Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Maclay Healthcare Center during CMS and state inspections, most recent first.
A cognitively impaired, high fall-risk resident with orthostatic hypotension and difficulty walking experienced a fall with fractures after the facility failed to monitor orthostatic BP as ordered and did not ensure safe ambulation practices. MD orders required monitoring for postural hypotension and documenting side effects of mirtazapine and antipsychotics on the MAR each shift, but records showed no orthostatic BP measurements, including no standing readings. Staff acknowledged they were not checking orthostatic BPs, and one LVN avoided standing measurements due to fear of a fall. The resident preferred open-back slip-on slippers, refused nonskid socks, and sometimes refused to use an assistive device, despite PT recommendations for supervised ambulation with a FWW and no training to ambulate more than a short distance without a device. The fall care plan did not address orthostatic BP monitoring, slipper use, or refusal of assistive devices. The resident ambulated about 71 ft in the hallway without an assistive device while wearing the slippers, appeared groggy, fell, and was found prone on the floor with severe left arm pain, later diagnosed with displaced fractures of the proximal humerus and great toe.
A resident with orthostatic hypotension, multiple fall-related diagnoses, and on antipsychotic medication was not monitored for orthostatic BP as ordered, with no standing BP readings documented over an extended period. A fall risk evaluation documented the resident as high risk but inaccurately recorded no recent falls, left the gait section incomplete, and understated the number of diagnoses contributing to falls, while also indicating no orthostatic BP drop without evidence that orthostatic BPs were taken. After a later fall and COC with severe left shoulder and arm pain, the resident remained on the floor until paramedics arrived, the COC form stated no orthostatic hypotension without documented orthostatic BP measurements, and required post-fall monitoring every shift for 72 hours was not documented on several shifts, contrary to facility policies and professional standards.
Surveyors found that staff failed to maintain accurate and timely medical record documentation for three residents. CNAs repeatedly recorded breakfast and lunch intake percentages at the same or nearly identical times in the afternoon, rather than documenting intake after each meal was consumed, for residents with dementia, muscle weakness, fractures, and other conditions on regular or CCHO diets. An LVN reported that a resident returned from a GACH in the morning, but the progress note entered by the ADON documented the return as occurring at night, creating a discrepancy in the recorded time of return. The DON acknowledged that documentation should reflect the accurate date and time and that the facility’s charting policy requires prompt, factual entries at the time care is provided or immediately afterward.
A resident with orthostatic hypotension, mobility impairment, and a history of falls was assessed as high fall risk, and physician orders required monitoring and documentation of postural hypotension and medication side effects on the MAR each shift. Despite this, staff did not document orthostatic BP monitoring, and Change in Condition evaluations after two falls either left the orthostatic assessment incomplete or indicated no orthostatic hypotension without recorded orthostatic BPs. The resident’s care plan, while identifying high fall risk and orthostatic hypotension, lacked specific interventions for orthostatic BP monitoring, the resident’s preference for open-toed, open-back rubber slippers, and the resident’s refusal to use an assistive device when ambulating, omissions confirmed by nursing staff and the DON as making the care plan incomplete.
A resident with acute kidney failure, pulmonary embolism, cognitive impairment, incontinence, and a fall history had physician orders for apixaban, daily constipation medications, and, after a fall, bilateral landing pads with bed and wheelchair alarms. The care plan included monitoring for anticoagulant side effects and constipation effectiveness, but staff documented apixaban administration without recording any side-effect monitoring, and did not notify the physician despite the resident’s repeated reports of prolonged constipation and requests for an enema. The resident’s fall care plan did not include the ordered bilateral landing pads, and both nursing staff and the DON acknowledged that this intervention was missing from the care plan, resulting in an incomplete, non-implemented person-centered care plan.
A resident with a stage 4 sacrococcyx pressure ulcer and bilateral unstageable heel ulcers did not receive wound care in accordance with provider orders and facility policy. On the scheduled reevaluation date for the sacrococcyx ulcer, no wound treatment was documented or provided, despite existing orders for daily Santyl and calcium alginate dressings. Later, after the wound provider changed heel ulcer orders from iodosorb to betadine, nursing staff continued to apply both betadine and iodosorb to the heels for several days without clarifying the conflicting orders, resulting in simultaneous use of two topical agents instead of following the updated single-agent regimen.
A resident with significant medical comorbidities and impaired cognition was on daily naloxegol and polyethylene glycol for constipation but experienced multiple days without a bowel movement and repeatedly complained of constipation and requested an enema. Nursing staff acknowledged that the resident complained "all the time" and reported a 13‑day period without a bowel movement, yet one LVN did not escalate the complaint to an RN or contact the physician, and an RN delayed and failed to properly document physician notification and did not initiate a change‑in‑condition (CIC) entry. Review of bowel records confirmed several days without documented bowel movements, and the DON stated that a CIC and prompt physician notification with PRN orders should have occurred under the facility’s change in condition policy.
A resident with essential HTN and intact decision-making capacity had a physician order for hydralazine 50 mg TID with instructions to hold the dose if SBP was below 110 mmHg. Review of the MAR showed that on one day in April, hydralazine was administered twice by two LVNs when the resident’s SBP readings were below the ordered hold parameter. In an interview, the DON confirmed that the hydralazine should have been held according to the physician order. Facility policy required that all medications be administered in accordance with prescribers’ orders.
A resident with acute kidney failure, pulmonary embolism with cor pulmonale, cognitive impairment, and a history of falls was prescribed apixaban 5 mg twice daily for PE/DVT. The care plan and the facility’s anticoagulation protocol required staff to monitor, document, and report signs of bleeding and other adverse reactions every shift. Review of the MAR showed the resident received apixaban over multiple days with no documented monitoring for bleeding or side effects. In an interview, the DON confirmed that apixaban carries bleeding and bruising risks, that the resident should have been monitored each shift, and that no such monitoring was documented.
The facility failed to follow its abuse investigation policy by not obtaining interviews or written statements from all staff assigned to residents involved in two separate resident-to-resident physical contact incidents. In one incident, a cognitively impaired resident with dementia and another resident with ESRD, COPD, and HTN had physical contact witnessed by an RN, but assigned LVNs and CNAs were not interviewed or documented as witnesses. In a second incident in the activity room, two cognitively intact residents using wheelchairs made contact, followed by physical contact between them; assessments showed no injuries, but assigned CNAs and an LVN were not interviewed, and no staff statements were documented for one of the residents. The facility’s abuse policy requires interviewing all relevant staff and obtaining signed, dated written witness statements, which the DON and administrator acknowledged was not done, resulting in incomplete investigations.
A resident with dementia and multiple chronic conditions was transferred to a hospital after an incident and remained there for several days, but two LVNs continued to document administration of ordered medications on the MAR during the period the resident was not in the facility. Progress notes clearly showed the dates of transfer and readmission, yet the MAR reflected doses of atorvastatin, levothyroxine, pantoprazole, and other medications as given in the interim. In interviews, the ADON and DON confirmed the resident’s absence during the documented administrations, acknowledged that the record was inaccurate, and noted that medications should have been documented as not given, contrary to the facility’s charting and documentation policy.
A resident with ESRD, COPD, and HTN, who was cognitively intact and had decision-making capacity, was ordered Lokelma for hyperkalemia but refused a scheduled dose. The MAR documented the refusal, yet no person-centered care plan was developed to address the medication refusal. During interviews, the ADON and DON acknowledged that the nurse should have notified the physician and that a care plan should have been created to address the refusal and ongoing management of hyperkalemia, contrary to the facility’s comprehensive care plan policy.
A facility failed to serve food in the correct texture for residents on pureed and soft bite-sized diets. A resident with dysphagia and other medical conditions was fed regular oatmeal with lumps instead of pureed oatmeal, and two other residents on pureed diets were also served regular oatmeal that was not smooth or IDDSI Level 4 compliant. The report also states that residents on SB6 diets received pork, mushrooms, and carrots that were finely chopped and minced, and that some pureed pancakes and sausages did not hold the proper puree form.
Improper Disposal of Meal Tickets Containing PHI: Meal tickets with residents' names, diets, and room numbers were observed in a trash container near the dishwashing area. The DS stated the tickets were returned to the kitchen after meals and thrown away in the trash, and acknowledged the documents contained protected information and that discarding them this way was a HIPAA violation. Facility policy stated meal tickets are generated from current diet orders in the EHR, and the privacy policy required confidentiality of resident personal and medical records.
Dirty fans and water-damaged room conditions affected multiple residents. A resident with respiratory diagnoses had an electric stand fan covered in gray dust, and staff including CNA, LVN, RTS, MDSC, DOM, and DON all identified the fan as dirty and linked cleaning responsibility to maintenance or housekeeping. Two other residents with significant medical needs also had a room with loose floorboards, warped wood, and wall damage from leaking pipes in the laundry area, and the DOM stated the leaks had been ongoing for weeks.
Bed Alarm Used Without Required Documentation A resident with hemiplegia/hemiparesis after CVA, CHF, and cognitive communication deficit had a bed pad alarm used for fall prevention without a physician order, informed consent, or a restraint assessment. The resident was assessed as high fall risk and had severe cognitive impairment with dependence for multiple ADLs. During observation, the bed alarm box was found hanging on the wall with the cord wrapped around the bed control cord and not functioning properly, and the MDSC confirmed the missing order, consent, and assessment.
Unnecessary Psychotropic Medication Monitoring Deficiencies: The facility failed to use specific, measurable behavioral monitoring for one resident receiving quetiapine and sertraline, documenting feelings such as hopelessness, sadness, loneliness, and highs and lows instead of objective behaviors. For another resident receiving Depakote and Rexulti, the record lacked monitoring for adverse effects, and staff stated the MAR did not include adverse-effect checks. The DON and LPN both stated psychotropic meds require specific behavior tracking and monitoring for side effects, but the documented orders and MAR did not reflect that.
Failure to Rotate Insulin Injection Sites: Licensed nursing staff did not rotate SQ insulin sites for two residents receiving insulin for DM. One resident with type 2 DM, CKD, and malnutrition had repeated injections in the same abdominal areas and left arm despite orders to rotate sites. Another resident with type 2 DM, CKD, retinopathy, and neuropathy also received repeated injections in the same abdominal areas and right deltoid despite orders allowing site rotation. The MDSC and DON stated site rotation is needed to prevent skin injury such as lipodystrophy, and the facility policy required rotation to prevent tissue damage.
Failure to Notify Physician of Elevated SBP: A resident with HTN, CHF, CKD stage 3, and prior stroke had an order for BP checks twice daily and to notify the physician if SBP was >140 mmHg. Multiple SBP readings above the ordered limit were documented, but there was no evidence the physician was notified. An LVN stated she did not follow the order, and the DON confirmed the notification and documentation requirements were not followed.
A facility failed to keep resident areas free of hazards and did not consistently follow fall-prevention and medication-safety processes. Staff observed a side table placed on a floor mat, frayed wires on a bed remote, unattended self-administered meds at the bedside without orders, an ordered bed pad alarm not in place for a high-fall-risk resident, and another resident’s bed alarm not functioning properly. The facility also did not complete required IDT post-fall reviews after a resident had repeated falls with documented pain and injury.
Medication administration errors exceeded the allowed rate when staff failed to follow ordered directions for three medications. An LVN gave aspirin without instructing the resident to chew it, applied lidocaine 5% without a dose specified in the order, and gave digoxin after checking a radial pulse instead of the ordered AP. The DON and MDSC stated the aspirin, lidocaine, and digoxin were not administered in accordance with the prescriber’s order and facility policy.
Failure to Rotate Insulin Injection Sites: Two residents with DM received repeated SQ insulin injections in the same abdominal and arm sites instead of rotated sites as ordered. Record review showed insulin glargine, Novolog, Humulin R, and insulin NPH/regular orders that included site rotation, while the LAR documented multiple consecutive injections in the same locations. The MDSC and DON both stated that not rotating insulin administration sites is a medication error.
A dietary employee prepared puree foods that failed the spoon tilt test, including a puree pancake that remained sticky and a cranberry yogurt mousse that was too thick and did not fall off the spoon. The DS and RD noted the texture issues, and the ADS did not check the breakfast puree food. The kitchen also had a dented can stored with other cans, wet-stacked pans, debris in clean pans, sticker residue on pitchers, diet tickets in the trash, burnt rice and fries, and hot foods served at improper temperatures.
Menu and tray accuracy failures occurred when dietary staff did not follow the standardized green bean recipe, the menu spreadsheet did not clearly identify pork and mushroom sauce portions, and several meal trays were served incomplete. A resident on a puree diet did not receive puree oatmeal, another resident’s tray was missing oatmeal, a third resident’s tray was missing coffee, and a fourth resident’s tray was missing margarine and jelly. Staff and the DON stated the trays and portions should have matched the diet orders and meal tickets.
Food service failed to keep meals palatable and at proper temperatures. A resident with respiratory failure, CHF, and HLD said the rice was too dry to eat, while another resident with DM, CKD, and HTN said the food had no taste and ate less, often choosing sandwiches instead of meals. Staff used a mixed vegetable recipe for green beans, and the DS described the beans as bland and olive green. Test tray observations found peach pie and pureed peach pie too cold, and breakfast items including pancakes, sausage, oatmeal, and milk were not at appropriate temperatures; other residents reported cold meals and desserts being placed on trays well before trayline.
A resident with DM, anemia, and dementia was served 4 oz. Magic Cup/HPN-related supplements without a physician order. The resident's OSR showed a CCHO/NAS pureed diet, but the tray ticket listed Magic Cup or protein drinks as a preference and staff served a Mighty Shake at lunch without verifying the ticket. The RD stated the supplements add calories and could affect blood sugar, and the DON stated a physician's order was needed for the supplements.
Late Meal Service and Trayline Delays: A resident with ESRD, type 2 DM, and hyperlipidemia was on a consistent carbohydrate, renal diet and reported that food from the kitchen comes out late. Meal service was not provided within the posted schedule, as trayline lunch and breakfast service started and ended late. The DS acknowledged the delays, stating the first breakfast cart should have come out at 7:15 a.m. and that tray passing was late because staff were trying to ensure tray accuracy.
Kitchen food storage and sanitation practices were deficient. Cooked poultry was left unlabeled, trays and shelving had sticker residue, freezer and storage areas had dirt and food debris, and a non-cleanable decorated cart was used on trayline. Clean pans had rice particles, dented cans were stored with usable cans, pans were stacked wet, and the pots and pans racks lacked a barrier from floor splatter. The DS acknowledged the issues during observation and interview.
Inaccurate Dialysis Access Documentation: A resident with ESRD and dependence on dialysis had the wrong access site documented on the Dialysis Communication Record on multiple occasions. An LVN recorded findings under an AV shunt site even though the resident had a right upper chest permacath, and the LVN acknowledged the entry was incorrect. The DON stated post-dialysis nursing assessment includes checking vital signs, the access site, and any bleeding, swelling, or dressing issues, and that the facility policy was not followed.
A resident with dementia, severe cognitive impairment, and total ADL dependence was receiving hospice services for Alzheimer’s disease. The facility did not ensure the hospice LVN and HA visited according to the hospice schedule, and hospice nursing and aide notes were missing from the binder and EHR for multiple visits. Staff stated the hospice documentation should have been readily available so the resident’s care and updates to the POC could be known.
The facility failed to follow infection control practices in several areas. Two residents had unlabeled urinals in a shared room, a resident on oxygen and HHN had NC and nebulizer tubing touching the floor, leaking pipes and water damage affected resident rooms and the laundry area, clean clothing in plastic bags was left on the floor in two residents’ rooms, and staff did not consistently wear gowns during care for residents on EBP. Residents involved had significant medical needs including COPD, dementia, CKD, wounds, and dependence for ADLs.
A facility failed to carry out its antibiotic stewardship monitoring for three residents receiving ATBs. One resident had cephalexin and fluconazole without complete adverse-effect monitoring, another had ertapenem and Zyvox without complete monitoring, and a third received cephalexin and levofloxacin even though surveillance forms showed the resident did not meet criteria, with missing shift-by-shift documentation of side effects and resident response. The DON, MDSC, and IP all confirmed gaps in monitoring and documentation required by facility policy.
Water leaks and water damage were observed in a resident room area and the laundry room. The DOM found loose floorboards and a dirty closet drawer with a white substance in a room shared by three residents, and stated the damage was related to leaking pipes and could be an infection control issue. In the laundry room, leaking pipes were catching water and soap suds in wash basins, a puddle was on the floor, and a bath blanket was being used to soak up water; the DOM stated the leaks had been present for several weeks and had caused damage to the residents' room.
Pest Control Failure in Food Services: A fly was observed in the dishwashing area, food storage area, and trayline during lunch service, including while the DS was present and trying to drive it away. The back door to the food storage area was observed open. The DS stated flies should not be in the kitchen because they could fall on food and cause cross-contamination, and he noted residents could develop diarrhea, stomach pain, and other stomach issues.
A resident with dementia, DM2, and severe cognitive impairment required substantial/maximal help with eating, but a CNA assisted the resident with lunch while standing over the resident in bed. The CNA acknowledged staff should sit at eye level during feeding to respect dignity, and an LVN and the MDSC both stated the CNA should have sat down while providing mealtime assistance.
Call Light Not Within Reach: A resident with muscle weakness, a history of falls, and high fall risk had a call light observed on the floor during an in-room observation. The resident’s CP required the call light to be within reach, and the RNA, MDSC, and DON all stated it should always be accessible so the resident could call for assistance. The facility policy also required ready access to call lights and checks at the beginning of each shift.
Advance Directive Acknowledgement Form Not Completed: The facility failed to document that a resident or RP was informed about advance directives and the right to accept or refuse medical treatment. The resident’s ADAF had missing initials on multiple acknowledgement statements and was not signed, and staff including the SSS, MDSC, and DON stated the missing initials and signature meant there was no clear evidence the required advance directive information had been provided.
A resident with intact cognition and a history of cellulitis and osteomyelitis was sent to the ER after a RLL venous ulcer was noted with green exudate, foul smell, and serosanguinous drainage. The facility did not complete a COC record for the event, and the MDSC and DON confirmed the documentation was missing key assessment details, provider and RP notification, and other required elements.
A resident admitted with depression, gait and mobility issues, and muscle weakness had an order for Duloxetine for depression, but no baseline care plan was developed and implemented within 48 hours of admission. The MDSC and DON stated the plan should have addressed the medication’s care instructions, monitoring, and adverse effects, including its Black Box warning.
A resident on EBP was observed receiving incontinence and morning care without the required PPE, and staff stated they did not know why the resident was on EBP because no EBP care plan had been developed. In a separate event, a resident with a history of falls had a bathroom fall, but the chart lacked an actual fall care plan for that incident even though staff and the DON stated falls should trigger an updated individualized CP with new interventions.
Failure to Apply and Properly Set LALMs: Two residents with pressure injuries did not receive ordered LALM care as directed. One resident with DM, mobility impairment, and stage 2 PIs had no LALM on the bed despite a physician order, and staff said the order had not been communicated to maintenance. Another resident with stroke-related deficits, severe cognitive impairment, and a stage 3 sacrococcyx PI was observed on a LALM set at 250 lbs despite a current weight of 125 lbs; staff and the DON stated the mattress should have been set by weight or comfort per the order and manufacturer guidance.
Enteral feeding care was not fully provided for a resident with a GT and severe cognitive impairment. The resident’s water flush bag was observed hanging with only the resident’s name and date, and an LVN stated it lacked the rate, frequency, and time it was hung. The DON confirmed the label did not show the needed details, and the facility policy required documentation of the formula, route, rate or bolus amount, and flushes.
Failure to Administer PRN Pain Medication According to Ordered Pain Levels: A resident with OA of the hip, spinal stenosis, and post-laminectomy syndrome reported whole-body pain, but MAR review showed PRN acetaminophen and hydrocodone-acetaminophen were not consistently given according to the ordered pain scale. Staff interviews confirmed that pain medication was administered without matching the resident’s reported pain level, and when severe pain was reported there was no PRN order for that level and no physician notification documented.
Incomplete post-dialysis assessment and documentation: A resident with ESRD and a chest permacath received HD, but the DCR and nursing notes were not completed to show the return time, VS, pain, or access-site assessment. The care plan and facility policy required post-HD monitoring, access-site checks, and documentation of pertinent resident status, but the LVN and DON confirmed the record was incomplete and the policy was not followed.
A resident with COPD, oxygen dependence, and a cognitive communication deficit received oxycodone 5 mg PRN, but an LVN did not immediately document the dose in the narcotic record. During review, the narcotic record showed 10 tablets available while the bubble pack had 9 tablets remaining, and the LVN stated she forgot to sign after giving the medication because she got busy. The DON stated narcotics must be closely tracked and documented as soon as possible.
Damaged Ativan Bubble Pack Left in Medication Cart: An LVN found a resident’s Ativan 0.5 mg bubble pack slot with a broken seal and tape covering the damage in a medication cart. The LVN stated it should have been discarded, and the DON stated nurses counting controlled meds should check container integrity because a broken seal affects the drug’s efficacy. Facility policy required damaged medication packaging and controlled substances like Ativan to be handled and disposed of according to policy.
A resident with moderate cognitive impairment and multiple health conditions was pushed by a roommate with a history of behavioral issues, resulting in a fall. The incident was witnessed and reported by staff and another resident, and both parties involved admitted to their actions. The facility's abuse prevention policy was not followed, leading to a failure to protect the resident from physical abuse.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
Staff did not immediately inform a resident, the resident's doctor, and a family member about situations such as injury, decline, or room changes that affected the resident, resulting in a breakdown of required communication.
Failure to Monitor Orthostatic BP and Enforce Safe Ambulation Practices Resulting in Fall With Fractures
Penalty
Summary
The deficiency involves the facility’s failure to prevent a fall with injury for a cognitively impaired resident with a known history of falls and orthostatic hypotension. The resident was admitted with diagnoses including orthostatic hypotension, difficulty walking, muscle weakness, history of falling, and restless leg syndrome, and a subsequent History and Physical documented that the resident lacked capacity to understand and make decisions. A fall risk evaluation identified the resident as high risk for falls, and an MDS assessment showed moderately impaired cognitive skills for daily decision making, with a need for supervision for transfers and walking 150 feet and set-up assistance for walking 50 feet with two turns. The resident’s care plan for falls, initiated at admission, identified high fall risk factors such as impaired balance, poor safety awareness, orthostatic hypotension, history of repeated falls, and possible medication side effects. The facility did not implement and follow physician orders and internal policies related to orthostatic blood pressure monitoring and fall prevention. Physician orders dated 2/13/2026 directed staff to monitor for side effects of mirtazapine and antipsychotic medications, including postural/orthostatic hypotension and drowsiness, and to document observations with tally marks on the MAR every shift. Review of the MAR and vital signs logs showed no documented evidence that orthostatic blood pressures, including standing blood pressures, were obtained. An LVN acknowledged that orthostatic blood pressures were not being checked and that there were no standing blood pressure readings. Another LVN stated she did not obtain standing blood pressures due to fear the resident might fall if the blood pressure dropped. The DON confirmed that orthostatic blood pressure should have been obtained in lying, sitting, and standing positions per physician orders and that there was no documentation that this monitoring occurred. The facility also failed to ensure the resident used appropriate footwear and assistive devices while ambulating, and did not incorporate these issues into the care plan. Staff interviews revealed that the resident preferred to wear personal purple rubber slip-on slippers, refused nonskid socks, and occasionally refused to use an assistive device, instead sometimes pushing a wheelchair as a walker. Physical therapy records indicated the resident was not trained to ambulate more than ten feet without an assistive device and that discharge recommendations specified ambulation as desired using a front-wheeled walker with staff supervision; the rehabilitation director stated the therapy department did not recommend slippers and was not aware of the resident’s refusal to use assistive devices or preference for slippers. The fall care plan did not include interventions addressing orthostatic blood pressure monitoring, the use of personal slippers, or the resident’s refusal to use assistive devices. On the night of the incident, staff observed the resident walking in the hallway from the room toward the nurses’ station, approximately 71 feet, without an assistive device and wearing the purple slippers; the resident appeared groggy, then fell forward and was later found prone on the floor, complaining of severe left arm pain. The resident reported having walked in the room without a walker or wheelchair, then leaving the room without an assistive device while wearing the slip-on slippers, and next recalled being on the floor in front of the nurses’ station with severe left arm pain. The resident sustained a closed displaced fracture of the proximal left humerus and a closed displaced fracture of the proximal phalanx of the left great toe, requiring transfer to an acute care hospital.
Failure to Monitor Orthostatic BP, Assess Fall Risk, and Monitor After Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice and physician orders for a resident with orthostatic hypotension and a history of falls. The resident was admitted with diagnoses including orthostatic hypotension, difficulty walking, muscle weakness, history of falling, and restless leg syndrome. A physician order dated 2/13/2026 directed staff to monitor for side effects of antipsychotic medications, including postural/orthostatic hypotension, and to document these side effects on the MAR every shift. Review of the MAR and vital sign logs from 2/10/2026 to 4/28/2026 showed no documented evidence that orthostatic blood pressures were obtained, specifically no standing blood pressure readings, despite the order and the resident’s risk factors. The facility also failed to appropriately assess the resident’s fall risk following a fall on 2/26/2026. The Fall Risk Evaluation dated 2/26/2026 showed a high fall risk score of ten and noted a history of multiple falls, but it inaccurately documented that the resident had no falls in the past 90 days. The Gait Evaluation section was not completed, and the form indicated there was no drop in orthostatic blood pressure between lying and standing, without any documented evidence that orthostatic blood pressures were actually taken. The Diagnosis Review section recorded only one to two diseases or diagnoses contributing to falls, although the resident had more than two such conditions. Following a subsequent fall and change of condition on 4/25/2026, the facility did not ensure consistent assessment and monitoring of the resident’s medical status. The Change in Condition Evaluation documented that the resident fell, complained of severe pain in the left shoulder and entire left arm, and did not tolerate range of motion of the left upper arm, and that the resident remained on the floor until paramedics arrived. The Functional Status Evaluation section stated the resident did not have orthostatic hypotension, but there was no documentation that orthostatic blood pressures were taken. Review of progress notes from 4/25/2026 to 4/28/2026 showed missing documentation of monitoring on multiple shifts, despite the expectation that the resident be monitored every shift for 72 hours after the change in condition. The DON and LVN acknowledged the lack of documentation of orthostatic blood pressures, fall risk elements, and post-fall monitoring, and the facility policies required timely, comprehensive assessments, orthostatic BP monitoring for at-risk residents, and ongoing monitoring after a change in condition.
Inaccurate Meal Intake and Return-from-Hospital Documentation in Medical Records
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records in accordance with accepted professional standards for three sampled residents. For one resident with orthostatic hypotension, difficulty walking, muscle weakness, history of falls, and restless leg syndrome, the admission record showed admission in early February and a physician order for a consistent carbohydrate diet. The resident’s MDS indicated moderately impaired cognitive skills for daily decision making. On a date in late April, an LVN stated that this resident returned from a general acute care hospital at 9:30 a.m., but the progress note entered by the Assistant Director of Nursing documented that the resident returned at 9:30 p.m. the same day, creating an inaccurate time of return in the medical record. The same resident’s nutritional task documentation for multiple days in April showed breakfast and lunch intake percentages recorded with identical or closely spaced afternoon times, such as both meals documented at 2:37 p.m., 2:06 p.m., 2:38 p.m., 2:41 p.m., 1:41 p.m., and similar patterns on other dates. CNA 3, who reviewed these records with the surveyor, stated that the documented times for the meal intake percentages were inaccurate and that meal intake should be documented after the meal had been consumed. This indicates that the timing of documentation for meal intake did not reflect when the meals were actually eaten. For a second resident with unspecified dementia, muscle weakness, and essential hypertension on a regular diet, the MDS showed intact cognitive skills for daily decision making. Review of this resident’s nutritional task records for April revealed that breakfast and lunch intake percentages were frequently documented at the same or nearly the same time, such as 12:30 p.m. and 12:31 p.m., or both meals at 1:43 p.m., 1:11 p.m., 1:41 p.m., 12:53 p.m., and other similar patterns. CNA 3 again stated that these documented times were inaccurate and that intake should be recorded after the meal was consumed. For a third resident with unspecified dementia, muscle weakness, and a displaced intertrochanteric fracture of the right femur on a regular diet, the MDS indicated severely impaired cognitive skills for daily decision making. This resident’s nutritional task records for April also showed breakfast and lunch intake percentages documented at the same or nearly the same time, including both meals at 12:53 p.m., 1:43 p.m., 1:42 p.m., 12:30 p.m., and 1:10 p.m. and 1:11 p.m. on another date. On one date, breakfast was documented at 2:32 p.m. and lunch at 12:33 p.m. CNA 3 stated that these times were inaccurate and reiterated that intake should be documented after the meal was consumed. In an interview, the DON stated that CNAs should document meal intake after residents consume their meals, that inaccurate documentation has the potential for inaccurate assessment that may lead to unidentified weight changes, and that documentation in the medical record should indicate the accurate date and time. The facility’s charting and documentation policy required prompt, accurate documentation at the time care is provided or immediately afterward, using clear, factual entries, which was not followed in these instances. These findings show that the facility did not ensure CNAs documented meal intake percentages at the correct time for three residents and did not ensure licensed nursing staff documented the accurate time of a resident’s return from the hospital, resulting in incomplete and inaccurate medical records.
Failure to Develop and Implement Comprehensive Fall-Prevention Care Plan
Penalty
Summary
Surveyors identified a failure to develop and implement a comprehensive, person-centered care plan with measurable objectives and interventions for a resident with multiple fall risk factors and orthostatic hypotension. The resident was admitted with diagnoses including orthostatic hypotension, difficulty walking, muscle weakness, history of falling, and restless leg syndrome, and was assessed as high risk for falls on admission with a fall risk score of 15. Physician orders dated shortly after admission directed staff to monitor for side effects of mirtazapine and antipsychotic medications, including postural/orthostatic hypotension and drowsiness, and to document observations with tally marks on the MAR every shift. However, there was no documented evidence in the medical record that orthostatic blood pressure monitoring was performed or that these ordered side-effect observations were consistently documented. The resident experienced at least two documented falls during the review period. A Change in Condition (COC) Evaluation on one date showed the resident was found sitting on the floor beside the bed, but the Functional Status Evaluation section that would indicate whether orthostatic hypotension was present was not completed. A subsequent COC Evaluation documented another fall while the resident was ambulating in the hallway, with complaints of severe pain in the left shoulder and arm and inability to tolerate range of motion of the left upper arm. In that COC Evaluation, the Functional Status Evaluation section indicated the resident did not have orthostatic hypotension, but there was no documentation that orthostatic blood pressures were taken to support that conclusion. Review of the resident’s care plan and staff interviews showed that the care plan did not address several known risks and preferences related to falls. The fall care plan, initiated on admission, identified the resident as high risk for falls due to impaired balance, decreased or poor safety awareness, orthostatic hypotension, history of repeated falls, and possible medication side effects, but it lacked specific interventions for orthostatic blood pressure monitoring, the resident’s use of personal open-toed, open-back rubber slippers, and the resident’s refusal to use an assistive device while ambulating. A CNA and an LVN reported that the resident preferred thick purple rubber slippers and occasionally refused to use a wheelchair or assistive device when walking, and the LVN acknowledged there was no documentation of orthostatic monitoring and that the care plan was incomplete. The DON confirmed that the resident’s preferences and refusals, as well as orthostatic blood pressure monitoring, should have been reflected in the care plan and that these risks were not identified or addressed in the plan, contrary to the facility’s care planning and nursing assessment policies requiring individualized, person-centered care plans based on ongoing assessments.
Failure to Implement and Complete Person-Centered Care Plan for Anticoagulation, Constipation, and Fall Prevention
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a complete, person-centered care plan for a resident with multiple complex medical conditions, including acute kidney failure, pulmonary embolism with acute cor pulmonale, and a history of falls. The resident was admitted with an order for apixaban, an anticoagulant, and the care plan dated 2/16/2026 included interventions to monitor for side effects and effectiveness of anticoagulant therapy, specifically listing signs such as blood in urine, black tarry stools, gastrointestinal symptoms, lethargy, bruising, and other adverse reactions. The Medication Administration Record for April 2026 showed that apixaban was administered twice daily from 4/1/2026 to 4/13/2026, but there was no documented monitoring of side effects on the MAR. During interview, the DON confirmed that residents on apixaban should be monitored for bleeding every shift with documentation on the MAR and acknowledged that the care plan intervention for anticoagulant monitoring was not followed. The deficiency also includes failure to implement the resident’s constipation care plan. The physician ordered naloxegol oxalate and polyethylene glycol daily for constipation, and the care plan for risk of constipation listed interventions of administering medications as ordered and monitoring for effectiveness with reporting of concerns to the physician. The MAR showed that both constipation medications were administered daily. However, the resident reported not having a bowel movement for 13 days and stated she had informed nurses without receiving new medication. Bowel elimination records from mid-March to mid-April documented multiple days without a bowel movement. Staff interviews revealed that the resident frequently complained of constipation, that staff were aware she was on routine constipation medications, and that there were no additional PRN constipation medications ordered. The resident reported requesting an enema about a week earlier that was not given, and staff confirmed there was no enema order and no documentation that the physician was notified about ongoing constipation, despite the care plan requirement to monitor effectiveness and report concerns. A further deficiency occurred in the failure to incorporate a physician-ordered fall prevention intervention into the resident’s care plan. After a documented change in condition on 2/26/2026, when the resident slid off the bed while attempting to go to the bathroom and was found sitting on the floor, the physician ordered bilateral landing pads and bed and wheelchair alarms. The change in condition evaluation recorded this order. However, review of the resident’s fall risk care plan dated 2/26/2026 showed that bilateral landing pads were not included as an intervention. During interviews, RN 2 and the DON acknowledged that the physician had ordered bilateral landing pads and that they were not reflected in the care plan, noting that care plans are intended to be a summary of care and should be complete with all interventions. The facility’s comprehensive care plan policy stated that all staff must follow the care plan and that it must include treatment orders and medication management, but in this case the ordered bilateral landing pads were not added to the care plan. Overall, the facility did not fully implement the resident’s existing care plans for anticoagulant monitoring and constipation, and did not develop a complete fall care plan that included the ordered bilateral landing pads. These actions and omissions resulted in a care plan that did not comprehensively guide staff in monitoring for anticoagulant side effects, responding to persistent constipation, or using all ordered fall-prevention measures, contrary to the facility’s own comprehensive care plan policy.
Failure to Provide and Follow Ordered Pressure Ulcer Treatments
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards for one resident with multiple pressure injuries. The resident was admitted with diagnoses including osteomyelitis, generalized muscle weakness, and hypertension, and had intact cognitive skills and capacity to make decisions per the H&P and MDS. A physician order dated 2/6/2026 directed daily treatment to a stage 4 sacrococcyx pressure ulcer extending to the bilateral buttocks, with a plan to reevaluate on 3/9/2026. A wound assessment on 3/4/2026 documented the stage 4 ulcer with specific measurements and noted that the wound provider performed debridement and ordered Santyl with calcium alginate daily and as needed. However, review of the Treatment Administration Record for March showed no documented wound treatment to the sacrococcyx ulcer on 3/9/2026, and the DON confirmed there was no documented treatment provided that day. A second component of the deficiency concerns the facility’s failure to follow updated wound provider orders for the resident’s bilateral heel unstageable pressure ulcers. On 3/4/2026, physician orders directed cleansing both heels with normal saline, patting dry, applying iodosorb, and covering with a dry dressing daily for 30 days. A subsequent wound assessment on 3/25/2026 indicated the wound provider ordered betadine and dry dressing daily to both heels, and physician orders dated the same day specified cleansing with normal saline, patting dry, applying betadine, and covering with a dry dressing daily for 30 days to each heel. The care plan was also updated on 3/25/2026 to reflect betadine treatment to the left heel. Despite the new 3/25/2026 orders, the March TAR showed that from 3/26/2026 through 3/31/2026, nurses administered both betadine and iodosorb daily to the resident’s heels. During interview and record review, the DON stated that treatment nurses should have called the wound provider to clarify which order to continue when the new betadine order was added, given the prior iodosorb order, and noted concern about a possible drug interaction and the combination being too strong for the resident’s skin. Treatment Nurse 1 confirmed that both betadine and iodosorb were applied to the bilateral heels during that period and stated that the wound care order should have been clarified when the wound provider was at the facility on 3/25/2026. Facility policies on pressure ulcer management and wound documentation required individualized care plans, appropriate wound solutions and dressings per provider guidelines, and documentation at each treatment that matches the TAR, which were not followed in these instances.
Failure to Promptly Notify Physician of Resident’s Ongoing Constipation
Penalty
Summary
The deficiency involves the facility’s failure to promptly notify the physician when a resident repeatedly reported constipation despite ongoing symptoms and documented bowel irregularities. The resident was admitted with significant medical diagnoses, including acute kidney failure, pulmonary embolism with acute cor pulmonale, and a history of falls. Physician orders at admission included daily naloxegol and polyethylene glycol for constipation. The resident’s H&P documented that she lacked capacity to understand and make decisions, and the MDS showed moderately impaired cognitive skills, a need for maximum assistance with ADLs, and that she was always incontinent of bowel function. The MAR for April showed that the ordered constipation medications were administered daily. During interviews, the resident reported she had not had a bowel movement for 13 days and stated she had informed nurses but no new medication was given. Review of the bowel elimination record from mid-March to mid-April showed multiple days with no bowel movement documented. One LVN stated the resident complained of constipation “all the time” and had most recently verbalized constipation the prior week; the LVN acknowledged she did not report this to the RN supervisor or notify the physician, and instead only told the resident she was already receiving naloxegol and polyethylene glycol. Another LVN reported that the resident said she had an order for an enema, but no such order was found in the medical record; this LVN reported the resident’s request for an enema and need for something to relieve constipation to the RN. The RN stated she was informed that the resident had not had a bowel movement for 13 days and that there was no PRN medication for constipation. The RN acknowledged that if there was no PRN medication, the physician should have been notified. She reported that she texted the physician during the night using the RN phone but had not documented this contact, and later review of the phone showed text messages sent only later that morning to two physician numbers, with no evidence of an earlier text at the time she initially claimed. The RN also stated there was no change-in-condition (CIC) documentation created for the resident’s constipation, and confirmed she did not create one. The DON stated that when the resident reported not having a bowel movement for 13 days, a CIC should have been created and the physician notified to obtain a PRN constipation medication, and that not notifying the physician delayed needed care. The facility’s change in condition policy required prompt recognition, assessment, provider notification, and documentation of changes in resident status, which was not followed in this case.
Failure to Follow Hydralazine Hold Parameters per Physician Order
Penalty
Summary
Surveyors identified a deficiency in the facility’s pharmaceutical services related to the administration of hydralazine for a resident with essential hypertension. The resident was admitted with diagnoses including osteomyelitis, generalized muscle weakness, and essential HTN, and had a physician’s order dated 2/2/2026 for hydralazine 50 mg by mouth three times daily, with instructions to hold the medication if the systolic blood pressure (SBP) was less than 110 mmHg. The resident’s History and Physical dated 2/4/2026 and MDS dated 2/9/2026 documented that the resident had the capacity to understand and make decisions and had intact cognitive skills for daily decisions. Review of the April 2026 MAR showed that on 4/10/2026, LVN 3 administered hydralazine at 1 p.m. when the resident’s blood pressure was 107/68 mmHg, and LVN 4 administered hydralazine again at 5 p.m. when the blood pressure was 105/67 mmHg, both below the ordered SBP hold parameter of 110 mmHg. During an interview and concurrent record review on 4/13/2026, the DON confirmed that the physician’s order required holding hydralazine when SBP was below 110 mmHg and acknowledged that the medication should have been held at both administration times on 4/10/2026. The facility’s undated Medication Administration Procedure, last reviewed on 4/24/2025, stated that all medications shall be administered in accordance with prescribers’ orders.
Failure to Monitor Anticoagulant Therapy for Signs of Bleeding
Penalty
Summary
The facility failed to ensure that a resident receiving apixaban, an anticoagulant, was monitored for side effects of bleeding as required by the resident’s care plan and facility policy. The resident was admitted with diagnoses including acute kidney failure, pulmonary embolism with acute cor pulmonale, and a history of falls, and had a physician’s order for apixaban 5 mg by mouth twice daily for pulmonary embolism/DVT. The resident’s history and physical documented that the resident did not have capacity to understand and make decisions, and the MDS showed moderately impaired cognitive skills and a need for maximum assistance with toileting, showering, dressing, and personal hygiene. The care plan for anticoagulant therapy directed staff to monitor for side effects and effectiveness and to monitor, document, and report adverse reactions such as blood-tinged urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle or joint pain, lethargy, and bruising. Review of the MAR for the month of April showed that the resident received apixaban twice daily from the 1st through the 13th, but there was no documented monitoring for bleeding or other side effects associated with apixaban. During an interview and concurrent record review, the DON acknowledged that apixaban is an anticoagulant with side effects of bleeding and bruising, and stated that the resident should have been monitored for bleeding every shift with documentation on the MAR. The DON confirmed that such monitoring was not documented. The facility’s anticoagulation clinical protocol required assessment for signs or symptoms of adverse drug reactions and monitoring for possible complications in individuals on anticoagulation, including nursing evaluation and communication with the physician if there was evidence of bleeding. Despite these requirements, there was no documentation that staff monitored or assessed this resident for bleeding while the resident was receiving apixaban.
Incomplete Abuse Investigations Due to Missing Staff Interviews and Statements
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse investigation policy by not fully interviewing or obtaining written statements from all staff assigned to residents involved in alleged resident-to-resident physical abuse incidents. For Resident 1, who was admitted with encephalopathy, unspecified dementia, and generalized muscle weakness and had moderately impaired cognitive skills, a Change of Condition Evaluation (CIC) dated 2/15/2026 documented that Resident 1 received physical contact from Resident 2. RN 1 witnessed and separated the residents and completed a head-to-toe assessment with no pain or injuries noted. The Director of Staff Development (DSD) stated that on that date RN 1, LVN 2, and CNA 2 were assigned to Resident 1. The Director of Nursing (DON) reviewed the facility’s staff interview document dated 2/15/2026 and confirmed that it contained statements from RN 1, two clinical students, and one clinical instructor, but there were no statements from LVN 2 or CNA 2, despite their assignment to Resident 1. For Resident 2, who was admitted with ESRD, COPD, and hypertension, the MDS and History and Physical indicated intact cognitive skills and capacity to understand and make decisions. A CIC dated 2/15/2026 documented that RN 1 witnessed Resident 2 make physical contact with Resident 1, separated them, and assessed Resident 2 with no pain or injury. The facility’s Five-Day Investigation Summary indicated that staff witness statements were reviewed. The DSD stated that on 2/15/2026, RN 1, LVN 1, and CNA 5 were assigned to Resident 2. However, upon review of the staff interview document dated 2/15/2026, the DON confirmed that only statements from RN 1, two clinical students, and one clinical instructor were present, and there were no statements from LVN 1 or CNA 5, even though they were assigned to Resident 2. For Resident 3, admitted with acute kidney failure, difficulty in walking, and generalized weakness, the MDS and H&P indicated intact cognitive skills and decision-making capacity. A CIC dated 2/16/2026 documented that Resident 3 maneuvered an electric motorized wheelchair in the activity room, and the wheelchair made contact with Resident 4’s wheelchair, after which Resident 4 turned, extended an arm toward Resident 3, and made physical contact. Staff intervened, separated the residents, and assessed them with no visible injury and no pain reported. CNA 4 stated she was assigned to Resident 3 and was with another resident when the incident occurred. LVN 3 stated she was informed that her resident (Resident 3) hit Resident 4 in the right shoulder. The DSD stated that RN 1, LVN 3, and CNA 4 were assigned to Resident 3 on 2/16/2026. The DON reviewed the staff interview document and confirmed it contained a statement from LVN 3 but no statement from CNA 4, despite her assignment to Resident 3. For Resident 4, admitted with acute embolism and thrombosis of a deep vein of the left lower extremity and hypertension, the H&P indicated capacity to understand and make decisions. A CIC dated 2/16/2026 documented that Resident 4 extended an arm toward Resident 3 and made physical contact, and that Resident 3 hit Resident 4’s left knee on the table. RN 1 offered pain medication, which Resident 4 refused, and assessed Resident 4 with no visible injuries. LVN 4 stated he was assigned to Resident 4 but was not in the activity room when the incident occurred and that RN 1 informed him of the incident; he stated he checked Resident 4 and found no pain or injury. The Activity Director reported that Activity Staff 1 observed Resident 4’s wheelchair bump into Resident 3’s wheelchair in the activity room. The DSD stated that RN 1, LVN 4, and CNA 3 were assigned to Resident 4 on 2/16/2026. The DON reviewed the staff interview document and confirmed that no staff statements were documented for this incident and specifically that there were no statements from LVN 4 or CNA 3. Review of the facility’s policy and procedure titled “Abuse Investigation and Reporting,” last reviewed 4/2025, showed that the individual conducting the investigation must, at a minimum, interview staff members on all shifts who had contact with the residents during the period of the alleged incident, interview roommates, family members, and visitors, review all events leading up to the alleged incident, and document the investigation completely and thoroughly. The policy further states that witness statements are to be obtained in writing, signed, and dated, either written by the witness or obtained by the investigator. The DON stated that, based on this policy, the investigations were not complete. The Administrator stated that for the allegations on 2/15/2026 and 2/16/2026, she interviewed RN 1 and Activity Staff 1 but did not interview the assigned staff for the involved residents, and acknowledged that the investigations for Residents 1, 2, 3, and 4 were incomplete.
Inaccurate MAR Documentation for Hospitalized Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate and complete medical record for one sampled resident by inaccurately documenting medication administration while the resident was hospitalized. The resident had been admitted with diagnoses including other encephalopathy, unspecified dementia, and generalized muscle weakness, and had multiple active physician orders for medications such as atorvastatin, levothyroxine, docusate, ferrous sulfate, lubiprostone, pantoprazole, quetiapine, and senna. The resident’s Minimum Data Set indicated moderately impaired cognitive skills for daily decisions. Record review showed that the resident was transferred to a general acute care hospital on 2/15/2026 at 7:20 p.m. following an incident in which another resident made physical contact; a head-to-toe assessment revealed no pain or injuries, and the physician ordered transfer for further evaluation. Progress notes documented the transfer on 2/15/2026 and the readmission from the hospital on 2/19/2026 at 3:02 p.m., confirming that the resident was not present in the facility between those dates and times. Despite the resident’s absence, the February 2026 Medication Administration Record showed that LVN 6 documented administration of atorvastatin, quetiapine, senna, docusate, ferrous sulfate, pantoprazole, and lubiprostone on specific dates and times while the resident was at the hospital, and LVN 7 documented administration of levothyroxine and pantoprazole during the same period. In interviews, the ADON confirmed that the resident was at the hospital during these documented administrations and stated that LVN 6 and LVN 7 should have verified the resident’s presence and identity before documenting medication administration, acknowledging that the medical record was inaccurate. The DON also stated that the nurses should not have documented medication administration when the resident was at the hospital and that medications should have been documented as not given, noting that the inaccurate medical record could cause confusion in care. The facility’s charting and documentation policy required that all medications and care be documented promptly and accurately according to facility and regulatory requirements. These failures had the potential to result in medication errors, cause confusion in care and the medical records containing inaccurate documentation.
Failure to Care Plan for Resident’s Refusal of Hyperkalemia Medication
Penalty
Summary
Surveyors identified a deficiency in the facility’s development and implementation of a person-centered comprehensive care plan related to a resident’s refusal of ordered medication. The resident was admitted with diagnoses including end stage renal disease, COPD, and essential hypertension. An MDS assessment documented that the resident’s cognitive skills for daily decision-making were intact, and a subsequent H&P stated the resident had the capacity to understand and make decisions. A physician’s order directed administration of Lokelma 10 grams orally on specific days for treatment of hyperkalemia. The MAR for the relevant month showed that on 2/1/2026 the resident refused the ordered Lokelma dose. During concurrent record review and interview, the ADON confirmed there was no care plan addressing the resident’s refusal of Lokelma and acknowledged that the nurse should have notified the physician and documented the refusal. The ADON stated that without a care plan for the refusal, there would be no intervention to correct the resident’s hyperkalemia and this could potentially cause further increase in potassium levels. In a separate interview, the DON stated that a care plan should have been developed for the resident’s medication refusal to create a new treatment plan to prevent further elevation of potassium, and that without such a care plan the resident’s hyperkalemia might not be corrected. The facility’s comprehensive care plan policy indicated that a CCP is to be developed for each resident to ensure individualized, resident-centered care addressing medical needs and updated based on resident conditions and preferences, which was not followed in this case.
Improper Texture-Modified Meals Served
Penalty
Summary
The facility failed to provide food prepared in a form designed to meet individual needs for residents on pureed and soft bite-sized diets. On 1/13/2026, the menu spreadsheet showed that residents on an IDDSI Level 4 pureed diet were to receive pureed oatmeal, pureed sausage patty, and pureed pancakes. However, during observation, no pureed oatmeal was on the steamtable, and the cook stated regular oatmeal had been prepared. The dietary supervisor stated no substitutions were made for breakfast, yet residents on pureed diets were served regular oatmeal instead of the ordered pureed oatmeal. Resident 14 had diagnoses including dysphagia, type 2 DM, and adult failure to thrive, and was ordered a CCHO, NAS, pureed Level 4 diet with thin liquids. Speech therapy documented moderate oropharyngeal dysphagia and indicated the resident required a pureed diet. During breakfast observation, Resident 14 was fed regular oatmeal with visible lumps and was noted to be receiving oatmeal that was not smooth or pureed. Staff interviews confirmed the tray had not been verified for oatmeal consistency before service, and CNA 2 stated the oatmeal was lumpy and not appropriate for a pureed diet. Resident 96 had diagnoses including dysphagia, HTN, and hyperlipidemia, and was ordered a fortified pureed Level 4 diet with moderately thick liquids. Speech therapy documented severe oropharyngeal dysphagia and stated a pureed diet was the safest at that time. During observation, Resident 96’s tray contained regular oatmeal with particles and lumps, and CNA 1 fed the resident the oatmeal. Resident 24 had diagnoses including oropharyngeal phase dysphagia, type 2 DM, and HTN, and was ordered a CCHO, pureed Level 4 diet with thin liquids. During observation, Resident 24 was served and ate regular oatmeal, and CNA 3 stated the oatmeal was not pureed and was not smooth in consistency. The report also states that residents on soft bite-sized diets were given pork mushroom and carrots that were finely chopped and minced, and that pureed pancakes and pureed sausages did not meet the expected texture standards on the plate.
Improper Disposal of Meal Tickets Containing PHI
Penalty
Summary
The facility failed to keep residents' personal and medical records private and confidential by allowing meal tickets containing protected health information to be discarded in a trash container. During observation on 1/14/2026 at 12:59 p.m., meal tickets were seen in the trash by the dishwashing machine area. The Dietary Supervisor stated the meal tickets were returned to the kitchen after each meal and then thrown out in the trash, and confirmed the tickets contained residents' names, diets, and room numbers. During interview, the Dietary Supervisor stated it was not appropriate for staff to throw the meal tickets in the trash because the documents contained protected information and doing so was a violation of HIPAA. The supervisor also stated that other people could obtain the residents' information and use it, and that this did not protect the privacy rights of the residents. Facility policy titled Meal Ticket Policy stated meal tickets are generated based on the resident's current diet orders documented in the EHR, and the Resident Privacy and Confidentiality Policy stated the facility will safeguard the confidentiality of all resident personal and medical records and limit access to authorized staff members and approved business associates.
Dirty Fans and Water-Damaged Resident Room
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for five sampled residents by leaving resident room equipment and living spaces in poor condition. Resident 65, who had diagnoses including dependence on supplemental oxygen, pneumonitis, pulmonary hypertension, and generalized muscle weakness, was observed in a room with an electric stand fan facing the resident that had strips of gray powder-like material on the front and back panels and on the blades. During the observation, CNA 8 stated the fan had a lot of gray dust in the front and back panel and said she was not sure who was responsible for cleaning the electric fans. LVN 10 also observed the dirty fan and stated maintenance was responsible for keeping electric fans and resident equipment clean to provide a homelike environment. The DOM later stated the maintenance department was responsible for maintaining the cleanliness of furnishings such as electric fans and other resident care equipment, and the MDSC reviewed the photo and stated the fan was dirty and had a lot of gray dust. Resident 55, who had diagnoses including cellulitis and lymphedema and had intact cognition, was also observed with an electric fan in the room that had dust buildup on the fan blades and on the front and back grill enclosure. The resident stated she had spoken to the Maintenance Department about it but the fan had not been cleaned. The RTS observed the same condition and stated the fan was dirty and needed to be cleaned to prevent the resident from getting a respiratory infection. The MDSC reviewed the photo of the fan and stated it was dirty and should have been cleaned by housekeeping, and the DON stated housekeeping was in charge of cleaning electric fans in the facility. The facility also failed to provide a homelike environment for Residents 33, 39, and 72 when their room was damaged by water leaks. Resident 33 had diagnoses including CHF and depression and required maximum assistance with ADLs; Resident 39 had diagnoses including heart failure and epilepsy and also required maximum assistance with ADLs; Resident 72 had diagnoses including DM and chronic myeloproliferative disease and required maximum assistance with ADLs. During observation with the DOM, the room had loose floorboards, and the closet drawer contained a white substance. The DOM stated the white substance was a result of water damage and could be a potential infection control issue. The DON stated the water damage in the room could create an infection control concern because moisture can promote mold and bacteria growth and stated the room did not look homelike. The DOM also observed leaking pipes in the laundry room, water puddling on the floor, and a bath blanket placed on the floor to absorb leaking water; the DOM stated the pipes had been leaking for several weeks and that the leaking water caused the water damage in the residents' room, including loose and damp laminate floor tiles, warped wood on the drawers and closet panels, and wall damage.
Bed Alarm Used Without Order, Consent, or Restraint Assessment
Penalty
Summary
The facility failed to ensure Resident 57 was free from the use of a physical restraint when a bed pad alarm was placed without a physician's order, informed consent, or a completed restraint assessment. Resident 57 was admitted and later readmitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction, congestive heart failure, and cognitive communication deficit. The history and physical dated 11/19/2025 indicated the resident did not have the capacity to understand and make decisions, and the MDS dated 11/27/2025 indicated severely impaired cognition and dependence for multiple ADLs. The record review showed the Order Summary Report did not contain a physician's order for the bed pad alarm, and the paper and electronic health records did not show that consent was obtained from the resident or responsible party for its use. Fall risk evaluations dated 11/18/2025, 11/20/2025, 12/4/2025, and 12/9/2025 identified the resident as high risk for falls, and the care plan for falls included a bed alarm and other fall precautions. The care plan also referenced actual fall incidents on 12/4/2025 and 12/9/2025. During observation on 1/12/2026, the resident was seen sitting at the edge of the bed, and the LVN stated the bed alarm box was hanging on the wall with the cord wrapped around the bed control cord closest to the plug and was not functioning properly. During interview and record review on 1/16/2026, the MDSC stated there was no physician's order, informed consent, or restraint assessment completed prior to application of the bed alarm, and stated the bed alarm was considered a restraint because it restricted the resident from getting up and moving freely.
Unnecessary Psychotropic Medication Monitoring Deficiencies
Penalty
Summary
The facility failed to ensure that psychotropic medications were prescribed and monitored with specific, measurable behavioral manifestations for one resident and failed to monitor for adverse effects of psychotropic medications for another resident. For one resident, the record showed diagnoses including major depressive disorder, schizoaffective disorder, bipolar disorder, and unspecified dementia. The resident was ordered quetiapine fumarate 25 mg at bedtime for mood stabilizer manifested by feelings of highs and lows, and sertraline 25 mg daily for depression manifested by feelings of hopelessness, sadness, and loneliness. The care plan referenced antidepressant and antipsychotic use with behavior monitoring, but the behaviors documented in the orders and monitoring were feelings rather than specific measurable behaviors. During interview, an LVN stated that antipsychotic and antidepressant medications are high-risk medications and that behavioral manifestations should be specific and measurable, with behaviors tallied each shift. The LVN stated that feelings are not specific measurable behaviors and that the resident's orders and monitoring should have included specific behaviors, but they did not. The DON reviewed the facility policy and stated that psychotropic medications are to be monitored through specific measurable behaviors communicated in the MAR, and that feelings are not measurable behaviors because different staff may interpret them differently. The DON stated the facility policy was not followed when the resident's quetiapine fumarate and sertraline were not monitored for resident-specific behavioral manifestations. For another resident, the record showed diagnoses including depressive episodes and anxiety disorders, with an H&P indicating the resident had capacity to understand and make decisions and an MDS indicating severe cognitive impairment. The resident had orders for Depakote 250 mg three times daily for bipolar disorder and Rexulti, and the care plan referenced monitoring/documenting side effects and effectiveness. During interview, the MDSC stated there was no order for monitoring adverse effects of Depakote and Rexulti and that the MAR did not contain any form of adverse-effect monitoring. The MDSC also stated the behaviors to be monitored for Depakote were not specific. The DON stated it was important to monitor for adverse effects of Depakote and Rexulti every shift because both medications have black box warnings, but the record review showed that such monitoring was not present.
Failure to Rotate Insulin Injection Sites
Penalty
Summary
Licensed nursing staff failed to rotate subcutaneous insulin administration sites for two residents who were receiving insulin for diabetes management. Resident 4 had diagnoses including type 2 DM with diabetic chronic kidney disease and mild protein-calorie malnutrition. The resident’s record showed orders for insulin glargine at bedtime with instructions to rotate the site, and Novolog before meals and at bedtime with permission to rotate the injection site. The location of administration record showed repeated injections in the same abdominal areas, including multiple doses in the left lower quadrant and right lower quadrant, as well as repeated use of the left arm. Resident 35 had diagnoses including type 2 DM with chronic kidney disease, retinopathy, and neuropathy. The resident’s orders included Humulin R before meals and at bedtime and insulin NPH 70/30 twice daily, both with instructions that the injection site may be rotated. The location of administration record showed repeated injections in the same abdominal areas, including multiple doses in the left upper quadrant and left lower quadrant, as well as repeated use of the right abdomen and right deltoid. During interview and record review, the MDS Coordinator stated there were multiple instances where licensed nurses did not rotate insulin administration sites for both residents. The MDS Coordinator stated rotating sites is intended to prevent discomfort and skin injury such as lipodystrophy, and that continued injection into lipodystrophy sites can affect absorption and cause hypo- or hyperglycemia. The DON stated licensed staff should have rotated the insulin sites for both residents unless it was the resident’s preference, and stated rotation is used to prevent skin injury such as lipodystrophy. The facility policy stated insulin injection sites must be rotated to prevent tissue damage, and the provided prescribing information for insulin products also stated to rotate injection sites to reduce the risk of lipodystrophy and localized cutaneous amyloidosis.
Failure to Notify Physician of Elevated SBP
Penalty
Summary
The facility failed to provide treatment and care in accordance with physician orders and the resident’s care plan for a resident with hypertensive heart disease with heart failure, acute on chronic CHF, CKD stage 3, and hemiplegia/hemiparesis following cerebral infarction. The resident’s record showed an order, carried out on 11/19/2025, to check blood pressure twice daily and notify the physician if systolic blood pressure (SBP) was greater than 140 mmHg. The resident’s care plan also directed staff to monitor vital signs and notify the physician of significant abnormalities, and the kidney medical group note stated that blood pressure control was essential to protect kidney function and that target SBP should be maintained below 140 mmHg. During review of the January 2026 MAR and progress notes, multiple SBP readings above the ordered parameter were identified without documented evidence that the physician was notified. These included SBP readings of 151, 145, 157, 152, 157, 145, 154, 144, 147, and 147 mmHg on various morning and evening checks. In concurrent interviews, an LVN stated that if the physician was notified, there should be documentation showing the order was carried out, and another LVN stated she had not notified the physician regarding an SBP above 140 mmHg since 11/2025 and did not follow the order, although she should have. The DON reviewed the facility policies on Quality of Care and Change of Condition and stated that physician orders include instructions for nursing care, that the physician should be notified when BP is outside ordered parameters, and that the notification should be documented. The DON also stated it was important to notify the physician when the resident’s SBP was above 140 mmHg to implement interventions to lower the BP and prevent another stroke or further loss of kidney function, but this was not done. The facility policies were not followed when the physician was not notified.
Environmental Hazards and Fall Prevention Failures
Penalty
Summary
The facility failed to keep the environment free of accident hazards for multiple residents. For one resident at high risk for falls, a side table was observed placed on top of a floor mat beside the bed. The resident had diagnoses including gait and mobility abnormalities, muscle weakness, and repeated falls, and the record showed severe cognitive impairment and need for substantial to supervision assistance with mobility and ADLs. Staff stated the floor mat was intended to provide a soft landing surface if the resident rolled or fell from bed, and that objects on top of the mat defeated that purpose. Another resident had frayed wires on the bed remote control. The resident’s record showed diagnoses including dementia, depression, and anxiety disorder, and the resident did not have capacity to understand and make decisions. Staff observed the frayed wires during room observation and stated the wires should not be present because they could predispose the resident to electrocution. The facility policy required equipment and structures to be maintained in good working order and rooms kept free of hazards. The facility also did not complete required post-fall interdisciplinary team reviews for a resident who fell twice in December 2025. The resident had diagnoses including aftercare following joint replacement surgery, history of falling, spinal stenosis, and post-laminectomy syndrome, and was assessed as high risk for falls. Records documented an unwitnessed fall when the resident slid to the floor from a wheelchair and another fall in the bathroom with knee discoloration, right ankle swelling, and pain rated 6 out of 10. Staff stated the facility process required an IDT meeting within 3 to 7 days after a fall, but there was no documented evidence that the meetings occurred. The facility also left self-administered medications unattended at the bedside for three residents without physician orders or self-administration assessments. These residents had records showing they were cognitively intact or able to understand and make decisions, but staff confirmed there were no assessments or orders authorizing bedside medication storage. In addition, one resident with severe cognitive impairment and high fall risk did not have the ordered bed pad alarm in place, and another resident’s bed alarm was not functioning properly. Staff stated the alarm should have been present and monitored each shift, and the resident remained at high risk for falls.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to keep its medication error rate below 5 percent, with 3 medication errors identified out of 37 opportunities for an overall error rate of 8.11 percent. The errors affected two residents during medication administration observations and record review. One resident had diagnoses including cerebral infarction, major depressive disorder, and generalized muscle weakness, and the other resident had systolic heart failure, paroxysmal atrial fibrillation, and atherosclerotic heart disease. For one resident, an LVN administered aspirin 81 mg without instructing the resident to chew the tablet before swallowing, even though the physician order specified that the tablet be chewed before swallowing. The same LVN also administered lidocaine 5% ointment to the resident without a dose being indicated in the physician order. During the observation, the LVN applied the lidocaine from the container using two fingers to the resident’s lower back and stated the order did not indicate how much to apply. The LVN also stated he did not check the medication package insert and did not know how much 5 grams was. For the second resident, an LVN administered digoxin 125 mcg by mouth for atrial fibrillation after checking the resident’s radial pulse instead of the apical pulse required by the order. The LVN stated he should have taken the apical pulse and acknowledged that using the radial pulse was a medication error. The facility’s DON and MDSC both stated that the apical pulse should have been used because it is more accurate and is the ordered parameter for determining whether digoxin could be given. The facility policy stated medications are to be administered in accordance with the prescriber’s order and manufacturer’s instructions.
Failure to Rotate Insulin Injection Sites
Penalty
Summary
The facility failed to ensure that two sampled residents were free from significant medication errors related to insulin administration because subcutaneous insulin injection sites were not rotated as ordered and as required by facility policy. The deficiency was identified during interview and record review for Resident 4 and Resident 35, both of whom had diabetes mellitus and were receiving insulin as a high-risk medication. For Resident 4, the record showed diagnoses including type 2 DM with diabetic chronic kidney disease and mild protein-calorie malnutrition. The resident’s orders included insulin glargine at bedtime with instructions to rotate the site, and Novolog sliding scale insulin with instructions that the injection site may be rotated. The location of administration record showed repeated injections in the same areas, including multiple doses in the abdomen-left lower quadrant and abdomen-right lower quadrant, with additional repeated use of the left arm. During interview, the MDSC stated there were multiple instances where licensed nurses did not rotate the insulin administration site, and stated that not rotating insulin administration site is a medication error. The DON stated staff should have rotated the sites unless it was the resident’s preference and also stated that not rotating insulin administration site is a medication error. For Resident 35, the record showed diagnoses including type 2 DM with chronic kidney disease, retinopathy, and neuropathy. The resident had orders for Humulin R sliding scale insulin and insulin NPH isophane & regular suspension 70-30, both with instructions that the injection site may be rotated. The location of administration record showed repeated injections in the same abdominal areas and repeated use of the right deltoid. During interview, the MDSC stated there were multiple instances where licensed nurses did not rotate the insulin administration site for Resident 35 and stated that not rotating insulin administration site is a medication error. The DON stated staff should have rotated the sites of insulin administration and stated that not rotating insulin administration site is a medication error. Facility policy and manufacturer information reviewed in the record stated that insulin injection sites must be rotated to prevent tissue damage and reduce the risk of lipodystrophy.
Unsafe puree texture and kitchen sanitation issues
Penalty
Summary
The facility failed to provide puree diet items with the required texture and consistency for residents on IDDSI Level 4 puree diets. During breakfast preparation, a dietary employee prepared puree ham and puree pancake, and the spoon tilt test showed the puree pancake did not fall off the spoon and left a thick film. The employee added hot water to the puree pancake because it was too thick, but did not repeat the spoon tilt test after the adjustment. The dietary supervisor later performed a spoon tilt test on the puree pancake and stated the texture was okay because it was smooth, although a thick film remained on the spoon. The dietary supervisor also stated the puree foods were still sticky and could get stuck in residents’ mouths and throat. The assistant dietary supervisor stated he did not check the breakfast puree food for the spoon tilt test. At lunch, the cranberry yogurt mousse for the puree diet did not fall off the spoon during the spoon tilt test, even with agitation and strong force. The dietary supervisor stated the mousse was too thick and residents might choke due to food getting stuck in their throat. The registered dietitian stated he did not observe and test the cold puree food, including the cranberry yogurt mousse, and said the assistant dietary supervisor was supposed to check it if the dietary supervisor was not present. The facility’s IDDSI Level 4 policy stated pureed foods must be smooth, uniform, free of lumps, and hold shape on a spoon, and the standardized recipes required the foods to pass the spoon tilt test and fork drip test at the start of service and every 15 minutes. The facility also had multiple food storage and sanitation issues observed in the kitchen. A dented can was stored with non-dented cans in dry storage. Storage racks had no physical barrier from the floor, pitchers had sticker residue, pans were stacked wet, and dirt debris was observed in clean pans. Diet tickets were found in the trash by the dishwashing area. In addition, rice was observed overcooked with burnt discoloration, French fries were burnt, and hot foods on the steamtable were not served at appropriate temperatures. The dietary supervisor and registered dietitian stated these conditions affected palatability, could reduce intake, and could result in residents not eating the food.
Menu and Tray Accuracy Failures
Penalty
Summary
The facility failed to follow its menu and tray accuracy processes for residents on regular, therapeutic, puree, and large portion diets. During a test tray and interview, the Dietary Supervisor and dietary staff identified that green beans were being prepared without following the standardized green bean recipe; the staff member stated she did not have the green bean recipe and instead used the mixed vegetable recipe with added butter and pepper, while the DS stated the green beans were bland and that the recipe should have been followed as written. The facility’s policy required standardized recipes to be followed without unauthorized substitutions or portion changes. The menu spreadsheet for regular and therapeutic diets listed pork with mushroom sauce, but the portion sizes were not clearly indicated for pork and mushroom sauce. During trayline observation, only one pan of pork was present and the portions varied. Three random pork slices weighed 2.69 oz, 3.26 oz, and 3.22 oz, while the DS stated the regular diet portion should be 3 oz of pork with 1 oz of mushroom sauce and that the large portion diet should receive 1 oz more pork for a total of 5 oz. The RD stated the spreadsheet was confusing because it did not clearly show the mushroom sauce as 1 oz and the pork as 3 oz, although the recipe reflected the correct portion sizes. Meal tray accuracy failures were also observed for multiple residents. One resident on a puree diet did not receive the ordered puree oatmeal on the breakfast tray, and the CNA stated the tray was missing the oatmeal; the DON later confirmed the tray should have included puree oatmeal, sausage patty, water, margarine, and syrup. Another resident’s breakfast tray was missing a bowl of oatmeal even though the tray ticket listed it, and the CNA stated the tray should have been checked for completeness before service. A third resident’s breakfast tray was missing coffee, and a fourth resident’s breakfast tray was missing margarine and jelly; staff stated the trays should have been checked for accuracy and completeness before being served. The report also identifies residents with diagnoses including diabetes, dysphagia, dementia, Alzheimer’s disease, CHF, anemia, quadriplegia, and severe cognitive impairment who were ordered specialized diets such as CCHO, NAS, puree level 4, thickened liquids, fortified diets, and large portions.
Food Not Served at Palatable Temperatures or with Acceptable Quality
Penalty
Summary
Food and drink were not consistently prepared and served in a palatable manner, with observations showing hard, bland, and improperly tempered items during meal service and test tray review. The facility failed to prepare food by methods that conserved appearance, flavor, and temperature when herbed rice was observed to be hard on the outside and soft on the inside, and [NAME] beans were described as bland, lacking salt flavor, and olive green in color. During the test tray review, peach pie was 66 F, pureed peach pie was 69 F, pancake was 120 F, sausage patty was 120 F, oatmeal was 120 F, and milk was 48.8 F. Resident 6 was admitted with acute and chronic respiratory failure, acute on chronic diastolic congestive heart failure, and hyperlipidemia, and the MDS indicated the resident understood others and made self-understood and needed set up and clean up assistance when eating. The resident was ordered a CCHO, regular, thin liquid, large portion diet. During interview, Resident 6 stated the rice on the plate was too dry and would not eat it. The facility menu spreadsheet showed regular and therapeutic diets were to include pork/mushroom sauce, herbed rice, mixed vegetables substituted with green beans, roll and margarine, peach pie, and beverage. Resident 63 was admitted with type 2 DM, CKD, and essential hypertension, and the MDS indicated the resident understood others and made self-understood and needed set up and clean up assistance when eating. The resident was ordered a CCHO, renal, soft bite sized, thin liquid diet. During interview, Resident 63 stated the food had no taste, did not like the alternatives, and ate less, often ordering sandwiches instead of regular meals. Staff stated there was no recipe for green beans and that mixed vegetable recipes were used in preparation, while the DS stated the green beans were bland, soft, and olive green in color and that the recipe for green beans called for green beans, salt, pepper, and margarine. Additional interviews with other residents showed complaints that food came out late and cold, was served cold at all three meals, and was not eaten when cold. Observations also showed desserts and pudding were set up on trays before trayline started, and the DS stated desserts had been on trays since 11:30 a.m. and that staff placed desserts and beverages in advance on the cart.
Therapeutic Diet Supplement Served Without Physician Order
Penalty
Summary
The facility failed to ensure therapeutic diets were prescribed by the attending physician for one sampled resident who was receiving 4 oz. Magic Cup or high protein nutrition (HPN) without a physician's order. The resident had diagnoses including type 2 diabetes mellitus, iron deficiency anemia, and dementia. The resident's history and physical indicated the resident had the capacity to understand and make decisions, while the MDS indicated severe cognitive impairment and that the resident required substantial to set up assistance with mobility and ADLs. The MDS also indicated the resident was on a therapeutic mechanically altered diet. The resident's order summary showed an order for a consistent carbohydrate/no added salt diet with pureed texture and thin liquids, but no order for 4 oz. Magic Cup or HPN. Despite this, the resident's tray meal ticket listed a beverage preference of 4 oz. Magic Cup or protein drinks. During observation, the resident's breakfast tray was missing coffee, and CNA 5 acknowledged the tray should have been checked for completeness before serving. During another observation, CNA 13 served the resident a Mighty Shake vanilla flavor at lunch without checking whether it was listed on the tray ticket, and the lunch tray ticket did not indicate 4 oz. Magic Cup or HPN. The RD stated that Magic Cup and HPN contain added calories and that giving them to a resident on a CCHO diet with diabetes could increase blood sugar levels. The RD also stated the HPN had been discontinued on 12/23/2025 and that there should be an order for Magic Cup or HPN if it was still being served. The DON stated staff should have checked the meal tray for accuracy and completeness and that a physician's order was needed to ensure the resident received supplements recommended by the RD in consultation with the physician.
Late Meal Service and Trayline Delays
Penalty
Summary
The facility failed to provide meals at regular times scheduled in accordance with resident needs, preferences, and requests when lunch was served late on 1/12/2026 and breakfast was served late on 1/13/2026. Resident 35, who was initially admitted on 7/13/2010 and readmitted with diagnoses including end stage renal disease, type 2 DM, and hyperlipidemia, was assessed as able to understand others and make self-understood and needed set up and clean up assistance with eating. Resident 35 was ordered a consistent carbohydrate, renal, regular texture, thin consistency, large portion diet. During an interview, Resident 35 stated the food from the kitchen comes out late. The facility’s meal schedule posted in the hallway listed breakfast from 7:15-8:15 a.m. and lunch from 12:15-1:15 p.m., but trayline lunch service did not start until 12:21 p.m. and finished at 1:31 p.m. Trayline breakfast service on the following day started at 7:22 a.m. and finished at 8:15 a.m. The Dietary Supervisor stated the breakfast first cart should have come out at 7:15 a.m. but was late, and that tray passing was late because kitchen staff and nurses were trying to make sure trays were accurate. The Dietary Supervisor also stated breakfast was scheduled for 7:15 a.m. to 8:15 a.m. but the trayline ended at 8:30 a.m. the prior day and was late. Resident council minutes also noted that food trays may get late for some residents. The Registered Dietitian stated residents have scheduled mealtimes, especially those with diabetes, to control sugar levels and so residents would not be hungry.
Kitchen Food Storage and Sanitation Deficiencies
Penalty
Summary
Safe and sanitary food storage and food preparation practices were not maintained in the kitchen. During observation, cooked poultry in the walk-in refrigerator was not labeled with the food item name, and the Dietary Supervisor stated prepared foods should be labeled with the product name, date prepared, and use-by date. The supervisor also stated the unlabeled chicken, chicken with butter, and hamburger patty should have been labeled because the name is needed to identify ingredients for residents with food allergies. Multiple sanitation issues were observed in food storage and preparation areas. Two trays in the walk-in refrigerator had ripped-off stickers and residue, sticker residue was present on walk-in freezer shelves and dry storage shelves, dirt and food debris were observed on the walk-in freezer floor, and dried sauce spills were seen on the dry storage wall. A cart with straw decoration, which the Dietary Supervisor identified as not having a cleanable surface, was used during trayline service. Clean pans on storage racks had rice particles on them, and the kitchen floors by the pots and pans storage racks had dirt and food debris. The Dietary Supervisor stated the pans needed to be rew washed because of the rice debris and that the floors under the racks needed deep cleaning. Additional storage and handling concerns were identified in the dry storage and pots and pans areas. Five dented cans were stored with non-dented cans, and the Dietary Supervisor stated they should have been separated for return. Pans were stacked wet in storage, and the Dietary Supervisor stated they should have been air dried before being stored. The pots and pans racks also did not have a physical barrier between the rack and the floor, and the Dietary Supervisor stated mop water could splatter onto the clean pots and pans during cleaning. The report identified 125 of 127 medically compromised residents who received food and ice from the kitchen as potentially affected by these conditions.
Inaccurate Dialysis Access Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one sampled resident with ESRD and dependence on renal dialysis by documenting the wrong dialysis access site on the Dialysis Communication Record on multiple occasions. Resident 11 was admitted with diagnoses including ESRD, dependence on renal dialysis, and acute posthemorrhagic anemia. The resident’s H&P indicated the resident could not make own decisions but could make needs known, and the MDS indicated the resident usually had the ability to make self-understood and understand others. The resident’s care plan directed staff to check and change the dressing daily at the access site, monitor and document vital signs twice a shift after dialysis on dialysis days, and monitor and report signs and symptoms of infection or bleeding at the access site. The Order Summary Report also indicated Enhanced Barrier Precautions related to a permacath on the right upper chest. During interview and record review, an LVN stated she documented bruit, thrill, and no pain under an AV shunt site on the Dialysis Communication Record, but acknowledged this was the incorrect site and that she should have documented the right upper chest permacath. The LVN stated that the incorrect entry could lead a reader to believe the resident had an AV shunt site and could suggest she did not check the resident’s permacath. The DON stated that after dialysis, licensed nurses assess vital signs and any change in condition, check for bleeding, swelling, and dressing status at the access site, and document these findings in the Dialysis Communication Record or nursing progress notes. The DON also stated the facility’s policy was not followed when the resident’s dialysis access site was documented as an AV shunt instead of a right upper chest permacath.
Hospice Visit Documentation and Scheduled Visits Not Consistently Provided
Penalty
Summary
The facility failed to ensure necessary hospice care was provided consistently for one resident receiving hospice services. The resident had a history of dementia, anxiety disorder, and falls, and was documented as having severely impaired cognition, total dependence for all ADLs, and no capacity to understand and make decisions. The resident was admitted under hospice care for Alzheimer’s disease and was receiving routine hospice services through Hospice Provider 2. The hospice binder and record review showed that the hospice plan of care called for an HA to visit twice weekly for personal grooming and an SN to visit one to two times per week and as needed. However, the calendar of visits and sign-in records did not show the LVN visiting on several scheduled dates, and did not show the HA visiting on a scheduled date. The MDS Coordinator stated the LVN should have visited on the scheduled dates and the HA should have visited as scheduled to ensure the resident’s needs were assessed and met. The review also found that hospice nursing and aide notes were missing from the resident’s clinical record and hospice binder for multiple dates. Staff stated hospice notes were supposed to be completed and placed in the binder as soon as visits were completed so facility staff would be aware of updates or changes in the plan of care. The MRD and DON stated the notes should have been readily available in the medical record, whether in paper form or uploaded to the EHR, and that the hospice provider’s visits and documentation were expected to be followed according to the schedule provided to the facility.
Infection Control Failures With Unlabeled Urinals, Contaminated Tubing, Water Intrusion, and EBP Noncompliance
Penalty
Summary
The facility failed to maintain infection prevention and control practices for multiple residents and areas of the building. Two residents who shared a room had urinals left unlabeled: one urinal was on a bedside rolling table and another was hanging from the foot of the other resident’s bed. The CNA interviewed stated the facility process is to label all urinals to prevent confusion and sharing between residents, and the DON confirmed urinals are supposed to be labeled with the resident’s room and name to prevent cross contamination. The residents involved had diagnoses including stroke-related weakness, CKD, dementia, epilepsy, and both required substantial to maximal assistance with bathing, dressing, and toileting. In another observation, a resident receiving oxygen therapy and HHN treatments had the NC tubing and HHN tubing touching the floor. The MDSC stated the tubing should be placed in a plastic bag and should not touch the floor because the floor is contaminated and bacteria can travel up the tubing. The resident had COPD, atrial fibrillation, and dependence on supplemental oxygen, and the record showed physician orders for oxygen therapy and HHN breathing treatments. The facility’s respiratory care policy stated oxygen cannula tubing should be kept in a plastic bag when not in use and nebulizer equipment should be stored in a plastic bag marked with the resident’s name and date between uses. The facility also failed to protect resident rooms from water intrusion and failed to keep clean items off the floor. The laundry room had leaking pipes, wash basins under the leaks, a puddle in front of the washing machines, and a bath blanket placed on the floor to absorb leaking water. The DOM stated the leaking pipes had caused water damage in the adjacent resident room, including loose and damp laminate floor tiles, warped wood, and wall damage, and stated the condition was a safety and infection control risk. In addition, clean clothing in clear plastic bags was observed on the floor in two residents’ rooms. Staff and the DON stated the clean clothes should not have been on the floor because the floor is considered contaminated and the clothing should have been stored in the residents’ closets or assigned cabinets. The facility further failed to follow enhanced barrier precaution practices. An LVN administered medication to a resident on EBP without wearing a gown, and staff were observed transferring another resident on EBP with a Hoyer lift without gowns. A CNA also provided continence and morning care to a resident on EBP while wearing a gown. The records for these residents showed orders for EBP related to wounds, dialysis, or MDRO prevention, and the facility’s EBP policy required staff to wear gowns and gloves for high-contact resident care activities and to don PPE before entering the resident area.
Antibiotic Stewardship Monitoring Not Completed
Penalty
Summary
The facility failed to implement its antibiotic stewardship program by not ensuring monitoring for adverse effects and appropriate antibiotic use for three residents receiving antibiotics. The report identified deficiencies involving Resident 35, Resident 7, and Resident 101, each of whom had antibiotic orders and care plan interventions that required monitoring for side effects and documentation of resident response. Facility policies required licensed staff to observe residents for side effects, signs of antibiotic resistance or secondary infections, and to document reactions, interventions, and provider notification in the EHR. For Resident 35, the record showed orders for cephalexin and fluconazole for infection prophylaxis related to a right lower leg wound and urinary tract/vaginitis prophylaxis. The MDS Coordinator stated the indication for fluconazole did not specify what infection was being prevented and that monitoring for adverse effects on cephalexin and fluconazole was incomplete. The resident’s care plan and the facility’s antibiotic stewardship and adverse reaction policies required observation for side effects and documentation, but the record review and interview showed this monitoring was not completed as expected. For Resident 7, the record showed orders for ertapenem for infection and Zyvox for pneumonia, with the care plan directing staff to monitor and document side effects and effectiveness every shift and report adverse reactions as needed. The MDS Coordinator stated monitoring for adverse effects on ertapenem and Zyvox was incomplete. The facility’s policies and the drug information reviewed for these antibiotics identified the need to observe for allergic reactions, diarrhea, blood pressure changes, seizures, and other adverse effects, but the documentation reviewed did not show that this monitoring was completed. For Resident 101, the record showed cephalexin for cellulitis of the left elbow and later levofloxacin for infection of the left elbow and increased WBC. The Infection Preventionist and MDS Coordinator stated the resident did not meet the criteria for cephalexin or levofloxacin based on the surveillance forms and available lab data, and that the physician should have been notified. The MDS Coordinator also stated there was no documentation that the resident was monitored for adverse side effects on multiple shifts during the antibiotic courses. The DON stated residents on antibiotic therapy were supposed to be monitored every shift for the duration of therapy plus three days and documented in progress notes, but that did not occur for this resident.
Water Leaks and Water Damage in Resident Rooms and Laundry Area
Penalty
Summary
The facility failed to maintain a functional and sanitary environment when water leaks were present in the laundry area and water damage was observed in resident rooms. During a concurrent observation and interview with the Director of Maintenance, Resident 33, Resident 39, and Resident 72's room had loose floorboards, and the DOM pulled out a closet drawer containing a white substance. The DOM stated the closet drawer was dirty and that the white substance was the result of water damage and could be a potential infection control issue for the residents in the room. In the laundry room, two wash basins were placed on the floor under leaking pipes, with one basin catching water and the other catching soap suds. A water puddle was observed in front of the washing machines, and a bath blanket was on the floor to absorb leaking water. The DOM stated the pipes had been leaking for several weeks and that the leaking pipes caused water damage in Resident 33, Resident 39, and Resident 72's room, including loose and damp laminate floor tiles, warped wood on the drawers and closet panels, and wall damage. The DON stated the water damage in the residents' rooms could create an infection control concern because moisture can promote mold and bacteria growth.
Pest Control Failure in Food Services
Penalty
Summary
The facility failed to maintain sanitary conditions in the food services department when a fly was observed in multiple kitchen areas during lunch service. During observation of the dishwashing area, a fly was seen flying around the area. A later observation of the food storage area also found a fly flying around the area, and the back door was observed open. During a concurrent observation and interview with the Dietary Supervisor, a fly was seen flying around the trayline area, and the Dietary Supervisor stated he was trying to drive it away from the trayline. Additional observation of the trayline later that day again showed a fly flying around the trayline. During interview, the Dietary Supervisor stated the facility should not have flies in the kitchen because the fly might fall on the food and could cause cross-contamination. He also stated residents could get sick with diarrhea, stomach pain, and stomach issues as a potential outcome of cross-contamination. The facility policy and procedure titled Pest Control Policy, dated 4/24/2025, stated the facility is committed to maintaining a clean, safe, and sanitary environment free from pests and that an effective pest control program is implemented to protect environmental safety in all departments, including dietary services and storage areas.
Failure to Preserve Dignity During Mealtime Assistance
Penalty
Summary
The facility failed to provide care in a manner that maintained Resident 39’s dignity when CNA 8 assisted the resident with lunch while standing over the resident. Resident 39 was admitted to the facility with diagnoses including dementia, DM2, and muscle wasting and atrophy, and the H&P indicated the resident had the capacity to understand and make decisions. The MDS indicated the resident was able to understand others and make needs known but had severely impaired cognition and required substantial/maximal assistance with eating. During a concurrent observation and interview, Resident 39 was lying in bed with the head of the bed elevated while CNA 8 assisted with lunch from a standing position. CNA 8 stated staff should be sitting at eye level while assisting residents with eating to respect dignity and acknowledged she forgot to get a chair. LVN 10 also stated CNA 8 was standing over the resident and that staff should sit at eye level while assisting residents with eating as a dignity issue and for resident safety. The MDS Coordinator stated staff should assist residents with eating at eye level and sitting down, and that CNA 8 should have grabbed a chair and sat down while assisting Resident 39.
Call Light Not Kept Within Reach
Penalty
Summary
The facility failed to keep the call light within reach of one sampled resident, Resident 94, during an observation in the resident’s room. Resident 94’s record showed admission and readmission dates, diagnoses including muscle weakness, history of falling, and cognitive communication deficit, and a history and physical indicating the resident had the capacity to understand and make decisions. The MDS indicated intact cognition and that the resident required substantial to set up assistance with mobility and ADLs. The resident’s fall risk evaluation identified the resident as high risk for falls, and the care plan included an intervention to ensure the call light was within reach and to encourage use of it for assistance as needed. During the concurrent observation and interview, Resident 94’s call light button was observed on the floor. The RNA stated the call light should always be within the resident’s reach so the resident could call for help when needed. The MDSC and DON both stated the call light should always be within reach, and the DON stated staff should have kept it within reach and that it was everyone’s responsibility to check its placement during rounding. The facility policy stated residents must have ready access to call light systems and that call lights must be checked at the beginning of each shift and after maintenance or repair.
Advance Directive Acknowledgement Form Not Completed
Penalty
Summary
The facility failed to ensure Resident 14’s medical record documented that advance directive information was discussed and acknowledged by the resident or the resident representative. Resident 14 was admitted on 4/18/2023 and readmitted on 12/22/2025 with diagnoses including depressive episodes and anxiety disorders. The resident’s H&P dated 12/24/2025 indicated the resident had the capacity to understand and make decisions, while the MDS dated 10/31/2025 indicated the resident had the ability to make self-understood and understand others and also had severe cognitive impairment; the MDS further indicated the resident and family participated in assessment and care goal setting. A review of the Advance Directive Acknowledgement Form dated 4/25/2023 showed missing initials from the resident or representative on statements indicating they had been given written materials about the right to accept or refuse medical treatments, informed of the right to formulate advance directives, informed that an advance directive was not required to receive treatment at the facility, and informed that any executed advance directive would be followed to the extent permitted by law. The form also indicated the resident had not executed an advance directive, and the form was not signed. The record noted the resident representative was contacted by phone during the interdisciplinary team process. During interviews, the Social Services Specialist stated the form was not completed because the initials and signature of the resident or representative were missing, and that the missing initials meant it was not clear whether the information had been provided. The Minimum Data Set Coordinator stated the form was obsolete and that the missing initials could support whether the required advance directive information was provided. The DON also reviewed the form and stated it was missing initials and was not signed, and that this did not align with the facility’s policy regarding wet signature attestation of the Advance Directive Acknowledgement Form.
Failure to Document Significant Change of Condition for Resident Sent to ER
Penalty
Summary
The facility failed to document a significant change of condition for a resident who was sent to the ER for a right lower leg venous ulcer with green exudate, foul smell, and serosanguinous drainage. Resident 81 had been admitted with diagnoses including cellulitis of both lower limbs and acute osteomyelitis of the left ankle and foot, and the resident’s H&P indicated the resident had capacity to understand and make decisions. The MDS also indicated intact cognition and the ability to make self-understood and understand others. A progress note documented that during routine treatment the resident’s right lower leg venous ulcer was observed with green exudate, foul smell, and serosanguinous drainage, and the physician was notified and advised transfer to the ER. During record review and interview, the MDSC stated she could not find a change of condition documentation for the event and identified missing components such as assessment findings, vital signs, mental status or behavior assessment, skin changes, immediate actions taken, and notification of the physician and resident representative. The DON stated licensed staff should have completed a change of condition record when the resident was sent to the ER and acknowledged the staff did not follow the facility policy.
Failure to Develop Baseline Care Plan for Duloxetine
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a resident who was admitted with diagnoses including depression, abnormalities of gait and mobility, and muscle weakness. The resident’s admission record showed an order for Duloxetine HCl 30 mg by mouth each morning for depression, with monitoring for verbalization of sadness. The resident’s history and physical indicated the resident did not have the ability to make decisions but could make needs known. During a concurrent interview and record review, the MDS Coordinator stated there was an order for Duloxetine for the resident but no baseline care plan had been developed and implemented. The MDS Coordinator stated it was important to develop and implement a baseline care plan for the use of Duloxetine to identify the plan of care, medication interventions, and prevention of adverse effects and the medication’s Black Box warning. The DON stated the licensed staff should have developed and implemented a baseline care plan for Duloxetine within 48 hours of admission so staff would know how to care for and administer the medication safely and identify adverse effects and report them to the attending physician.
Failure to Implement EBP and Post-Fall Care Planning
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident placed on Enhanced Barrier Precautions (EBP). The resident’s record showed diagnoses including type 2 diabetes mellitus and dementia, and the resident’s history and physical indicated the resident had the capacity to understand and make decisions. The minimum data set later indicated the resident had severe cognitive impairment. An order summary report showed an order for EBP requiring staff to use gowns and gloves for high-contact resident care activities every shift. During a concurrent observation and interview, a CNA was observed providing incontinence care and morning care to the resident while wearing only a mask and a glove. The CNA stated a gown, glove, and mask should have been worn during the care to prevent cross-contamination of infection and stated she did not know why the resident was on EBP. A licensed nurse later reviewed the resident’s medical diagnosis, order summary report, and care plans and stated there was an order for EBP isolation but was not sure why the resident was placed on it. The nurse also stated there was no care plan developed and implemented for EBP for the resident. The facility also failed to develop and implement an actual fall care plan for another resident after a fall that occurred in the bathroom when both feet buckled inward and the resident fell to the floor. The resident had diagnoses including aftercare following joint replacement surgery, history of falling, cervical spinal stenosis, and post-laminectomy syndrome. The resident’s minimum data set showed the resident required substantial to maximal assistance with several activities of daily living and partial to moderate assistance with others. The resident already had a care plan for being high risk for falls and another care plan related to a prior wheelchair slide to the floor, but there was no documented evidence that an actual fall care plan was developed and implemented for the 12/19/2025 fall. Facility staff and the DON stated the facility process was to assess the resident, notify the physician, complete a change of condition form, and update the care plan with new interventions after a fall, but this was not documented for the actual fall.
Failure to Apply and Properly Set Low Air Loss Mattresses
Penalty
Summary
The facility failed to provide pressure ulcer care consistent with professional standards for two residents with existing pressure injuries. For one resident admitted with diabetes, gait and mobility abnormalities, and muscle weakness, the record showed physician orders for a low air loss mattress (LALM) for wound management and treatment of stage 2 pressure injuries to the left heel and sacrococcyx. During observation, the resident’s bed did not have the LALM in place. The licensed nurse stated she was not aware of the order until the time of the interview, and maintenance staff stated he had just been informed that the resident had an order for the LALM. The DON stated the staff should have carried out the order the same day it was written and that the delay occurred because licensed staff failed to communicate the order to maintenance. For the second resident, who had a history of stroke, severe cognitive impairment, total dependence for ADLs, and a stage 3 sacrococcyx pressure injury, the record showed an order for a LALM to be set per resident comfort every shift. The resident’s current weight was documented as 125 pounds. During observation, the resident was lying on a LALM set at 250 pounds. The resident was unable to state whether the mattress was comfortable. The LVN stated nurses are supposed to ensure the LALM is set according to resident weight per manufacturer guidelines or per resident comfort if the resident can verbalize it. The DON reviewed the resident’s order, care plan, Braden Scale, photograph of the mattress setting, and current weight, and stated the resident was unable to communicate comfort and that the LALM should have been set according to weight. The manufacturer’s guideline provided by the facility stated to determine the patient’s weight and set the control knob to that weight setting. The facility policy also stated that pressure relieving devices must be properly set up and positioned according to manufacturer instructions and monitored for skin integrity, device functionality, and resident comfort.
Enteral Feeding Water Flush Bag Not Properly Labeled
Penalty
Summary
The facility failed to ensure appropriate care and services were provided for a resident receiving enteral feeding. Resident 72 was admitted with diagnoses including cognitive communication deficit, hemiplegia and hemiparesis following cerebral infarction, and generalized muscle weakness. The resident’s H&P stated the resident did not have the capacity to understand and make decisions, and the MDS indicated severely impaired cognition, total dependence for ADLs, and receipt of tube feeding. The resident had physician orders for a water flush via gastrostomy tube at 50 ml/hr every four hours for hydration and an enteral feeding order at 50 ml/hr for 20 hours. The care plan directed staff to flush the tube per order to minimize the risk for complications related to tube feeding. During observations on 1/12/2026 and 1/13/2026, the resident’s water flush bag was hanging and labeled only with the resident’s name and date. During a concurrent observation and interview, an LVN stated the bag did not indicate the administration rate, frequency of the water flush, or the time it was hung, and stated those details should be on the label. During a later interview and record review with the DON, the photograph of the water flush bag was reviewed and the DON stated it did not indicate the administration rate, frequency, or time hung. The DON also stated the manufacturer’s insert for the water flush bag indicated the feeding set should not be used for greater than 24 hours due to the risk of bacterial contamination and overall system accuracy. The facility policy required enteral feeding orders to include flush volume and frequency and required documentation of the formula, route, rate or bolus amount, and flushes.
Failure to Administer PRN Pain Medication According to Ordered Pain Levels
Penalty
Summary
The facility failed to provide pain management consistent with the resident’s physician orders and assessed pain level for one resident who had diagnoses including aftercare following joint replacement surgery, spinal stenosis of the cervical region, osteoarthritis of the right hip, and post laminectomy syndrome. The resident’s assessment indicated she could understand others and make herself understood, but she required substantial to maximal assistance with several activities of daily living and partial to moderate assistance with others. Her care plan identified an alteration in musculoskeletal status related to severe OA of the right hip and included a goal that she remain free from pain or at a level of discomfort acceptable to her, with analgesics to be given as ordered. The physician orders included hydrocodone-acetaminophen for pain rated 4 to 6 out of 10, acetaminophen for mild pain rated 1 to 3 out of 10, and a pain monitoring scale using the 0 to 10 numeric rating system. During observation, the resident stated she had pain in her whole body and that acetaminophen did not help. Review of the MAR and progress notes showed that on multiple occasions the resident reported pain levels that did not match the medication administered or no medication was given at all. On one occasion, hydrocodone-acetaminophen was not administered when the resident’s pain was rated 7; on another, it was not administered when pain was rated 8. Acetaminophen was also not administered when pain was rated 4 and when pain was rated 6. During interviews, an LVN stated the facility process was to administer PRN pain medication based on the resident’s reported numeric pain level and to document the pain level and medication in the MAR. The LVN stated that when the resident reported severe pain, the nurse should have called the physician because there was no PRN medication ordered for severe pain, but this was not done. Another LVN stated hydrocodone-acetaminophen was given without checking the physician order for the pain level, and that the physician should have been notified that there was no order to treat severe pain. The DON confirmed that pain is subjective, PRN pain medication should correspond to the resident’s reported pain level, and that acetaminophen and hydrocodone-acetaminophen were not administered per the physician’s orders and the facility’s policies.
Incomplete post-dialysis assessment and documentation
Penalty
Summary
The facility failed to ensure safe, appropriate dialysis care for a resident receiving hemodialysis when the post-dialysis assessments form was not completed after dialysis treatment. Resident 11 was admitted with diagnoses including end-stage renal disease, dependence on renal dialysis, and acute posthemorrhagic anemia. The resident’s record also showed that the resident had a permacath on the right upper chest and required staff assistance with activities of daily living while dialysis treatment was performed in the facility. Resident 11’s care plan directed staff to check and change the access-site dressing daily, monitor vital signs twice a shift after dialysis on dialysis days, and monitor and report signs and symptoms of infection or bleeding. The facility’s Hemodialysis Residents Policy required completion of the Dialysis Communication Record and documentation of vital signs, weight, and pertinent observations regarding resident status. During record review and interviews, the Dialysis Communication Record for 12/23/2025 was identified as incomplete, and there was no documentation in the nursing progress notes or on the Dialysis Communication Record showing the time the resident returned from dialysis, vital signs, pain, or catheter location. The LVN stated that documentation on the Dialysis Communication Record and nursing progress notes is used to show what treatment the resident received and to confirm the resident was checked for complications after dialysis. The DON stated that after a resident returns from dialysis, licensed nurses assess vital signs, check for changes in condition, review for new orders, and inspect the access site for bleeding, swelling, and dressing integrity, and stated the facility policy was not followed for this resident on 12/23/2025.
Failure to Timely Document Controlled Medication Administration
Penalty
Summary
The facility failed to provide pharmaceutical services to ensure accurate administration and documentation of a controlled medication for Resident 87. Resident 87 was admitted with diagnoses including COPD with acute exacerbation, dependence on supplemental oxygen, and cognitive communication deficit. The history and physical stated the resident could not make own decisions but could make needs known. The order summary included oxycodone hydrochloride 5 mg, one tablet by mouth every four hours as needed for pain management. During observation, interview, and record review, LVN 3 was found with Resident 87's oxycodone 5 mg bubble pack and the narcotic and hypnotic record. LVN 3 stated she forgot to sign the narcotic record after giving the medication earlier because she got busy, and said she was going to sign it. She also stated she should have signed it as soon as she gave the medication because it is part of the order and must be accounted for at the time it is given. The narcotic record showed 10 tablets available, while the bubble pack had 9 tablets remaining. The DON stated licensed nurses should document medications as soon as they are able, and that narcotics are closely tracked and documented.
Damaged Ativan Bubble Pack Left in Medication Cart
Penalty
Summary
Facility staff failed to discard Resident 116’s Ativan 0.5 mg when bubble pack slot #27 was found damaged, with the seal broken and covered with tape in Medication Cart 1 at Station 200. During a concurrent observation and interview, an LVN observed the damaged bubble pack and stated she had not noticed the broken seal covered with tape, did not know when the tape had been placed, and stated the medication should have been discarded and destroyed. She also stated it was not the facility’s practice to cover a bubble pack with tape once the seal is broken. During an interview with the DON, the DON stated licensed nurses counting controlled medications should check the integrity of the container and ensure it is sealed and secure, and that a broken or damaged seal would affect the efficacy of the drug. The DON stated the LVN should have removed the tablet from the bubble pack, placed it inside a plastic container, stapled it, and handed it over to be discarded. Facility policy stated damaged or makeshift medication labels are to be returned to the pharmacy for relabeling or destroyed, and controlled substances such as Ativan are subject to special handling, storage, disposal, and record keeping.
Failure to Protect Resident from Physical Abuse by Roommate
Penalty
Summary
A deficiency occurred when a resident was not protected from physical abuse by another resident. On the day of the incident, two residents sharing a room were involved in a physical altercation. One resident, who had a history of behavioral and emotional challenges, became upset after his roommate had a bowel movement on his own bed and threatened to do the same on the other resident's bed. The upset resident then pushed his roommate in the back with three fingers, causing the roommate to fall to the floor in a semi-sitting position, leaning on his right side. The resident who was pushed had multiple diagnoses, including schizoaffective disorder, major depressive disorder, and osteoarthritis, and required moderate assistance with several activities of daily living. The resident's cognitive functioning was moderately impaired. The resident who did the pushing had intact cognitive functioning but a documented history of verbal disagreements with his roommate. Multiple staff members, including an LVN and an RN, confirmed that the incident was an act of physical abuse and recognized the potential for injury. The incident was witnessed and reported by another resident and staff, and both residents involved admitted to their actions during interviews. The facility's abuse prevention policy, which maintains zero tolerance for abuse, was not upheld in this instance, as the resident was subjected to physical abuse by another resident while under the care of the facility.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors during the review of facility practices and records. The deficiency centers on the facility's failure to ensure that all required parties were promptly informed when significant events impacting the resident occurred.
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 3,679 citations issued within 25 miles in the last 12 months — including the 25 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 Sylmar
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Grove Post-acute Care Center | 1.1 mi | ★★★★★ | 41 | 0 |
| Mountain View Conv Hosp | 1.2 mi | ★★★★★ | 41 | 0 |
| Astoria Healthcare Center | 1.4 mi | ★★★★★ | 24 | 2 |
| Country Manor Healthcare | 2 mi | ★★★★★ | 26 | 0 |
| Ararat Nursing Facility | 2.6 mi | ★★★★★ | 25 | 1 |
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.