy requires vital signs to be checked prior to administering medications, which was not adhered to in this case. For Resident 11, an order for gabapentin had an incorrect indication of parkinsonism, and an order for amiodarone did not include heart rate monitoring. The DON and CP verified these discrepancies, noting that heart rate monitoring is essential due to the risk of bradycardia associated with amiodarone. The facility's policy mandates that the provider pharmacy screen new medication orders for key parameters, including appropriate indications, which was not followed. These failures had the potential for inadequate care and unrecognized side effects of the medications.
Failure to Ensure Resident Was Free from Unnecessary Psychotropic Medications
Penalty
Summary
The facility failed to ensure a resident was free from unnecessary psychotropic medications. Specifically, the facility did not consider a Gradual Dose Reduction (GDR) of psychotropic medications after the resident experienced multiple falls. The resident, diagnosed with insomnia, bipolar disorder, anxiety disorder, and major depressive disorder, had physician orders for paroxetine, trazodone, and aripiprazole. Despite the resident falling on several occasions, the Director of Nursing (DON) confirmed that no GDR was attempted, which was against the facility's policy and procedure for antipsychotic medication use. Additionally, the facility did not complete a baseline Abnormal Involuntary Movement Scale (AIMS) for the resident's use of aripiprazole, as verified by the DON and Social Services Director (SSD). The care plan for the resident's bipolar disorder also lacked specific target symptoms, interventions, and potential adverse effects. These deficiencies were confirmed during interviews and record reviews with the DON and SSD, and they were in violation of the facility's policies and procedures for psychotropic medication use.
Medication Administration Errors
Penalty
Summary
The facility had an 11.11% medication error rate when three medication errors out of 27 opportunities were observed during a medication pass for two residents. For Resident 145, Carvedilol was administered without food, and magnesium oxide and ferrous sulfate were given simultaneously, which could affect the absorption of the iron supplement. Observations and interviews confirmed that these medications were not administered according to the manufacturer's specifications, potentially compromising their therapeutic effects. For Resident 38, Metformin was administered without food, despite the manufacturer's instructions to give it with a meal to minimize gastrointestinal upset. The medication was scheduled at 4 p.m., but the resident's dinner was not until 5 p.m., and no snack was provided prior to the medication administration. These practices were not in line with the facility's policy to administer medications in a manner that enhances their therapeutic effect and prevents interactions.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper medication storage and labeling of medications. During an observation and interview with an LVN, an opened multi-dose insulin vial and an insulin pre-filled pen were found without labeling for their open dates. The manufacturing labels indicated that the insulin vial should be discarded 31 days after opening and the insulin pen 56 days after first use. Additionally, an expired insulin pen and four expired over-the-counter medications were found during another observation and interview with an LVN. The expired medications included a pre-filled insulin pen, a bottle of Calcium + D3 tablets, a bottle of a vitamin and mineral supplement, a bottle of allergy medication, and a bottle of CoQ10 softgels. The facility's policy and procedure for the storage of medications indicated that drug containers with missing, incomplete, improper, or incorrect labels should be returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals should be returned to the dispensing pharmacy or destroyed. The observations and interviews revealed that the facility did not adhere to these policies, leading to the potential for residents to receive medications with reduced efficacy.
Failure to Properly Document Resident's Death
Penalty
Summary
The facility failed to maintain accurate and systematically organized documentation in accordance with accepted professional standards and practices for one resident when the pronouncement of death was not properly documented. Resident 41, who had multiple serious medical conditions including palliative care, atherosclerotic heart disease, hemiplegia, hemiparesis following a stroke, and dysphagia, passed away. The progress notes indicated the resident's death at 5:40 a.m., but detailed documentation about the resident's status before death and the pronouncement of death was lacking. The nurse's notes were inconsistent and did not include a detailed assessment, date, time, and the name of the nurse who pronounced the death. During interviews and record reviews, the Minimum Data Set Coordinator (MDSC) and the Director of Nursing (DON) confirmed the deficiencies in the documentation. The MDSC noted that the registered nurse should have documented a detailed assessment and the pronouncement of death, while the DON acknowledged that the nurse's documentation was confusing and not well-organized. The facility's policy on documenting the death of a resident was not followed, as it required appropriate documentation of all information pertaining to a resident's death, including the date, time, and the name and title of the individual pronouncing the resident dead.
Failure to Offer Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure that two residents, Resident 10 and Resident 35, were offered and/or received the pneumococcal conjugate vaccine 20 (PCV20). During an interview and record review, the infection preventionist (IP G) confirmed that Resident 10, who was admitted on an unspecified date, had a history of receiving the pneumococcal polysaccharide vaccine (PPSV23) on June 26, 2022. However, IP G missed offering the PCV20 to Resident 10 when reviewing her immunization record. Similarly, Resident 35, who was admitted on an unspecified date, had a history of receiving PPSV23 on March 19, 2019, but was not offered the PCV20 by IP G during the review of his immunization records. The facility's policy and procedure, revised in October 2019, stated that all residents should be offered pneumococcal vaccines to prevent pneumonia/pneumococcal infections. The policy also required assessments of pneumococcal vaccination status within five working days of a resident's admission. According to the CDC's recommendations reviewed on February 13, 2023, adults aged 65 years or older who have only received PPSV23 should be given one dose of PCV15 or PCV20, administered at least one year after the most recent PPSV23 vaccination. The failure to follow these guidelines led to the deficiency identified in the report.
Failure to Report Allegations of Abuse
Penalty
Summary
The facility failed to implement their abuse policy for two residents, resulting in unreported allegations of abuse. Resident 19, who has multiple diagnoses including Type 2 Diabetes Mellitus, Dysarthria, Anarthria, Depression, Insomnia, and Schizophrenia, alleged verbal abuse by a Certified Nurse Assistant (CNA). The CNA reportedly made a joke about Resident 19 eating too much like a pig, which led to vomiting. Although the incident was documented and reported to the Medical Director, Responsible Party, Ombudsman, and Department of Health, it was not reported to Adult Protective Services (APS) as required by the facility's policy. The Administrator confirmed during an interview that the incident was not reported to APS. Resident 146, who reported financial abuse by a caregiver prior to admission, also had his allegation unreported to APS. The resident stated that the caregiver took his bank card and spent his money without consent. The Social Service Director (SSD) confirmed that the allegation should have been reported to APS according to the facility's abuse policy. The facility's policy, dated July 2017, mandates that all alleged violations involving abuse, neglect, exploitation, or mistreatment be reported to APS, but this was not followed in the cases of Resident 19 and Resident 146.
Deficiency in Room Square Footage
Penalty
Summary
The report identifies that several multi-resident rooms in the facility provided less than the required 80 square feet per resident. Specifically, Room 3 had 74.25 square feet per resident, Room 10 had 78.48 square feet per resident, and Room 23 had 76.30 square feet per resident. Despite these measurements, it was observed that the staff and residents were able to move freely within the rooms, and the residents received adequate care. Both staff and residents did not express concerns regarding the square footage of the rooms.
Failure to Report Abuse Incident
Penalty
Summary
The facility failed to follow its abuse reporting policy for one of the residents. The incident involved a resident with major depressive disorder and bipolar disorder, who was observed by a licensed nurse (LN A) yelling and cursing at another resident before pushing the other resident's wheelchair with such force that it rolled approximately 20 feet. Despite the severity of the incident, there was no documentation indicating that LN A reported the incident to the facility's abuse coordinator or any other relevant authorities as required by the facility's policy. During interviews, another licensed nurse (LN B) confirmed that the actions of the resident constituted abuse and should have been reported. LN B also confirmed that there was no documentation of the incident being reported to the abuse coordinator, the Ombudsman, the California Department of Public Health (CDPH), or the police. LN A, when contacted, vaguely remembered the incident but did not recall if she reported it. The facility's policy mandates that all alleged violations involving abuse must be reported to several authorities, including the state licensing agency, the Ombudsman, and law enforcement officials.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Nursing homes near Salinas
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Salinas Valley Post Acute | 0.6 mi | ★★★★★ | 29 | 0 |
| Pacific Coast Post Acute | 0.6 mi | ★★★★★ | 5 | 0 |
| Coastal Post Acute | 2.2 mi | ★★★★★ | 0 | 0 |
| Windsor The Ridge Rehabilitation Center | 2.2 mi | ★★★★★ | 13 | 0 |
| Carmel Hills Care Center | 12.2 mi | ★★★★★ | 31 | 0 |
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