Above average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Laurel Heights Community Care during CMS and state inspections, most recent first.
A dented can of tomato sauce was found stored on a kitchen shelf, contrary to facility policy requiring separation and return of damaged cans. The Dietary Service Supervisor and Infection Preventionist both acknowledged the potential risk of foodborne illness from using dented cans.
A resident with vascular dementia who was placed on hospice did not have a comprehensive, person-centered care plan developed within 7 days of assessment, and there was no documented collaboration with the hospice IDT or evidence of hospice progress notes in the chart, contrary to facility policy.
A resident receiving hospice services did not have a written agreement in place between the facility and the hospice agency, resulting in unclear responsibilities and lack of communication. Staff were unable to locate the required agreement or hospice progress notes, and key admission details were missing from the resident's chart. The facility's policy requires such agreements and coordinated care plans, but these were not available during the survey.
Two rooms were found to house three residents each, providing only 71.33 square feet per resident instead of the required 80 square feet. Despite interviews with a resident and CNAs indicating no reported issues with space or care provision, the rooms did not meet regulatory standards for minimum space per resident.
A resident with severe Lewy body dementia and parkinsonism fell from a mechanical lift during a transfer by an untrained temporary CNA, resulting in head trauma and death. The CNA used an incorrect sling size, and the facility failed to provide proper orientation and training on lift use. The resident's care plan lacked specific instructions for safe transfers, and the facility used incompatible equipment, violating safety guidelines.
The facility failed to employ a full-time dietitian or qualified dietetic supervisor, resulting in inadequate supervision and training in Food and Nutrition Services. The Registered Dietitian provided insufficient consultation, contributing to multiple deficiencies in food service operations, placing 27 residents at risk.
The facility failed to ensure kitchen staff competency in critical areas such as calibrating food thermometers, cooling down TCS food, monitoring dishmachine temperature and sanitizer strength, and temperature monitoring for trayline food and food storage coolers. Observations revealed improper calibration of thermometers, lack of cooldown logs, inadequate dishwashing procedures, and inaccurate temperature documentation, potentially leading to food contamination and illness for residents.
The facility failed to follow the planned menu and serving sizes, leading to the potential for inadequate and/or inappropriate nutrients served to residents. Observations showed discrepancies between the spreadsheet and the actual food served, including incorrect serving sizes and inappropriate foods for therapeutic diets.
The facility failed to serve food that was flavorful and at a palatable temperature, potentially leading to decreased food intake for 27 residents. Observations revealed that food temperatures were not properly measured, and several items were below recommended temperatures. A test tray audit confirmed the food was not warm and was bland in flavor.
The facility failed to serve food in a safe and sanitary manner, including improper monitoring of TCS foods, cross-contamination risks from raw meat stored next to produce, and unclean utensils and equipment. Additionally, the kitchen had peeling paint and built-up residue, and TCS food was not discarded according to storage recommendations.
The facility failed to ensure ongoing communication between the nursing home and the dialysis facility for a resident with end-stage renal disease. The Dialysis Communication Records were not consistently completed, and staff interviews confirmed the importance of this documentation for patient safety and continued care.
The facility failed to ensure the appropriate texture of pureed food for 10 residents, leading to the potential risk of aspiration. Observations and interviews revealed that the pureed foods served were too thin and runny, not meeting the required consistency standards.
The facility failed to implement infection prevention and control measures, including improper handling of a urine drainage bag, inadequate hand hygiene between tasks, and failure to sanitize a call light. These actions were confirmed by the Infection Preventionist as breaches of infection control protocols.
The facility failed to provide the required 80 square feet of living space per resident in two rooms, each housing three residents with only 71.3 square feet per resident. Despite no noted issues in care provision or storage space, the facility did not meet regulatory requirements.
The facility failed to provide reasonable accommodation for a resident's needs when his call light was found on the floor and not plugged in. The resident, who had severe cognitive impairment, was unable to reach the call light, and it was not sanitized before being placed back within reach, violating the facility's policies and infection control protocols.
A facility failed to complete a comprehensive assessment and monitor weight weekly for a resident after an unplanned, significant weight gain of 9.4% in one month. The resident, with multiple diagnoses including Alzheimer's disease and chronic kidney disease, did not receive the necessary assessment for the significant weight change, and the facility's policies were not followed.
The facility failed to include a physician's order for heel protectors in a resident's care plan, despite the resident's high risk for pressure ulcers and significant medical conditions. Observations and staff interviews confirmed the omission, highlighting a gap in the resident's individualized care plan.
The facility failed to prevent pressure ulcers for a resident by not following the physician's order to apply bilateral heel protectors. Despite being at high risk for pressure injuries, the resident was observed without heel protectors on multiple occasions. Staff confirmed the oversight, acknowledging the increased risk due to the resident's immobility and condition.
The facility failed to monitor a resident for side effects associated with the use of Trazodone, a psychotropic medication prescribed for insomnia. Despite the medication being administered over a period of time, there was no documentation of side effect monitoring, which was confirmed by staff interviews. The facility's policy mandates such monitoring, but it was not followed in this instance.
A facility failed to date an opened Aspart insulin bottle, leading to the use of potentially expired medication for a resident with Type 2 diabetes and chronic kidney disease. The LVN discarded the undated bottle and obtained a new one, which was properly dated before administration.
The facility failed to maintain a kitchen refrigerator free of significant ice build-up, with over one inch thick ice covering the interior and a dented rubber gasket compromising the seal. Maintenance staff confirmed that refrigerators should not have ice build-up.
Dented Can Found in Kitchen Storage
Penalty
Summary
The facility failed to maintain safe and sanitary food storage conditions in the kitchen when a can of Hunt's Tomato Sauce with a dent was found on a storage room shelf. During an observation with the Dietary Service Supervisor (DSS), the dented can was identified, and the DSS acknowledged that the can should not have been stored and needed to be discarded or returned to the supplier. The DSS and Infection Preventionist both confirmed that dented cans could pose a risk of foodborne illness if used. Review of the facility's policy indicated that all dented cans are to be separated from remaining stock and returned to the purveyor for a refund, but this procedure was not followed prior to the surveyor's observation.
Failure to Collaborate with Hospice in Timely Care Plan Development
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan within 7 days after the completion of a comprehensive assessment for a resident receiving hospice services. Specifically, there was no documented participation or collaboration with the hospice interdisciplinary team (IDT) in revising or updating the resident's care plan, despite the resident being admitted with a primary diagnosis of vascular dementia and being placed on hospice care. The care plan did not reflect input from the hospice provider, and there were no hospice progress notes present in the resident's chart. Interviews with facility staff revealed that after being informed by a PACE agency physician that the resident would be on hospice, a significant change assessment was completed, and the resident's family was notified. However, the Director of Nursing confirmed that there was no IDT meeting or documented collaboration with the hospice agency in the care planning process. The facility's own policy requires a coordinated plan of care between the facility, hospice agency, and resident/family, but this was not followed in this case.
Lack of Written Hospice Agreement and Coordination
Penalty
Summary
The facility failed to provide a written agreement with the hospice agency that defined the services to be provided, respective responsibilities, and established a process for communication and collaboration for a resident receiving hospice services. Staff interviews revealed that the Registered Nurse/Infection Preventionist was unable to locate the required hospice agreement and had been attempting to obtain it from the Program of All-Inclusive Care for the Elderly (PACE) agency without success. The RN/IP also stated uncertainty regarding the facility's responsibilities and noted that clinical notes from the hospice provider were not shared with the facility. Additionally, there were no hospice progress notes present in the resident's chart. Further review indicated that the Director of Nursing only recently began receiving hospice notes from the PACE agency, and that a Licensed Vocational Nurse from the contracted hospice agency had admitted and assessed the resident. However, the admitting date and hospice diagnosis were missing from the charts of three residents, including the one sampled. The facility's policy requires a signed agreement outlining responsibilities and a coordinated plan of care, but this documentation was not present or available at the time of the survey.
Resident Rooms Below Minimum Square Footage Requirement
Penalty
Summary
The facility failed to ensure that two resident rooms met the required minimum of 80 square feet per resident for multiple occupancy rooms. Observations during the initial tour revealed that both rooms were occupied by three residents each, with a total room size of 214 square feet, resulting in only 71.33 square feet per resident. The rooms were divided by curtains, and each resident had access to bedside stands and storage space. Interviews with residents and CNAs indicated that, despite the limited space, they did not report issues with sharing the room or performing care tasks such as using a Hoyer lift or moving a Geri-chair. A review of facility-submitted documents showed that the administrator had requested a waiver for variance in room size, acknowledging the shortfall in square footage per resident. The documentation confirmed the measurements of the affected rooms and described the arrangements for privacy and storage, but did not meet the regulatory requirement for space per resident.
Failure to Prevent Avoidable Fall During Transfer
Penalty
Summary
The facility failed to prevent an avoidable fall for a resident who was being transferred using a mechanical lift device by a Certified Nursing Assistant (CNA) from a temporary staffing agency. The CNA was not trained by the facility on the use of the Hoyer lift and assumed to have been trained by the agency. During the transfer, the resident, who had severe Lewy body dementia and unspecified secondary parkinsonism, began jerking, causing them to slide from the sling and fall, resulting in head trauma and subsequent death. The investigation revealed that the CNA used a half sling that was too large for the resident, who typically used a medium-sized sling. The facility's policy required the use of a full sling for residents who were totally dependent, as the resident was. The care plan for the resident did not specify the type and size of sling to be used, nor did it address the resident's specific needs during transfers, such as their tendency to jerk due to contractures. Interviews with staff indicated that the facility did not provide orientation to temporary staff on the use of mechanical lift devices and the appropriate sling sizes for residents. The facility's policy on hiring temporary staff required orientation, but this was not followed. Additionally, the facility used a sling from a different manufacturer than the lift, which was against the manufacturer's safety guidelines, further contributing to the unsafe transfer conditions.
Failure to Employ Qualified Dietetic Supervisor and Provide Sufficient RD Consultation
Penalty
Summary
The facility failed to comply with Federal regulations related to the oversight of food service operations by not employing a full-time dietitian or a qualified dietetic supervisor. The Kitchen Supervisor (KS) had completed coursework to become a dietary manager but did not take the certification exam. This lack of a qualified, full-time supervisor resulted in inadequate supervision, training, and knowledge among staff to carry out Food and Nutrition Services safely and sanitarily. The facility's document showed that the Registered Dietitian (RD) was contracted to provide about 15 consultation hours per month, which was insufficient for the needs of the department. The Registered Dietitian (RD) did not provide sufficient consultation to the Food and Nutrition Services department. The RD was responsible for consulting with administration, observing food preparation and service, supporting the dietetic service supervisor, and providing in-service education. However, the RD only worked at the facility for about four hours once a week and did not have documentation to show what issues were identified or discussed with the kitchen staff. The RD also did not conduct in-service trainings when issues were identified and did not report all issues to the Administrator (ADM). During the Re-certification Survey, multiple issues were identified, including kitchen staff and supervisor competency, not following the planned menu, unpalatable food, inappropriate texture of pureed food, and unsafe and unsanitary food storage, preparation, and service. These deficiencies placed 27 residents at risk for foodborne illness and decreased nutrient intake. The lack of a qualified, full-time supervisor and sufficient consultation from the RD contributed to these issues.
Kitchen Staff Competency and Food Safety Deficiencies
Penalty
Summary
The facility failed to ensure kitchen staff competency in several critical areas, including calibrating food thermometers, cooling down Time/Temperature Control for Safety (TCS) food, monitoring dishmachine temperature and sanitizer strength, and temperature monitoring for trayline food and food storage coolers. Observations revealed that the Kitchen Supervisor (KS) and Cook 2 were unable to properly calibrate food thermometers, with KS incorrectly stating the calibration temperature and failing to adjust the thermometer correctly. Additionally, the facility lacked a cooldown log for TCS foods, and staff were unaware of the proper cooling procedures and corrective actions required when food temperatures were not within safe limits. The facility's dishwashing procedures were also found to be inadequate. KS and Cook 2 demonstrated a lack of understanding of the correct dishmachine water temperature and failed to document accurate temperatures consistently. The dishmachine temperature log showed multiple instances of temperatures below the required range. Furthermore, the facility did not have a proper procedure for manual dishwashing using a two-compartment sink, and the sanitizer strength used for food contact surfaces was not tested correctly. Temperature monitoring for trayline food and food storage coolers was insufficient. KS failed to document food temperatures accurately during trayline service, and the recorded temperatures did not match the observed temperatures. The facility's policy required temperatures to be recorded twice daily, but observations showed that temperatures were often recorded only once a day, and the documented temperatures were not accurate. These deficiencies had the potential to result in contamination of food and/or utensils and equipment, leading to illness caused by pathogens for the residents who received food from the kitchen.
Failure to Follow Planned Menu and Serving Sizes
Penalty
Summary
The facility failed to follow the planned menu, which had the potential to result in inadequate and/or inappropriate nutrients served to residents. During an observation and interview, the Kitchen Supervisor (KS) provided a document titled 'Week at a Glance' that showed the menu for the Regular diet but did not include therapeutic diets or serving sizes. KS was unable to explain how serving sizes and foods for therapeutic diets were determined during trayline and admitted to not following the spreadsheet that listed the correct serving sizes and foods for different diets. The Registered Dietitian (RD) confirmed that KS needed to follow the spreadsheet during trayline, but the review showed discrepancies between the spreadsheet and the actual food served. During trayline food service, various observations showed that the serving sizes and foods did not match the planned menu. For example, pureed chicken was served with a number 8 scoop instead of the number 6 scoop listed on the spreadsheet, and canned pears were served instead of cake for the No Concentrated Sweets diet. Additionally, Renal diets received the same food as Regular diets, which included Spanish Rice that was not appropriate for Renal diets. The KS admitted to not following the spreadsheet, and the RD confirmed that the spreadsheet was not being followed. Further observations showed that a resident on a Renal diet received potatoes instead of the Parslied Rice listed on the spreadsheet. The KS confirmed that the resident should have received rice and not potatoes. The facility's failure to follow the planned menu and serving sizes as listed on the spreadsheet had the potential to result in inadequate and/or inappropriate nutrients served to residents, leading to nutrient-related medical complications.
Failure to Serve Food at Palatable Temperatures
Penalty
Summary
The facility failed to serve food that was flavorful and at a palatable temperature, which had the potential for decreased food intake leading to nutrient-related complications for 27 residents. The facility's policy required food temperatures to be taken and recorded before service, with specific temperature guidelines for different food items. However, during an observation, it was noted that the staff member, KS, did not measure the temperatures of all food items before starting the trayline. When temperatures were eventually measured, several food items, including chicken and vegetables, were found to be below the recommended temperatures. Additionally, the food was served on plates and bowls stored at room temperature and transferred to residents using an open cart, which likely contributed to the food cooling down further before reaching the residents. A test tray audit conducted by the Registered Dietitian (RD) confirmed that the food served to residents was not at the appropriate temperatures and was bland in flavor. The RD acknowledged that she did not conduct test trays to assess food temperatures upon delivery to the residents and stated there were no complaints about the food. However, a review of 27 residents' Brief Interview for Mental Status (BIMS) assessments showed that many residents had severe to moderate cognitive impairments, which could explain the lack of complaints. The RD confirmed that no additional devices were used to keep the food warm during service, further contributing to the deficiency.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to serve food in a safe and sanitary manner, leading to multiple deficiencies. Time/Temperature Control for Safety (TCS) foods were not monitored for cool down, as evidenced by the lack of a cool down log and improper storage of cooked meat and rice. Observations showed that the cooked pork and rice were not cooled to the required temperatures and were stored uncovered on a preparation table before being placed in the refrigerator. Interviews with the Kitchen Supervisor and Cook 2 confirmed that there was no documentation for cooling food temperatures, and the Registered Dietitian was unaware that cooling was taking place for certain foods. Raw meat was improperly stored next to produce, leading to potential cross-contamination. Observations of the reach-in refrigerator showed raw meat stored directly next to fresh produce, with some produce bags coming into direct contact with raw chicken. The facility's policy and procedure required raw meat to be stored separately from ready-to-eat food to prevent cross-contamination, but this was not followed. The Registered Dietitian acknowledged that it was not ideal to store raw thawing meat next to produce and that food should be stored according to required cooking temperatures. The facility also failed to maintain clean and properly conditioned utensils and equipment. Observations revealed that food processors, cutting boards, and various cooking tools were either dirty or in poor condition. The food processors had significant residue and scratches, and the cutting boards were heavily scratched and had residue embedded in them. Additionally, the shelving, cabinets, and drawers in the kitchen had peeling paint and built-up residue and grime. The Registered Dietitian was aware of the wood surfaces and peeling paint but did not provide recommendations to the administrator about replacing or repairing these areas. Furthermore, TCS food was not discarded according to storage recommendations, and a storage container holding coffee was not cleaned before refilling. The freezer gasket was also not maintained clean, with particles and residue embedded in it.
Failure to Ensure Ongoing Communication for Dialysis Services
Penalty
Summary
The facility failed to ensure ongoing communication between the nursing home and the dialysis facility for a resident requiring dialysis services. The resident, who was admitted with end-stage renal disease, attended dialysis treatments three times a week. However, the Dialysis Communication Records (DCR) were not consistently completed by the dialysis facility on multiple occasions, including specific dates in February, March, and April. This section of the DCR is crucial for documenting fluid removal and any changes in the resident's condition during dialysis, which was not done as required. During interviews, both a Licensed Vocational Nurse (LVN) and the Director of Staff Development (DSD) confirmed the importance of the DCR being completed by the dialysis staff. The DSD emphasized that if the DCR is not filled out by the dialysis facility, the nursing home staff should follow up via fax or telephone to ensure the information is obtained. The facility's policy and procedure for dialysis patients also outlined the necessity of communication and documentation between the nursing home and the dialysis provider, which was not adhered to in this case.
Failure to Ensure Appropriate Texture of Pureed Food
Penalty
Summary
The facility failed to ensure the appropriate texture of pureed food was served to residents, which had the potential to cause aspiration. The deficiency was identified through observation, interview, and document review. The Daily Spreadsheet for lunch indicated that pureed diets were to be served, including pureed Spanish Rice and pureed Zucchini and Yellow Squash. According to the Ala Carte Menus Diet Manual, pureed foods should have a smooth, lump-free, extremely thick consistency and must pass the fork drip and spoon tilt test. However, the pureed foods served were found to be very thin and runny, not meeting the required consistency standards. During an observation and interview, the Kitchen Supervisor admitted that the pureed food was soupy and had to be served in bowls to prevent it from running together. A test tray conducted with the Registered Dietitian confirmed that the pureed rice was too thin and watery, and the pureed vegetables were the consistency of thick cream soup. Both did not hold their shape on a spoon and were pourable, failing to meet the required consistency. The pureed chicken was not assessed due to insufficient quantity. This failure affected 10 residents who were prescribed a pureed diet, putting them at risk of aspiration.
Infection Control Deficiencies
Penalty
Summary
The facility failed to implement infection prevention and control measures in several instances. Resident 131's urine drainage bag was observed touching the floor on multiple occasions, and the staff was unaware of the proper protocol to keep the bag off the floor and covered. The Infection Preventionist confirmed that the urine drainage bag should be kept off the floor to prevent contamination and infection. The facility's policy did not specify that the urine drainage bag should be covered, indicating a gap in the guidelines provided to the staff. Staff members also failed to perform proper hand hygiene between clean and dirty tasks. For instance, a Certified Nursing Assistant (CNA) did not wash her hands after removing gloves and proceeded to handle various items in Resident 131's room, including the bed remote controller and a comb. The Infection Preventionist confirmed that hand hygiene should be performed between tasks and after glove removal to prevent contamination and infection. Additionally, staff did not sanitize Resident 9's call light after it was picked up from the floor and placed on the resident's bed. The Infection Preventionist acknowledged the need for sanitizing the call light to prevent infection. Furthermore, a laundry staff member did not wash her hands after handling a cart with dirty linens, which the Infection Preventionist confirmed was a breach of infection control protocols. The facility's hand hygiene policy emphasized the importance of hand hygiene in preventing the spread of infections, but these practices were not consistently followed by the staff.
Failure to Provide Adequate Living Space per Resident
Penalty
Summary
The facility failed to provide the required 80 square feet of living space per resident in two of 14 resident rooms. Specifically, rooms [ROOM NUMBERS] each had three residents occupying a total of 214 square feet, resulting in only 71.3 square feet per resident. This deficiency was observed during a survey on 4/15/24. Despite the Certified Nursing Assistant (CNA) stating that there were no issues in providing care, and no concerns being noted regarding the provision of care or storage space for personal items during the survey, the facility did not meet the regulatory requirement for room size.
Failure to Provide Reasonable Accommodation for Resident's Call Light
Penalty
Summary
The facility failed to provide reasonable accommodation for Resident 9's needs when his call light was found on the floor and not plugged into the wall socket. During an observation, the resident was awake, alert, and responsive in bed, but his call light was not within reach. A certified nurse assistant (CNA3) was asked to check the call light, which was found on the floor and not functioning because it was unplugged. After plugging it in, the call light was placed on the resident's bed cover without being sanitized, which was against infection control protocols. Resident 9 was admitted with diagnoses of major depressive disorder, vascular dementia, and type 2 diabetes, and had a severe cognitive impairment with a BIMS score of 6. The facility's policy requires that call lights be within the resident's reach and sanitized before use, but these protocols were not followed. Interviews with staff confirmed that the call light should be within reach and sanitized, highlighting a failure to adhere to the facility's policies and procedures regarding resident care and infection control.
Failure to Monitor Significant Weight Gain
Penalty
Summary
The facility failed to complete a comprehensive assessment and monitor weight weekly for a resident after an unplanned, significant weight gain of 9.4% in one month. The facility's policy required that any weight change greater than 5 pounds within 30 days be retaken the next day for confirmation, and if verified, the physician and responsible party should be notified. Additionally, the resident should be weighed weekly for monitoring. However, these steps were not followed for the resident in question, who had a weight gain from 113.6 pounds to 125.4 pounds between January and February 2024. The resident, who had diagnoses including non-traumatic intracranial hemorrhage, Alzheimer's disease, dysphagia, and chronic kidney disease, did not receive the necessary assessment for the significant weight change. The Minimum Data Set (MDS) assessments were completed quarterly and yearly, but no assessment was conducted for the significant weight gain in February 2024. Interviews with the Director of Staff Development (DSD) confirmed that the significant weight change was not assessed or monitored as required by the facility's policies.
Failure to Implement Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for one of the sampled residents, specifically Resident 26. Resident 26's care plan did not include the physician's order to use heel protectors, which are essential devices designed to prevent and treat pressure ulcers. Despite the physician's order dated 3/11/24, and the resident's high risk for pressure ulcers as indicated by a Braden Scale score of 13, the care plan did not reflect this critical intervention. Observations on 4/15/24 and 4/17/24 confirmed that Resident 26 was not wearing heel protectors, and staff interviews corroborated that the care plan lacked this necessary detail. Resident 26 was admitted with significant medical conditions, including acute non-traumatic intracranial hemorrhage and hemiparesis, which limited movement in both lower extremities. The care plan noted the resident's impaired mobility and history of skin issues but failed to include the use of heel protectors. Staff, including a CNA and an LVN, acknowledged the omission and confirmed that the care plan should have included the physician's order to ensure proper care. The Director of Staff Development also stated that the care plan should reflect physician's orders to guide staff in implementing appropriate interventions to prevent pressure ulcers.
Failure to Apply Heel Protectors as Ordered
Penalty
Summary
The facility failed to provide care to prevent pressure ulcers for one of the residents when the physician's order to apply bilateral heel protectors was not carried out. Resident 26, who was admitted with diagnoses including acute non-traumatic intracranial hemorrhage and hemiparesis, was identified as high risk for pressure injuries with a Braden Scale score of 13. Despite the physician's order dated 3/11/24 to apply heel protectors at all times, observations on 4/15/24 and 4/17/24 revealed that Resident 26 was not wearing the heel protectors while in bed. Certified Nursing Assistant (CNA) 2 and Licensed Vocational Nurse (LVN) 1 confirmed that the heel protectors were not applied as ordered, acknowledging the risk of pressure ulcers due to the resident's condition and immobility. During interviews, both CNA 2 and the Director of Staff Development (DSD) confirmed that the physician's orders should have been followed to prevent pressure ulcers. The DSD emphasized that Resident 26's bedbound status and bony prominences increased her risk for developing pressure ulcers, and the heel protectors were a necessary preventative measure. The facility's policy on the prevention of pressure ulcers, which includes guidelines for using devices like heel protectors to keep heels off the bed, was not adhered to in this case, leading to the identified deficiency.
Failure to Monitor Side Effects of Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medications by not monitoring for side effects associated with the use of Trazodone. The resident was admitted with a diagnosis of insomnia and had an order for Trazodone 50 mg, to be administered as needed at bedtime. The Medication Administration Record indicated that the medication was administered from 4/5/24 to 4/17/24, but there was no documentation of side effect monitoring during this period. This was confirmed by a Licensed Vocational Nurse who acknowledged the importance of monitoring for side effects. Interviews with staff, including another Licensed Vocational Nurse, the Director of Staff Development, and the Pharmacist Consultant, emphasized the necessity of monitoring for side effects of psychotropic medications like Trazodone. They highlighted the potential risks such as increased sedation and rapid decline in the resident's condition. The facility's policy on the use of psychotropic medications also mandates ongoing evaluation and documentation of the resident's response to the medication, which was not adhered to in this case.
Failure to Date Opened Insulin Bottle
Penalty
Summary
The facility failed to ensure that an Aspart insulin bottle was dated when first opened for use. During an observation and interview, a Licensed Vocational Nurse (LVN) was found using an undated Aspart insulin bottle for a resident with multiple diagnoses, including Type 2 diabetes mellitus and chronic kidney disease. The LVN admitted to not knowing when the bottle was opened and subsequently discarded it to obtain a new one. The new bottle was properly dated before administration. This incident was observed during a blood sugar test for the resident, which showed a high blood sugar level of 349 mg/dL, necessitating the administration of 5 units of Aspart insulin. The facility's policy and procedure on labeling and storage of medications were reviewed and found to be in accordance with state and federal laws. However, the practice of not dating the insulin bottle when first opened was identified as a deficiency. The review of various sources, including the American Diabetes Association and Mayo Clinic, indicated that opened insulin vials should be used within 28 days to maintain potency. The failure to date the insulin bottle could lead to the administration of expired or less potent medication, posing a risk to the resident's health.
Failure to Maintain Refrigerator in Safe Condition
Penalty
Summary
The facility failed to maintain one of three food refrigerators free of significant ice build-up, which had the potential to affect the quality and safety of food stored inside. An observation revealed a milk dispensing refrigerator in the kitchen with over one inch thick ice build-up covering the majority of the interior sides and ceiling. Additionally, the rubber gasket on the door was dented and not intact, compromising the seal needed to keep cool air inside. Maintenance staff confirmed that refrigerators should not have ice build-up.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near San Francisco
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pacific Heights Transitional Care Center | 0.1 mi | ★★★★★ | 6 | 0 |
| Victorian Post Acute | 0.5 mi | ★★★★★ | 0 | 0 |
| Sequoias San Francisco Convalescent Hospital | 0.6 mi | ★★★★★ | 13 | 0 |
| Central Gardens Post Acute | 0.7 mi | ★★★★★ | 0 | 0 |
| San Francisco Health Care | 0.9 mi | ★★★★★ | 5 | 0 |
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