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 Lincoln Square Post Acute Care during CMS and state inspections, most recent first.
Failure to reposition a resident with a history of a resolved pressure ulcer, active MASD, incontinence, decreased bed mobility, and dependence on staff for pressure relief led to the resident remaining on her back in the same position for more than two hours. The resident reported buttocks and back pain, and the ADON, CNA, LTNs, and DON acknowledged the resident had fragile skin, a prior pressure injury, and a care plan requiring frequent turning and repositioning.
A resident with multiple chronic conditions, intact cognition, and a care plan intervention to promote hydration was observed in bed with dry mouth and lips and stated she was thirsty. Although a water pitcher was on the overbed table, it was out of reach and no cup was available. The resident said she could not reach the water and had needed a drink before without being able to access it. An LN confirmed the pitcher was not within reach, and the ADON and DON stated water should be kept within the resident’s reach.
Failure to assess pain and provide repositioning for a resident with chronic pain. A resident with multiple pain-related diagnoses and intact cognition was observed lying flat in bed, grimacing, and reporting severe pain in the buttocks and back while remaining in the same position for more than 2 hours. The LN did not fully assess the pain during the med pass, and the resident did not receive timely non-pharmacological interventions such as repositioning before Tylenol and later Norco were given; the DON acknowledged the resident was not repositioned despite the care plan.
Unsafe food storage, thawing, and hair restraint practices were observed in the kitchen. Open boxes of lettuce and cheese were placed on the floor, a dietary aide wore a hairnet that did not fully cover her hair, dry goods were left unsealed or on the floor, uncooked spinach was thawed near open chemical buckets, and food-related items were stored with cleaning supplies. The DS, cook, RD, and ADM confirmed the practices did not meet facility standards for safe food handling.
Improperly Covered Trash and Dumpster Lids: A kitchen trash can was observed with its lid propped open, and a dumpster lid in the outside refuse area was also observed open. The cook confirmed the trash can was not closed, and the DS stated the dumpster lid should have been closed to prevent contamination and pests. The RD and ADM both stated that trash and dumpster lids should remain covered or closed, consistent with the facility sanitation policy and FDA Food Code requirements.
A resident with COPD, oxygen dependence, heart failure, and weakness received nebulizer treatments, but the nebulizer tubing was left on top of the machine instead of being stored in a protective bag after use. An LPN and the DON confirmed the tubing was not stored as required. The facility also did not implement or document Legionella water management control measures, including testing water temperature, pH, and disinfectant levels, flushing stagnant water, or documenting biofilm cleaning, despite these controls being identified in the WMP.
Delayed Completion of Comprehensive MDS Assessments: The facility failed to complete required comprehensive MDS assessments for four residents, including admission and annual assessments that were overdue. The residents had significant medical histories such as CVA-related deficits, AFib, aphasia, HTN, hyperlipidemia, dysphagia, contractures, and muscle weakness. The MDS Coordinator Nurse confirmed the assessments were not completed, and the DON stated these assessments were expected to be completed on time because they identify resident needs and trigger care planning.
Missed Quarterly MDS Assessments: The facility failed to complete quarterly MDS assessments for four residents whose assessments were overdue. The residents had significant medical conditions including DM2, COPD with chronic respiratory failure, hemiplegia/hemiparesis with dysphagia and CKD, and a femur fracture with prostate cancer and immunodeficiency. The MDSN confirmed the assessments were not completed, and the DON stated quarterly assessments are expected to identify changes in resident needs and support timely interventions.
Pain medications were administered outside ordered pain-level parameters for several residents. One resident with RA, chronic pain, and intact cognition received acetaminophen instead of ordered morphine for higher pain ratings; another resident with dementia and a left hip joint had hydrocodone given for moderate pain even though no order addressed that level. Additional residents with dementia, MS, opioid dependence, and severe cognitive impairment received acetaminophen or morphine for pain ratings outside the prescribed ranges, and one resident reported hydrocodone made her feel weird and lost without documentation of side effects or MD notification.
Dignity and Respect During Mealtime Assistance: Staff referred to one resident as a feeder during a meal and assisted another resident with lunch while standing over the resident instead of at eye level. The residents had significant medical and functional needs, and the DON, MDSN, and nursing staff stated that residents should be addressed by name and assisted with meals in a respectful, eye-level manner.
Call Light Not Within Resident Reach: A resident with dementia, gait and balance problems, muscle weakness, and need for assistance with personal care was observed sitting in a wheelchair near the bed while the call light was wrapped around the bed siderail and not within reach. The resident stated he could not find or reach it, and an LNS confirmed it was inaccessible and that the resident could not propel himself in the wheelchair. The DON stated call lights must be within residents’ reach, and the care plan and facility policy both addressed keeping the call light accessible.
A resident was not provided a homelike environment when his bathroom toilet was out of order, had no water, and showed buildup in the bowl. Staff confirmed the bathroom had not been working for weeks, and the resident had to be assisted to another resident’s bathroom instead of using his own. The ADON stated the facility policy was not followed and that the resident should have had a room with a working bathroom.
Failure to develop a comprehensive care plan for a resident who refused the COVID-19 vaccine. The resident had multiple diagnoses including schizoaffective disorder, epilepsy, glaucoma, visual loss, anxiety disorder, repeated falls, and alcohol dependence in remission. The LNS and DON confirmed there was no care plan to address the vaccine refusal or the resident’s increased infection risk, and the resident later tested positive for COVID-19 during a facility outbreak.
A resident with COPD, chronic respiratory failure with hypoxia, and a history of lung cancer complained of shortness of breath, but the LPN did not obtain an ordered oxygen saturation or administer the ordered PRN albuterol neb before the resident was sent to the hospital. The LN and DON confirmed the physician orders were not followed and no respiratory assessment was documented when the resident’s condition changed.
Unnecessary Medication Administration: A resident with orthostatic hypotension, HTN, and repeated falls received Propranolol outside the ordered SBP hold parameters on four occasions. The MAR review and ADON interview confirmed the doses were given despite the physician’s hold instructions, and the ADON stated it was important to follow the ordered parameters.
Failure to Reassess Long-Term Levofloxacin Use: A resident with a chronic left knee/thigh wound and prior abscess drainage remained on full-dose levofloxacin for chronic suppressive therapy without documented clinical justification, stop date, or ongoing reassessment. Staff and the MD acknowledged there were no follow-up wound cultures or infection screenings to confirm continued need, and a pharmacist had requested a stop date or documentation for indefinite use. The resident was also on palliative care, and the family requested continuation of the antibiotic.
A resident reported that a nurse spoke to him in a rude manner in the snack room, allegedly accusing him of being a thief and stating he would be the main suspect if items went missing. The resident told a nurse supervisor about the interaction and later described it as verbal abuse to another nurse, a transition-of-care nurse with his insurance, and the Ombudsman. One nurse on duty confirmed the resident said he felt abused and reported this to the supervisor. The involved nurse denied calling the resident a thief and did not actually report the incident to administration despite initially claiming she had, and no documentation of the event was found in the EMR. The concern was handled as a grievance rather than an abuse allegation, and the facility did not follow its abuse policy requiring immediate reporting of known or suspected abuse to the administrator and external authorities.
A resident with severe cognitive impairment exited the facility through an unsecured rear Dining Room door and was missing for over an hour before staff noticed. The resident, who had not previously been identified as an elopement risk, sustained injuries after falling outside and was found at a nearby hospital. The door lacked an alarm or Wander Guard system at the time, and staff were unaware of the resident's absence until a routine check during dinner service.
The facility failed to protect residents' privacy by discarding meal tickets containing sensitive information in the kitchen garbage. Observations showed a Dietary Aide disposing of these tickets improperly, and interviews with staff confirmed the lack of a proper disposal process. The Registered Dietician and DON acknowledged this practice violated HIPAA and facility policies.
The facility failed to maintain food safety standards, with expired and improperly labeled food, non-food items in storage, and unclean equipment. Expired strawberries and tomatoes were found, and food items lacked proper labeling. Non-food items were stored in the dry food area, and the coffee machine's water filter was not maintained. A dirty fan, wet pans, and a dirty ice machine further compromised safety. These issues were confirmed by the Dietary Service Supervisor and Registered Dietician, posing a risk of illness to residents.
The facility failed to maintain proper garbage disposal, as observed with overflowing trash bins and open lids, contrary to the facility's normal process. Staff interviews confirmed the importance of closed lids to prevent pest issues, aligning with FDA guidelines on waste management.
The facility failed to implement an antibiotic stewardship program, leading to inappropriate antibiotic prescriptions for two residents. Antibiotics were prescribed without meeting infection criteria, and there was a lack of documentation and communication with medical staff. The facility's policies on antibiotic use were not followed, contributing to the deficiency.
A facility failed to maintain the dignity of a resident by not covering the resident's genital area with a sheet while sleeping. A CNA confirmed the exposure and acknowledged the expectation for covering residents to prevent loss of dignity. The ADON emphasized the importance of covering residents for dignity and making rounds to ensure decency. The resident preferred not wearing undergarments for easier bathroom use. The facility's policy requires staff to protect resident privacy.
A resident with type 2 diabetes experienced a hypoglycemic event after staff administered rapid-acting insulin without proper parameters and failed to notify the physician when the resident refused a meal. The insulin order lacked specific instructions on when to hold the medication, leading to a dangerously low blood glucose level and the need for emergency treatment.
A facility failed to accurately document narcotic medications for a resident under hospice care, leading to discrepancies in the Medication Administration Record (MAR). The resident, with chronic kidney disease and a non-pressure chronic ulcer, was prescribed Morphine Sulfate for pain management. Both facility LNs and hospice nurses administered the medication, but coordination and documentation were lacking. The Director of Nursing confirmed inaccuracies in the MAR, and the facility's policy for medication administration was not followed.
A resident was given an antibiotic without meeting the facility's criteria for its use, as required by the antibiotic stewardship program. The necessary Infection Screening Evaluation was not completed before the medication was administered, and there was no communication with the medical doctor about the lack of criteria met. The Pharmacist Consultant indicated that the antibiotic was not needed, and the facility's policies on infection prevention and control were not followed.
A resident with chronic kidney disease and a non-pressure chronic ulcer received incorrect dosages of Morphine Sulfate due to discrepancies between physician orders, MAR, and CDR. The facility's failure to follow medication administration policies led to the administration of incorrect dosages, as confirmed by the DON.
The facility failed to properly label, store, and dispose of medications, as observed with an unlabeled psyllium fiber supplement, an unlabeled cough medicine, and medications for a discharged resident found in the medication cart. The DON confirmed that these practices did not align with facility policy, posing a risk of medication errors.
A facility failed to implement proper infection prevention practices, leading to a deficiency. A resident was placed in a room with another who tested positive for RSV without Droplet Isolation Precautions. Additionally, a resident who tested positive for RSV was not placed under isolation precautions until several days later, increasing the risk of infection transmission. The facility's policy for Transmission-Based Precautions was not followed, resulting in a deficiency.
A facility failed to document the offer and consent for an influenza vaccine for a resident with COPD and dementia. The resident's conservator was not reached for consent, and no documentation of attempts was made. The facility's policy required annual vaccine offers and documentation of refusals.
A facility failed to submit a new Level I PASRR for a resident with schizophrenia, leading to an incomplete Level II Mental Health Evaluation. The resident was isolated for health precautions, and the necessary new Level I screening was not conducted, potentially risking the resident's care. The ADON and DON confirmed the oversight, acknowledging the risk of inadequate treatment and monitoring.
A resident was discharged with a discontinued medication due to a failure in medication reconciliation. The resident, who had been prescribed Mirtazapine for depression, was sent home with the medication despite it being discontinued. The error was identified during a review of discharge records, and the responsible nurse was counseled and no longer worked at the facility.
Failure to Reposition Resident With Skin Integrity Issues
Penalty
Summary
Failure to implement repositioning interventions for a resident with a history of a resolved sacrococcygeal pressure ulcer, active MASD to the right buttock, bowel and bladder incontinence, decreased bed mobility, and dependence on staff for repositioning resulted in the resident remaining on her back in the same position for more than two hours while in bed. The resident was admitted with multiple chronic conditions including type 2 diabetes mellitus with diabetic chronic kidney disease, rheumatoid arthritis, anxiety disorder, recurrent right shoulder dislocation, muscle weakness, chronic pain syndrome, bilateral shoulder pain, spondylosis, osteoarthritis, gout, and repeated falls. Her skin observation tool documented right buttock MASD, and her care plan identified altered skin integrity related to decreased bed mobility, incontinence, and history of a resolved ulcer. During observation, the resident was found lying on her back in bed with the head of the bed slightly elevated and stated she had wounds on her buttocks and pain in her buttocks and back. She remained in the same position during repeated observations over the next several hours and stated she had not changed position in bed. The ADON acknowledged she had remained in the same position since the earlier observation. CNA 1 stated the resident had been turned for incontinent care at about 10:00 AM and then placed back flat on her back, where she remained. LTN 1 and LTN 2 acknowledged the resident had fragile skin, a history of pressure injury, recent resolved MASD, and that staying in one position could result in skin breakdown. The care plan directed staff to turn and reposition several times per shift and as needed, and the DON stated staff were expected to reposition the resident at least every two hours. The facility policy also stated residents in bed should be on at least an every-two-hour repositioning schedule.
Resident Unable to Access Water When Thirsty
Penalty
Summary
The facility failed to ensure that Resident 1 had access to water and fluids when the resident complained of dry mouth, dry lips, and thirst. Resident 1 was admitted with multiple diagnoses including diastolic heart failure, type 2 diabetes mellitus with diabetic chronic kidney disease, rheumatoid arthritis, anxiety disorder, recurrent right shoulder dislocation, muscle weakness, chronic pain syndrome, spondylosis, osteoarthritis, diverticulosis, gout, and repeated falls. The resident’s BIMS score was 14, indicating intact cognition, and the care plan included interventions to promote good hydration. During observation, Resident 1 was lying in bed with the head of bed slightly elevated, repeatedly moistening her lips with her tongue, and her mouth and lips appeared dry. A water pitcher was present on the overbed table but was placed out of Resident 1’s reach, and no cup was available at the bedside. Resident 1 stated she was thirsty and could not reach the water pitcher, and also stated this was not the first time she needed a drink and could not access the water. LN 1 confirmed the pitcher was not within reach and that no cup was available, and stated staff should have poured water into a cup and ensured it was within Resident 1’s reach. The ADON stated the resident’s water was considered a personal item and should be kept within reach, and the DON stated staff were expected to ensure water was within residents’ reach.
Failure to Assess Pain and Reposition a Resident With Chronic Pain
Penalty
Summary
The facility failed to timely fully assess a resident’s pain and failed to provide non-pharmacological interventions, including repositioning, for a resident with multiple chronic pain-related diagnoses. The resident was admitted with diagnoses including type 2 diabetes mellitus with diabetic chronic kidney disease, rheumatoid arthritis, anxiety disorder, recurrent right shoulder dislocation, muscle weakness, chronic pain syndrome, pain in both shoulders, spondylosis, primary generalized osteoarthritis, gout, and repeated falls. The resident’s BIMS score was 14, indicating intact cognition, and the care plan identified alteration in comfort/pain with interventions that included assessing pain intensity and using non-pharmacological pain interventions such as repositioning. During observation, the resident was found lying on her back in bed with the head of the bed slightly elevated, grimacing and reporting pain all over her body, primarily in her buttocks and back, rating it 7 out of 10. The resident stated she had wounds on her buttocks, that no one had asked about her pain, and that she had not received pain medication. The resident was mostly dependent for rolling and repositioning and therefore relied on staff for pressure relief. Despite this, the resident remained in the same position in bed for more than two hours during repeated observations, and the CNA stated the resident had been turned for incontinent care at about 10:00 AM and then placed back on her back, where she remained. The LN stated pain assessments were done during the first medication pass, but also acknowledged she did not assess the resident’s pain characteristics, including pain level or location, during that time and that the resident did not receive pain medication then. The MAR showed Tylenol was given at 12:23 PM for pain rated 3 out of 10, and Norco was later ordered and administered at 1:24 PM when the pain level was 8 out of 10. The DON acknowledged the resident was not provided non-pharmacological interventions, including repositioning, before Norco was administered, and acknowledged the resident was not repositioned while in bed during the observation period despite the care plan intervention requiring repositioning.
Unsafe Food Storage, Thawing, and Hair Restraint Practices
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 63 residents receiving meals from the kitchen. During observation, two open cardboard boxes containing lettuce and cheese were placed on the kitchen floor in front of the freezer, and dietary staff confirmed the boxes were open, had holes on the bottom, and exposed the food items to the floor. A dietary aide also wore a hairnet that did not fully cover the back of her head, and both the aide and the cook confirmed that all hair should be covered. In the dry storage room, a mesh bag of onions was observed on the floor, a bag of cereal was tied in a plastic bag but not stored in a sealed container, and an open paper bag of flour was not stored in an airtight container. The cook confirmed the onion bag was open and on the floor, the cereal was not sealed in a container, and the flour was not stored in an airtight container. In the kitchen, nine bags of uncooked spinach were thawing under running water in the middle compartment of a three-compartment sink while open buckets containing chemicals were present in the adjacent sink compartments. A plastic food cart cover in an open box, an open box of gloves, and grill cleaner were stored together in a cabinet with cleaning supplies, a dust bin, and a broom. The dietary supervisor stated there was no issue with storing food-related items with cleaning supplies, while the registered dietitian and administrator reviewed the observations and confirmed that food should be stored off the floor, in sealed containers, thawed away from chemicals, and that hair and facial hair must be fully covered with appropriate hairnets. The facility policy and the FDA Food Code cited in the report also addressed safe food handling, dry storage off the floor, cross-contamination prevention, and hair restraints.
Improperly Covered Trash and Dumpster Lids
Penalty
Summary
The facility failed to ensure garbage and refuse were properly contained in the kitchen and outside dumpster areas for a total census of 64 residents. During an observation in the kitchen with the Dietary Supervisor, a trash can was seen with its lid propped open. In a concurrent observation and interview, the cook confirmed the trash can was not closed and stated it should have been fully covered with a lid. During a separate observation in the outside dumpster area with the Dietary Supervisor, one of the dumpsters was observed with its lid propped open. The Dietary Supervisor stated the dumpster lid should have been closed to prevent contamination and pests. The Registered Dietitian stated that trash bins inside the kitchen and outside dumpster areas should remain covered to prevent pest exposure, and the Administrator stated that dumpster lids should remain closed at all times. The facility policy titled Sanitation stated that garbage and refuse containers are to be properly contained in dumpsters/compactors with lids or otherwise covered, and the FDA Food Code cited that refuse receptacles shall have tight-fitting lids, doors, or covers.
Nebulizer Tubing Not Stored Properly and Legionella Water Management Controls Not Implemented
Penalty
Summary
The facility failed to practice appropriate infection prevention and control measures when Resident 102’s nebulizer tubing was not stored in a protective bag after use. Resident 102 was admitted with chronic obstructive pulmonary disease, dependence on supplemental oxygen, heart failure, muscle weakness, and need for assistance with personal care. The physician’s order included ipratropium-albuterol solution via nebulizer every two hours as needed for shortness of breath and wheezing. During observation, Resident 102 was found in bed with the nebulizer machine on the bedside table, and the nebulizer mask and tubing were placed on top of the machine rather than in the protective storage bag. The resident stated that a nurse administered the treatment and then placed the tubing on top of the nebulizer machine. A nurse later confirmed that the tubing was not in the protective storage bag and stated that not storing it there after use could spread infection. The MAR showed the nebulizer treatment had last been administered earlier that day, and the nurse supervisor stated the tubing had been left on a surface for eight hours, increasing the risk of contamination and infection transmission in the facility. The facility also failed to implement identified control measures in its Legionella Water Management Program. The Director of Maintenance stated that the facility did not test water temperature, pH, or chlorine, did not flush water in stagnant areas, and did not document cleaning of bacteria buildup on wet surfaces. Review of the water management program showed control points were identified, but the licensed nurse supervisor stated the control measures were not implemented or documented, including testing water temperature, pH, and disinfectant levels, flushing stagnant or slow-moving water, and documenting biofilm cleaning. The DON stated that control measures should be implemented and documented as part of the program, and that without monitoring, Legionella could grow in the building.
Delayed Completion of Comprehensive MDS Assessments
Penalty
Summary
The facility failed to ensure comprehensive MDS assessments were completed within the required time frame for 4 of 30 sampled residents. Resident 52 was admitted with diagnoses including acute embolism, thrombosis of the left lower extremity, hemiplegia and hemiparesis, paroxysmal atrial fibrillation, and dysphagia. During a concurrent interview and record review, the MDS Coordinator Nurse verified that the admission MDS assessment was due on 2/5/26 and confirmed it had not been completed as of 3/25/26. Resident 68 was admitted with diagnoses including hemiplegia and hemiparesis, aphasia, hyperlipidemia, and atherosclerotic heart disease of the native coronary artery. The MDS Coordinator Nurse reviewed the MDS tracking and confirmed that the annual MDS assessment was due on 2/11/26 and had not been completed as of 3/25/26. Resident 76 was admitted with diagnoses including unspecified atrial fibrillation, hyperlipidemia, polyosteoarthritis, and muscle weakness, and the MDS Coordinator Nurse confirmed that the annual MDS assessment was due on 2/15/26 and was still not completed as of 3/25/26. Resident 87 was admitted with diagnoses including essential hypertension, hyperlipidemia, spondylosis, contracture of the right foot, contracture of the left foot, and dysphagia. The MDS Coordinator Nurse confirmed that the annual MDS assessment was due on 2/8/26 and had not been completed as of 3/25/26. The MDS Coordinator Nurse stated that if a comprehensive assessment was not performed within the required time frame, the resident's current condition and care needs would not be accurately reflected, and that the assessment triggered care plan initiation. The DON stated that comprehensive MDS assessments were expected to be completed within the required time frame and that failure to complete them could delay identification of residents' needs.
Missed Quarterly MDS Assessments
Penalty
Summary
The facility failed to ensure quarterly MDS assessments were completed for 4 of 30 sampled residents. Resident 55 was admitted with diagnoses including type 2 diabetes mellitus, diplopia, muscle weakness, need for assistance with personal care, atrioventricular block, and repeated falls. Resident 46 was admitted with COPD, chronic respiratory failure, cachexia, and an anxiety disorder. Resident 56 was admitted with hemiplegia and hemiparesis, dysphagia, chronic kidney disease, and muscle weakness. Resident 84 was admitted with a lower femur fracture, pain, malignant neoplasm of the prostate, and immunodeficiency. During concurrent interview and record review with the MDSN, each resident's MDS tracking showed a quarterly assessment due date that had passed, but the assessment had not been completed as of the review. Resident 55's quarterly assessment was due on 2/12/26, Resident 46's on 2/19/26, Resident 56's on 2/7/26, and Resident 84's on 2/11/26. The MDSN confirmed that the quarterly assessments were not completed for any of these residents at the time of the review. The MDSN stated that if a resident's quarterly assessment was not performed within the required time frame, the resident's current condition and care needs would not be accurately reflected, which could prevent the care plan from being accurately updated and could result in inappropriate interventions. The DON stated that quarterly assessments were expected to be completed within the required time frame and that they identified changes in healthcare needs and helped staff provide timely interventions. Facility policy stated that quarterly MDS assessments are conducted at least every 92 days, that OBRA-required assessments include quarterly assessments, and that MDS information should consistently reflect progress notes, plans of care, and resident observations/interviews.
Pain medications given outside ordered pain-level parameters
Penalty
Summary
The facility failed to provide safe, appropriate pain management for multiple residents when pain medications were administered outside of the ordered pain-level parameters and when some residents did not have an ordered medication to address the pain level that was assessed. The report identified six sampled residents affected by these issues: Resident 10, Resident 12, Resident 31, Resident 45, Resident 46, and Resident 47. Resident 10 had diagnoses including rheumatoid arthritis, chronic pain syndrome, bilateral shoulder pain, and osteoarthritis, and had intact cognition with a BIMS score of 14. The physician ordered acetaminophen 325 mg, 2 tablets, for mild pain rated 1-3, and morphine 100 mg/5 ml for moderate pain rated 4-6 or severe pain rated 7-10. The MAR showed acetaminophen was given for pain ratings of 4, 7, and 8, and morphine was not given as ordered for those documented pain levels. There was no documentation that the physician was contacted when acetaminophen was given above the ordered parameter. Resident 12 had dementia, a BIMS score of 0, and a left artificial hip joint. The physician ordered acetaminophen 500 mg for mild pain rated 1-3 and hydrocodone-acetaminophen 5/325 mg for severe pain rated 7-10, with no order addressing pain rated 4-6. The MAR showed hydrocodone-acetaminophen was given for documented pain rated 6, and the record review found no physician contact to address the lack of an order for moderate pain. Resident 31 had dementia, cord compression, and lumbar spinal stenosis, with a BIMS score of 6. Orders were in place for acetaminophen 500 mg for mild pain and 2 tablets for moderate pain rated 4-6, but there was no order for pain rated 7-10. The MAR showed acetaminophen 500 mg, 2 tablets, was given multiple times for pain ratings above the ordered range, including ratings of 7 and 8, and there was no documentation that the physician was contacted about the out-of-range administration or the need for a revised pain regimen. Resident 45 had multiple sclerosis and intact cognition with a BIMS score of 13. The physician ordered acetaminophen 325 mg for mild pain rated 1-3 and hydrocodone-acetaminophen 5/325 mg, 2 tablets, for moderate or severe pain rated 4-10. The MAR showed acetaminophen was given for pain ratings of 4, 5, 6, 7, and 8, outside the ordered mild-pain parameter. The resident stated that hydrocodone-acetaminophen made her feel "weird" and "lost," but the record did not document side effects or physician notification related to those complaints. Resident 46 had opioid dependence and intact cognition with a BIMS score of 15. The physician ordered acetaminophen 325 mg for mild to moderate pain and morphine sulfate 100 mg/5 ml for severe pain rated 7-10 or shortness of breath. The MAR showed morphine was administered for documented pain ratings of 0, 5, and 6, outside the severe-pain parameter, and there were no progress notes showing physician contact about the out-of-range administration. Resident 47 had contusion of the right knee, gout, osteoarthritis, and a right artificial knee joint, with a BIMS score of 1. The physician ordered acetaminophen 325 mg, 2 tablets, for mild pain rated 1-4, but the MAR showed it was given for pain ratings of 5, 6, and 8, with no documentation that the physician was contacted about pain above the ordered range or the medication being given outside the parameter.
Dignity and Respect During Mealtime Assistance
Penalty
Summary
The facility failed to ensure residents were treated with dignity and respect for 2 of 30 sampled residents. Resident 52 was admitted with dysphagia oropharyngeal phase and hemiplegia/hemiparesis following cerebral infarction affecting the left non-dominant side. During a dining room observation, LN 1 and CNA 2 were preparing to pass the meal tray to Resident 52 when CNA 2 stated to LN 1, "No, she is a feeder," in reference to the resident, then placed the tray in front of her. CNA 2 later stated Resident 52 was a feeder because she required assistance with meals, and CNA 1 acknowledged that referring to the resident as a feeder was inappropriate. LN 1 and the LNS stated that labeling residents as feeders was inappropriate and that residents should be addressed by name and treated with dignity and respect. Resident 101 was admitted with diagnoses including encephalopathy, hepatorenal syndrome, hypo-osmolality and hyponatremia, schizophrenia, anxiety disorder, depression, muscle weakness, need for assistance with personal care, abnormalities of gait and mobility, arthropathy, and GERD. During a concurrent observation and interview in Resident 101's room, CNA 1 was assisting the resident with lunch while standing over the resident at the side of the bed rather than positioning at eye level. The MDSN stated CNA 1 was not at eye level and should have been positioned at eye level to promote dignity and provide respectful care. CNA 1 later stated that sitting at eye level was the best practice to maintain interaction and help the resident feel comfortable during care, and the DON stated staff were expected to maintain eye-level interaction and not stand over residents while assisting with meals.
Call Light Not Within Resident Reach
Penalty
Summary
The facility failed to accommodate the needs of Resident 18 when the resident’s call light was not within reach. Resident 18 was admitted with diagnoses including gram-negative sepsis, urinary tract infection, obstructive and reflux uropathy, dementia, abnormalities of gait and balance, muscle weakness, need for assistance with personal care, and a personal history of venous thrombosis and embolism. During observation, Resident 18 was sitting in a wheelchair on the left side of the bed near the foot of the bed, and the call light was wrapped around the left bed siderail and not visible from the resident’s position. Resident 18 stated he could not find or reach the call light. The Licensed Nurse Supervisor confirmed that Resident 18 was sitting in the wheelchair near the bed and that the call light was wrapped around the left bedside rail and not within reach. The LNS stated Resident 18 was not able to propel himself in the wheelchair and required assistance, and that he could fall if he attempted to reach the call light. The DON stated call lights must be within residents’ reach and answered promptly by staff. Resident 18’s care plan included keeping personal items and the call light within reach, and the facility policy stated to ensure the call light is accessible to the resident.
Nonfunctioning Resident Bathroom
Penalty
Summary
The facility failed to ensure a homelike environment for Resident 17 when the resident’s bathroom toilet was not functioning. During a concurrent observation and interview with the resident’s family member, the bathroom door had a sign stating “do not use,” and the toilet had no water with red and black buildup visible in the bowl. The family member stated Resident 17 did not like having to go to another resident’s bathroom to use a toilet and that the facility had to assist the resident to another resident bathroom instead of using his own bathroom. Licensed staff verified that Resident 17’s bathroom was not working and stated it had not been working for weeks. The Director of Maintenance stated the bathroom had not been functional for as long as he had worked at the facility. The ADON confirmed the facility policy was not followed and stated Resident 17 should have been provided a room with a working bathroom so he could use his own bathroom instead of going to another resident’s room. The facility policy on Homelike Environment stated staff and management maximize, to the extent possible, characteristics that reflect a personalized, homelike setting, including a clean, sanitary, and orderly environment.
Failure to Care Plan for COVID-19 Vaccine Refusal
Penalty
Summary
The facility failed to develop a comprehensive care plan for Resident 63 after the resident refused the COVID-19 vaccine in April 2025. Resident 63 was admitted with diagnoses including schizoaffective disorder, epilepsy, glaucoma, visual loss, anxiety disorder, repeated falls, and alcohol dependence in remission. Review of the informed consent form showed the resident refused the vaccine, and the Licensed Nurse Supervisor confirmed that no care plan was in place to address the refusal or the resident’s increased risk for infection during a COVID-19 occurrence in the facility. During the facility’s COVID-19 occurrence in September 2025, Resident 63 tested positive for COVID-19. The SBAR communication form and progress note documented the positive test, and the DON stated that residents who refused the COVID-19 vaccine required a care plan with specific interventions to address the refusal and alert staff to the increased risk for infection. The facility’s Infection Prevention and Control Program policy stated that prevention of infection includes instituting measures to avoid complications or dissemination, educating staff, and immunizing residents and staff, and the Care Plans policy stated that a comprehensive, person-centered care plan with measurable objectives and timetables is developed and implemented for each resident.
Failure to Follow Respiratory Orders for Shortness of Breath
Penalty
Summary
The facility failed to provide necessary care and treatment for a resident who complained of shortness of breath. The resident had multiple respiratory-related diagnoses, including COPD, chronic respiratory failure with hypoxia, and a history of lung cancer. When the resident reported shortness of breath at 6:00 p.m., the most recent vital signs had been taken earlier, and the last documented oxygen saturation was 96% on room air at 4:18 p.m. The record showed that the primary care clinician was notified at 6:05 p.m., and the resident was transferred to the hospital at 6:30 p.m. Review of the MAR and physician orders confirmed that the resident had orders for PRN albuterol nebulizer treatment every 6 hours for shortness of breath and for oxygen saturation checks as needed for signs or symptoms of shortness of breath or respiratory distress. The LN and DON both confirmed that the ordered albuterol treatment was not given, oxygen saturation was not obtained at the time of symptoms, and no respiratory assessment was documented before transfer. The MD stated that oxygen saturation is an important assessment during shortness of breath and that oxygen and/or a breathing treatment could have been provided at the time of symptoms.
Unnecessary Medication Administration
Penalty
Summary
The facility failed to ensure that one sampled resident was free from unnecessary drug administration when Resident 63 received Propranolol outside of the ordered hold parameters four times between February and March 2026. Resident 63 was admitted with diagnoses including orthostatic hypotension, hypertension, and repeated falls. The order summary dated 3/27/26 showed Propranolol HCl 10 mg by mouth three times daily for hypertension with instructions to hold if SBP was less than 100. During a concurrent interview and record review on 3/27/26, the ADON reviewed Resident 63’s February and March 2026 MAR and verified that Propranolol was administered on 2/11/26 at 1:00 p.m., 2/24/26 at 1:00 p.m., 3/3/26 at 9:00 a.m., and 3/5/26 at 9:00 a.m. outside of the medication order hold parameters. The ADON stated it was important to follow the parameters as ordered by the physician and noted that Resident 63 was at risk for side effects of Propranolol including drowsiness, headaches, and lethargy. The facility policy titled Administering Medications stated medications are to be administered in a safe and timely manner and as prescribed, and that vital signs are checked or verified prior to administering medications when necessary.
Failure to Reassess and Document Long-Term Antibiotic Use
Penalty
Summary
The facility failed to ensure antibiotic use was supported by ongoing reassessment and documented justification for a resident who was receiving levofloxacin for extended or long-term use. The resident was admitted with diagnoses including palliative care, anxiety, atrial fibrillation, and a chronic nonhealing left knee and thigh wound with abscess that had been surgically drained during a hospitalization in April 2025. The hospital discharge summary dated 4/9/25 indicated treatment for a left knee/distal thigh deep abscess with incision and drainage on 4/1/25, and the discharge plan from Infectious Disease included levofloxacin 750 mg every 48 hours through 4/21/25. Review of the resident’s electronic record showed levofloxacin 750 mg by mouth every 48 hours was ordered again on 6/26/25, two months after the last hospitalization, without clinical justification or supporting notes in the medical record. An orthopedic note dated 7/18/25 stated the resident was three months post I&D of the deep abscess and was continued on suppressive therapy with levofloxacin 250 mg every 48 hours for chronic use, which was increased to 750 mg every 48 hours by the facility’s primary MD. The resident was later placed on palliative care with comfort measures while continuing the antibiotic. During record review and interviews, staff acknowledged there were no subsequent wound cultures obtained to reassess continued levofloxacin use and no later infection screenings after the 7/17/25 infection screening evaluation to determine whether the resident still had an active infection or needed the antibiotic. A pharmacist recommended updating the order with a stop date or documenting the reason for indefinite continuation, and the handwritten response indicated the resident would continue levofloxacin per family request. The DON stated there was no documented education for the family regarding the risks and benefits of prolonged antibiotic use, and the MD stated the resident had been restarted on full-dose levofloxacin for long-term use without documented clinical justification or progress notes addressing effectiveness, with no follow-up from Infectious Disease to determine whether continuation was appropriate.
Failure to Report Resident’s Allegation of Verbal Abuse
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of verbal abuse in accordance with its abuse policy and mandated reporting requirements. A resident, admitted in 2025, stated that in the early morning hours of 1/10/26 he went to the snack room to get hot water for coffee and a licensed nurse told him he could not go into the snack room. The resident reported that this nurse accused him of being a thief and told him that if anything went missing he would be the number one suspect. The resident stated that the way the nurse spoke to him felt like verbal abuse and slander. He reported the incident to the licensed nurse supervisor, who told him he could enter the snack room to get hot water and that she would take care of it. In subsequent interviews, the involved nurse (LN 1) acknowledged asking the resident not to go into the snack room at night and to use the call light so staff could get snacks or hot water for him, explaining that night shift staff kept their belongings in the snack room. LN 1 denied calling the resident a thief or saying he would be the number one suspect if anything was missing. LN 1 stated she wrote a progress note in the electronic medical record and reported the incident to administration, but could not identify to whom she reported it and ultimately confirmed she did not actually report it, stating she did not see the relevance. Review of the resident’s electronic medical record showed no progress note documenting the incident. The facility’s grievance binder showed that the nurse supervisor completed a grievance form on 1/12/26 after the resident reported that a nurse was rude and told him it was not okay to take food from the snack room at night; the grievance did not characterize the concern as abuse. Additional interviews showed that the resident described the incident as verbal abuse to individuals outside the immediate facility chain. A transition-of-care nurse from the resident’s insurance reported that on 1/27/26 the resident called and stated he was verbally abused by a nurse, leading to a three-way call attempt to the Ombudsman’s office during which the resident left a voicemail stating he was verbally abused. Another nurse on duty the night of the incident (LN 2) stated the resident told him that a nurse had called him a thief and that he felt abused; LN 2 reported the incident to the nurse supervisor. The Ombudsman reported receiving a message that the resident had called on 1/26/26 and, upon returning the call, the resident stated that a nurse verbally assaulted him but did not provide the nurse’s name. The facility’s Elder/Dependent Adult Abuse policy required that any mandated reporter who has knowledge of an incident that reasonably appears to be abuse, or is told by an elder that they have experienced behavior constituting abuse, must immediately report the known or suspected abuse to the administrator and appropriate external authorities within specified time frames. Despite the resident’s statements to staff and others that he felt verbally abused, the allegation was not reported as required by policy and state law.
Resident Elopement and Injury Due to Unsecured Exit Door
Penalty
Summary
A deficiency occurred when a resident with a history of diabetes mellitus, chronic kidney disease, and spinal stenosis exited the facility through an unlocked rear Dining Room door and was missing for approximately one and one-half hours before staff became aware. The resident, who had a Brief Interview for Mental Status (BIMS) score of 6 indicating severe cognitive impairment, was found to have left the facility in her wheelchair and was later discovered at a nearby hospital emergency department after sustaining a fall and injuries, including facial lacerations and contusions. The incident was captured on facility camera footage, which showed the resident leaving through the rear Dining Room door, crossing the street, and moving out of camera view. Prior to the incident, the resident had not been assessed as being at risk for elopement, as indicated by multiple Elopement/Wandering Risk Assessments completed before the event, all scoring below the threshold for elopement risk. The resident had intermittent confusion and was ambulatory with assistance, including the ability to self-propel in a wheelchair. The facility had equipped the resident with a wheelchair alarm that sounded when she stood up, but there was no Wander Guard device in place before the incident. The rear Dining Room door, through which the resident exited, did not have an alarm or Wander Guard system at the time of the event. Staff became aware of the resident's absence during the dinner tray pass, after which a search was initiated, and the resident was eventually located at the hospital. Interviews with staff and administration confirmed that the rear Dining Room door was not considered a hazard prior to the incident, as the resident had not previously attempted to leave the facility. The door was not locked or alarmed, and its status as an exit was misunderstood among staff, with some believing it was not a designated fire exit. The lack of adequate supervision and environmental safeguards contributed to the resident's unsupervised exit and subsequent injury.
Improper Disposal of Meal Tickets Compromises Resident Privacy
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of residents' personal and medical records by improperly disposing of meal tickets in the kitchen garbage bin. During observations, it was noted that a Dietary Aide discarded uneaten food, used napkins, and residents' meal tickets into the trash. These meal tickets contained sensitive information such as residents' names, unit, room, and bed numbers, diet orders, allergies, food notes, and preferences. The Dietary Service Supervisor confirmed the practice and acknowledged the lack of a proper disposal process for these meal tickets. Interviews with the Registered Dietician and the Director of Nursing revealed that the practice of throwing meal tickets in the trash did not meet their expectations and violated HIPAA regulations. The Registered Dietician stated that the meal tickets should have been shredded to prevent unauthorized access to residents' information. The Director of Nursing emphasized that the meal tickets are part of the residents' medical records and should be shredded to protect against unauthorized access. The facility's policies on health information and confidentiality also indicated the need to secure residents' information against unauthorized access.
Food Safety and Storage Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food safety, as evidenced by several deficiencies observed during a kitchen tour. Expired food items, including strawberries and tomatoes, were found in the reach-in refrigerator and dry storage, posing a risk of foodborne illnesses to residents. Additionally, food items were improperly labeled and dated, which could lead to the consumption of spoiled food. The Registered Dietician acknowledged that the quality of produce was overlooked, and the findings did not meet the facility's expectations. Non-food items, such as folding chairs, were improperly stored in the dry food storage room, which is designated solely for food storage. The Dietary Service Supervisor was unable to provide a reason for the placement of these chairs. Furthermore, the water filter for the coffee machine was not changed according to the manufacturer's guidelines, and there was no tracking system in place to monitor the filter's usage. This oversight could result in contaminants entering the water supply. Additional issues included a dirty fan in the food preparation area, wet tray line pans and a food processor bowl, and a dirty ice machine. The fan, covered in a grey fuzzy substance, posed a risk of contaminating food with particles. Wet pans and a food processor bowl could foster the growth of microorganisms, while the ice machine's unclean condition could lead to resident illness. These conditions were confirmed by the Dietary Service Supervisor and the Registered Dietician, who stated that they did not meet the facility's expectations and could potentially make residents sick.
Improper Garbage Disposal Leading to Potential Pest Infestation
Penalty
Summary
The facility failed to maintain proper disposal of garbage and refuse, as observed during a survey. On the specified date, the trash bin for the facility was found overflowing with trash bags, and the lid was placed completely behind the bin. This situation was confirmed during an interview with a staff member, who indicated that the trash service had left the bins in that condition. The open and overflowing trash bins were not in line with the facility's normal process, as stated by the Dietary Services Supervisor, who emphasized the importance of keeping dumpster lids closed to prevent pest infestations. Further interviews with the Registered Dietician reinforced the expectation that dumpster lids should be closed and that garbage should not overflow to avoid sanitation issues and potential pest problems. The report references the 2022 Food Code by the FDA, which outlines the necessity of proper storage and disposal of garbage to minimize odors, prevent attraction and breeding of pests, and maintain sanitary conditions. The failure to adhere to these guidelines posed a risk of insect and rodent infestation due to the improper handling of waste.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to consistently implement an antibiotic stewardship program, which is crucial for ensuring that antibiotics are used only when necessary and appropriate. This deficiency was observed in the cases of two residents, where the Loeb and McGeer criteria were not consistently applied to assess the initiation and appropriateness of continued antibiotic use. For Resident 122, an antibiotic was prescribed for a suspected upper respiratory infection without meeting the necessary infection criteria, and there was no documentation of an infection screening evaluation on the day the antibiotic was first prescribed. In the case of Resident 56, an antibiotic was prescribed following a family member's request, despite the resident not meeting the infection screening criteria. The Infection Screening Evaluation was completed two days after the antibiotic was started, and it did not support the reason for the antibiotic prescription. There was no record of communication with the medical doctor to address the discrepancy between the prescribed antibiotic and the infection criteria. The facility's policies on antibiotic stewardship and infection prevention were not adhered to, as evidenced by the lack of appropriate documentation and communication regarding antibiotic prescriptions. The Pharmacist Consultant noted that inappropriate antibiotic orders were not addressed in stewardship meetings, as he was not invited to participate. This lack of adherence to established protocols and communication failures contributed to the deficiency in the facility's antibiotic stewardship program.
Failure to Maintain Resident Dignity by Ensuring Privacy
Penalty
Summary
The facility failed to ensure the dignity of Resident 119 by not covering the resident's genital area with a sheet while he was sleeping in bed. This incident was observed during a concurrent observation and interview with a Certified Nursing Assistant (CNA), who confirmed that the resident's genitals were exposed. The CNA acknowledged the expectation for residents' private parts to be covered to prevent a loss of dignity and feelings of shame. The Assistant Director of Nursing (ADON) also stated that residents should be covered with a sheet for dignity and that staff should make rounds to ensure residents are decently covered. Resident 119 mentioned a personal preference for not wearing undergarments to facilitate easier bathroom use. The facility's policy on Quality of Life - Dignity, revised in February 2020, indicates that staff should promote, maintain, and protect resident privacy, including bodily privacy.
Failure to Administer Insulin with Proper Parameters Leads to Hypoglycemic Event
Penalty
Summary
The facility failed to provide quality care to a resident with type 2 diabetes mellitus and diabetic chronic kidney disease when staff administered rapid-acting insulin without appropriate parameters. The insulin order did not include specific instructions on when to hold or not administer the insulin, leading to the administration of 10 units of Insulin Lispro to the resident when their blood glucose (BG) level was 129. This administration occurred despite the resident's responsible party indicating that the resident did not take insulin at home. Following the insulin administration, the resident refused their scheduled meal, which was not communicated to the physician by the staff. As a result, the resident experienced a hypoglycemic event with a dangerously low BG level of 36, requiring emergent medical treatment. The facility's documentation indicated that the resident was observed to be sleepy and sweaty, and emergency interventions, including the administration of a Glucagon Emergency Kit and orange juice with sugar, were necessary to stabilize the resident's condition. Interviews with facility staff, including a licensed nurse and the Director of Nursing, revealed that there was a lack of communication and clarification regarding the insulin order. The staff did not contact the physician to clarify the order or obtain hold parameters, which could have prevented the hypoglycemic event. The facility's protocols emphasized the importance of considering the risk of hypoglycemia and incorporating physician-ordered parameters into the care plan, which was not adhered to in this case.
Inaccurate Documentation of Narcotic Medication for Resident in Hospice Care
Penalty
Summary
The facility failed to ensure safe pharmaceutical services for a resident, identified as Resident 55, by not accurately documenting narcotic medications in the Medication Administration Record (MAR) when removed from the Controlled Drug Record (CDR). This discrepancy was observed during a review of Resident 55's records, which indicated that the dosages of Morphine Sulfate, a narcotic medication prescribed for pain, were not accurately recorded. The Director of Nursing (DON) confirmed that the staff documented Resident 55's doses of Morphine Sulfate inaccurately on the MAR for November and December 2024, and that the facility policy was not followed. Resident 55 was admitted with diagnoses including chronic kidney disease and a non-pressure chronic ulcer of the right midfoot and heel. The resident was under hospice care, which involved both facility licensed nurses (LNs) and hospice nurses administering Morphine Sulfate for pain management. However, there was a lack of coordination and documentation between the facility staff and hospice nurses regarding the administration of the medication. The hospice nurse, LN 2, stated that medications given by hospice nurses were obtained from the facility's medication cart and documented by facility LNs, but the hospice binder for Resident 55 was not found. The facility's policy and procedure for medication administration emphasized the importance of the 'Five Rights'—right resident, right drug, right dose, right route, and right time—and required a triple check of these rights during medication preparation. Despite these guidelines, the facility failed to maintain accurate records of the narcotic medication administration, which could potentially impact the well-being of Resident 55. The facility's policy also outlined responsibilities for administering prescribed therapies, including those determined appropriate by hospice, but these were not adequately followed in this case.
Failure to Adhere to Antibiotic Stewardship Program
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications. Resident 56 was administered an antibiotic, Levofloxacin, despite not meeting the criteria established by the facility's antibiotic stewardship program. The antibiotic was prescribed for chest congestion and left ear pain, but the necessary Infection Screening Evaluation was not completed prior to the initiation of the medication. The Nurse Consultant confirmed that the evaluation, which should have been done before starting the antibiotic, was only completed two days later and did not support the use of the antibiotic for the reasons it was prescribed. During a review of the resident's medical records, it was found that there was no communication with the medical doctor regarding the lack of criteria met for the antibiotic prescription. The Pharmacist Consultant noted that had the antibiotic been active during his drug regimen review, he would have recommended against its use, as the resident did not meet the infection criteria. The Pharmacist Consultant also highlighted that Levofloxacin is not typically prescribed for bronchitis unless there is a history of it progressing to pneumonia, which was not documented in this case. The facility's policies on infection prevention and antibiotic stewardship were not adhered to, as the protocols for monitoring antibiotic use and ensuring appropriate prescriptions were not followed. The facility's policy required that prescribers provide complete antibiotic orders with indications for use, which was not done in this instance. The failure to follow these protocols resulted in the unnecessary administration of an antibiotic to Resident 56, which could lead to adverse effects and the development of antibiotic-resistant organisms.
Resident Received Incorrect Dosage of Narcotic Pain Medication
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when the resident received more than the prescribed dose of a narcotic pain medication for over a month. The resident, who was admitted with chronic kidney disease and a non-pressure chronic ulcer, was prescribed Morphine Sulfate in varying concentrations and dosages over time. However, discrepancies were found between the physician's orders, the medication administration records (MAR), and the controlled drug record (CDR), leading to the administration of incorrect dosages. The physician's orders for Morphine Sulfate changed multiple times, specifying different concentrations and dosages for pain management. Despite these changes, the facility's records indicated that the resident received doses that were inconsistent with the prescribed orders. The Director of Nursing (DON) confirmed that the doses documented as given were less than those removed from the medication cart, indicating a failure to administer the correct dose. This discrepancy was attributed to errors in documentation by the staff, who did not follow the facility's policy on medication administration. The facility's policy required a triple check of the five rights of medication administration, which include the right resident, drug, dose, route, and time. However, this procedure was not followed, leading to the administration of incorrect dosages. The DON acknowledged that the staff failed to clarify the physician's orders, resulting in the resident not receiving the correct dose of pain medication. This oversight had the potential to impact the resident's quality of life and well-being.
Medication Storage and Labeling Deficiency
Penalty
Summary
The facility failed to ensure medications were labeled, stored, and disposed of according to standards of practice for a census of 57 residents. During an observation and interview, it was found that an opened, unlabeled container of psyllium fiber supplement and an opened, unlabeled bottle of cough medicine were stored in the medication cart. Additionally, medications for a discharged resident were also found in the medication cart. The Licensed Nurse (LN) acknowledged that these items should not have been in the medication cart and removed them. The Director of Nursing (DON) confirmed that medications for discharged residents should be removed from the medication cart, locked in a cabinet in the medication storage room, and destroyed routinely. The DON stated that the presence of discharged residents' medications in the cart posed a risk of being administered to another resident in error. The facility policy required open dates to be placed on medications, but this was not followed, as acknowledged by the DON. The facility's policy and procedure for the storage of medications indicated that medications should be stored safely and securely, with expiration dating and open dates clearly labeled, which was not adhered to in this instance.
Failure to Implement Droplet Isolation Precautions for RSV
Penalty
Summary
The facility failed to implement proper infection prevention practices for a census of 57 residents, leading to a deficiency. Resident 171 was placed in a room with another resident who tested positive for RSV without Droplet Isolation Precautions in place. This oversight occurred on December 15, 2024, and was confirmed through observation and interviews with facility staff. The lack of isolation precautions increased the risk of infection transmission to Resident 171, who was not tested for RSV as he showed no symptoms at the time. Resident 9, who tested positive for RSV on December 11, 2024, was not placed under Droplet Isolation Precautions until December 16, 2024. This delay in implementing isolation measures was confirmed by the facility's Infection Preventionist, who acknowledged that the facility's policy was not followed. The absence of isolation precautions for Resident 9 exposed other residents, staff, and visitors to the risk of RSV infection. The facility's policy, as outlined in their procedure for initiating Transmission-Based Precautions, was not adhered to in these cases. The policy requires that precautions be implemented when a resident has a confirmed infection and is at risk of transmitting it to others. The failure to follow this policy resulted in a deficiency, as the necessary precautions were not in place to prevent the spread of infection within the facility.
Failure to Document Influenza Vaccine Offer and Consent
Penalty
Summary
The facility failed to provide the influenza vaccine to one of the five sampled residents, identified as Resident 11, as there was no documented evidence in the resident's medical record that the vaccine had been offered, given, or refused. Resident 11 was admitted to the facility in 2022 with diagnoses including chronic obstructive pulmonary disease and dementia. The resident's admission record listed a conservator as the responsible party, with contact information provided. During a review of Resident 11's electronic medical record with the Infection Preventionist (IP), it was confirmed that there was no record of the influenza vaccination being offered or administered for the current flu season. The IP stated that attempts were made to contact the conservator for consent, but no response was received, and there was no documentation of these attempts in the medical record. In an interview with the Director of Nursing (DON) and the Nurse Consultant (NC), it was stated that the influenza vaccine was available and offered to residents starting in September, with documentation required on the consent form if the vaccine was given or declined. The DON indicated that the expectation was for the IP to document any attempts to obtain consent from a resident's responsible party. If contact could not be made, staff were expected to continue trying weekly and document these attempts in the resident's medical record. The facility's policy on the influenza vaccine, dated October 2019, required that all residents without medical contraindications be offered the vaccine annually, with refusals documented in the medical record.
Failure to Complete Required PASRR Evaluation
Penalty
Summary
The facility failed to submit a new Level I Preadmission Screening and Resident Review (PASRR) for a resident diagnosed with schizophrenia, who was admitted in 2022. The initial Level I PASRR indicated a positive result for suspected mental illness, necessitating a Level II Mental Health Evaluation. However, this evaluation was not completed because the resident was isolated as a health or safety precaution. The facility was required to submit a new Level I screening to reopen the case, but this was not done, potentially placing the resident at risk of not receiving necessary care or services. During interviews and record reviews, the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) confirmed that the Level II evaluation was not completed and a new Level I screening was not conducted. The ADON acknowledged that the resident's behavior could worsen without proper treatment, and the DON noted the potential for missing behavior monitoring and proper treatment, which could put both the resident and the facility at risk. The facility's policy on PASRR was reviewed, and it was confirmed that the policy was not followed, as a new Level I screening should have been completed to reflect the resident's mental health diagnosis.
Medication Reconciliation Failure at Discharge
Penalty
Summary
The facility failed to accurately complete a medication reconciliation for a resident at the time of discharge, resulting in the resident being sent home with a discontinued medication. The resident, who was admitted with diagnoses including depression and muscle weakness, was initially prescribed Mirtazapine, which was later discontinued. However, during the discharge process, Mirtazapine was included among the medications sent home, despite not being listed in the discharge instructions. The error was confirmed during a review of the resident's discharge records by the Director of Nursing and a Licensed Nurse. The nurse responsible for the discharge was counseled and no longer worked at the facility. The facility's policy required that medications be reconciled and verified against current physician orders, but this process was not followed, leading to the inclusion of the discontinued medication in the resident's discharge medications.
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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 Stockton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Good Samaritan Rehab And Care Center | 0.3 mi | ★★★★★ | 1 | 0 |
| Hampton Post Acute | 1.1 mi | ★★★★★ | 17 | 0 |
| Noble Care Center | 1.2 mi | ★★★★★ | 5 | 0 |
| Fulton Gardens Post Acute, Llc | 1.7 mi | ★★★★★ | 20 | 0 |
| Brookside Care Center | 2.1 mi | ★★★★★ | 22 | 0 |
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