Above average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Medical Hill Healthcare Center during CMS and state inspections, most recent first.
Pharmaceutical services were not maintained to ensure ordered meds were available and controlled substances were accurately documented. A resident with schizoaffective disorder did not receive chlorpromazine when it was unavailable, and a resident with atrial fibrillation missed Eliquis doses when the med was not on hand. In addition, multiple PRN controlled substances were signed out on the CDR without matching MAR documentation, including lorazepam, oxycodone, and Roxicodone.
Medication storage and labeling practices were not maintained. In medication carts, a discontinued unlabeled oral med was found in active stock, another discontinued PRN med remained stored, and several meds with different routes were kept together, including inhalers, an oral solution, lozenges, a neb solution, eye drops, and topical gel. An unopened insulin vial labeled to refrigerate until opened was also stored at room temperature. Staff and the CP stated the meds should have been labeled, separated by route, removed when discontinued, and refrigerated as directed.
A facility failed to keep accurate MAR/CDR documentation for controlled meds for four residents. One resident also had a lorazepam order backdated after a verbal order, and multiple lorazepam, oxycodone, and Roxicodone doses were signed out on the CDR but not documented on the MAR until later backdated progress notes were entered. The DON, MRDs, and CP stated the records should match and be documented promptly, and the report noted the inaccurate recording had the potential for abuse and drug diversion.
A resident with impaired mobility and need for assistance with personal care was planned for discharge home with a hospital bed and Hoyer lift, but caregiver training was not provided and discharge coordination was incomplete. The DON, ADOR, and CM gave conflicting accounts about caregiver availability and discharge notice, and the Community Case Manager stated the facility did not contact her to coordinate the discharge. On the day of discharge, the resident was sent to the hospital after reporting symptoms, and the ED note documented anxiety about having nowhere to go.
Call lights were not kept within reach for two residents. One resident with paraplegia and severe cognitive impairment had the call light wrapped around the bed side rails, and another resident with moderate cognitive impairment and limited neck movement had the call light tucked in a nightstand drawer and stated she had no way to call the nurse. The facility policy stated staff must ensure the call light is nearby to the resident.
Licensed nursing staff did not complete a full assessment for two residents when they could not explain why one resident was grinding her teeth and why another resident required 1:1 supervision. One resident with major depressive disorder and cognitive impairment was observed with audible jaw grinding, while the record later noted bruxism. Another resident with schizophrenia and a suicide attempt history was observed with a 1:1 sitter, but the assigned LVN did not know the reason for the sitter. The DON stated staff should understand these needs because the information is helpful in caring for the resident.
A resident with dementia and dysphagia was ordered a pureed diet with honey thick liquids and 1:1 meal assist as needed, but was observed eating regular noodles and chicken offered by another resident’s family. No staff were present in the dining room at the time, and the assigned CNA had left the area, leaving the resident unsupervised during the meal.
A resident with schizoaffective disorder and anxiety received lorazepam without a valid physician order. The MAR showed the medication was administered before the order was entered, the ADON said she relied on a verbal order and told nursing staff it was okay to give it, and there was no documentation explaining the resident’s behaviors or the rationale for the PRN use. The RP said he was not contacted for informed consent, and the CP stated controlled psychotropic orders could not be renewed verbally except in limited emergency circumstances.
A CNA provided direct care to a resident in an EBP room without adequate PPE, wearing only a facemask and gloves while changing the resident’s brief. The room had an incorrect Contact Precaution sign posted, and the DON later replaced it with an EBP sign. The resident had diagnoses including urinary retention and sepsis, an order for Contact Precaution related to ESBL, and an indwelling urinary catheter.
A resident with a history of stroke and requiring personal care assistance reported being handled roughly and spoken to inappropriately by a CNA. The Social Service Director did not treat the complaint as suspected abuse due to the resident's confusion, resulting in the incident being filed only as a grievance and not reported to authorities or thoroughly investigated, contrary to facility policy.
A facility failed to report an alleged sexual assault involving a resident with anxiety and schizophrenic disorders to the appropriate authorities within the required timeframe. The Neurobehavioral Unit Director received the report from the resident's conservator, but the allegation could not be substantiated due to the resident's inability to focus and recall the incident. Despite this, the facility's policy required immediate reporting to the state licensing agency, ombudsman, and law enforcement, which was not done.
The facility failed to provide timely account statements and transaction receipts for residents' personal funds, affecting four residents. Residents and their conservators were not informed about account balances or spending details, impacting their rights to access funds for personal purchases. Interviews revealed that the Business Office Manager was behind in sending out quarterly reports and did not provide receipts, despite the facility's policy requiring management and accounting of residents' personal funds.
A staff member failed to maintain proper hand hygiene during meal service, handling food with gloved hands without changing gloves or washing hands after touching non-food items. This breach in sanitary practices had the potential to affect all residents receiving meals.
The facility failed to ensure accurate MDS assessments for two residents, leading to incorrect documentation of visual and nutritional statuses. A resident who was legally blind was inaccurately recorded as having adequate vision, while another resident was incorrectly documented as receiving parenteral feeding and having a feeding tube. The MDS Nurse and the Dietary Director were responsible for these inaccuracies, as confirmed by the DON and the Administrator.
A facility failed to resubmit a Level I PASRR for a resident who stayed longer than 30 days, despite having severe cognitive impairment and active mental health diagnoses. The resident was initially exempt from the PASRR due to a 30-day Exempted Hospital Discharge. Interviews with staff confirmed the oversight, but no documentation showed the PASRR was resubmitted.
A resident undergoing dialysis exceeded their prescribed daily fluid restriction due to the facility's failure to monitor and communicate the restriction effectively. Despite having a care plan in place, the resident's fluid intake records showed multiple instances of excess consumption. Staff interviews revealed a lack of awareness and communication regarding the fluid restriction, and the resident had access to a water pitcher without proper monitoring.
A facility failed to transcribe an oxygen order into the EHR for a resident with respiratory needs. Despite a handwritten order for oxygen being documented, it was not entered into the EHR until a survey was conducted. Observations showed the resident receiving oxygen, but there was no documentation in the administration records. Interviews confirmed the oversight occurred after the resident's return from a transfer.
Pharmaceutical Services and Controlled Drug Documentation Failures
Penalty
Summary
Pharmaceutical services were not provided in a manner that ensured routine medications were available for administration and that controlled drug records were accurately maintained for six sampled residents. The facility failed to provide chlorpromazine for a resident with schizoaffective disorder and failed to have Eliquis available for a resident with atrial fibrillation during medication administration. In both instances, nursing staff administered the remaining routine medications without the missing ordered medication being given. A resident admitted with schizoaffective disorder had a physician order for chlorpromazine hydrochloride 25 mg, two tablets daily, and the MAR showed the medication was not received on 8/6/25. During medication pass observation, RN 1 stated the chlorpromazine tablets were not available and administered the resident’s other morning medications without it. Another resident admitted with hypertension and atrial fibrillation had an order for Eliquis 2.5 mg twice daily, and the MAR showed missed doses on 8/5/25 and 8/6/25. Progress notes documented that the medication was on order, unavailable, and had run out. During observation, RN 1 stated the Eliquis was not available, informed the ADON, and then administered the resident’s other morning medications without the Eliquis. The facility also failed to maintain accurate controlled drug records for four residents receiving PRN controlled substances. For one resident, the CDR showed seven signed-out doses of lorazepam that were not documented on the MAR. For a second resident, the CDR showed three signed-out doses of lorazepam that were not documented on the MAR. For a third resident, the CDR showed two signed-out doses of oxycodone that were not documented on the MAR. For a fourth resident, the CDR showed two signed-out doses of Roxicodone that were not documented on the MAR. The consultant pharmacist stated staff were expected to document controlled substances on both the CDR and MAR, and the medical record director stated the CDR should reflect the MAR for accurate recording of controlled drugs.
Medication Storage and Labeling Deficiencies
Penalty
Summary
Safe medication storage and labeling practices were not maintained for a census of 119. In medication cart #3, a box containing Resident 59’s discontinued cholestyramine light oral packets was found in an active storage area without a label and with the top lid missing. During the observation, the DSD and LVN 3 could not initially identify who the medication belonged to, and after checking the EHR, LVN 3 identified it as Resident 59’s discontinued medication. The DSD stated prescription medications should have labels to prevent mistakes or errors and that unlabeled medications could be given to other residents. Medication storage practices also showed multiple medications with different routes of administration stored together in the same compartment. In medication cart #3, two inhalers, haloperidol oral solution, nicotine lozenges, and Proventil nebulizer solution were stored together in one compartment in an active storage area. The DSD stated the medications should have been separated by route of administration to prevent contamination between the medications. In another observation, Resident 70’s cyclosporine ophthalmic emulsion was stored together with Resident 29’s diclofenac sodium 1% gel, and the ADON stated she needed to verify the facility policy for storing medications. Additional storage issues were identified in medication cart #4 and medication cart #2. Resident 65’s discontinued hydroxyzine 25 mg oral tablet remained stored in medication cart #4, and LVN 4 stated it should have been discarded and destroyed by two licensed nurses because it had the risk of being given to the wrong residents. Resident 86’s unopened insulin vial with a pharmacy label stating refrigerate until opened was stored at room temperature in medication cart #2, and LVN 1 stated it should have been refrigerated and that incorrect storage could have decreased its effectiveness. The consultant pharmacist stated discontinued medications should have been removed from carts, medications should have had proper labeling, medications should have been stored by route of administration, and unopened insulin vials should be kept refrigerated until opened.
Inaccurate controlled substance documentation and backdated entries
Penalty
Summary
The facility failed to ensure accuracy of medical records for four sampled residents when controlled substance documentation did not match between the controlled drug records (CDR), medication administration records (MAR), and progress notes. For Resident 24, who was admitted with schizoaffective disorder and anxiety disorders, a physician order for lorazepam 2 mg as needed was created on 8/5/25 with a start date of 8/1/25, resulting in a four-day backdate. The Assistant Director of Nursing stated she received a verbal order on 8/1/25 and could not recall why the order was not entered right away. The Consultant Pharmacist stated controlled drugs such as lorazepam could not be renewed or reordered verbally unless written and signed by the physician, and only a pharmacist may receive verbal orders for controlled drugs from the physician in emergency situations. Resident 24’s CDR showed eight doses of lorazepam signed out between 7/18/25 and 8/2/25 that were not documented on the MAR. Progress notes for those doses were created later, with effective dates matching the administrations but creation dates ranging from 4 to 18 days later. Similar discrepancies were found for Resident 121, who had schizoaffective disorder and a lorazepam order; three doses were signed out on the CDR but not documented on the MAR, and corresponding progress notes were created 4 to 9 days later. Resident 29, who had polyneuropathy and chronic pain, had two oxycodone doses signed out on the CDR without MAR documentation, and progress notes for those doses were created two days later. Resident 69, who had a right clavicle fracture, had two Roxicodone doses signed out on the CDR without MAR documentation, and progress notes were created 3 to 4 days later. The Consultant Pharmacist stated that when a controlled substance is pulled out, nursing staff are expected to document on both the CDR and MAR, and that failure to match the records would be considered a discrepancy. The Medical Record Directors stated the CDR should reflect the MAR, documentation should be completed as soon as medication is given, and the resident’s chart should contain complete and accurate documentation. Facility policies stated controlled substance prescriptions must be valid and complete, controlled substances must be reconciled through records including MARs, and medication administration must be recorded immediately following administration. The report also stated that inaccurate recording of controlled substances had the potential for abuse and drug diversion.
Discharge planning and notice were not completed effectively
Penalty
Summary
The facility failed to ensure an effective discharge process for Resident 132 when caregiver training and discharge notice were not provided in a timely manner. Resident 132 was admitted with diagnoses including dislocation of the left knee, difficulty walking, dislocation of the left hip prosthesis, and need for assistance with personal care. The physician ordered discharge to home with a hospital bed and Hoyer lift, and the care plan included discharge planning interventions to arrange home modifications, coordinate in-home support services, and address caregiver availability, capability, and training needs. During interviews, the DON stated discharge planning had begun and that Resident 132 had mentioned having a friend as a caregiver, but the DON did not know whether caregiver training had been completed. The ADOR stated Resident 132 would need assistance with all ADLs at home and that if a caregiver was present, training would be needed for care transfers and Hoyer lift transfers; the ADOR also stated no caregiver training was provided. The CM stated the necessary DME had been delivered before the planned discharge date and that a Community Case Manager had arranged for a caregiver, but the CM did not verify this with the Community Case Manager and did not involve the resident's brother or sister in discharge planning. On the day of discharge, Resident 132 was sent to the hospital after complaining of stroke-like symptoms. The Ombudsman stated Resident 132 was wheelchair-bound, had no caregiver, no power in the apartment, and that the property manager had left the apartment unlocked. The Community Case Manager stated the facility did not contact her to coordinate discharge and that she would have informed the facility that Resident 132 did not have a caregiver or resources at home. The ED record noted Resident 132 was being discharged from the facility and then reported abdominal pain, left shoulder pain, and anxiety about having nowhere to go. The CM later stated discharge notice was to be given on the day of discharge and that she did not keep a copy or document it in the clinical record.
Call Lights Not Kept Within Reach for Two Residents
Penalty
Summary
The facility failed to ensure the call lights were within reach for two residents, Resident 40 and Resident 94. Resident 40 was admitted with diagnoses including paraplegia and epilepsy, and the MDS dated 7/9/25 showed a BIMS score of 5, indicating severe cognitive impairment, along with a need for staff assistance with turning and repositioning in bed. Resident 94 was admitted with diagnoses including anxiety disorder, major depressive disorder, and morbid obesity, and the MDS showed a BIMS score of 12, indicating moderate cognitive impairment, with a need for staff assistance with turning and repositioning while in bed. During a concurrent observation and interview on 8/4/25 at 12:47 p.m., Resident 94 stated she was not feeling well and had no way to call the nurse, and said she could not find the call light or know its location. At 12:56 p.m., LVN 1 found Resident 94's call light tucked away in the nightstand drawer, and Resident 94 stated she could not see it due to limited neck movement. LVN 1 also found Resident 40's call light wrapped around the left side rails of the bed, and stated Resident 40 had limited range of motion in the upper extremities and would not be able to unwrap the call light from the side rails. The facility policy titled Answering the Call Light stated staff must ensure the call light is nearby to the resident.
Incomplete Assessment of Resident Behaviors and Supervision Needs
Penalty
Summary
Licensed nursing staff did not perform a complete assessment for two sampled residents when they were unable to explain key behaviors and care needs. One resident, admitted with major depressive disorder and documented as unable to identify the correct day, month, or year, was observed sitting in a wheelchair in the hallway moving her jaw side to side and producing an audible grinding/clicking sound. The assigned LVN and RN stated they did not know why she was making the sound, and the DON also stated she was not sure and would need to investigate. The record later showed the resident had bruxism and had reported to staff that it was due to getting food out of her teeth, with lorazepam listed for anxiety and related symptoms including bruxism. A second resident, admitted with schizophrenia and documented as unable to identify the correct current day, year, or month, had a care plan noting a history of a suicide attempt and an intervention for 1:1 supervision. When observed in his room with a 1:1 sitter, the assigned LVN stated he did not know why the resident had a sitter and said it would be good to know so he could care for him appropriately. During interview, the DON stated staff would be expected to understand why a resident was with a 1:1 sitter or why someone may be grinding their teeth because that information is helpful in caring for the resident. The facility policy stated that a comprehensive, person-centered care plan is developed and implemented for each resident.
Failure to Supervise Resident on Pureed Diet During Meals
Penalty
Summary
The facility failed to ensure an environment free of accident hazards and adequate supervision during meals when Resident 67, who had dementia and dysphagia, was observed eating regular consistency food despite an order for a pureed texture with honey thick liquids and 1:1 assist with meals as needed. Resident 67 was admitted in March 2025 and, as of the 8/7/25 order summary, remained on the pureed diet order. During the 8/4/25 observation in the front dining room, Resident 67 was seated with two other residents and accepted noodles and cut-up chicken offered by another resident’s family, then ate the noodles with a fork while some food fell from her mouth. At the time of the observation, no staff were present in the dining room. RN 1 stated Resident 67 was not his patient and he did not go to the dining room to check on her. DSD stated CNA 1 was assigned to monitor the dining room, but later found CNA 1 in another resident’s room and directed CNA 1 to check on Resident 67. CNA 1 stated he had stepped out of the dining room to give food to another resident and that Resident 67 needed assistance with meals. LVN 1 stated it was very important for staff to supervise Resident 67 during mealtimes to prevent aspiration or choking accidents, and neither LVN 1 nor ADON could explain the facility’s dining protocol or the number of staff assigned to monitor the dining room.
Psychotropic Medication Given Without Valid Physician Order
Penalty
Summary
Resident 24, who was admitted with schizoaffective disorder and anxiety disorders, received lorazepam without a physician's order. The record showed an order for lorazepam oral tablet 2 mg, one tablet by mouth every four hours as needed for anxiety manifested by over concern with anything for 14 days, but the order was created on 8/5/25 even though it was dated 8/1/25. The Medication Administration Record showed the resident received lorazepam on 8/2/25 at 5:30 a.m. and on 8/3/25 at 5:00 a.m. The progress note for the 8/2/25 administration was also created on 8/5/25 and reflected that lorazepam was administered. During interview, the ADON stated she received a verbal order from the physician on 8/1/25 around 10:00 p.m. and told the charge nurse it was okay to administer the medication, but she could not recall why the order was not entered right away. She also stated she believed informed consent had been obtained by the physician before the medication was given. The resident's RP stated the facility did not contact him to obtain informed consent for lorazepam. The ADON later stated she could not find documentation from the physician showing the rationale for continued PRN lorazepam use, and there was no documentation explaining why lorazepam was given or what behaviors the resident exhibited on 8/2/25 and 8/3/25. The consultant pharmacist stated psychotropic medication such as lorazepam could not be renewed or reordered verbally unless written and signed by the physician, and that only a pharmacist may receive verbal orders for controlled drugs from the physician in emergency situations.
Infection Control PPE Not Used During Resident Care
Penalty
Summary
The facility failed to follow infection control and prevention measures when a CNA provided direct care inside a resident’s Enhanced Barrier Precaution room without adequate PPE. During observation, the resident’s room was identified by an LVN as an Enhanced Barrier Precaution room, but a Contact Precaution sign was posted on the door. The LVN stated she would ask the DON about the incorrect sign. The CNA was observed inside the room at the resident’s bedside providing care. During interview, the DON stated the sign should have indicated Enhanced Barrier Precaution and removed the Contact Precaution sign, replacing it with the correct sign. The CNA later stated she had been in the room changing the resident’s briefs and was wearing only a facemask and gloves, not a gown, because the resident tended to grab her during care. The resident’s record showed diagnoses including urinary retention and sepsis, an order for Contact Precaution related to ESBL, and an indwelling urinary catheter. The facility policy on Enhanced Barrier Precaution stated that contact precautions apply when a resident is infected or colonized with any MDRO, has a wound, or has an indwelling medical device.
Failure to Timely Report and Investigate Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident who had a history of cerebral infarction and required assistance with personal care. The resident's responsible party informed the facility that a female CNA was rough and rude during care, and the resident described being handled roughly and spoken to inappropriately by the CNA. Despite this, the Social Service Director (SSD) did not treat the complaint as an allegation of abuse, citing the resident's confusion and inability to recall details during an interview. The incident was only filed as a grievance, and no further investigation or follow-up, such as interviewing the roommate or monitoring for psychosocial changes, was conducted. The SSD reported the incident to the Abuse Coordinator, who determined the allegation was unfounded due to the resident's confusion. The Director of Staff Development and the Director of Nursing both acknowledged that the allegation should have been treated as suspected abuse, reported, and investigated according to policy, which requires immediate reporting to state and local agencies. The facility's policy defines 'immediately' as within two hours for allegations involving abuse or serious bodily injury, but this protocol was not followed in this case.
Failure to Report Alleged Sexual Assault
Penalty
Summary
The facility failed to report an allegation of sexual assault involving a resident to the appropriate authorities within the required timeframe. The incident involved a resident who was admitted to the facility with anxiety disorder and schizophrenic disorder. The Neurobehavioral Unit Director (NBUD) received a report of the alleged sexual assault from the resident's conservator. An investigation was conducted, but the allegation could not be substantiated due to the resident's inability to focus and recall the incident. Despite this, the facility's policy required immediate reporting of such allegations to the state licensing certification agency, the local/state ombudsman, and law enforcement officials. During interviews, the NBUD and the facility's Administrator acknowledged that the allegation should have been reported to the proper authorities, but it was not. The facility's policy and procedure on abuse, neglect, exploitation, or mistreatment clearly stated that any suspicion of abuse should be reported immediately, defined as within two hours of the allegation. The failure to report the allegation as required had the potential to result in a lack of protection for residents alleging abuse.
Failure to Provide Timely Account Statements and Receipts for Residents' Personal Funds
Penalty
Summary
The facility failed to provide timely account statements and transaction receipts for residents' personal funds, affecting four residents. The facility did not notify residents or their conservators about the amount of funds in their personal accounts, track spending, or submit quarterly report statements on time. This failure impacted the residents' rights to have informed and easy access to their funds for personal purchases. Resident 1, admitted in July 2023 with a diagnosis of malignant neoplasm of the bladder neck and a BIMS score of 7 indicating moderately impaired cognitive status, had a conservator who sent $50 monthly for personal expenses. However, the conservator was unaware of the account balance or spending details, as they had not received quarterly statements or itemized receipts. Resident 2, with a BIMS score of 14 indicating cognitive intactness, was unaware of the funds available in their account and had not received any quarterly reports. Resident 3, with a BIMS score of 15 indicating cognitive intactness, last made purchases nine months ago but did not receive itemized receipts or quarterly account statements. Resident 4, with a BIMS score of 6 indicating severe cognitive impairment, and their conservator also did not receive quarterly reports or receipts. Interviews with facility staff revealed that the Business Office Manager was behind in sending out quarterly reports and did not provide receipts to residents or conservators, despite the facility's policy requiring management and accounting of residents' personal funds.
Failure in Hand Hygiene During Meal Service
Penalty
Summary
The facility failed to ensure that staff prepared and served food in a sanitary manner, as observed during a meal service. A staff member, identified as [NAME] #4, was seen handling plates and serving utensils with gloved hands but did not change gloves or wash hands after leaving the meal service line to retrieve food items from the oven. This occurred multiple times during the meal service, where [NAME] #4 handled grilled cheese sandwiches and pasta with gloved hands without performing hand hygiene or changing gloves, despite handling non-food items such as the oven door. During interviews, [NAME] #4 did not recall touching the pasta with her hands but acknowledged that she should not have touched food items while on the serving line. She also admitted that she should have washed her hands and changed gloves after handling non-food items. The Dietary Director confirmed that staff should use utensils rather than their hands while plating foods on the meal service line. This failure in hand hygiene practices had the potential to affect all 115 residents receiving meals from the dietary department.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for two residents, leading to deficiencies in documenting their visual and nutritional statuses. Resident #2, who was legally blind, had an MDS assessment indicating adequate vision, which was incorrect. The MDS Nurse confirmed that the resident's visual status was not captured accurately, despite the resident's care plan indicating impaired visual function. The Director of Nursing (DON) and the Administrator both acknowledged that the MDS should accurately reflect the resident's condition, and the MDS Nurse was responsible for ensuring this accuracy. Resident #86's MDS assessment inaccurately documented the resident as receiving parenteral/intravenous feeding and having a feeding tube, which was not the case. The Dietary Director, responsible for the dietary section of the MDS, admitted to coding the section incorrectly. The DON reiterated that each department was responsible for their section of the MDS and its accuracy, with the MDS Nurse overseeing the overall accuracy. The Administrator also confirmed the responsibility of the MDS Nurse in ensuring the MDS accurately reflected the resident's true condition.
Failure to Resubmit PASRR for Resident Exceeding 30-Day Stay
Penalty
Summary
The facility failed to ensure a Preadmission Screening and Resident Review (PASRR) was completed for a resident who remained in the facility longer than 30 days. The resident was admitted from a hospital with diagnoses including schizophrenia, bipolar disorder, and anxiety disorder, and was initially exempt from a Level I PASRR due to a 30-day Exempted Hospital Discharge. However, the facility did not resubmit the Level I PASRR Screening as required when the resident's stay exceeded 30 days. The resident's care plan indicated risks for decreased psychosocial wellbeing and other mental health issues, and the Minimum Data Set (MDS) assessment showed severe cognitive impairment with active diagnoses of anxiety disorder, bipolar disorder, and schizophrenia. Interviews with the MDS Nurse, Director of Nursing, and Administrator confirmed that the PASRR should have been resubmitted, but there was no documented evidence of this action being taken.
Failure to Monitor Fluid Restrictions for Dialysis Resident
Penalty
Summary
The facility failed to monitor and implement physician-prescribed fluid restrictions for a resident undergoing renal dialysis. The resident had a physician's order for a daily fluid restriction of 1200 mL, which was not adhered to, as evidenced by documentation showing the resident exceeded this limit on multiple occasions. The facility's policy on fluid management required verification of physician orders and adherence to specific instructions, but these were not effectively followed. The resident, who was cognitively intact and required assistance with eating, was admitted with end-stage renal disease and was dependent on dialysis. Despite having a care plan that included monitoring fluid intake and output, the resident's fluid intake records showed numerous days where the intake exceeded the prescribed limit. Interviews with staff revealed a lack of awareness and communication regarding the resident's fluid restrictions, contributing to the oversight. Observations and interviews indicated that the resident had access to a thermal water pitcher, which was not monitored for consumption. The Dietary Director admitted that the fluid restriction was not reflected on meal tickets, and the Director of Nursing acknowledged the expectation for fluid restrictions to be communicated and monitored across departments. The Administrator also expected adherence to fluid restriction orders, but the lack of communication and monitoring led to the deficiency.
Failure to Transcribe Oxygen Order into EHR
Penalty
Summary
The facility failed to ensure that an order for oxygen use was transcribed into the electronic health record (EHR) for a resident reviewed for respiratory care. The resident, who was admitted with a medical history including end-stage renal disease, malignant neoplasm of the rectum, anemia, and pneumonia, required intermittent oxygen due to shortness of breath. A handwritten order for oxygen was documented on a Comprehensive Physician's Order Sheet on January 24, 2024, but was not transcribed into the resident's EHR until March 12, 2024, during the survey. Observations revealed that the resident's oxygen concentrator was infusing oxygen at varying rates, yet there was no documentation in the Treatment Administration Record or Medication Administration Record for February and March 2024 regarding the administration of oxygen. Interviews with a registered nurse and the Director of Nursing confirmed that the order for oxygen was not transcribed into the active physician's orders after the resident's return to the facility following a transfer. This oversight resulted in a failure to maintain accurate and complete medical records in accordance with professional standards.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Oakland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mcclure Post Acute | 0 mi | ★★★★★ | 16 | 0 |
| Oakland Healthcare & Wellness Center | 0.6 mi | ★★★★★ | 12 | 0 |
| St Paul's Towers | 0.7 mi | ★★★★★ | 0 | 0 |
| The Rehabilitation Center Of Oakland | 0.8 mi | ★★★★★ | 2 | 0 |
| Lake Park Healthcare Center | 1 mi | ★★★★★ | 3 | 0 |
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