Below average — CMS composite of the measures below.
The next survey window likely opens around March 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 Live Oak Rehab Center during CMS and state inspections, most recent first.
Failure to Notify RP of Change in Dental Treatment Plan: A resident with depression, gout, and muscle weakness was scheduled for a dental extraction, but the procedure was cancelled when the resident arrived and the RP was not notified. RN staff acknowledged they did not inform the RP of the change, and the DON stated the resident/resident representative has the right to know about changes in the treatment plan.
A resident with dementia, weakness, and dependence for all ADLs developed unexplained discoloration/bruising on the thigh while under 1:1 observation. A CNA reported the resident was frequently flailing her hands and kicking her legs during monitoring, but staff could not determine how the injury occurred. The LVN, DON, and ADM all stated the source of the bruise was unknown, and the care plan did not address the resident’s flailing and kicking behaviors.
Call Light Not Within Resident’s Reach: A resident with a history of falls, vascular parkinsonism, cataract, and dementia was observed sitting in a wheelchair and slouching while the call light was placed on the bed out of reach. The resident stated she was uncomfortable, needed repositioning, and could not reach the call light to alert staff. CNA and DON both confirmed the call light should be within reach, and the care plan and facility policy directed staff to keep it accessible.
Failure to assist a resident with meals: A resident with dementia, malnutrition, underweight status, and failure to thrive was care planned for tray setup, assistance, and verbal cues during meals, and the MDS showed partial/moderate assistance was needed with eating. During observation, the resident was left with the lunch tray in the hallway without staff assistance, was only told to eat while staff cared for another resident, and the tray was later removed after only one spoonful had been eaten. The LVN and DON both stated the resident needed assistance, supervision, and cueing while eating.
Two residents had respiratory equipment left on the floor and not maintained as ordered. One resident’s oxygen tubing was found disconnected from the concentrator and lying on the floor, and the RN supervisor reconnected it without sanitizing it. Another resident’s nasal cannula and nebulizer tubing were observed touching the floor while the oxygen concentrator was running. Staff stated the tubing should be kept in a clean setup bag when not in use and changed if it touches the floor, and facility policies required secure oxygen setup, observation, and infection control practices.
Failure to Monitor Insulin and IV Antibiotic Therapy: Two residents receiving insulin were not documented as being monitored for signs and symptoms of hypo- and hyperglycemia, despite care plan interventions directing staff to observe for those changes. One resident also received two IV antibiotics for an MRSA wound, but staff did not document monitoring for antibiotic side effects as outlined in the care plan, and nursing staff stated there were no monitoring orders or documentation showing the care plan was followed.
Incorrect Portion Size Served for Lunch Entrée: During lunch tray line assembly, a dietary worker used a 1 oz portion spoon to serve sweet and sour sauce with vegetables even though the spring menu specified a 2 oz serving. The DSS confirmed the menu requirement and stated correct portion sizing is important to ensure residents receive necessary nutrients and enhance digestion; the facility's P&P also required standardized portion sizes and labeled portion utensils.
Unsafe Temperature for Cooked Chicken During Meal Service. Kitchen staff failed to ensure cooked chicken reached the required 165 F during lunch tray line assembly; the chicken measured 140 F when checked by the DSS. The DSS stated poultry must be held at 165 F to prevent foodborne illness, and the facility P&P for Food Preparation and Service required poultry to reach 165 F.
Food Labeling, Hand Hygiene, and Cart Cleanliness Deficiencies: The DSS observed multiple food items in the kitchen without required labels, including prepared sandwiches and chicken thighs that lacked preparation, thaw, and/or use-by dates. During tray line assembly, the DSS picked up an alcohol wrap from the floor without changing gloves or performing hand hygiene, then used the same gloves to place a thermometer into cooked chicken. Three food carts also had dried white stains on their doors, and the DC stated kitchen staff should have maintained cart cleanliness to prevent food borne illness.
Infection control practices were not followed for a resident with a dirty TF machine, in the laundry clean area where used cups, paper towels, and splatter stains were found near clean linens, and during G-tube medication administration for a resident on EBP. An LVN donned gloves but forgot to wear a gown before checking G-tube placement and giving meds and enteral feeding, despite the care plan requiring gloves and gowns for device care.
Damaged Wall Surfaces in Resident Rooms: Two residents had wall surfaces behind their headboards that were discolored and scratched, which did not meet the facility's homelike environment policy. One resident had dementia, muscle weakness, and repeated falls with moderate assistance needs for several ADLs, while the other had dementia, failure to thrive, and severe cognitive impairment with dependence for most ADLs. The MS stated the damage was caused by the bed hitting the wall during transfers and acknowledged the rooms were not homelike.
Failure to protect a resident’s PHI occurred when an LPN dispensed medication and left the laptop on with the resident’s eMAR displayed and facing the hallway while residents and staff passed by. The resident had renal insufficiency, asthma, COPD, and colon cancer, and was cognitively intact and independent in several ADLs. The LPN stated the screen should be turned off to secure privacy and prevent others from seeing medication and medical information.
Call Light and TV Not Kept Accessible: A resident with dementia, muscle weakness, and repeated falls was observed with the call light left near the feet instead of within reach, despite the care plan calling for it to be kept accessible. The resident’s TV was also unplugged and the remote did not work, and CNA, RNS, and Maintenance interviews confirmed the call light and TV setup were not as intended.
Failure to provide oral care for a dependent resident. A resident with CVA-related diagnoses and dysphagia was severely cognitively impaired and dependent for oral hygiene and multiple ADLs. Staff observed white crust in the resident's mouth on repeated checks, while CNA and RNS interviews confirmed oral care was expected each shift and the facility policy required assistance with oral care for residents unable to perform ADLs independently.
A resident with adult failure to thrive, dehydration, and severe cognitive impairment did not receive tube feeding as ordered. The physician ordered Jevity 1.2 at 55 ml/hr for 20 hours via pump, but staff observed the feeding container still full at 1500 ml, and an LVN stated the resident had not received any feeding since the container was hung. Another LVN later confirmed the resident was not receiving the TF as ordered, and the DON reviewed the facility’s enteral nutrition policy during the investigation.
PICC Line Care Deficiency: A resident admitted with a PICC line was not assessed or documented on admission, the physician’s order to discontinue the line was not followed, and the PICC dressing was not changed on admission or weekly as required. The RN supervisor stated the line should have been documented, removed per the MD order, and redressed, while the resident’s chart and observations showed the PICC remained in place with an old dressing.
Medication Administration Identification Failure: An LPN administered medications to a resident after checking the eMAR photo but not the armband, despite the facility policy requiring resident identification before medication administration using two identifiers such as the ID band, photo, or verification by other staff. The DON confirmed licensed nurses must use two identifiers to ensure the right medication is given to the right resident.
Improper Labeling and Storage of an Opened Medication Bottle: An opened Promethazine bottle used for a resident with renal insufficiency, asthma, COPD, and colon cancer was observed in Medication Cart 2 without a visible open date or expiration date. An LPN dispensed the medication without checking those dates, and both the LPN and DON were unable to locate the required labeling on the bottle.
Diet Order Not Followed for Resident with Soft and Bite-Sized Diet: A resident with HTN, hx of SBO, COPD, and dementia was ordered a NAS, soft and bite-sized diet with thin fluids, but was observed at lunch with a whole quarter-size chicken on the plate. Staff and the Dietary Consultant confirmed the chicken was served whole instead of being cut into smaller bite-sized pieces, and the resident did not attempt to eat the meal.
A resident with dementia, muscle weakness, a history of repeated falls, and documented moderate cognitive impairment was observed scooting off a wheelchair, a behavior that staff, including the ADSD, LVN, and RN supervisor, reported had been occurring since admission and for several months. Despite the resident’s dependence on staff for multiple ADLs and the facility’s policy requiring comprehensive person-centered care plans with measurable objectives and timeframes, review of care plans over an extended period showed no care plan addressing the resident’s frequent scooting or sliding from the wheelchair or bed, as confirmed by the DON.
A resident with moderate cognitive impairment and dependence in ADLs was previously subjected to an attempted kiss in a hallway by another resident with dementia, psychosis, and largely intact cognition. Although this earlier inappropriate contact was stopped by an LVN, the second resident’s care plan was not updated to address the behavior. Later, a CNA found the same resident on top of the cognitively impaired resident in her room, kissing her on the lips and touching her breast while she tried to turn her face away, and the resident later nonverbally confirmed being touched on her breasts and genital area. Staff interviews and record review showed that the lack of a behavior-focused care plan and monitoring after the first incident contributed to the subsequent sexual abuse.
A resident with aphasia, moderate cognitive impairment, and a prior history of gangrene from wrapping behavior was observed with red discoloration and a constricting mark on a finger while tangled call light cords and coiled bed control cables hung within reach on the bed. Staff, including an LVN and multiple CNAs, acknowledged that the resident had a known pattern of wrapping cords, gown strings, and GT tubing around her fingers and that these items posed a safety hazard, yet cords and cables were left accessible and prior incidents were not reported to other staff. The DON confirmed the resident’s history and behavior, recognized the cords and cables as hazards, and acknowledged that the resident’s care plan did not include specific problems or interventions addressing her wrapping behavior, despite a facility policy requiring identification and mitigation of safety risks.
The facility failed to report an allegation of resident-to-resident abuse to required agencies within the two-hour timeframe specified in its abuse policy. Two residents with dementia and significant ADL needs were involved in an incident in the activity/dining room in which one allegedly struck the other, as observed by a CNA. The CNA stated an LVN said she would make a report, but the CNA did not notify the Administrator or other staff that day, and the LVN reported learning of the allegation the following day. Several days later, the DSD informed the DON and Administrator, who then conducted an internal investigation but did not notify the State Survey Agency, APS, law enforcement, or other required entities, despite facility policy defining such alleged hitting or slapping as abuse that must be reported within two hours.
A resident with heart failure, severe cognitive impairment, and dependence in most ADLs did not have transportation arranged by facility staff for scheduled outside PCP appointments. Family reported two missed PCP appointments, while the social worker stated only one transportation arrangement had been made and that she was unaware of one of the appointments. Review of physician orders showed a one-time order for an outside appointment on one date but no order for the later PCP visit, and licensed nurses were responsible for placing transportation orders in the transportation communication binder.
A resident with a history of falls, muscle weakness, and dementia experienced an unwitnessed fall. The LVN who discovered the fall did not immediately notify the physician, DON, or responsible party, despite facility policy and the resident's care plan requiring such notification. The incident was only reported several days later, as confirmed by record review and staff interviews.
The facility did not consistently post accurate and updated nurse staffing and DHPPD information as required by its policy, resulting in outdated postings and discrepancies between scheduled and actual staff present. Staff responsible for posting were not available or trained to complete the task on weekends and holidays, leading to residents and visitors not being informed of current staffing levels.
A resident with cognitive impairment and recent hip surgery sustained a right hip dislocation, which was confirmed by x-ray and led to hospital transfer. The facility did not report this unusual occurrence to the state agency within the required 24-hour timeframe, contrary to its own policy.
A resident with multiple complex diagnoses, including dementia and recent hip surgery, developed a right hip dislocation of unknown origin shortly after admission. Despite facility policy requiring investigation of injuries of unknown source, no investigation was conducted, as staff incorrectly assumed the injury predated admission. Both the DON and administrator confirmed the lack of investigation, contrary to facility procedures.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, increasing the risk of resident accidents.
A resident's care plan was found to be incomplete, missing measurable timetables and specific actions to address all identified needs. Surveyors observed that the care planning documentation did not fully meet regulatory requirements for individualized and comprehensive care.
A CNA physically abused a resident with severe cognitive impairment by grabbing the resident's shirt in a manner that caused choking and then slapping the resident's back after the resident threw water at the CNA. The incident was witnessed by staff and confirmed by surveillance video, and was in direct violation of the facility's abuse prevention policy.
The facility failed to secure medications properly, with OTC drugs stored in an unlocked central supply room and a vial of Lorazepam found in an unlocked fridge. The storage room, accessible to various staff, contained unlocked cupboards with OTC medications, violating the facility's policy requiring secure storage accessible only to authorized personnel.
The facility failed to provide appetizing and palatable meals to two residents, leading to dissatisfaction and potential risks for unplanned weight loss. One resident, with dietary preferences due to medical conditions, received meals that did not align with her needs. Another resident expressed dissatisfaction with the quality and repetitiveness of meals, leading to skipped meals. Test trays confirmed poor meal quality, with issues in texture and flavor, contrary to the facility's policies on food preparation and accommodation of needs.
The facility failed to follow proper food handling practices, including storing expired food, mixing personal and resident food, and improper labeling of dry food items. Chemicals were stored with food, and a staff member did not practice proper hand hygiene, leading to potential cross-contamination. These actions violated the facility's policies and put residents at risk of foodborne illnesses.
A facility failed to maintain a resident's dignity during mealtime assistance when a CNA stood above the resident while feeding, contrary to policy. The resident, with cognitive impairment and requiring assistance, was observed being fed by a standing CNA, which was confirmed as inappropriate by the DON.
A facility failed to conduct a Level 2 PASARR for a resident with schizophrenia, despite a Level 1 PASARR indicating the need for further evaluation. The resident, who had severe impaired cognition and required assistance with daily activities, exhibited confusion and aggression. The facility's failure to follow up on the necessary evaluation left them without recommendations for the specialized care needed for the resident's mental health condition.
A resident with multiple fractures experienced inadequate pain management due to the facility's failure to update her care plan to include a physician-ordered Fentanyl patch. Despite the resident's constant pain, the care plan was not revised to reflect the new intervention, leading to a lapse in pain management. The DON confirmed the care plan should have included details on the Fentanyl patch's administration and handling.
A non-English speaking resident with dementia did not have access to a communication board or translation services, leading to unmet needs and confusion. The resident was dependent on staff for daily activities and had severe cognitive impairment. Staff failed to use available resources for communication, and the facility's policy for supporting communication was not followed.
A resident requiring total assistance with personal hygiene was found with dirty fingernails and a thick brown crust around the nail bed, indicating a lack of proper nail care. Despite the resident's medical conditions and need for dependent care, observations and interviews revealed that the facility staff failed to maintain the resident's nail hygiene, potentially leading to infection.
A resident with hemiplegia and aphasia was not provided with age-appropriate activities, negatively affecting his well-being. Despite his interest in music, reading, and news, the facility failed to assess and offer suitable activities. The resident expressed dissatisfaction with the options available, and staff confirmed the lack of age-appropriate activities. The facility's policies on dignity and accommodation of needs were not effectively implemented.
A resident with significant weight loss and cognitive impairments did not receive the required feeding assistance as per the RNA program in place. Staff failed to document the resident's nutritional intake accurately, with CNA unaware of the resident's dietary needs and RNA occupied with other residents. The facility's policies on feeding assistance and weight management were not followed, risking further health complications for the resident.
A resident with multiple fractures experienced severe pain due to the facility's failure to reorder a Fentanyl patch in advance, as per policy. The patch was not available when needed, and the resident's pain was not reassessed or managed effectively, despite her expressing severe discomfort. The staff did not administer Norco or follow the care plan, resulting in the resident suffering unnecessary pain.
A facility failed to provide trauma-informed care for a resident with PTSD, leading to potential re-traumatization. The resident, with a history of sexual assault, required specific care preferences, such as female staff and drawn curtains, which were not communicated to the staff. The absence of a trauma assessment and care plan for the resident's PTSD was a significant oversight, as acknowledged by the Social Services Director and DON.
A facility failed to follow a physician's order to administer Oyster Shell Calcium/D tablets with food to a resident with dementia and fractures. The LVN gave the medication without food, believing it unnecessary since the resident had eaten earlier. The IPN confirmed that medications ordered with food should be given within 15-20 minutes of eating to prevent adverse effects and ensure absorption.
A resident with GERD and a dislike for tomatoes was repeatedly served meals containing tomatoes, despite her preferences being documented. Additionally, a specific meal request due to a toothache was not honored, leading to frustration. The facility's policies for accommodating dietary needs were not followed, resulting in miscommunication and unmet dietary preferences.
The facility failed to follow infection control measures for two residents. A resident's Foley catheter drainage bag was found touching the floor without a basin, contrary to the care plan. Another resident's G-tube was handled by a nurse without wearing a gown, violating Enhanced Barrier Precautions. These deficiencies were confirmed by staff interviews and facility policies.
A visitor failed to wear required PPE while visiting a resident in contact isolation due to Klebsiella pneumoniae and UTI. Despite signage and facility policy mandating gloves and gowns, the visitor was observed without them, risking the spread of infection. Staff confirmed the importance of PPE to protect residents and visitors.
Two residents in the facility were found with call lights out of reach, posing a risk for delayed care and potential injury. One resident, with hemiplegia and cognitive impairment, had their call light on the floor, while another resident with hemiparesis had theirs on a nightstand. A CNA and the DON acknowledged the importance of accessible call lights for timely assistance.
The facility did not post the required nurse staffing information at the start of each shift, as observed on a specific day. The Administrator confirmed that the Daily Nursing Staffing form was not posted for the morning shift, and the Director of Staff Development admitted forgetting to update and post the information. This oversight was contrary to the facility's policy, which requires daily posting of nurse staffing data for each shift.
The facility inaccurately reported 100% COVID-19 vaccination for staff, while only 30% were vaccinated. The Infection Preventionist Nurse lacked a current vaccination list, and the facility did not have copies of vaccination cards for some staff, violating their policy. This placed residents and staff at risk for COVID-19 infection.
Failure to Notify RP of Change in Dental Treatment Plan
Penalty
Summary
The facility failed to ensure that the Responsible Party (RP) of one sampled resident was notified of a change in the resident’s treatment plan. Resident 1 was admitted with diagnoses including depression, gout, and muscle weakness. The Minimum Data Set dated 4/3/2026 indicated the resident was independent in cognitive skills for daily decision making and required varying levels of assistance with activities of daily living, including substantial to maximal assistance with toileting hygiene, showering/bathing, and personal hygiene, and supervision or touching assistance with oral hygiene, dressing, and footwear. The resident’s Order Summary dated 5/7/2026 indicated the resident was scheduled to go for a dental extraction on 5/8/2026 at 10:30 AM. RN Supervisor 1 stated the resident was transferred to the dental appointment but the dental extraction was cancelled when the resident arrived, and the RP was not informed of the cancellation. RN 1 stated he should have called the RP to notify them of the cancelled dental extraction. RN 2 stated he received report about the cancellation but did not call the RP, and acknowledged the RP should have been notified because it is the resident’s/resident representative’s right to be informed of changes in the treatment plan. The facility’s Resident Rights policy stated the resident has the right to be notified of medical condition changes and to be informed of and participate in care planning and treatment, and the DON stated the resident/resident representative has the right to know about changes in the treatment plan.
Failure to Supervise Resident With Agitation and Unexplained Thigh Bruise
Penalty
Summary
The facility failed to provide safety measures and supervision for a resident who had generalized muscle weakness, abnormal posture, unspecified anemia, and unspecified dementia with behavioral disturbance. The resident’s MDS indicated moderately impaired cognitive skills for daily decision making, dependence with all daily activities, and that walking was not attempted due to medical condition or safety concerns. During a change of condition assessment on 5/3/2026, the resident was noted to have discoloration on the left thigh, and a CNA later stated she discovered a bruise on the left thigh while changing the resident around 4 AM. The CNA reported that she had been the resident’s 1:1 sitter for two consecutive nights and stated the resident was frequently flailing her hands and kicking her legs during monitoring, but she did not know how the bruise occurred. The LVN stated the CNA reported the bruise, that she assessed the resident and informed the DON, and that the resident could not recall how or where the bruise was acquired. The DON and Administrator also stated they could not determine how the resident got the skin discoloration on the left thigh. The five-day follow-up report stated the resident verbalized pain on the left inner thigh and had anxiety-related behaviors including flailing and kicking during episodes of agitation, which may place her at an increased risk for accidental injury. The care plan dated 5/3/2026 did not include interventions for the resident’s flailing hands and kicking legs. The facility’s policy on injuries of unknown origin required investigation and development of measures to prevent recurrence, and the abuse/neglect policy stated the administrator is responsible for determining actions needed for resident protection when an injury of unknown source is reported.
Call Light Not Within Resident’s Reach
Penalty
Summary
The facility failed to accommodate the needs and preferences of one sampled resident by not ensuring the call light was within reach. Resident 2 had diagnoses including history of falling, vascular parkinsonism, cataract, and dementia. The resident’s care plan for fall risk, revised 3/9/2026, directed staff to keep the call light within easy reach and encourage use for assistance, and the ADL/self-care care plan, revised 4/13/2026, also directed staff to place the call light within easy reach. During a concurrent observation and interview on 5/1/2026 at 12:14 PM, Resident 2 was sitting in a wheelchair near the lower right side of the bed and slightly slouching, while the call light was observed on the left upper corner of the bed. Resident 2 stated she was uncomfortable, needed repositioning, and could not reach the call light to alert staff for assistance. CNA 1 stated the call light was not within the resident’s reach but should be, and the DON stated the call light should always be within the resident’s reach so staff can provide care or assistance without delay. The facility’s Resident Call System policy stated each resident is provided a means to call staff directly for assistance from the bed, wheelchair, toileting/bathing facilities, and from the floor.
Failure to Assist Resident With Meals
Penalty
Summary
The facility failed to ensure that one sampled resident with dementia, protein-calorie malnutrition, a body mass index below normal range, underweight status, and adult failure to thrive was provided assistance while eating. The resident’s care plan, revised 9/4/2025, directed staff to set up the meal tray, assist and give verbal cues if needed, allow enough time to eat, bring the resident to the dining room at mealtime, offer substitutes for refused or poorly eaten meals, and encourage adequate intake as tolerated. The resident’s MDS dated 3/3/2026 showed moderate cognitive impairment and indicated the resident required partial/moderate assistance with eating. During observation on 5/1/2026 at 12:30 PM, the resident was seen in the hallway with the lunch tray, not eating, and with no staff nearby or assisting. At 12:49 PM, the resident was again observed with no staff around and no one assisting with the meal. At 1:06 PM, an LVN was observed telling the resident to eat while continuing to care for another resident. At 1:16 PM, a CNA removed the lunch tray after only one spoonful had been consumed. The LVN stated the resident required assistance with eating and did not have assistance during lunchtime, and the DON stated the resident needed supervision, hand guidance, and cueing while eating.
Oxygen and Nebulizer Equipment Left on the Floor
Penalty
Summary
The facility failed to provide oxygen therapy as ordered for two residents reviewed for respiratory care. One resident had diagnoses including acute respiratory failure with hypoxia, type II diabetes mellitus with hyperglycemia, and pneumonia, and the MDS indicated severely impaired cognitive skills and dependence for most activities of daily living. During observation, the resident’s oxygen tubing was found lying on the floor and not connected to the oxygen concentrator. The RN supervisor then connected the tubing to the concentrator after picking it up from the floor without sanitizing it, and stated this created an infection control issue because the tubing may have been contaminated with bacteria from the floor. For that resident, the physician’s order directed oxygen at 2 LPM via nasal cannula continuously, with titration up to 5 LPM if oxygen saturation was less than 92% for shortness of breath or wheezing. The care plan directed monitoring of vital signs every shift and frequent visual checks, and the RN supervisor stated the oxygen should be administered at all times and that licensed staff should ensure the tubing was properly connected to the resident and concentrator. The facility’s oxygen administration policy required checking tubing and ensuring equipment was securely fastened, observing the resident after setup, and documenting the rate, route, rationale, frequency, duration, and assessment data. A second resident with diagnoses including unspecified asthma and atrial fibrillation was observed with the nasal cannula lying on the floor while the oxygen concentrator was running, and the nebulizer mask tubing was also touching the floor. The resident had orders for oxygen at 2 LPM via nasal cannula, with titration up to 4 LPM as needed for shortness of breath or wheezing, and for acetylcysteine solution via nebulizer every 8 hours for mucous secretions. Staff interviews stated the nasal cannula and nebulizer tubing should be kept in a clean setup bag when not in use, labeled and dated, and changed if they touch the floor to prevent infection and cross contamination. The facility’s nebulizer and infection control policies stated the equipment should be rinsed and disinfected, changed every seven days or per protocol, and used to maintain a safe, sanitary environment and prevent transmission of infections.
Failure to Monitor Insulin and IV Antibiotic Therapy
Penalty
Summary
The facility failed to monitor two residents for signs and symptoms of hypoglycemia and hyperglycemia while they were receiving insulin therapy, and failed to monitor one resident for side effects while receiving two IV antibiotics. Resident 5 had diagnoses including metabolic encephalopathy, type II DM, and CKD, and his MDS indicated moderately impaired cognitive skills and extensive assistance needs with daily care. His physician orders included Insulin Glargine daily and Insulin Aspart before meals with sliding-scale coverage, and the care plan directed staff to observe for signs and symptoms of hypoglycemia and hyperglycemia. During interview and record review, the RN supervisor stated there were no orders for monitoring these signs and symptoms and no documentation showing that staff monitored the resident or followed the care plan. Resident 12 had diagnoses including an MRSA wound of the right foot, type II DM with hyperglycemia, cellulitis, and gangrene of the right lower extremity, and the MDS indicated severely impaired cognitive skills and dependence for most activities of daily living. The physician orders included Insulin Glargine every 12 hours and Insulin Lispro before meals with sliding-scale coverage. The care plan directed staff to monitor for signs and symptoms of hypoglycemia and hyperglycemia, but the IPN and RN stated there was no documentation that this monitoring occurred and no monitoring order was present. They stated that without documentation, the monitoring was not shown to have been done. Resident 12 also had physician orders for Ceftriaxone Sodium and Vancomycin HCl for the MRSA wound. The care plan for risk of side effects related to these antibiotics directed staff to administer the IV antibiotics separately, flush the lines before and after administration, and monitor for side effects such as hives, shortness of breath, diarrhea, or DRESS syndrome. The IPN and RN stated there was no documentation that the resident was monitored for antibiotic side effects, and the RN stated the side effects of the two antibiotics should have been monitored specifically for each medication.
Incorrect Portion Size Served for Lunch Entrée
Penalty
Summary
The facility failed to prepare the correct amount of sweet and sour sauce with vegetables served during lunch on 4/8/2026 in accordance with the spring menu and the facility's Food Preparation Policy. During a concurrent observation and interview in the kitchen at 11:56 AM, [NAME] 1 was observed using a 1 oz portion spoon to scoop the sweet and sour sauce with vegetables onto residents' plates. During the same observation, the Dietary Service Supervisor reviewed the 4/8/2026 spring menu and confirmed that the serving size for sweet and sour sauce with vegetables was 2 oz. The Dietary Service Supervisor stated that using the correct portion-size spoon is important to ensure residents receive necessary nutrients and to enhance digestion. Review of the undated Food Preparation Policy showed that meals must comply with the approved menu and portion control standards, and that standardized portion sizes and labeled portion utensils must be used during meal service.
Unsafe Temperature for Cooked Chicken During Meal Service
Penalty
Summary
Food and drink were not ensured to be palatable, attractive, and at a safe and appetizing temperature when kitchen staff failed to prepare chicken at the required safe temperature during lunch tray line assembly. During a concurrent observation and interview in the facility kitchen, the Dietary Service Supervisor was observed checking the temperature of cooked chicken, which measured 140 degrees Fahrenheit. The Dietary Service Supervisor stated that cooked chicken must be kept at 165 degrees Fahrenheit to prevent residents from developing foodborne illness. Review of the facility's Policy and Procedure titled Food Preparation and Service, revised November 2022, showed that poultry must reach an internal temperature of 165 degrees Fahrenheit to kill or sufficiently inactivate pathogenic microorganisms.
Food Labeling, Hand Hygiene, and Cart Cleanliness Deficiencies
Penalty
Summary
The facility failed to follow its food storage and handling policies when eight food items were observed without required labeling. During a kitchen observation with the Dietary Service Supervisor (DSS), four bags of prepared sandwiches in the refrigerator had no preparation date or use-by date, and four bags of chicken thighs in the refrigerator had no item name, thaw date, or use-by date. The DSS stated that prepared sandwiches should be labeled with a preparation date and use-by date, and that frozen items should be labeled with the item name, thaw date, and use-by date. The DSS also stated the chicken thighs had been placed in the refrigerator for thawing and were not labeled as required by the facility's policy. The facility also failed to maintain proper hygiene during tray line assembly and failed to keep food carts clean. During observation, the DSS picked up an alcohol wrap from the floor without changing gloves and did not perform hand hygiene before using the same gloved hand to place a thermometer into a tray of cooked chicken on the steam table. In a separate observation, three food carts had dried white stains on their doors. The Dietary Consultant stated kitchen staff should have maintained cleanliness of the food carts to prevent food borne illnesses. The facility's policy stated that food service employees are to prepare, distribute, and serve food in a manner that complies with safe food handling practices, including proper hygiene and sanitation.
Infection Control Practices Not Followed for Tube Feeding Care, Laundry Clean Area, and Enhanced Barrier Precautions
Penalty
Summary
Standard infection prevention and control practices were not followed for a resident with a feeding tube. Resident 3 had diagnoses including metabolic encephalopathy, diabetes mellitus, depression, and dementia, and the MDS indicated severely impaired cognitive skills and dependence for multiple activities of daily living. During observations in the resident’s room, the tube feeding machine was running and had beige-colored stains all over it on two separate occasions. The Infection Preventionist Nurse stated the machine was dirty, the stains might have been dried formula, and staff should have cleaned the machine before using it for infection control. In the laundry room, infection control practices were not maintained in the clean folding area. During observation, two disposable paper cups, including one filled with ice and one empty used cup, were sitting on the tabletop in the clean area. The Environmental Services Supervisor stated there should be no cups in the clean area because of infection control. Later, light brown splatter stains were observed on the lower shelf where folded clean linens were stored, and the curtains covering the shelves showed grayish discoloration along the lower hem. The supervisor stated the curtains needed to be laundered and that the dried brown stains on the bottom shelf were possibly from a spilled drink. Two used crumpled paper towels were also observed left on top of the shelf where clean residents’ clothes were hung and stored, and the supervisor stated used paper towels should not be left in the clean area because of infection control. Resident 89, who had a feeding tube and was on Enhanced Barrier Precautions due to the G-tube, also had deficient infection control during medication administration. The resident’s record showed severe cognitive impairment, dependence for multiple care activities, and orders for G-tube medications and enteral feeding. The care plan required Enhanced Barrier Precautions with gloves and gowns. During observation, an LVN entered the room, donned gloves, unclamped the G-tube, checked placement, administered medication and formula, flushed the tube, and then removed her gloves and washed her hands. The LVN stated she forgot to wear a gown before checking the G-tube residual and administering medications. Other nursing staff stated that residents with G-tubes were on Enhanced Barrier Precautions and that staff were required to wear PPE, including gloves and gowns, before G-tube care and medication administration.
Damaged Wall Surfaces in Resident Rooms
Penalty
Summary
The facility failed to maintain a scratch-free, non-discolored wall surface in the rooms of two sampled residents reviewed for environment, which was cited as not providing a homelike environment in accordance with facility policy. Resident 47 was admitted with diagnoses including unspecified dementia with anxiety, muscle weakness, and repeated falls. His MDS dated 2/5/2026 indicated moderately impaired cognitive skills for daily decision making and varying levels of assistance with bathing, dressing, toileting hygiene, personal hygiene, eating, oral hygiene, and toilet transfer. During observation on 4/7/2026, the wall behind Resident 47's headboard was noted to have discoloration and multiple scratches, and the resident shook his head and pointed to the wall to show his dislike of its condition. Resident 48 was initially admitted and later readmitted with diagnoses including adult failure to thrive and unspecified dementia with anxiety. His MDS dated 3/23/2026 indicated severely impaired cognitive skills and dependence for oral hygiene, toileting hygiene, bathing, dressing, footwear, and sit-to-lying, with substantial/maximal assistance needed for eating via tube feeding. During observation on 4/8/2025, the wall behind Resident 48's headboard was also observed to have discoloration and multiple scratches. The Maintenance Supervisor stated the damage was caused by the bed hitting the wall multiple times during bed transfers and stated this was not a homelike environment for the residents. The facility's policy on Homelike Environment states residents are to be provided with a safe, clean, comfortable, and homelike environment.
Failure to Protect Resident PHI During Medication Administration
Penalty
Summary
The facility failed to protect the confidentiality of one resident’s electronic medication administration record during medication administration. During a concurrent observation and interview, an LVN dispensed the resident’s medication and left the laptop screen turned on with the resident’s eMAR displayed, with the monitor facing the hallway while three residents and four staff were walking by. The resident involved was admitted and re-admitted to the facility, had diagnoses including renal insufficiency, asthma, COPD, and colon cancer, and was assessed in the MDS as having intact cognitive skills for daily decision making and being independent in several activities of daily living. During the interview, the LVN stated staff need to make sure the laptop is turned off to secure privacy of the resident’s information and that the laptop monitor should be turned off when stepping away from the medication cart because anyone, including residents or staff, might see the resident’s medication information and other medical problems on the screen. The facility’s policy on Protected Health Information stated that personnel with access to resident and facility information are responsible for ensuring such information is managed and protected to prevent unauthorized release or disclosure.
Call Light and TV Not Kept Accessible
Penalty
Summary
The facility failed to ensure Resident 47 had a homelike environment when the resident’s call light was not kept within arm’s reach and the resident’s television was not set up for use. Resident 47 was admitted with diagnoses including unspecified dementia with anxiety, muscle weakness, and repeated falls. The resident’s MDS dated 2/5/2026 indicated moderately impaired cognitive skills for daily decision making and that the resident required varying levels of assistance with bathing, dressing, toileting hygiene, personal hygiene, eating, oral hygiene, and toilet transfer. The care plan for risk for fall/injury, revised on 2/16/2026, included an intervention to keep the call light within reach. During an observation on 4/6/2026, Resident 47’s call light was observed near the resident’s feet and not within reach, and the resident was seen reaching unsuccessfully for it with the feet. In a concurrent interview, a CNA stated the call light and TV cord were near the resident’s feet and that the call light should be within reach so the resident could request assistance and switch on the TV. On 4/8/2026, the resident’s TV was observed off, the resident handed the TV remote to the surveyor and pointed to the power button, and the remote did not work. During a concurrent observation and interview on 4/9/2026, Maintenance stated the TV should not have been unplugged from the wall and the batteries should be replaced to keep the remote working. The RNS also stated the call light should not be left near the resident’s feet and the TV power cord was not supposed to be unplugged.
Failure to Provide Oral Care for a Dependent Resident
Penalty
Summary
The facility failed to provide oral care for one sampled resident who was unable to perform activities of daily living independently. Resident 103 was admitted and later readmitted to the facility with diagnoses including occlusion and stenosis of the right middle cerebral artery and dysphagia oral pharyngeal phase. The resident's MDS dated 1/12/2026 indicated severe impairment in cognitive skills for daily decision making and dependence for oral hygiene, toileting hygiene, bathing, dressing, footwear, personal hygiene, and sitting to lying. During observations on 4/6/2025 and 4/7/2025, Resident 103's mouth was observed with white crust. During interviews, CNA 5 stated oral care was very important for dependent residents to prevent infection and maintain dignity, and the RNS stated CNAs were expected to provide oral care to Resident 103 each shift. The facility policy titled Supporting Activities of Daily Living stated residents unable to carry out ADLs independently would receive services necessary to maintain good nutrition, grooming, and personal and oral hygiene, including assistance with oral care.
Tube Feeding Not Administered as Ordered
Penalty
Summary
The facility failed to ensure that Resident 48’s tube feeding was administered in accordance with the physician’s order. Resident 48 was admitted and later readmitted to the facility with diagnoses including adult failure to thrive, dehydration, and unspecified dementia with anxiety. The MDS dated 3/23/2026 indicated the resident was severely cognitively impaired, dependent for multiple activities of daily living, and required substantial to maximal assistance with eating via tube feeding. A physician order dated 2/13/2026 directed Jevity 1.2 at 55 ml per hour for 20 hours via pump to provide 1100 ml/1320 kcal per day, starting at 12 PM and off at 8 AM or until the dose was completed. During observation and interview on 4/8/2026 at 8:35 AM, the resident’s tube feeding bottle was observed to still be full at 1500 ml, and LVN 2 stated that if the feeding had started at 1 AM at the ordered rate, the container should have shown approximately seven hours of feeding used and should not have remained full. LVN 2 stated the resident had not received any feeding since the container was hung at 1 AM. Later that day, LVN 3 also observed the bottle still at 1500 ml and stated the resident was not receiving the tube feeding as ordered for 10 hours. The DON reviewed the facility’s Enteral Nutrition - Safety Precautions policy during the investigation.
PICC Line Not Assessed, Removed, or Redressed as Ordered
Penalty
Summary
Failure to provide safe, appropriate administration of IV fluids occurred for one resident with a PICC line. The resident was admitted and later readmitted with diagnoses including chronic kidney disease, GERD without esophagitis, and anxiety disorder, and the clinical admission form dated 4/3/2026 indicated mildly impaired cognitive skills. On 4/6/2026, the resident was observed asleep in bed with a PICC line in the left upper arm covered by a clear dressing dated 3/27/2026. The clinical admission form did not indicate the resident had a PICC line upon admission, and the PICC line was not documented in any assessments or progress notes. The RN supervisor stated the resident should have been assessed and documented on admission, but he did not know the resident had a PICC line. The record also showed a progress note dated 4/3/2026 at 9:30 PM stating the physician said the resident did not need antibiotics and gave the okay to discontinue the resident's midline. The RN supervisor stated this telephone order should have been entered into the physician's orders and the PICC line should have been removed as ordered. The resident's PICC line dressing was still dated 3/27/2026, and the LVN stated the dressing should have been changed 72 hours after admission. The RN supervisor stated the dressing should have been changed on admission and every seven days or as needed, and that not changing it could cause infection and accidental pulling.
Medication Administration Identification Failure
Penalty
Summary
The facility failed to ensure licensed staff used two person identifiers before administering medications for one sampled resident. Resident 38 was admitted and re-admitted to the facility with diagnoses including renal insufficiency, asthma, COPD, and colon cancer. The resident's MDS dated 3/18/2026 indicated intact cognitive skills for daily decision making and independence in several activities of daily living. During an interview, LVN 1 stated she checked Resident 38's eMAR with the resident's picture but did not check the resident's armband to confirm identity before giving medications. LVN 1 stated she should have checked the armband as part of the medication administration process. The DON stated licensed nurses need to use two person identifiers before medication administration and may use the eMAR with the resident's picture, the armband, or another licensed staff member to verify the correct resident. The facility's Medication Administration- General Guidelines policy stated residents are identified before medications are administered by checking the identification band, checking photographs attached to the medical record, or verifying identification with other facility personnel.
Improper Labeling and Storage of an Opened Medication Bottle
Penalty
Summary
The facility failed to ensure proper labeling and storage of an opened Promethazine bottle used for Resident 38. Resident 38 was admitted and re-admitted to the facility and had diagnoses including renal insufficiency, asthma, COPD, and colon cancer. The resident’s MDS indicated intact cognitive skills for daily decision making and independence in several activities of daily living. During a concurrent observation with LVN 1, the Promethazine bottle was taken into Medication Cart 2 without a visible open date or expiration date, and LVN 1 dispensed 10 mL from the bottle without checking for those dates. When the bottle was reviewed again, LVN 1 could not find the open date or expiration date and stated she did not know when the bottle had been opened or when it expired. During a later observation and interview, the DON also could not find the open date or expiration date on the bottle and described it as sticky and lacking the required labeling. The facility policy stated medications must be labeled with the date dispensed and expiration date, and improperly or inaccurately labeled medications are to be rejected and returned to the pharmacy.
Diet Order Not Followed for Resident with Soft and Bite-Sized Diet
Penalty
Summary
The facility failed to follow the diet order for one sampled resident, Resident 92, who was admitted and re-admitted to the facility and had diagnoses including hypertension, a history of SBO, COPD, and dementia. The resident’s MDS dated 3/10/2026 indicated moderately impaired cognitive skills for daily decision making, setup or clean-up assistance for eating, supervision or touching assistance for oral hygiene and personal hygiene, and that the resident was on a mechanically altered diet and therapeutic diet. A physician’s order dated 1/8/2026 specified a NAS diet with soft and bite-sized texture, thin fluids, and rice soup with meals. During observation on 4/6/2026 at 12:53 PM, Resident 92 was seen in the dining room attempting to leave and did not attempt to eat the lunch served. The resident’s plate had a whole quarter-size chicken, while the meal ticket indicated soft and bite-sized, NAS, and thin fluids. During interview and record review, staff stated the chicken had been served whole and should have been cut into smaller bite-sized pieces. The Dietary Consultant also confirmed the chicken was served whole and stated the kitchen staff did not follow the dietary order for small bite-sized pieces.
Failure to Develop Care Plan for Resident Scooting From Wheelchair
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop an individualized, resident-centered care plan with measurable objectives, timeframes, and interventions to address a resident’s behavior of scooting off her wheelchair. The resident had diagnoses including muscle weakness, dementia, and a history of repeated falls, and an MDS dated 3/6/2026 documented moderate cognitive impairment and dependence on staff for multiple ADLs, including hygiene, dressing, and toileting. Despite these conditions, there was no care plan addressing the resident’s ongoing behavior of sliding or scooting off her wheelchair. During observation on 4/2/2026, the resident was seen scooting herself off her wheelchair in the patio area. Multiple staff interviews confirmed that this behavior had been present for an extended period: the Assistant Director of Staff Development reported noticing it since 10/2025, the LVN stated the resident had a longstanding tendency to slide off her wheelchair or bed, and the RN Supervisor indicated the behavior had been present since admission. When the resident’s care plans dated 4/25/2025 to 4/1/2026 were reviewed, the DON confirmed there was no care plan addressing the scooting behavior, despite the facility’s policy requiring comprehensive person-centered care plans with measurable objectives, timeframes, and interventions that are revised as resident conditions change.
Failure to Prevent Resident-to-Resident Sexual Abuse After Prior Inappropriate Contact
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from sexual abuse by another resident after a prior incident of inappropriate sexual behavior. One resident (Resident 1) had a history of cerebrovascular disease with cerebral infarction, aphasia, anxiety disorder, and was assessed as moderately impaired in cognitive skills for daily decision-making. Resident 1 was dependent on staff for multiple activities of daily living, including personal hygiene, transfers, and toileting. Another resident (Resident 2) had diagnoses including COPD, psychosis, anxiety disorder, and dementia, but was assessed as cognitively intact and required only supervision or limited assistance with mobility and self-care tasks. On 12/17/2025, a change of condition note documented that Resident 2, while propelling his wheelchair toward his room, stopped in the hallway and attempted to get up and kiss Resident 1 on the cheek while both were in their wheelchairs. LVN 2 intervened and was able to stop Resident 2 from kissing Resident 1 and immediately separated the two residents. Despite this documented attempt at inappropriate physical contact, Resident 2’s care plan was not updated to address this behavior. During a later review, the MDS Coordinator confirmed that Resident 2 did not have a care plan for inappropriate behavior related to the attempted kiss and stated that a care plan with interventions such as close monitoring and activities to keep Resident 2 occupied should have been developed. On 3/7/2026, CNA 1 observed Resident 1 lying on her bed in her room while Resident 2 was on top of her, touching her breast and kissing her on the lips. CNA 1 reported that Resident 1 was trying to move her face away from Resident 2. LVN 1, summoned to the room, saw CNA 1 wheeling Resident 2 out and was told that Resident 2 had been on top of Resident 1, kissing her lips and touching her breasts; LVN 1 identified this as sexual abuse. In a subsequent interview, Resident 1 nonverbally confirmed that a male resident had entered her room and touched her breasts and the top of her vaginal area, demonstrating the areas touched. Resident 2 denied inappropriate behavior when questioned, stating he only intended a greeting. The Director of Nursing acknowledged that the facility failed to prevent the abuse because another incident occurred between the two residents after the earlier event.
Failure to Control Environmental Hazards for Resident With Known Finger-Wrapping Behavior
Penalty
Summary
The facility failed to maintain a resident environment free from accident hazards by allowing accessible call light cords and bed control cables for a resident with known behaviors of wrapping items around her fingers. The resident, who had aphasia following cerebral infarction, a history of gangrene on a finger from wrapping behavior prior to admission, and moderate cognitive impairment, was dependent for most activities of daily living. During observation, the resident was seen in a customized wheelchair with red discoloration and a darker red band around her left middle finger, and she nodded when asked if she had placed her finger in the tangled call light cord beside her bed. The resident’s bed was observed with tangled call light cords hanging on the inner side of the upper quarter bed side rail and coiled bed control cables hanging on the upper left side of the bed. Staff interviews confirmed prior knowledge of the resident’s behavior and the associated hazards. An LVN stated the resident could twist and wrap her fingers with the coiled bed control cables and tangled call light cords, and that these should be kept away from the resident because she was not capable of using them. CNAs reported being informed in a staff huddle that the resident liked to play with and tie things around her fingers, and at least two CNAs had personally observed the resident wrapping cords or gown strings and GT tubing around her fingers on previous occasions, but did not report these incidents to other staff. The DON acknowledged the resident’s prior history of gangrene from wrapping behavior, confirmed that tangled cords and cables were safety hazards for this resident, and noted that the resident’s care plan lacked any problem or interventions specific to her wrapping behavior, despite an existing generic risk-for-injury care plan. The facility’s policy on Safety and Supervision of Residents stated that the environment should be as free from accidental hazards as possible and that safety risks are to be identified through training, monitoring, and reporting, but this was not implemented for this resident’s known behavior.
Failure to Timely Report Alleged Resident-to-Resident Abuse to Required Agencies
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of resident-to-resident abuse to required local, state, and federal authorities within two hours, as required by facility policy. Two residents were involved in the alleged incident. One resident had chronic respiratory failure, unspecified dementia, and peripheral vascular disease, and was documented in a recent H&P as lacking capacity to understand and make decisions, while a later MDS showed modified independent cognitive skills for daily decision-making and a need for assistance with activities of daily living. The second resident had unspecified dementia, type 2 DM, and peripheral vascular disease, was documented in an H&P as lacking capacity to understand and make decisions, and was assessed on the MDS as having severely impaired cognitive skills and being dependent or needing assistance for most ADLs. On a Sunday, CNA 1 observed an interaction in the activity/dining room and stated it looked as if the second resident struck the first resident. CNA 1 reported that on the day of the alleged incident, an LVN said she would make a report, but CNA 1 did not report the alleged incident to the Administrator or any other facility staff that day. LVN 1 later stated she was informed by a CNA the day after the alleged incident that the second resident allegedly slapped the first resident. The Director of Staffing informed the DON and Administrator of the alleged incident several days later, at which time the DON spoke with CNA 1, who reported that the two residents allegedly hit each other in the activity room. The Administrator acknowledged that the alleged incident occurred on a Sunday and that he was not informed until several days later, after which he investigated the incident internally without reporting it to any outside agencies. The DON stated the facility did not report the alleged incident of abuse because it was investigated within the facility and there was no evidence that it occurred, but also stated that alleged hitting or slapping of a resident is considered abuse and, per facility policy, should have been reported within two hours to the appropriate agencies. The facility’s written policy on abuse, neglect, exploitation, or misappropriation requires that any suspicion of abuse be immediately reported to the Administrator and to specified external agencies, defining “immediately” as within two hours of an allegation involving abuse. Despite this policy, the facility did not report the allegation involving these two residents to the State Survey Agency, APS, law enforcement, or other listed entities.
Failure to Arrange Transportation for Outside PCP Appointments
Penalty
Summary
The facility failed to ensure transportation was arranged for a resident to attend all scheduled outside primary care physician (PCP) appointments as ordered. The resident was admitted with diagnoses including heart failure, unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. A Minimum Data Set dated 7/18/2025 documented that the resident had severely impaired cognitive skills for daily decision making and was dependent in multiple activities of daily living, including eating, oral hygiene, toileting hygiene, bathing, lower body dressing, footwear, and personal hygiene, and required substantial/maximal assistance for transfers and ambulation. These conditions indicated the resident relied on staff for coordination of care and transportation to medical appointments. Family interview revealed that the resident had two outside PCP appointments scheduled on 8/4/2025 and 8/20/2025, and that no transportation was arranged by the facility for either appointment. The social worker stated that only one transportation arrangement had been made by the facility for an outside PCP appointment and explained that a physician order was required to arrange transportation, with licensed nurses responsible for placing the appointment order in the transportation communication binder. The social worker further stated she was unaware of the resident’s 8/20/2025 PCP appointment. Review of the Physician Orders Summary Report dated 7/16/2025 showed an order for a one-time outside appointment on 8/4/2025 at 11:00 AM, but there was no indication of an order for the PCP appointment on 8/20/2025.
Failure to Immediately Notify Physician and Responsible Party After Resident Fall
Penalty
Summary
The facility failed to immediately notify the physician and responsible party following an unwitnessed fall involving a resident with a history of falls, muscle weakness, dementia, and abnormal gait and mobility. The resident was assessed as being at risk for falls and was severely impaired in cognitive skills, requiring substantial to maximal assistance with daily activities. The care plan specifically indicated that the physician should be notified in the event of a fall. Despite these documented risks and care instructions, the resident experienced an unwitnessed fall, and the incident was not reported to the physician or responsible party until several days later. Record reviews and interviews revealed that the fall occurred in the resident's room, where the resident was found on the floor by an LVN. The LVN did not report the incident to the physician, DON, or responsible party, stating she did not think it was significant. The facility's policy required notification of the physician in the event of an accident or incident of unknown source, but this protocol was not followed. The responsible party confirmed they were not informed of the fall, and the delay in notification was acknowledged by facility leadership during interviews.
Failure to Post Accurate and Updated Nurse Staffing Information
Penalty
Summary
The facility failed to ensure accurate and updated posting of Direct Care Service Hours Per Patient Day (DHPPD) and Daily Posted Nurse Staffing in accordance with its own policy. Observations and interviews revealed that the posted staffing information was outdated, with the most recent posting dated several days prior to the survey. Review of sign-in sheets and interviews with the Registered Nurse Supervisor and Payroll staff confirmed discrepancies between scheduled and actual staff present, as well as a lack of clarity regarding who was responsible for posting staffing information on weekends and holidays. The Payroll staff, who typically completed the postings, was not present on weekends or holidays, and other staff were not trained or assigned to complete this task. The facility's policy required that nurse staffing data be posted daily and within two hours of the beginning of each shift, but this was not consistently followed. The Administrator and Payroll staff both acknowledged that the policy was not adhered to, particularly on weekends and holidays when responsible personnel were absent. As a result, residents and visitors were not provided with current information regarding facility census, staffing, and actual hours worked by staff, as required by the facility's procedures.
Failure to Timely Report Resident Injury to State Agency
Penalty
Summary
The facility failed to report an unusual occurrence to the Department within 24 hours as required by its own policy and procedure. Specifically, the facility did not notify the Department when it became aware that a resident had sustained a further injury and dislocation of the right hip. The incident was identified on 1/9/2025, when an x-ray conducted at the facility confirmed the right hip dislocation. The resident, who had a history of right upper thigh fracture, recent right hip joint replacement, encephalopathy, difficulty walking, and muscle weakness, was noted to have moderate cognitive impairment and required substantial to maximal assistance with activities of daily living and mobility. The nursing progress notes and SBAR form indicated that the resident was transferred to a general acute care hospital for further evaluation after complaining of pain and discomfort. During an interview, the facility administrator acknowledged that the injury was not reported to the state agency as required. Review of the facility's policies confirmed that such unusual occurrences and injuries of unknown origin must be reported to appropriate agencies within 24 hours, but this protocol was not followed in this case.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to investigate an injury of unknown source for one of four sampled residents, as required by its own policy and procedure. The resident in question was admitted with multiple diagnoses, including a right thighbone fracture, aftercare following right hip surgery, Parkinson's disease, and dementia. Upon review of the resident's records, it was found that shortly after admission, the resident experienced pain and discomfort in the hip, which led to an x-ray revealing a right hip dislocation. The resident was subsequently transferred to a general acute care hospital for further evaluation. During interviews, the DON acknowledged that staff did not know how the resident sustained the hip dislocation and admitted that no investigation was conducted, mistakenly believing the injury had occurred prior to admission. The facility's policy, however, clearly states that injuries of unknown origin are to be reported and thoroughly investigated, with the administrator responsible for initiating such investigations. Both the DON and the administrator confirmed that the required investigation was not performed in this case.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Incomplete Care Plan Lacking Measurable Actions
Penalty
Summary
A deficiency was identified due to the failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care. This omission was observed during the review of resident records and care planning documentation, where surveyors noted the absence of comprehensive and individualized care planning as required.
Physical Abuse of Resident by CNA
Penalty
Summary
A certified nurse assistant (CNA) assigned to provide one-to-one monitoring for a resident with severe cognitive impairment engaged in physical abuse. The resident, who had diagnoses including delirium, depression, dementia, and mood disorder, required varying levels of assistance with daily activities and was noted to have severe impairment in decision-making abilities. On the day of the incident, the CNA grabbed the resident's shirt from the back, causing the shirt to choke the resident at the neck area as the resident stood up from a chair. Following this, as the resident turned and threw a cup of water at the CNA's face, the CNA responded by slapping the resident's back with a loud smacking noise. Multiple staff members, including two other CNAs and the facility administrator, witnessed the incident. The administrator also reviewed surveillance video, which confirmed that the CNA grabbed the resident's shirt and slapped the resident's back. Staff interviews indicated that such physical actions are not permitted, even in response to resident aggression. The facility's policy on abuse, neglect, and exploitation clearly states that residents have the right to be free from abuse, including physical abuse, and that staff are to be adequately prepared for caregiving responsibilities, especially for residents with behavioral or cognitive issues. The CNA's actions were in direct violation of this policy, as confirmed by the administrator and corroborated by video evidence and staff testimony.
Medication Storage Deficiencies
Penalty
Summary
The facility failed to ensure the secure storage of medications, as observed during a survey. In the central supply room, over-the-counter (OTC) medications such as loperamide, ClearLax, Vitamin D, and fish oil were stored on shelves in an unlocked room. The Maintenance Supervisor confirmed that the gate to the room was unlocked, which was against the facility's policy that requires such medications to be stored securely. In another instance, a liquid vial of Lorazepam, a controlled medication, was found in an unlocked medication fridge. The Registered Nurse Supervisor acknowledged that controlled medications should be kept in a locked refrigerator accessible only to licensed staff. The Director of Nursing emphasized the importance of securing controlled medications to prevent misuse or loss, as per the facility's policy. Additionally, the facility's storage room, which had a door code access, contained unlocked cupboards with various OTC medications. The RN Supervisor confirmed that the storage room was accessible to a wide range of staff, including CNAs and housekeeping, which was not in line with the policy that restricts access to authorized personnel only. The facility's policy mandates that medications be stored securely and only accessible to licensed or authorized staff, which was not adhered to in these instances.
Failure to Provide Appetizing and Palatable Meals
Penalty
Summary
The facility failed to provide appetizing and palatable meals to two residents, leading to dissatisfaction and potential risks for unplanned weight loss. Resident 61, who has gastro-esophageal reflux disease and type 2 diabetes, was served a meal that did not align with her dietary preferences, as it contained tomatoes, which she dislikes, and was too spicy. Observations of test trays revealed that the meals were not visually appealing, with dull colors and unappetizing textures, such as sticky and gummy mashed potatoes and bland, watery rice. Resident 82, diagnosed with unspecified hypertension, type 2 diabetes, and major depressive disorder, expressed dissatisfaction with the quality of meals, describing the chicken as rubbery and low quality. Despite communicating her concerns to the Dietary Staff Supervisor, she was informed that the menu could not be changed due to budget constraints. The resident reported that the food was not appetizing or flavorful, leading her to sometimes skip meals. Test trays sampled by staff, including the Administrator and Dietary Staff, confirmed the poor quality of the meals, noting issues with texture and flavor. The facility's policies and procedures on food preparation and accommodation of needs were not adhered to, as meals were not prepared to preserve nutritive value, flavor, and appearance, nor were substitutes provided for unacceptable food items.
Deficiencies in Food Handling and Hygiene Practices
Penalty
Summary
The facility failed to adhere to proper food handling practices as outlined in its policies and procedures, leading to several deficiencies. During an inspection, it was observed that expired food items, such as an opened bottle of cranberry juice, were stored in Refrigerator 3. Additionally, a staff member's personal food container was found in the same refrigerator, which is against the facility's policy to prevent contamination. Furthermore, dry food items in storage were not labeled with both delivery and use-by dates, which is necessary for proper inventory management and safety. In the kitchen, it was noted that micro-kill germicidal alcohol wipes were stored alongside food items like Nestle ThickenUp instant food and drink thickener, violating the policy that prohibits storing chemicals with food items. Moreover, a dietary staff member was observed not practicing proper hand hygiene. The staff member handled food without washing hands after touching potentially contaminated surfaces, such as the trash can lid, and did not wear gloves when handling ready-to-eat foods, which could lead to cross-contamination. Interviews with the Dietary Staff Supervisor and the Director of Nursing confirmed these observations and acknowledged the potential for cross-contamination and infection control issues. The facility's policies clearly state the importance of hand hygiene and proper storage practices to prevent foodborne illnesses, yet these were not followed, putting residents at risk of exposure to pathogens.
Failure to Maintain Resident Dignity During Mealtime Assistance
Penalty
Summary
The facility failed to promote dignity and respect for a resident, identified as Resident 44, during mealtime assistance. Certified Nursing Assistant 6 (CNA 6) was observed standing above the resident's eye level while assisting with feeding, which is against the facility's policy and procedure for maintaining resident dignity. This action was noted during two separate observations, where CNA 6 was seen standing while feeding Resident 44, who was seated in a wheelchair and a merry walker, respectively. Resident 44, who was admitted with diagnoses of metabolic encephalopathy and generalized muscle weakness, required assistance with eating as per her care plan. The facility's policy explicitly states that staff should be at eye level with residents during feeding to ensure dignity and respect. Interviews with CNA 6 and the Director of Nursing confirmed that the staff should not stand over residents while assisting them with meals, aligning with the facility's policy to provide a dignified dining experience.
Failure to Conduct Level 2 PASARR for Resident with Schizophrenia
Penalty
Summary
The facility failed to ensure a Level 2 Preadmission Screening and Resident Review (PASARR) was conducted for a resident diagnosed with schizophrenia. The resident was admitted with a diagnosis of schizophrenia and had severe impaired cognition, requiring various levels of assistance for daily activities. Despite a Level 1 PASARR conducted at the hospital indicating the need for a Level 2 evaluation, the facility did not follow up with the appropriate agency to conduct this evaluation. This oversight meant the facility did not have the necessary recommendations for specialized services or care for the resident. Observations and interviews revealed that the resident often exhibited confusion, aggression, and non-compliance with care, which were not adequately addressed due to the lack of a Level 2 PASARR evaluation. The Director of Nursing acknowledged the failure to follow up on the Level 2 PASARR, which placed the resident at risk for unmet needs, as the facility lacked guidance on the appropriate care and services required for the resident's mental health condition.
Failure to Update Care Plan for Pain Management
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for Resident 197, which resulted in inadequate pain management. Resident 197 was admitted with multiple fractures and was assessed to have constant pain that affected her sleep and daily activities. Despite a physician's order for a Fentanyl patch to manage severe pain, the care plan was not updated to include this pharmacological intervention. This oversight was confirmed during an interview with the Infection Prevention Nurse, who acknowledged that the care plan should have been revised to reflect the new pain management strategy. During an observation and interview, Resident 197 expressed severe pain and indicated that her Fentanyl patch had not been reapplied after removal. The Director of Nursing confirmed that the care plan should have included details on the administration and handling of the Fentanyl patch, including potential side effects and safety measures. The facility's policy requires ongoing assessment and timely updates to care plans as residents' conditions change, which was not adhered to in this case.
Failure to Provide Communication Support for Non-English Speaking Resident
Penalty
Summary
The facility failed to ensure that a non-English speaking resident, identified as Resident 60, had access to a communication board or translation services, which was necessary for effective communication due to the resident's severe cognitive impairment and dependency on staff for activities of daily living. The resident, who was admitted with a diagnosis of dementia and had severely impaired cognitive skills, was observed to be unable to make herself understood or understand others. The care plan for Resident 60 indicated a risk for unmet needs related to communication difficulties, with interventions including the use of a communication board or translation services. During an observation, a Certified Nursing Assistant (CNA) attempted to communicate with Resident 60 using hand gestures and English, which the resident did not understand, resulting in confusion. The CNA did not find a communication board in the resident's room and did not seek assistance from staff who spoke the resident's language. Interviews with the Director of Staff Development and the Director of Nursing revealed that the staff member who could translate was unavailable, and not all staff had been trained on using translation services. The facility's policy required appropriate support and assistance with communication, which was not provided in this case.
Failure to Provide Adequate Nail Care for a Resident
Penalty
Summary
The facility staff failed to provide adequate nail care for a resident who required total physical assistance with personal hygiene. The resident, identified as Resident 80, was observed with dirty fingernails and a thick brown crust around the nail bed on multiple occasions. The resident's care plan indicated a need for assistance with activities of daily living, including grooming and trimming of fingernails, due to cognitive and physical deficits. Resident 80 was admitted with several medical conditions, including cerebral infarction, respiratory failure, unspecified dementia, and peripheral vascular disease. The resident was assessed as needing dependent care for personal hygiene and other daily activities. Despite these needs, observations revealed that the resident's fingernails were not being properly cleaned or maintained, as evidenced by the presence of dirt and potential fungal infection. Interviews with the resident's family and the Director of Nursing confirmed the deficiency in care. The family member noted the lack of daily cleaning and the presence of fungus on the resident's nails. The Director of Nursing acknowledged that certified nursing assistants were responsible for providing ADL care, including nail cleaning, and stated that it was unacceptable to leave a resident with dirty nails, as it could lead to infection and harm.
Failure to Provide Age-Appropriate Activities for Resident
Penalty
Summary
The facility failed to assess and provide specific resident-preferred activities and interests for a resident, which had the potential to negatively affect the resident's sense of self-worth and psychosocial well-being. The resident was admitted with diagnoses including hemiplegia, unspecified sequelae of nontraumatic intracerebral hemorrhage, and aphasia. The resident's Minimum Data Set (MDS) indicated that it was very important for him to engage in favorite activities, listen to music, read, and keep up with the news. However, the care plan did not adequately address these preferences, and the resident was not provided with activities appropriate for his age. Observations and interviews revealed that the resident spent most of his time in bed using an electronic device and watching television, and he expressed dissatisfaction with the activities offered, stating that there was nothing suitable for his age in the Activity Room. The Certified Nursing Assistant (CNA) confirmed that the resident always refused to participate in activities, possibly due to the lack of age-appropriate options. The Activities Director admitted to not asking the resident about specific activities he wanted to do and acknowledged that staying in the room all day could negatively impact the resident's well-being. The Director of Nursing (DON) emphasized the importance of tailoring activities to the resident's age and ethnicity and stated that the facility lacked a policy for assessing residents' preferred activities annually. The facility's policies on dignity and accommodation of needs highlighted the importance of promoting residents' well-being and accommodating individual preferences, but these were not effectively implemented in the resident's case. The Activity Director's job description also required evaluating residents' interests and ensuring they have an adequate activity plan, which was not fulfilled for this resident.
Failure to Provide Adequate Feeding Assistance and Documentation
Penalty
Summary
The facility failed to provide adequate feeding assistance to a resident, identified as Resident 79, who was experiencing significant weight loss. Despite being on a Restorative Nursing Assistant (RNA) feeding program for breakfast and lunch, the resident did not receive the necessary assistance as ordered by the physician. The resident, who had a history of metabolic encephalopathy, rectal cancer, dementia, and hemiparesis, was on a therapeutic diet and required a change in food texture. The resident's Minimum Data Set indicated a need for setup or cleanup assistance for eating, and the resident had severe cognitive impairments affecting daily decision-making. On specific dates, the facility staff failed to accurately and timely document the resident's nutritional intake. A review of the resident's records showed discrepancies in the reported food intake, with one instance of no documentation for a meal. Interviews with staff revealed a lack of awareness regarding the resident's weight loss and the RNA feeding program. Certified Nursing Assistant 7 (CNA7) did not assist the resident with eating due to language barriers and was unaware of the resident's dietary needs. Additionally, RNA1, who was responsible for assisting the resident, was occupied with other residents and did not report the resident's low food intake to the nursing staff. The facility's Director of Nursing acknowledged the inadequate documentation and staffing assignments that did not align with the resident's needs. The lack of consistent oversight in the RNA implementation was noted as a risk for further weight loss and health complications for the resident. The facility's policies on the Restorative Feeding Program and Nutrition Impaired/Unplanned Weight Loss were not followed, as staff failed to monitor and document the resident's nutritional intake accurately, compromising the resident's health and dietary needs.
Failure in Timely Pain Management for a Resident
Penalty
Summary
The facility failed to provide timely and effective pain management for Resident 197, who was admitted with multiple fractures and assessed to have constant pain that frequently limited daily activities. The resident's care plan included the use of a Fentanyl patch and Norco for pain management. However, the facility did not reorder the Fentanyl patch five days in advance as per policy, resulting in the patch not being available when needed. This led to the resident experiencing severe pain without the scheduled pain relief. On the day the Fentanyl patch was due to be replaced, it was removed by LVN 1 at 9 AM, but the replacement patch was not applied because it had not been delivered by the pharmacy. Despite the resident expressing severe pain and requesting both the Fentanyl patch and Norco, the staff did not administer the Norco or reassess the resident's pain in a timely manner. The resident was observed in distress, rubbing her leg, grimacing, and crying, indicating a significant lapse in pain management. Interviews with the Infection Prevention Nurse and the Director of Nursing revealed that the facility's procedures for pain assessment and medication ordering were not followed. The charge nurse failed to order the Fentanyl patch in advance, and the resident's pain was not reassessed after the patch was removed. The facility's policy required pain to be reassessed every 30 minutes after the onset of acute pain, but this was not done, leading to the resident suffering unnecessary pain for several hours.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for a resident diagnosed with PTSD, which could lead to re-traumatization and severe psychosocial harm. The resident, who had a history of sexual assault, was admitted with diagnoses including PTSD, type 2 diabetes mellitus, and major depressive disorder. The resident required varying levels of assistance with daily activities and had moderately impaired cognitive skills for decision-making. During observations and interviews, it was noted that the resident preferred to have her curtains drawn and requested female staff, indicating discomfort with male voices. However, the staff, including CNAs and LVNs, were not informed of the resident's PTSD diagnosis or her specific triggers, such as male presence and light sensitivity. This lack of communication and awareness among the staff about the resident's trauma history and triggers was a significant oversight. The Social Services Director and the Director of Nursing acknowledged the absence of a trauma assessment and a care plan specifically addressing the resident's PTSD and triggers. The facility's policy required behavioral assessments and care plans to be developed based on comprehensive evaluations, but these were not implemented for the resident. The failure to conduct an interdisciplinary team meeting and develop a care plan for the resident's PTSD was a critical deficiency in the facility's care provision.
Failure to Administer Medication with Food as Ordered
Penalty
Summary
The facility failed to adhere to a physician's order regarding the administration of Oyster Shell Calcium/D tablets to a resident, identified as Resident 54. The physician's order specified that the medication should be given with food. However, during an observation, it was noted that the Licensed Vocational Nurse (LVN 2) administered the medication approximately one and a half hours after the resident had eaten breakfast, without providing any additional food. The LVN believed that since the resident had already eaten earlier, there was no need to provide food with the medication. The resident, who was admitted with a diagnosis of dementia and multiple fractures, required setup assistance with eating due to mildly impaired cognitive skills. The facility's Infection Prevention Nurse (IPN 1) confirmed that best practices dictate that medications ordered to be given with food should be administered within 15-20 minutes of eating to prevent adverse effects and ensure proper absorption. The facility's policy on administering medications also mandates adherence to prescriber orders, including any specified time frames. The failure to follow these guidelines increased the risk of adverse reactions or reduced effectiveness of the medication for Resident 54.
Failure to Accommodate Resident's Dietary Preferences
Penalty
Summary
The facility failed to provide food that accommodated the dietary preferences and intolerances of a resident, identified as Resident 61. The resident, who was cognitively intact and had specific dietary preferences due to gastro-esophageal reflux disease (GERD) and a dislike for tomatoes, was served meals that did not align with her stated preferences. Despite having a preference sheet indicating her dislike for tomatoes, Resident 61 was served jambalaya containing tomatoes, which she could not eat due to her GERD. On another occasion, Resident 61 requested a specific meal of chicken noodle soup and rice due to a toothache, but was instead served a regular diet tray that did not meet her request. The Dietary Supervisor confirmed that the resident had communicated her meal preference earlier in the day, but the kitchen staff failed to provide the correct meal. This miscommunication led to Resident 61 receiving meals that she could not consume, causing frustration and dissatisfaction. The facility's policy and procedure for accommodating resident needs and food preparation were not followed, as the resident's food dislikes were not properly recorded or communicated to the kitchen staff. The Registered Dietician confirmed that the resident's meal ticket should have reflected her dislike for tomatoes, and alternatives should have been offered. The Dietary Supervisor acknowledged the oversight and the impact it had on the resident's dining experience.
Infection Control Failures in Catheter and G-tube Management
Penalty
Summary
The facility failed to adhere to infection control measures for two residents, leading to potential exposure to harmful bacteria and viruses. For Resident 49, the deficiency involved the improper handling of an indwelling catheter drainage bag. The resident's care plan specified that a basin should be placed under the Foley catheter drainage bag to prevent it from touching the floor, as this could lead to urinary tract infections. However, during an observation, the drainage bag was found touching the floor without a basin underneath, contrary to the facility's policy and procedure for catheter care. In the case of Resident 299, the deficiency was related to the failure of a licensed nurse to follow Enhanced Barrier Precautions (EBP) while handling the resident's feeding tube. The nurse administered medications via the G-tube wearing only gloves, without the required gown, despite signage indicating the need for such precautions. The nurse acknowledged the oversight, attributing it to the absence of a PPE cart outside the room, which could lead to cross-contamination and spread of bacteria. Both deficiencies were confirmed through interviews with facility staff, including a CNA, a treatment nurse, and the Director of Nursing, who all acknowledged the importance of following the infection control measures outlined in the residents' care plans and facility policies. The facility's policies clearly indicated the need for these precautions to prevent infections and ensure resident safety.
Visitor Non-Compliance with PPE in Isolation Room
Penalty
Summary
The facility failed to ensure that a visitor for one of the residents adhered to the required personal protective equipment (PPE) protocols while in a contact isolation room. The resident in question was admitted with diagnoses including a urinary tract infection (UTI) and Klebsiella pneumoniae, necessitating contact isolation precautions. Despite the presence of a contact isolation sign indicating the need for an isolation gown and gloves, a family member was observed at the resident's bedside without wearing the required PPE. This oversight was confirmed by a Licensed Vocational Nurse (LVN) who acknowledged the importance of PPE in preventing the spread of infectious bacteria. Further interviews with the Infection Preventionist Nurse (IPN) and a review of the facility's policy and procedure on transmission-based precautions highlighted the necessity for visitors to wear gloves and a disposable gown upon entering isolation rooms. The IPN reiterated the critical role of PPE in protecting both the resident and visitors from exposure to bacteria, especially given the resident's compromised immune system. The facility's policy, revised in September 2022, mandates these precautions to prevent the transmission of infections to other residents.
Call Lights Not Within Reach for Residents
Penalty
Summary
The facility failed to ensure that call lights were placed within reach for two residents, leading to a potential delay in care and increased risk of injury. Resident 2, who was admitted with hemiplegia and hemiparesis following a stroke, was observed with their call light on the floor, out of reach. This resident was cognitively impaired and dependent on staff for various activities of daily living, including toileting and mobility. During an observation, a Certified Nursing Assistant (CNA) confirmed that the call light was not within reach, which is crucial for residents to call for assistance. Similarly, Resident 3, who had hemiparesis and peripheral vascular disease, was observed with their call light on the nightstand, also out of reach. This resident was cognitively impaired and dependent on staff for daily activities. The CNA acknowledged the importance of having the call light within reach to prevent residents from attempting to get out of bed on their own, which could lead to falls. The Director of Nursing emphasized the necessity of having call lights accessible to ensure timely assistance. The facility's policy on the call system was reviewed, highlighting the requirement for residents to have a means to call staff for help.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post the nurse staffing information at the start of each shift on 11/13/2024, as required by their policy. This deficiency was identified during an observation and interview conducted at the nursing station with the Administrator at 2:01 PM. The Administrator acknowledged that the Daily Nursing Staffing form, which should indicate both projected and actual nursing hours, had not been posted for the morning shift (7 AM - 3 PM) on that day. The Director of Staff Development, responsible for updating and posting this information daily at 9 AM, admitted during an interview at 2:11 PM that she forgot to post the staffing information for the morning shift. The facility's policy, revised in August 2022, mandates the daily posting of nurse staffing data for each shift, including the number of nursing personnel providing direct care to residents. The failure to adhere to this policy resulted in the potential for residents and visitors to be unaware of the nursing hours and the number of nurses working each shift.
Inaccurate COVID-19 Vaccination Records for Staff
Penalty
Summary
The facility failed to maintain accurate records of employee COVID-19 vaccination status, which is a critical component of infection prevention and control. During a review of the facility's National Healthcare Safety Network (NHSN) reporting from January to June 2024, it was found that the facility inaccurately reported 100% COVID-19 vaccination for staff, while in reality, only 30% of employees were vaccinated. The Infection Preventionist Nurse (IPN) confirmed the discrepancy and admitted to not having a current vaccination list for the facility's employees. Further investigation revealed that the facility did not have copies of COVID-19 vaccination cards for specific staff members, including a Licensed Vocational Nurse and a Certified Nursing Assistant. The facility's policy, dated May 2024, mandates that copies of vaccination proof should be kept for both staff and residents. The Administrator acknowledged that the facility should have a list and copies of staff vaccination cards upon hiring, as per their policy. This deficiency in documentation and reporting placed residents and staff at risk for potential COVID-19 infection.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 7,034 citations issued within 25 miles in the last 12 months — including the 34 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near San Gabriel
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ivy Creek Healthcare & Wellness Centre | 0.2 mi | ★★★★★ | 13 | 0 |
| San Gabriel Valley Medical Ctr D/p Snf | 0.2 mi | ★★★★★ | 17 | 0 |
| Royal Vista Care Center | 0.3 mi | ★★★★★ | 31 | 0 |
| Broadway Healthcare Center | 0.6 mi | ★★★★★ | 18 | 0 |
| Alhambra Healthcare & Wellness Centre, Lp | 0.9 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.