Average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Laurel Convalescent Hospital during CMS and state inspections, most recent first.
Food Served Below Required Hot Holding Temperature: Test trays observed at breakfast and lunch showed hot items, including eggs, biscuits, sweet and sour chicken, and puree pasta, served below the facility's required 140 F threshold. The DSS and RD verified the temperatures with the facility thermometer, and the DSS acknowledged the foods were not at the required temperature when served.
The facility failed to follow infection control practices during resident care and monitoring. A CNA removed gloves after caring for a resident on EBP, did not perform hand hygiene, and then entered another resident’s room with new gloves. Another CNA changed linens for a resident on EBP without wearing a gown, and a third CNA assisted a resident on EBP with transfer-related care while wearing gloves but no gown. The facility also did not change a resident’s oxygen humidifier as ordered and could not provide documented hand hygiene surveillance for several months.
Hot Meals Served Below Required Temperature: Two residents reported that hot meals were often served cold, and resident council minutes showed the same complaint had been raised by multiple residents. During tray observation, hot items on the test tray were measured well below the facility's stated serving temperature, while the DSS confirmed hot foods should be served at or above 140 F and the facility policy required food to be attractively served at the proper temperature.
Dignified Meal Assistance Not Maintained: A RNA and two CNAs were observed feeding three residents while standing during lunch, including a bedbound resident and two residents in the dining room. One CNA said there was no room to sit, another said she normally stands while feeding residents, and the DON confirmed the facility’s meal-assistance policy was not being followed.
A resident with CKD, hemiplegia, and hemiparesis had an order for Divalproex Sodium for poor impulse control and agitation, but the informed consent for the psychotropic medication was incomplete and lacked the required signatures from the provider and the resident and/or RP. The RN confirmed the consent was not complete, and the DON stated the facility’s psychotherapeutic drug informed consent policy was not followed.
Advance directive documentation was not completed for a resident admitted with acute respiratory failure with hypoxia, sepsis, and generalized muscle weakness. The chart contained no advance directives form, and the SSD and DON stated the form should have been completed upon admission or documented as addressed per the facility's P&P.
A resident with a fractured lower leg, osteoporosis, acute kidney failure, and a history of falls had a care plan and MD order requiring pain location to be documented when PRN hydrocodone-acetaminophen was given. The MAR showed the medication was administered 16 times, but the pain site was left blank in the progress notes for 9 administrations, and no other charting identified the location of pain. The DON confirmed the required pain-location documentation was missing.
RN 2 failed to document one resident’s Omeprazole dose on the MAR and recorded another resident’s Famotidine dose at the wrong time. The residents had orders for GERD treatment, and the DON confirmed the facility’s medication administration policy requiring documentation directly after administration was not followed.
A resident with encephalopathy, depression, and a hx of traumatic brain injury had a PRN Ambien order entered into the EHR without a frequency. The DON, CC, and pharmacy consultant all acknowledged the order should have included how often the med could be given, and the facility policy required medication orders to include dosage and frequency.
Medication administration errors exceeded the allowed rate when an RN gave Famotidine outside the scheduled time window, administered Omeprazole earlier than the meal-related order allowed, and gave Hydralazine even though the SBP did not meet the physician-ordered parameter. The DON confirmed the facility P&P requiring medications to be given according to written orders and within the scheduled timing guidelines was not followed.
A resident with hemiplegia/hemiparesis, HTN, and breast cancer had a physician order for large portions TID, but during breakfast tray line the tray was plated with only one 1/3 cup scoop of eggs instead of the ordered 2/3 cup, along with two biscuits. The DSS first confirmed the tray contents and then acknowledged the resident should have received two scoops of egg per the production sheet. The resident stated she was supposed to receive large portions but sometimes felt she did not get them as ordered.
A resident’s bed was found not to function properly: the foot section would not elevate, and the head and foot controls were reversed. The resident said the problem had existed since admission and staff had been notified, but the bed was not removed from service or tagged for repair. CNA confirmed the issue, and the MD later verified the bed was not in safe operating condition. Review of the maintenance log showed no work request was documented for the repair, and the MD acknowledged the facility policy was not followed.
A resident developed pressure injuries, including deep tissue injuries and open wounds, while in the facility. The facility failed to notify the resident's family about the new wounds and treatments. The resident was admitted without wounds, but they developed during the stay, contrary to the facility's policies on pressure injury prevention and family notification.
The facility failed to maintain the kitchen refrigerator temperature at the required 40 degrees Fahrenheit or lower, with observed temperatures reaching 45 and 49 degrees Fahrenheit. Staff interviews confirmed the risk of food-borne illness due to these elevated temperatures, which could affect all residents receiving food from the kitchen.
Two residents in the facility were found with unclean and untrimmed fingernails, despite their care plans requiring assistance with grooming. One resident, dependent on staff for all ADLs, had black and curled nails, while another, with moderate cognitive impairment, had long and dirty nails. Staff acknowledged the oversight, attributing it to communication lapses and the resident's recent admission.
A resident with a history of chronic kidney disease and urinary issues had an unsecured indwelling catheter, contrary to facility policy. Despite orders to secure the catheter every shift, an observation revealed the absence of a securement device. Staff interviews confirmed the expectation for securement, but the device was not in place.
The facility failed to follow its policy on timely response to call lights, affecting two residents. One resident reported long delays in receiving diaper changes, while another experienced waits of up to three hours for assistance. An observation confirmed that a call light went unanswered, with staff failing to check the call light panel as required by policy.
A resident with multiple health issues experienced the reopening of pressure injuries, indicating a failure in the facility's wound care policy. Additionally, a CT scan was ordered for the wrong foot, which could have delayed treatment for a suspected infection.
A resident with partial paralysis and dementia fell out of bed and was roughly handled by a CNA, who pulled the resident by one arm back onto the bed, causing the resident's hip to rub against the footrest. The CNA also verbally abused the resident by saying, 'Stop that! you're being annoying!' This incident was witnessed and overheard by multiple staff members. The facility's policy on abuse and mistreatment was not followed.
The facility failed to follow their policy when staff did not promptly notify the physician and alternative physician for a change of condition for a resident with a history of multiple medical conditions. Despite initial notification, no follow-up was made to contact an alternative physician or the Medical Director, resulting in a delay in treatment.
A resident with end-stage renal disease missed a scheduled dialysis session due to the facility's failure to arrange transportation. The resident was prepared and waiting, but the transportation service was unaware of the pick-up. The facility's policy on arranging transportation was not followed, leading to the missed treatment.
A resident with multiple diagnoses experienced a significant drop in blood sugar and oxygen levels. Despite the CNA reporting the resident's unresponsiveness and difficulty eating to the LVN, appropriate actions were not taken in a timely manner. The DON and Administrator confirmed a delay in treatment and lack of proper documentation and assessment.
The facility failed to document blood sugar results for a resident with type 2 diabetes mellitus, despite orders for regular checks and insulin administration. Inconsistent documentation practices and incorrect order input led to incomplete records in the MAR, as confirmed by nursing staff and the DON.
A resident with multiple serious diagnoses did not receive prescribed IV antibiotics upon admission due to the facility's failure to obtain the medications in a timely manner. The resident was sent back to the hospital at the request of the resident's daughter due to the unavailability of the IV antibiotics.
The facility failed to report an allegation of abuse involving a resident within the required timeframe. The incident, which occurred over a weekend, was not reported to outside agencies until two days later due to staff unawareness and miscommunication.
Food Served Below Required Hot Holding Temperature
Penalty
Summary
The facility failed to ensure potentially hazardous foods were maintained at or above 140 degrees Fahrenheit at the time of service to residents. During observation and interview, the last meal tray cart was brought out of the kitchen and the last resident tray was removed while temperatures were taken on test trays. At breakfast, the puree tray had eggs at 108 degrees F and biscuits at 125 degrees F, and the regular tray had eggs at 104 degrees F and a biscuit at 104 degrees F. The Dietary Services Supervisor and the Consultant Registered Dietician verified the temperatures with the facility thermometer, and the DSS stated hot foods should be served at or above 140 degrees F. At lunch, the test tray with puree foods had sweet and sour chicken at 130 degrees F and puree pasta at 135 degrees F, and the regular tray had sweet and sour chicken at 130 degrees F. These temperatures were again verified by the DSS and CRD 1 using the facility thermometer. The DSS stated the temperatures were better than breakfast but still were not at 140 degrees F as required by the facility's policy. The facility's Food Preparation Policy stated hot food must be greater than or equal to 140 F and that food should be served at the proper temperature.
Infection Control Failures During Resident Care and Surveillance
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices were followed during resident care and monitoring activities. During a concurrent observation and interview, CNA 3 removed gloves after assisting a resident on enhanced barrier precautions (EBP), did not perform hand hygiene, and then entered another resident’s room and put on a new pair of gloves to provide care. CNA 3 stated she forgot and was in a rush, and acknowledged she did not wash her hands or use alcohol-based hand sanitizer after removing the gloves and before putting on new gloves. The DON and IP both stated staff were supposed to perform hand hygiene immediately after glove removal, and the facility’s infection prevention policy and CDC guidance were reviewed as part of the finding. The facility also failed to follow EBP requirements for Resident 3, who had diagnoses including dementia, hemiplegia and hemiparesis of the right dominant side, and attention to gastrostomy. CNA 4 was observed changing Resident 3’s dirty linens while wearing gloves only and not wearing a gown, despite a posted sign indicating staff must wear gloves and a gown for high-contact activities including changing linens, changing briefs, and assisting with toileting. CNA 4 stated she had forgotten to wear a gown while assisting the resident and changing linens. The DON and IP stated staff were supposed to wear a gown and gloves for direct care and linen changes for residents on EBP, and the facility’s EBP policy identified changing linens and changing briefs or assisting with toileting as activities requiring gown and glove use. The facility further failed to follow a physician order for Resident 41’s oxygen humidifier. Resident 41 had diagnoses including COPD, asthma, and pleural effusion. The physician ordered the humidifier to be changed every Sunday on night shift, but during observation the humidifier was labeled with a date of March 2, 2026, and had not been changed by March 8, 2026 as ordered. The LVN acknowledged it should have been changed on Sunday, and the DON confirmed the order was not followed. In addition, the facility did not provide tracking compliance for hand hygiene surveillance for November 2025 through February 2026; the IP stated surveillance had been conducted but not documented and that the standardized hand hygiene monitoring form had not been used during her time in the role. The facility also failed to ensure CNA 6 wore a gown while assisting Resident 45, who was on EBP and had diagnoses including acute cholecystitis, UTI, and difficulty of walking, during transfer-related care in the resident’s room. CNA 6 stated she knew both gloves and a gown were required but had not worn a gown, and the DON confirmed the policy was not followed.
Hot Meals Served Below Required Temperature
Penalty
Summary
The facility failed to ensure that hot foods were served at an appetizing and palatable temperature for two residents who reported that their hot meals were often delivered cold. Resident 86 stated that when her food was cold she did not like to eat as much because she did not like it that way. Resident 47 stated that her food, which was supposed to be hot, was also often served cold, and that she ate it cold because she had to eat to survive even though she did not like it that way. Resident council meeting minutes from January 27, 2026, documented resident complaints that hot food was being served cold during mealtimes. During observation on March 11, 2026, breakfast trays were checked and the test tray showed hot items below the facility's stated serving temperature, with puree eggs at 108 degrees F and puree biscuits at 125 degrees F, and regular eggs and a biscuit at 104 degrees F. The Dietary Services Supervisor stated hot foods should be served at or above 140 degrees F, and the facility's Food Preparation Policy stated hot food must be greater than or equal to 140 F and should be attractively served at the proper temperature.
Dignified Meal Assistance Not Maintained
Penalty
Summary
The facility failed to ensure a dignified dining experience for three residents when staff assisted them with meals while standing. Resident 19, who was admitted with dementia, epilepsy, and was bedbound, was observed in the dining room on March 9, 2026 at 12:42 PM while a Restorative Nursing Assistant fed the resident while standing. During the observation, the RNA stated she stood because the chair was too high and uncomfortable. At the same time, Resident 76, who had schizophrenia, chronic kidney disease, and general weakness, was observed in the dining room being fed by a CNA while the CNA was standing. The CNA later stated she tried to sit down but could not because there was no room. Resident 1, who was admitted with encephalopathy, lobar pneumonia, and dementia, was observed in the resident's room lying in bed while a CNA stood next to the bed and fed lunch. The CNA stated she normally stands while feeding residents and that she stood because Resident 1 was a slower eater. The DON reviewed the facility's Assistance with Meals policy, which states residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity, including not standing over residents while assisting them with meals, and stated the policy was not being followed.
Incomplete Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that Resident 63 and/or the resident’s representative were fully informed about psychotropic medication treatment when the resident’s informed consent for Divalproex Sodium (Depakote) was not updated and was not signed by a provider or by the resident and/or representative. Resident 63 was admitted with chronic kidney disease, hemiplegia, and hemiparesis following cerebral infraction, and had a physician order dated July 25, 2025 for Divalproex Sodium oral capsule delayed release sprinkle 125 mg, 4 capsules by mouth twice daily for poor impulse control manifested by getting agitated easily, leading to verbal and physical aggression. A review of the informed consent dated October 10, 2025 showed it was incomplete and lacked the required signatures. During interview, the RN verified that Resident 63 did not have a complete informed consent for Divalproex Sodium/Depakote and stated the physician should discuss the risks and benefits of the medication with the resident and/or representative before the medication is given. The DON reviewed the facility’s Psychotherapeutic Drug Informed Consent policy and stated the informed consent was not signed, so the policy was not followed.
Advance directive documentation not completed for admitted resident
Penalty
Summary
The facility failed to ensure its policy and procedure for advance directives was completed for one of 24 residents reviewed, Resident 87. Resident 87 was admitted with diagnoses of acute respiratory failure with hypoxia, sepsis, and generalized muscle weakness. During observation on March 9, 2026, Resident 87 was lying in bed in her room with the head of the bed elevated. A record review of Resident 87's chart found no advance directives form. During interview and record review with the SSD on March 10, 2026, the SSD stated there was no advance directives form completed and that it should have been done. The SSD stated it is important to address advance directives and ensure documentation is completed in the medical record so staff know the resident's code status and, if an advance directive exists, can obtain a copy and follow the instructions contained in it. During interview and record review with the DON on March 11, 2026, the facility's Advance Directives policy dated September 2022 was reviewed, which stated that prior to or upon admission the SSD or designee inquires about the existence of any written advance directives. The DON stated the policy was not followed and that the advance directives form should have been completed upon admission or there should have been a note in the medical record indicating the advance directives was addressed.
Pain Location Not Documented With PRN Analgesic Administration
Penalty
Summary
Failure to provide safe, appropriate pain management occurred for a resident with a fractured left lower leg, age-related osteoporosis, acute kidney failure, and a history of falling. The resident’s care plan identified pain monitoring interventions that included assessing the characteristics of pain, including location, duration, and quality. A physician’s order for hydrocodone-acetaminophen 5-325 mg every 6 hours as needed for pain also directed staff to document the pain site in the progress notes. The resident received hydrocodone-acetaminophen 16 times between March 6 and March 12, 2026, but the progress notes left the pain location blank for 9 of those 16 administrations. No other documentation in the clinical record identified the location of pain for those administrations. During interview and record review, the DON stated staff were expected to document the pain location every time the medication was given and confirmed the location of pain was not documented as required.
Inaccurate Medication Administration Documentation
Penalty
Summary
Facility staff failed to accurately document medication administration for two residents. For Resident 45, who was admitted with acute cholecystitis, a urinary tract infection, and difficulty walking, there was a physician order for Omeprazole DR 20 mg twice daily for GERD, to be given 30 minutes before meals. During a medication administration observation, RN 2 administered the Omeprazole at 5:50 AM, but during a later review of the MAR, RN 2 stated the dose was not documented because it was not scheduled for her shift and confirmed she did not document the medication she administered. For Resident 82, who was admitted with heart failure, dysphagia, and muscle weakness, there was a physician order for Famotidine 20 mg once daily for GERD. During a medication administration observation, RN 2 administered the Famotidine at 5:19 AM, but the MAR showed the medication documented as given at 6:53 AM. RN 2 stated she forgot to sign the MAR at the time the medication was administered and later documented the administration at 6:53 AM, even though it had been given earlier. The DON reviewed the facility's Medication Administration-General Guidelines and stated the policy requiring documentation directly after administration was not followed.
Incomplete PRN Ambien Order Lacked Administration Frequency
Penalty
Summary
Ensure each resident's drug regimen was free from unnecessary drugs was not met when Resident 85 had a physician order for Zolpidem Tartrate ER 6.25 mg, given 1 tablet by mouth as needed for insomnia, that did not include a frequency for administration. Resident 85 was admitted with diagnoses including encephalopathy, depression, and a history of traumatic brain injury. The order was entered on February 25, 2026, and remained active for 15 days before being discontinued on March 11, 2026. During interview and record review, the DON acknowledged the order lacked a frequency and stated it should have included one so the resident would not be overdosed. The CC, who entered the order into the EHR, stated she forgot to enter the frequency. The facility's Pharmacy Consultant also stated medication orders were supposed to have a frequency indicated so staff would know how often the medication could be administered. The facility policy titled Medication and Treatment Orders stated medication orders must include the drug name and strength, number of doses, start and stop date or duration, and dosage and frequency of administration.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to keep the medication error rate below 5 percent. Surveyors observed 3 medication errors out of 29 opportunities for error, affecting 3 of 13 observed residents, for an overall error rate of 10.34 percent. The errors involved Famotidine for Resident 82, Omeprazole for Resident 45, and Hydralazine for Resident 27. Resident 82 had diagnoses including heart failure, dysphagia, and muscle weakness. The physician order dated March 10, 2026, directed Famotidine 20 mg by mouth once daily for GERD, and the MAR listed a scheduled administration time of 6:30 AM. During observation on March 11, 2026, RN 2 administered Famotidine at 5:19 AM. During interview, RN 2 stated the medication should have been given within 60 minutes of the scheduled time and acknowledged that the 5:19 AM administration was 11 minutes early and outside the acceptable time range. Resident 45 had diagnoses including acute cholecystitis, UTI, and difficulty walking. The physician order dated March 10, 2026, directed Omeprazole DR 20 mg capsule by mouth twice daily for GERD, to be given 30 minutes before meals, and the MAR listed 7:30 AM as the scheduled time. During observation on March 11, 2026, RN 2 administered Omeprazole at 5:40 AM. RN 2 stated the medication should have been administered 30 minutes before meal and acknowledged the 5:40 AM administration was 50 minutes early and outside the order parameters. Resident 27 had diagnoses including metabolic encephalopathy, UTI, and pseudomonas aeruginosa disease. The physician order dated January 19, 2026, directed Hydralazine HCL 10 mg by mouth every 6 hours as needed for HTN when SBP was greater than 160 mmHg. During observation on March 11, 2026, RN 2 administered Hydralazine for a blood pressure of 160/110. RN 2 stated the medication was to be given only if SBP was greater than 160 and acknowledged that the resident’s SBP of exactly 160 did not meet the ordered parameter.
Incorrect Large Portion Breakfast Tray
Penalty
Summary
The facility failed to ensure dietary staff prepared and served the large portion sizes ordered for one resident who had hemiplegia and hemiparesis, hypertension, and malignant neoplasm of the left breast. The resident had a physician order dated March 15, 2025, for large portions three times daily, and the care plan identified nutrition difficulty related to aging, missing teeth, and muscle weakness with a goal of avoiding unplanned weight changes and an intervention for diet as ordered. During breakfast tray line observation on March 11, 2026, the resident's tray was plated with only one 1/3 cup scoop of eggs and two biscuits. The facility's food production worksheet indicated residents ordered large portions were supposed to receive two scoops of egg for a total of 2/3 cup and two biscuits. The Dietary Service Supervisor initially confirmed the tray contained two biscuits and one scoop of eggs, then reviewed the worksheet and stated residents with large portions were supposed to receive two scoops of egg, not one. The resident later stated she was supposed to receive large portions of food but sometimes felt she did not receive them as ordered.
Bed Malfunction Not Reported or Repaired
Penalty
Summary
The facility failed to ensure Resident 86’s bed was maintained in safe operating condition. Resident 86 was admitted with diagnoses including spinal stenosis of the lumbar region, fibromyalgia, and arthrodesis status. During observation in the resident’s room, the bed was tested and found not to function properly: the foot section would not elevate when activated, and the hand control functions were reversed so that the head control raised the foot section and the foot control raised the head section when operable. Resident 86 stated the bed had not been functioning properly since admission and that staff had been notified, and also stated the bed was supposed to be replaced. Resident 86 said the ability to raise the feet was needed for comfort. During a concurrent observation and interview, CNA 2 confirmed the bed was not functioning as intended and acknowledged the controls were reversed. CNA 2 stated the bed had not been removed from service or tagged for repair. The Maintenance Director later verified the bed was not functioning in a safe operating condition and stated maintenance was not aware of the problem. Review of the March maintenance log for the unit showed no work request documented for the bed repair. Review of the facility’s Maintenance Service policy showed maintenance was responsible for keeping equipment safe and operable and for maintaining work order requests; the Maintenance Director acknowledged the policy was not followed.
Failure to Prevent Pressure Injuries and Notify Family
Penalty
Summary
The facility failed to prevent the development of pressure injuries in a resident who was diabetic, obese, immobile, and at risk for skin breakdown. The resident developed deep tissue injuries on the left heel, left great toe, and first metatarsal, as well as a fluid-filled blister on the right medial foot. Additionally, the resident acquired open wounds on the left elbow and sacral area. The facility did not notify the resident's family about the left elbow and sacral open wounds and the wound treatment. The resident was admitted with no wounds, but the facility's records indicate that the wounds developed during the resident's stay. The Treatment Nurse acknowledged that the family was not notified and that follow-up calls should have been made. The Assistant Director of Nursing confirmed that the wounds developed in the facility and that the family was not notified. The facility's policies on pressure sore management and prevention of pressure injuries emphasize the importance of assessing residents for pressure injury risk factors and notifying families of changes in a resident's condition, which were not adhered to in this case.
Refrigerator Temperature Non-Compliance
Penalty
Summary
The facility failed to maintain the kitchen refrigerator temperature at 40 degrees Fahrenheit or lower, as required by their policy. During multiple observations on 11/11/2024, the refrigerator temperature was recorded at 45 degrees Fahrenheit and later at 49 degrees Fahrenheit. The Dietary Supervisor confirmed the temperature readings and acknowledged that such temperatures could impact food safety. The facility's policy clearly stated that the refrigerator temperature should be 40 degrees Fahrenheit or lower, yet the observed temperatures exceeded this limit. Interviews with facility staff, including the Dietary Supervisor, Regional Dietician, Director of Nursing, and Administrator, revealed a consensus that the refrigerator temperature should not exceed 41 degrees Fahrenheit to prevent food-borne illnesses. The Regional Dietician emphasized the risk of food-borne illness if the temperature remained at 45 degrees Fahrenheit for an extended period. The Administrator acknowledged the discrepancy between the observed temperatures and the facility's policy, which could potentially affect all residents receiving food from the kitchen.
Failure to Maintain Residents' Fingernail Hygiene
Penalty
Summary
The facility failed to ensure that the fingernails of two residents were clean and trimmed, as required by their care plans and facility policy. Resident #2, who has a history of dementia and cognitive impairment, was observed with black and curled fingernails. Despite being dependent on staff for all activities of daily living (ADLs), the necessary grooming was not provided. Certified Nurse Aide (CNA) #1 acknowledged noticing the issue weeks prior and reported it to a nurse, but no action was taken. Registered Nurse (RN) #3 confirmed that the resident's fingernails needed trimming and was unaware of the issue until it was brought to her attention. Resident #136, who has moderate cognitive impairment and requires assistance with personal hygiene, was also found with long and dirty fingernails. The resident expressed a desire to have their nails cut, but this had not been done since their admission. Restorative Nurse Aide (RNA) #5 and RN #3 both acknowledged the resident's nails were in need of care, and RNA #5 attributed the oversight to the resident being newly admitted. The Director of Nursing and the Administrator both stated that they expected residents' fingernails to be clean and trimmed regularly.
Failure to Secure Indwelling Catheter
Penalty
Summary
The facility failed to ensure that a resident's indwelling catheter was secured with a securement device, as required by their policy. The policy, revised in August 2022, mandates that catheters remain secured to reduce friction and movement at the insertion site. Resident #52, who was admitted to the facility in July 2022, had a medical history that included chronic kidney disease, benign prostate hypertrophy, obstructive and reflex uropathy, and urinary tract infection. The resident's quarterly Minimum Data Set indicated moderate cognitive impairment and the presence of an indwelling catheter. An order from September 2024 directed staff to secure the catheter tubing with an anchor every shift to prevent dislodgement. During an observation in November 2024, it was noted that Resident #52's catheter was not secured with a securement device. Interviews with staff, including an LVN and the Director of Nursing, confirmed that a securement device should have been in place. The LVN was unaware of why the device was missing, while the DON emphasized the importance of having a leg band or anchor device for all residents with catheters. The facility's Administrator also stated that nurse aides were expected to verify the presence of the securement device every shift and notify the nurse if it was absent.
Failure to Respond to Call Lights in a Timely Manner
Penalty
Summary
The facility failed to adhere to its policy of answering resident call lights in a timely manner, which compromised the care of two residents. Resident 1, who was admitted with conditions including enterocolitis, muscle weakness, and hypertension, reported that it took hours for the nursing staff to change her diaper regardless of when she activated the call light. Similarly, Resident 2, who had a history of myocardial infarction, muscle weakness, and type 2 diabetes, stated that he sometimes waited up to three hours for assistance, and on occasions, staff would leave without providing the needed help and not return. During an observation, a call light was heard for an extended period without being answered. A Certified Nursing Assistant (CNA) claimed not to have heard the call light, attributing the sound to the Director of Staff Development (DSD) office. However, it was later confirmed that the sound originated from a resident's room. The DSD acknowledged that staff failed to follow the guidelines and policy, which required checking the call light panel to determine the source of the sound. This oversight in responding to call lights placed the residents' psychosocial health and safety at risk.
Pressure Injury Management and CT Order Error
Penalty
Summary
The facility failed to prevent the reopening of two pressure injuries for a resident, which placed the resident's health and safety at risk. The resident, who was admitted with conditions including contracture of the right knee, vascular dementia, and a flaccid neuropathic bladder, experienced a reopening of a Stage 4 coccyx wound and a Stage 3 left hip wound. Despite the facility's policy on pressure injury prevention, the resident's wounds reopened, indicating a lapse in the implementation of the policy. The facility's policy required regular assessment and repositioning of residents at risk for pressure injuries, but the reopening of the wounds suggests these measures were not effectively carried out. Additionally, there was a miscommunication regarding a physician's order for a CT scan. The order was incorrectly placed for the resident's right foot instead of the left, which was the site of concern for potential osteomyelitis. This error was acknowledged by the Assistant Director of Nursing and the Director of Nursing, who confirmed that the order was written for the wrong foot. The Treatment Nurse also noted that the right heel wound had resolved, and the focus was on the left heel, yet the CT order was not corrected before the resident was sent out, potentially delaying appropriate treatment.
Failure to Protect Resident from Physical and Verbal Abuse
Penalty
Summary
The facility failed to protect Resident 1 from physical and verbal abuse. Resident 1, who had partial paralysis of the left side of the body following a stroke and dementia, fell out of bed. A Certified Nursing Assistant (CNA 1) pulled Resident 1 by one arm back onto the bed, causing the resident's hip to rub against the footrest. During this incident, CNA 1 verbally abused Resident 1 by saying, 'Stop that! you're being annoying!' This was witnessed by a Registered Nurse Supervisor (RNS) and overheard by a Minimum Data Set/Licensed Vocational Nurse (MDS/LVN 1) and a Licensed Vocational Nurse/Infection Preventionist (LVN/IP). The RNS had instructed CNA 1 to wait while she put on gloves, but CNA 1 did not comply and proceeded to handle Resident 1 roughly. The facility's Administrator, who was not in position at the time of the incident, reviewed the records and interviews and concluded that the facility had failed to protect Resident 1 from abuse. The facility's policy and procedure titled 'Abuse and Mistreatment of Residents,' dated May 3, 2023, was not followed. This policy outlines the prevention guidelines and procedures for reporting and addressing concerns of abuse, neglect, and mistreatment, which were not adhered to in this case.
Failure to Promptly Notify Physician for Change of Condition
Penalty
Summary
The facility failed to follow their policy when staff did not promptly notify the physician and alternative physician for a change of condition for one resident. The resident, who had a medical history including type 2 diabetes mellitus, osteoporosis, hypertension, rheumatoid arthritis, and muscle contracture of the left lower leg, experienced redness, swelling, and tenderness in the left foot. Despite the CNA alerting the nurse and the nurse assessing the resident, the physician was notified but did not respond, and no follow-up was made to contact an alternative physician or the Medical Director as per the facility's policy. The deficiency was identified during a review of the resident's records and interviews with the Registered Nurse Supervisor and the Administrator. The records showed that the physician was initially notified but did not respond, and the follow-up attempts were not made until much later, resulting in a delay in treatment. The facility's policy clearly stated that in the event of a change in condition, the physician should be called promptly, and if unreachable, an alternative physician or the Medical Director should be contacted. The Administrator acknowledged that the staff did not follow this policy, leading to a delay in addressing the resident's condition.
Failure to Provide Transportation for Dialysis Treatment
Penalty
Summary
The facility failed to ensure that a resident was provided transportation for his dialysis treatment appointment. The resident, who had a history of end-stage renal disease requiring hemodialysis, missed his scheduled dialysis session due to the facility's failure to arrange transportation. The resident was prepared for dialysis and waiting with paperwork and a sack lunch, but the transportation did not arrive. The CNA notified the charge nurse, and it was discovered that the transportation service was unaware of the scheduled pick-up. The dialysis center was contacted to reschedule the appointment for the following day, and the resident's medical director and family were informed. Orders were given to monitor the resident for fluid overload due to the missed dialysis session. During an interview, the Director of Nursing acknowledged that the resident should not have missed his dialysis treatment and that the staff should have called and notified the transportation services upon the resident's return from the hospital. The facility's policy and procedure on transportation, which states that social services will help residents obtain transportation as needed, was not followed. The Administrator confirmed that the staff did not adhere to the facility's policy, resulting in the missed dialysis treatment for the resident.
Failure to Properly Assess and Notify Physician of Change in Condition
Penalty
Summary
The facility failed to properly assess and notify the physician and responsible party of a change in condition for a resident, leading to a delay in treatment and transfer to an acute hospital. The resident, who had multiple diagnoses including encephalopathy, sepsis, type 2 diabetes mellitus, and MRSA, experienced a significant drop in blood sugar levels and oxygen saturation. Despite the CNA reporting the resident's unresponsiveness and difficulty eating to the LVN, appropriate actions were not taken in a timely manner. The CNA observed the resident's condition deteriorating during breakfast and lunch, noting that the resident was not staying awake and had to have food removed from her mouth. The CNA reported these observations to the LVN, who checked the resident's respirations but did not perform a full assessment or notify the physician. It was only after the resident's family expressed concern in the afternoon that the LVN took further action, resulting in the administration of glucagon and the calling of emergency services. Interviews with the DON and Administrator confirmed that there was a delay in treatment and a lack of proper documentation and assessment. The facility's policy on handling changes of condition was not followed, leading to a failure in providing timely and appropriate care for the resident. The deficiency was acknowledged by both the DON and the Administrator, who agreed that better assessment and documentation were needed.
Failure to Document Blood Sugar Results
Penalty
Summary
The facility failed to continually document blood sugar results in the medical record for a resident with multiple diagnoses, including type 2 diabetes mellitus. The resident was admitted with orders for regular blood sugar checks and insulin administration. However, the Medication Administration Record (MAR) for March and April 2024 lacked complete documentation of blood sugar results, and there was no clarification of a sliding scale for insulin administration. Interviews with various nursing staff revealed inconsistencies in documentation practices, with some nurses documenting results in progress notes instead of the MAR, and others noting the absence of a sliding scale in the orders. The Director of Nursing (DON) acknowledged that the order was input incorrectly, and parameters were not added, leading to the lack of documentation in the MAR. The facility's policy and procedure for obtaining a fingerstick glucose level and charting and documentation were reviewed, indicating that blood sugar results should be documented. Despite this, the resident's blood sugar results were not consistently recorded, and the admitting orders were not properly clarified. The Administrator confirmed the absence of documentation in the medical record for the resident, highlighting a significant lapse in tracking the resident's blood sugar patterns and results, which is crucial for managing diabetes effectively.
Failure to Administer IV Antibiotics as Prescribed
Penalty
Summary
The facility failed to ensure that a resident received intravenous antibiotic medications as prescribed by the physician. The resident, who was admitted with multiple serious diagnoses including encephalopathy, sepsis, and MRSA, did not receive the prescribed IV antibiotics upon admission. The resident's medical records indicated that the antibiotics were to be administered daily, but the facility did not have the medications available until the day after the resident was admitted. This delay in treatment occurred despite the facility's policy that medications should be administered within one hour of their prescribed time. Interviews with the Registered Nurse Supervisor, Director of Nursing, and Administrator revealed that the facility did not receive the IV medications from the pharmacy in a timely manner. The resident was sent back to the hospital at the request of the resident's daughter due to the unavailability of the IV antibiotics. The facility's policy on administering medications was not followed, leading to a delay in the resident's treatment and placing the resident's health and safety at risk.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility failed to ensure staff reported an allegation of abuse to outside agencies within the timeframe specified by the facility's policy and federal regulations. Resident 1, who had diagnoses including heart failure, major depressive disorder, schizophrenia, and monoplegia of the upper limb, reported being hit by another resident on February 10, 2024. The incident was reported to a Licensed Vocational Nurse (LVN 1), who assessed the resident and sent her to the emergency room based on the physician's recommendation. However, the LVN did not inform the facility's abuse prevention coordinator or other relevant authorities about the incident immediately, as required by the facility's policy and federal regulations. The Social Worker (SW 1) confirmed that the incident was not reported to outside agencies until February 12, 2024, two days after the facility staff was made aware of the allegation. The delay occurred because the incident happened over the weekend, and the staff responsible for reporting and investigating abuse incidents were not present. The Director of Staff Development (DSD) acknowledged that the incident should have been reported immediately but cited miscommunication as the cause of the delay. A review of the facility's policies indicated that any suspicion of abuse must be reported immediately to the administrator and other officials according to state law. The policy defines 'immediately' as within two hours for allegations involving abuse or serious bodily injury, or within 24 hours for other allegations. The LVN involved stated she was unaware of the process for reporting abuse on weekends, which contributed to the delay in reporting the incident involving Resident 1.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 942 citations issued within 25 miles in the last 12 months — including the 5 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Fontana
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Citrus Nursing Center | 3.3 mi | ★★★★★ | 0 | 0 |
| Rialto Post Acute Center | 3.7 mi | ★★★★★ | 14 | 1 |
| Community Convalescent Center Of San Bernardino | 5.2 mi | ★★★★★ | 0 | 0 |
| Community Hospital Of San Bernardino Dp Snf | 5.2 mi | ★★★★★ | 19 | 0 |
| Shandin Hills Behavior Therapy Center | 6.8 mi | ★★★★★ | 7 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.