Above average — CMS composite of the measures below.
A standard survey is most likely before 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 Mesa Verde Post Acute Care Center during CMS and state inspections, most recent first.
Pureed menu items were not prepared according to the written recipes for several residents on a pureed diet. A cook was observed making pureed Curry Lemon Chicken, Peas with Onions, Garlic Rice, and wheat rolls using amounts of broth, milk, thickener, and bread that did not match the facility’s recipe instructions, and the RD later verified the pureed foods should follow the regular recipe with the least amount of liquid and thickener.
Improper Cooling Documentation and Wet Blender Storage: The facility failed to properly monitor the cooling of TCS foods when tuna salad and egg salad had temperature logs without the times temperatures were taken, and both items remained above 41 degrees F during the cooling process. The facility also stored a blender while its inside was still wet and covered, and an LPN verified it had not been air dried.
Unnecessary PRN Ativan Given Without Documented Target Behaviors: A resident with no capacity to make decisions received PRN Ativan for anxiety/agitation, but the MAR lacked documentation showing the targeted behaviors were present before multiple doses were administered. The resident’s care plan and physician orders required staff to monitor and record the behavior symptoms, and both an LVN and the DON stated the medication should not be given if the targeted behaviors were not displayed.
The facility failed to develop person-centered care plans for three residents’ identified needs. Two residents had documented weight loss changes, including one with significant recent loss and another with ongoing loss, but their plans of care did not address those changes. Another resident had intact cognition and a physician order for bupropion HCL for depression, yet the care plan did not include the antidepressant use or related interventions. Staff, including RN, MDS Coordinator, LVN, and DON, verified the missing care plan documentation.
A resident who fell from a wheelchair and sustained a forehead laceration did not have the required neuro checks documented after the incident or after return from the hospital. In addition, two residents with Wander Guard devices had placement orders and care plans, but the record lacked physician orders and documentation for functionality checks, and staff interviews confirmed the missing monitoring documentation.
Failure to Assess Significant Unplanned Weight Loss: A resident with MS, protein calorie malnutrition, and Alzheimer's disease had a 21.8-lb., 10.2% unplanned weight loss over 6 months. The RD did not complete a nutritional assessment, there was no physician order for a planned weight loss regimen, and the IDT did not meet in a timely manner to evaluate the weight loss as required by facility policy.
A resident with dysphagia and a GT had physician orders for Jevity 1.2 at 55 ml/hr and a water flush at 70 ml per hour via GT pump, but staff did not have the water flush programmed into the pump when observed. During a concurrent review, an LVN verified the order and then programmed the flush into the GT pump. The resident’s record also noted an elevated BUN and a nutritional intervention to adjust the water flush to 70 ml per hour via GT pump.
A facility failed to provide ordered respiratory care for two residents. One resident’s oxygen tubing storage bag was not routinely changed as required by policy, and an LVN acknowledged it should have been changed. Another resident used a CPAP machine, but staff did not clean the mask and equipment per the manufacturer’s guidance or the physician’s order; staff interviews showed the CPAP manual was not available and one LVN admitted the mask had not been cleaned as ordered.
A resident with ESRD on hemodialysis had a physician-ordered 1500 ml/day fluid restriction, but staff did not accurately monitor or document intake. CNA documentation reflected only meal tray fluids, with daily totals below the ordered amount and some missing entries, and the record lacked weekly I&O summaries. RN and LVN both verified the fluid monitoring was not accurate per the order.
A resident with impaired cognition and inability to make her own medical decisions was observed with bilateral U grab bars elevated in bed. The chart showed a physician order for the grab bars for ADL care changes, mobility, positioning, and as an enabler, but the medical record did not contain informed consent for their use. CNA and LVN interviews confirmed the grab bars were being used for turning and repositioning in bed.
The facility failed to meet pharmaceutical service needs for three residents. A resident receiving insulin had repeated subcutaneous injections in the same sites without rotation, a resident with intact cognition had PRN Norco removed and signed out but not documented on the MAR as administered, and an LVN crushed a delayed-release divalproex tablet and gave it in applesauce along with other crushed meds. Facility policy and cited medication guidance required proper site rotation, accurate MAR documentation, and swallowing delayed-release divalproex whole.
Failure to Educate on Safe Handling of Outside Food: The facility did not ensure staff and visitor education on safe food handling when food from outside was brought in for resident consumption. The policy called for education on safe cooling/reheating, hot/cold holding temps, cross-contamination prevention, and hand hygiene, but the in-service focused on policy specifics and storage/labeling rather than those safe food handling practices. The admission packet also did not include the outside food policy or related safe food handling information.
The facility failed to maintain complete infection surveillance documentation for multiple residents with symptom onset in the summer of 2025, as the IP did not document whether each case met HAI, CAI, or McGeer Criteria. The facility also failed to follow its hand hygiene policy during medication administration when an LVN removed gloves, put on a new pair, and administered eye drops to a resident without performing hand hygiene between glove changes.
A resident’s medical record did not contain a copy of the advance directive, even though a social services note stated the resident had one on file. The resident had no mental capacity to make decisions, had a full code/CPR order, and the Case Manager/SSD verified the directive should have been in the chart and uploaded to the EMR.
Failure to Obtain NOMNC and SNF ABN Signatures: A resident with no capacity to make medical decisions had an undated NOMNC and an SNF ABN in the record, but both lacked the resident or representative signature. The BOM documented phone and email contact with the responsible party about the end of Medicare Part A coverage and stated there was no documentation of follow-up to have the responsible party review and sign the forms.
Failure to trim a resident's fingernails resulted in poor grooming and personal hygiene. A resident reported repeatedly asking staff for nail care, but staff told him they did not trim fingernails. Surveyors observed all 10 fingernails to be long with brown stains, and both a CNA and an LVN verified the nails should have been trimmed; the DON acknowledged the findings.
Facility Assessment Missing Required Input and Staffing Elements: The facility's Facility Assessment did not include active involvement from required participants such as direct care staff, residents, resident reps, or family members, and it also lacked a plan to maximize recruitment and retention of direct care staff, weekend resource planning, and a contingency plan for staffing needs. During review, the Administrator acknowledged being unaware of the updated CMS requirements and confirmed the missing elements in the assessment.
A resident’s MAR was incomplete and inaccurate, with an oxygen saturation entry documented as 137% during a day shift and a missing dinner meal percentage entry. RN verified the oxygen saturation value was a typographical error and acknowledged the missed meal documentation, and the DON was informed of the findings.
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.
A resident's transfer or discharge was not managed in a way that met their needs and preferences, and the facility did not ensure the resident was adequately prepared for a safe transition.
Medications were not securely stored as required, with one resident's diabetes medication found hidden in another resident's closet for several days after being taken by a CNA, and another resident's prescribed zinc oxide cream left in a bedside drawer. These actions violated facility policy and resulted in unauthorized access to medications.
A resident with type two diabetes mellitus was improperly discharged from the facility without necessary documentation and communication. The discharge planning indicated the resident would have a caregiver, but the facility failed to provide a discharge/transfer report, including evidence of teaching or training for the resident and caregiver. Interviews revealed that the discharge protocol was not followed, as no education or training was provided, and the caregiver was not present or contacted during the discharge.
A resident was discharged with home health services, but the facility failed to document a referral to a home health agency, risking the resident's post-discharge care. The order included follow-up by home health PT/OT/RN and a PCP visit, but no referral documentation was found. The SSD discussed the discharge with the resident but could not provide evidence of the referral, which was acknowledged by the Administrator and DON.
A facility administered COVID-19 and influenza vaccines to a resident without obtaining consent from the designated surrogate decision maker, despite the resident lacking capacity to make healthcare decisions. The resident's family member was the authorized decision maker, but the facility failed to inform them or obtain their consent prior to vaccination.
The facility failed to maintain accurate medical records for two residents. One resident's decision-making capacity entry was improperly corrected without a date or initials. Another resident's fall was not accurately documented in their LTC Evaluation note, despite being recorded in a Post Fall Evaluation. These discrepancies were confirmed by the DON.
The facility failed to assess two residents for the ability to self-administer medications. One resident self-administered insulin without a physician's order or care plan documentation, despite an assessment indicating they were not capable. Another resident was ordered to self-administer an antibiotic without proper assessment, despite fluctuating decision-making capacity. Staff were unaware of the lack of documentation supporting these actions.
The facility failed to ensure call lights were within reach and responded to in a timely manner for several residents. Residents were found with call lights on the floor, out of reach, and reported long wait times for assistance, particularly during night shifts. These issues were verified by staff and posed risks to residents' well-being.
The facility failed to develop comprehensive care plans for two residents, leading to deficiencies in addressing their specific medical needs. One resident with a CVAD for IV antibiotic treatment lacked a care plan for its use, confirmed by the RN and DON. Another resident, requiring a cervical collar and TLSO brace, did not have a care plan addressing their application and noncompliance, with staff unaware of the resident's refusal to comply.
A resident who required a cervical collar after being hit by a car was not wearing it as ordered by the physician. The facility's staff, including the DOR, RNA, and LVNs, were unaware or did not act on the physician's order, and the resident's non-compliance was not documented or addressed. The DON and MDS Coordinator confirmed the oversight and lack of follow-up with an orthopedic specialist.
A resident was found to have cigarettes stored in their room, contrary to the facility's policy requiring secure storage of smoking materials. Despite the care plan indicating that smoking materials should be stored in a designated box, staff allowed the resident to keep them in their room. This posed a risk of fire and serious injuries to other residents.
A resident with a suprapubic catheter and recurrent UTIs was found with a urinary drainage bag on the floor, posing a risk for CAUTI. The resident admitted to placing the bag on the floor and was not educated by the facility about the risks. Staff confirmed the improper positioning and acknowledged the need for proper catheter care.
The facility failed to provide proper respiratory care for four residents by not labeling nasal cannulas and improperly storing nebulizer and CPAP masks. Staff confirmed these deficiencies, which were not in line with the facility's policies requiring proper storage and labeling of respiratory equipment.
A resident requiring dialysis care did not receive proper assessment and monitoring of their dialysis access site upon returning from the dialysis clinic. The facility's staff failed to conduct and document necessary assessments, as required by the facility's policy, leading to a deficiency in care.
The facility failed to document the administration of controlled pain medications for two residents, as required by their policy. An LPN confirmed that the medications were removed but not recorded in the MAR, indicating a lapse in pharmaceutical services.
A facility failed to act on a Pharmacy Consultant's recommendation for a resident's medication regimen. The resident was prescribed buspirone for anxiety, but the Consultant noted that the diagnosis was too subjective and recommended a specific behavior be documented. There was no evidence that the physician was notified or that the recommendation was acted upon. An RN claimed to have followed up with the physician but could not provide documentation.
The facility failed to remove expired medications from two medication carts. In Medication Cart B, expired vials of injectable sterile water were found, confirmed by an RN. In Medication Cart A, an open package of budesonide inhalation solution past its use-by date was discovered, verified by an LVN. This oversight violated the facility's policy on medication storage, risking the administration of expired medications to residents.
The facility did not adhere to menu and portion control guidelines, impacting residents' nutritional needs. The cook deviated from the recipe for pureed Spinach Au Gratin by omitting margarine and cheese, and used a #12 scoop instead of the required #8 scoop for serving, leading to incorrect portion sizes. These issues were confirmed by the DSS during observations and interviews.
The facility failed to maintain sanitary conditions in the kitchen, with issues such as improper labeling and dating of food, unsanitary kitchen equipment, and inadequate air drying of utensils. Observations included unlabeled frozen foods, a dirty ice machine, and marred cutting boards, all of which could lead to foodborne illnesses among residents.
A facility failed to follow its policy on food storage brought by visitors for a resident. Unlabeled food containers were found in the resident's room, and the facility did not provide the resident and family with the policy guidelines as part of the admission packet. Staff interviews confirmed awareness of the issue but showed a lack of consistent communication and enforcement of the policy.
The facility failed to properly dispose of trash, as one of three dumpsters was found overflowing with boxes, preventing the lid from fully closing. This was confirmed by the Director of Maintenance, violating FDA Food Code 2013, 5-501.113, which requires waste receptacles to be covered with tight-fitting lids.
The facility failed to maintain confidentiality and accuracy in resident records. Confidential resident rosters were mistakenly included in a publicly accessible binder, and a resident's weight was inaccurately recorded due to a unit conversion error. The Administrator and DON confirmed these errors during interviews.
The facility failed to implement proper infection control practices, as observed when a CNA placed briefs and blue chucks on an isolation cart for distribution, risking contamination and infection spread. The CNA acknowledged the inappropriate handling of these items.
The facility failed to maintain essential equipment safely, with improper cleaning and sanitizing of the ice machine and mismatched serial numbers for the glucometer. The ice machine was not cleaned per manufacturer guidelines, and the glucometer's serial number did not match the quality control log, posing risks to resident safety.
The facility failed to conduct accurate and complete entrapment assessments for residents using bed rails, risking potential entrapment and injury. Observations showed residents with elevated side rails, but the maintenance director could not provide documentation of bed inspections or entrapment risk assessments. Measurements revealed gaps that could entrap a resident's arm or hand, confirming deficiencies in the facility's bed inspection process.
A facility failed to provide necessary GT care for a resident when the tube feeding bottle label lacked the start time and nurse's initials. Observations revealed non-compliance with the facility's policy, which required labeling with specific details. Interviews with staff confirmed the oversight, and the resident, who lacked decision-making capacity, had a physician's order for Jevity 1.2 feeding formula. This failure posed potential risks for complications and infections.
Pureed Menu Recipes Not Followed
Penalty
Summary
The facility failed to ensure menus were followed for eight residents who received a pureed diet, including two final sampled residents and six nonsampled residents. The deficiency involved the pureed Curry Lemon Chicken, pureed Peas with Onions, pureed Garlic Rice, and pureed wheat rolls, where the prepared foods did not match the written recipes and menu requirements. The facility’s policy stated food served should adhere to the written menu, and the dietitian later verified that pureed foods should follow the regular recipe with the least amount of liquid and thickener, and that regular broth should not be used in place of salt-free broth when pureeing foods. For the pureed Curry Lemon Chicken, a cook was observed preparing nine servings and stated she followed the pureed meat recipe for 12 servings, but she placed ten three-ounce portions of chicken into the Robot Coupe, added three cups of curry sauce, and used five heaping tablespoons of thickener. For the pureed Peas with Onions, the cook was observed preparing nine servings and used a size 12 scoop of peas, added 2/3 cup of liquid, stated the peas were cooked in chicken broth, and then added six tablespoons of thickener. The nutrition facts for the chicken flavored base used to cook the peas showed one teaspoon provided 970 mg of sodium. For the pureed Garlic Rice, the cook was observed preparing nine servings and used 11 scoops of garlic rice, 1.5 cups of milk, and seven tablespoons of thickener. For the pureed wheat rolls, the cook used 12 scoops of crumbled bread, two cups of milk, and 1.5 tablespoons of thickener, and later stated the breadcrumbs used were from toasted bread. The facility’s cook spreadsheet indicated the pureed wheat roll should have received a #16 scoop, and the observations showed the pureed items were prepared with ingredients and amounts that did not follow the documented recipes.
Improper Cooling Documentation and Wet Blender Storage
Penalty
Summary
The facility failed to ensure food safety and sanitation guidelines were followed when the cooling process for time/temperature control for safety (TCS) foods was not monitored correctly. Review of the Cooling Monitor Log for September showed that tuna salad and egg salad prepared on 9/16/25 had temperature entries documented without the times the temperatures were taken. The first logged temperature for the tuna salad was 67 degrees F and the second was 42 degrees F, and the first logged temperature for the egg salad was 72 degrees F and the second was 52 degrees F. [NAME] 2 and the DSS verified that the log was missing the times for the temperatures taken and that both items were above 41 degrees F. They also verified the temperatures should have been recorded every hour and up to four hours until reaching 41 degrees F or less. The DSS stated both items had been discarded. The facility also failed to ensure one blender was air dried after cleaning and sanitizing. During the initial kitchen tour on 9/15/25 at 0828 hours, the inside of the blender was observed wet and stored with the top on. [NAME] 1 verified the blender was not air dried. The RD later verified that equipment and utensils should be air dried.
Unnecessary PRN Ativan Given Without Documented Target Behaviors
Penalty
Summary
The facility failed to ensure one of five sampled residents, Resident 12, was free from unnecessary psychotropic medication use when PRN Ativan was administered without documented evidence that the targeted behaviors were present before the medication was given. The facility’s P&P required psychoactive medication orders to include a specific behavior manifestation and required residents to have the right to be free from chemical restraints, and the medication administration policy required licensed nurses to document the reason for PRN medications. Resident 12 was admitted to the facility with no capacity to understand and make decisions, and the care plan addressed Ativan use for anxiety disorder with interventions to monitor, record, and document target behavior symptoms. The physician’s orders directed Ativan 0.5 mg every six hours as needed for anxiety manifested by agitation as evidenced by attempting to hit staff, and another order directed staff to monitor and record the target behaviors. Review of the MAR showed multiple Ativan administrations in August and September 2025 without documented evidence that Resident 12 displayed the targeted behaviors before receiving the medication. During interviews, an LVN stated the medication was given PRN for anxiety manifested by agitation and that it should not be administered if the resident did not display the targeted behaviors; the DON stated the resident should not receive the PRN psychotropic medication if the targeted behaviors were not present.
Missing Care Plans for Weight Loss and Antidepressant Use
Penalty
Summary
The facility failed to develop comprehensive person-centered care plans that reflected the individual care needs of three sampled residents. Facility policy required care plans to include measurable objectives and timeframes for residents’ medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment, and the change-in-condition policy required licensed nurses to assess changes, determine appropriate interventions, and update the care plan when applicable. Resident 28 had a documented change in condition on 9/8/25 showing weight loss of 24.4 lbs., a 4% decrease over six months and a 17.4 lbs., 10% decrease over three months. Review of the resident’s plan of care did not show documentation that a care plan was developed to address the weight loss. During an interview and concurrent record review, RN 1 verified that no care plan had been developed for the resident’s weight loss. Resident 18 had a documented change in condition on 7/11/25 showing a weight loss of 8.2 lbs. in one week, but the plan of care did not show a care plan developed to address that change. The MDS Coordinator verified there was no care plan for the weight loss and stated there should have been one. Resident 21 had intact cognition, with an H&P showing capacity to understand and make decisions and a BIMS score of 15, and had a physician order for bupropion HCL 150 mg daily for depression manifested by low motivation on ADLs. The plan of care did not show a care plan problem or interventions for the antidepressant use, and LVN 1 verified that no care plan had been developed and stated nurses should have been monitoring for signs and symptoms of depression and documenting goals and interventions.
Failure to complete post-fall neuro checks and monitor Wander Guard functionality
Penalty
Summary
The facility failed to ensure Resident 18 received the required neurological checks after a fall. On 1/2/25 at 2345 hours, Resident 18 fell from a wheelchair and sustained a laceration to the left forehead. The resident’s care plan later included neurological assessment interventions, and the resident was transferred to an acute care hospital at 0005 hours on 1/3/25. The medical record did not show a neurological assessment completed 15 minutes after the fall incident. The record also did not show neurological assessments after Resident 18 was readmitted to the facility on 1/4/25. The facility’s Fall Management Program stated that after an unwitnessed fall or a witnessed fall with suspected or known head injury, licensed nurses were to complete neurological checks at the ordered frequency for up to 72 hours. Review of the record failed to show neurological assessments completed for the required monitoring period after the fall and after the resident returned to the facility. The facility also failed to monitor the functionality of Wander Guard devices for Residents 30 and 68. Both residents were observed with Wander Guard devices on their left wrists, and both had care plans and physician orders addressing placement of the devices every shift. However, the records did not show physician orders for functionality checks, and the maintenance log did not contain documented evidence of monthly functionality monitoring. Staff interviews confirmed that placement checks were done by nursing staff, while maintenance was responsible for functionality checks, but documentation of those functionality checks was not available.
Failure to Assess Significant Unplanned Weight Loss
Penalty
Summary
The facility failed to ensure acceptable nutritional status was maintained for one resident who had a significant unplanned weight loss of 21.8 lbs., or 10.2% in six months. The resident had diagnoses including multiple sclerosis, protein calorie malnutrition, and Alzheimer's disease. Review of the resident's weight records showed a weight of 191.4 lbs. compared with 213.2 lbs. several months earlier, and the MDS reflected that the resident had experienced 10% or more unplanned weight loss in the past six months and was not on a physician-prescribed weight loss regimen. The Registered Dietitian verified that no nutritional assessment was completed in June to address the significant weight loss and that no nutritional assessment was completed between June and September. The RD also verified there was no physician order for a planned weight loss regimen and no resident-centered plan of care reflecting such a regimen. Facility policy required residents with significant weight loss to be assessed, with the information analyzed to identify causes and problems related to the resident's condition and needs. The Director of Nursing verified the significant unplanned weight loss occurred and that the RD did not complete a nutritional assessment in June. The DON also verified the Interdisciplinary Team did not meet in June to discuss the resident's significant unplanned weight loss, although the facility's policy required the IDT to evaluate weight changes of 10% in 180 days to determine the cause and needed interventions. The DON stated the IDT met later to discuss the weight loss, but not in the month when the significant loss should have been addressed.
GT Water Flush Not Programmed as Ordered
Penalty
Summary
The facility failed to provide appropriate care and services for the use of a GT for one of one final sampled resident reviewed for GT feeding. Resident 3 had dysphagia and a GT, and the medical record showed physician orders for Jevity 1.2 at 55 ml/hr via pump for 20 hours and a water flush at 70 ml per hour for 20 hours via GT pump. The resident’s care plan addressed dependence on GT feeding for hydration and nourishment and directed staff to follow the current MD feeding orders. On 9/19/25, Resident 3 was observed in bed with GT feeding infusing at 55 ml/hr, and a water bag was hanging and dated 9/19/25. However, the water flush was not programmed into the GT pump to show how much water flush the resident was receiving. During a concurrent observation, interview, and record review with LVN 3, the LVN was unable to show that the water flush had been programmed, verified the physician’s order for 70 ml per hour via GT pump, and then was observed programming the water flush into the pump. The resident’s nutritional risk assessment also noted an elevated BUN on 7/24/25, with the intervention to adjust the water flush to 70 ml per hour via GT pump.
Respiratory Equipment Not Maintained as Ordered
Penalty
Summary
The facility failed to provide necessary respiratory care services for two residents. One resident used oxygen at 2 liters per minute via nasal cannula, and the facility’s policy required oxygen tubing, masks, and cannulas to be changed no more than every seven days and dated each time they were changed. During an initial tour, the resident’s oxygen tubing was dated 9/15/25, but the clear oxygen storage bag holding half of the tubing was dated 9/7/25. An LVN acknowledged the bag should have been changed and stated it should be changed for infection control and prevention. The facility also failed to ensure another resident’s CPAP machine was cleaned according to the manufacturer’s user cleaning guidelines. The resident was cognitively intact and used a ResMed AirSense 10 CPAP machine. The facility’s CPAP policy required the mask, nasal pillows, tubing, and headgear to be cleaned with warm soapy water daily and allowed to air dry, and the resident’s physician ordered the mask to be cleaned with soap and water daily and the filter cleaned weekly. During observation, the CPAP machine was found on the bedside table with the tubing and mask inside a clear plastic bag, and the resident stated he had not seen facility staff clean the CPAP machine since admission. Staff interviews showed inconsistent understanding of responsibility for CPAP cleaning, but multiple licensed nurses acknowledged they were responsible for cleaning the equipment and one LVN admitted she had not cleaned the CPAP mask as ordered. An RN stated the licensed nurses were responsible for cleaning the CPAP equipment after each use, but also verified the CPAP manual was not available and was not aware of the manufacturer’s cleaning recommendation. The DON was informed and verified the findings.
Inaccurate Monitoring of Fluid Restriction for a Dialysis Resident
Penalty
Summary
Resident 2, who had end stage renal disease and required hemodialysis, had a physician’s order for a 1500 ml daily fluid restriction. The order specified that dietary staff were to provide 720 ml of fluid and nursing staff were to provide 780 ml, divided across shifts. The facility’s Fluid Restrictions policy required licensed nurses to initiate strict intake measurements, record all fluids on the intake and output record, total the amount each 24 hours, compare it to the fluid restriction guidelines, remove the water pitcher and cup from the room, and review intake and output summaries weekly. Resident 2’s MDS showed the resident was cognitively intact and coded for dialysis. Review of the resident’s fluid intake task from 9/3/25 through 9/16/25 showed only meal tray fluids documented by CNAs, with daily totals ranging from 250 ml to 720 ml and some missing intake entries. Examples included 510 ml on 9/3/25, 250 ml with missing entries on 9/7/25, and 310 ml with missing entries on 9/14/25. The medical record did not show other documentation that the 1500 ml daily restriction was met, and weekly intake and output summaries addressing adequacy and documentation accuracy were not documented. CNA 1 stated he recorded only the fluids consumed from the meal tray, LVN 4 verified the resident’s fluid intake was not properly monitored and documented, and RN 1 confirmed the monitoring was not accurate per the physician’s order and that no weekly summary was documented. During observation, no water pitcher was present at the bedside, and the resident stated he had been told to limit fluids and only had milk and some juice with meals.
Missing Informed Consent for Bilateral Bed Grab Bars
Penalty
Summary
The facility failed to ensure informed consent was obtained and completed for Resident 7’s bilateral U grab bars. The report states the facility’s policy on bed rails, revised 5/30/24, required the ordering physician to obtain informed consent from the resident or resident representative before bed rails were used. Resident 7 was observed in bed with the bilateral U grab bars elevated during the initial tour on 9/15/25 and again during a follow-up observation on 9/17/25. Resident 7 was admitted to the facility on [DATE]. Her H&P dated 7/24/25 stated she was unable to make her own medical decisions, and her quarterly MDS showed a BIMS of 9, indicating moderate impaired cognition. The order summary report for 9/2025 showed a physician’s order dated 7/28/22 for bilateral grab bars for ADL care changes, mobility, positioning, and as an enabler. Review of the medical record did not show informed consent for the bilateral U grab bars. CNA 6 stated the grab bars were used for turning and repositioning while in bed, and LVN 1 confirmed the resident currently used them for turning in bed and stated informed consent should be obtained for safety measures and updated when the physician’s order changed.
Medication Administration and Documentation Deficiencies
Penalty
Summary
The facility failed to provide pharmaceutical services to meet residents’ needs for three residents. For Resident 9, who was ordered insulin lispro subcutaneously before meals and at bedtime using a sliding scale, the facility’s location of administration record showed repeated injections given in the same subcutaneous sites without rotation, including multiple administrations to the right lower quadrant and multiple administrations to the left lower quadrant over several dates in August 2025. The facility’s policy required selecting an appropriate injection site and documenting the site used, and the insulin package insert stated injection sites should be rotated to reduce the risk of lipodystrophy and localized cutaneous amyloidosis. For Resident 71, who had a BIMS score of 15 and an order for hydrocodone-acetaminophen 5-325 mg one tablet by mouth every six hours as needed for moderate pain, the Individual Narcotic Record showed the Norco was removed and signed out on two occasions, but the September 2025 MAR did not show documentation that the medication was administered on those dates. The facility’s medication administration policy stated medications are to be administered according to physician orders, current best practices, and regulations, and that the time and dose administered are to be recorded in the resident’s medication record. The DON verified the medication was dispensed but not documented on the MAR. For Resident 12, during a medication administration observation, an LVN prepared and administered fluticasone nasal spray, loratadine 10 mg, divalproex delayed release 500 mg, and quetiapine fumarate 25 mg. The LVN was observed crushing the loratadine, divalproex, and quetiapine tablets and giving them in applesauce, and later verified that the divalproex delayed release medication should not have been crushed because it was a delayed release tablet that slowly releases medication effects. The National Library of Medicine source cited in the report stated divalproex delayed-release tablets should be swallowed whole and not split, chewed, or crushed.
Failure to Educate on Safe Handling of Outside Food
Penalty
Summary
The facility failed to ensure that staff and resident visitors were educated on safe food handling practices when food from outside the facility was brought in for resident consumption. The facility’s matrix showed 76 residents consumed an oral diet. The facility’s policy titled Foods Brought in by Visitors, revised 4/24/25, stated that families and visitors should be assisted to understand safe food handling practices, including safe cooling and reheating processes, hot and cold holding temperatures, preventing cross contamination, and hand hygiene. Review of the facility’s in-service lesson plan and attendance record titled Food Brought by Visitors showed an in-service was conducted by the DSD on 1/17/25 and covered policy interpretation and implementation, including policy specifics, but did not include safe food handling practices. RN 1 stated families were educated on risks, benefits, storage location, storage timeframe, and labeling and dating food items, and also stated she had received an in-service on safe food handling from the DSD. The admission packet did not include the outside food policy or any information regarding safe food handling. The DSD stated staff were in-serviced on microwave use, labeling and dating outside food, perishable food timeframes, and storage timeframes, and the Admission Director stated the policy was not included in the admission packet and that no specific safe food handling information was discussed when the policy was handed to family members. The Administrator and DSS verified and acknowledged these findings.
Infection Surveillance Documentation and Hand Hygiene Failures
Penalty
Summary
The facility failed to implement its infection prevention and control program by not maintaining an accurate and complete infection control surveillance program for June, July, and August 2025. The facility’s Infection Control Surveillance policy dated 3/1/14 stated the Infection Preventionist conducts ongoing surveillance for HAIs and epidemiologically significant infections and documents whether infections meet HAI, CAI, or do not meet McGeer Criteria. Review of the Antibiotic Stewardship Record Log on 9/19/25 showed that for multiple residents, including residents with symptom onset dates in June, July, and August 2025, the log did not indicate whether each case was HAI, CAI, or did not meet McGeer Criteria. During interview and document review, the Infection Preventionist verified that the documentation was missed, and the DON later acknowledged the findings. The facility also failed to follow its hand hygiene policy during medication administration. The Hand Hygiene policy revised 9/2020 stated hand hygiene should be performed before and after removing PPE. During observation of medication administration for a resident receiving multiple oral medications and eye drops, an LVN was observed removing gloves after administering oral medications, donning a new pair of gloves, and then administering eye drops without performing hand hygiene between glove changes. When interviewed, the LVN stated hand hygiene should be performed before donning a new pair of gloves and verified that it was not done during the observation. The Administrator and DON were informed and acknowledged the finding.
Missing Advance Directive in Resident Record
Penalty
Summary
The facility failed to maintain a copy of Resident 33’s advance directive in the resident’s medical record. The report states that Resident 33 was admitted to the facility and later readmitted, and that an Advance Healthcare Directive Acknowledgment form showed the resident had no advance directive and did not want information at that time. The resident also had a physician order for full code and CPR, and the H&P examination documented that Resident 33 had no mental capacity to make decisions. A Quarterly Social Service Progress Note stated that information on how to execute an advance directive was provided and that Resident 33 had an advance directive on file, but no copy of the advance directive was present in the medical record. During a concurrent interview and record review, the Case Manager/SSD verified that a copy of the advance directive should be in the resident’s medical record and uploaded into the electronic medical record. The Administrator and DON were later informed and acknowledged the findings.
Failure to Obtain Medicare Non-Coverage Notices and Signatures
Penalty
Summary
The facility failed to provide the written Notice of Medicare Non-coverage (NOMNC) form CMS-10123 and the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) form CMS-10055 for one of three residents reviewed for beneficiary notification. Resident 15 was admitted to the facility and had an H&P examination dated 2/25/25 stating the resident had no capacity to understand and make medical decisions. The NOMNC in the record was undated and showed the effective date for the end of skilled nursing service coverage as 3/24/25, but the section for the resident or representative signature was blank. The record also showed the Business Office Manager called the resident’s responsible party on 3/21/25 to notify them that the Medicare-covered Part A stay was ending on 3/24/25. The SNF ABN stated that beginning 3/25/25, the resident may have to pay out of pocket for care not covered by Medicare, but the document did not show a signature from the resident or authorized representative. The Optional Form to Document Alternate Delivery for the NOMNC showed the responsible party was contacted by telephone on 3/21/25 and by email on 3/24/25, and the confirmation of refusal to sign section was blank. During interview, the BOM stated the responsible party requested the forms be sent by email and that she did not have documentation showing follow-up to have the responsible party review and sign the NOMNC and SNF ABN forms.
Failure to Trim Resident Fingernails
Penalty
Summary
The facility failed to provide the necessary care and services to ensure one resident maintained good grooming and personal hygiene when the resident's fingernails were not trimmed. Facility policy stated that nail care is given to clean the nail bed and keep nails trimmed, with CNAs trimming fingernails except for residents with diabetes or circulatory impairments, and licensed nurses trimming those residents' nails. High-risk residents and residents with certain toenail conditions are referred to a podiatrist. Resident 11, who was admitted and later readmitted to the facility, stated during the resident council meeting that he had repeatedly requested fingernail trimming and was told staff did not trim residents' fingernails. During observation, all 10 fingernails were noted to be long with brown-colored stains on the back of the fingernails. The resident stated he had requested trimming three weeks earlier and repeated that staff had not done anything about his fingernails. CNA 2 observed the nails and stated they were long and should have been trimmed, while LVN 2 also verified the nails should have been trimmed and stated CNAs could trim residents' fingernails. The DON was informed and acknowledged the findings.
Facility Assessment Missing Required Input and Staffing Elements
Penalty
Summary
The facility failed to ensure its Facility Assessment addressed required elements, including active involvement of direct care staff and other required participants in developing the assessment, resources necessary to care for residents including weekends, a plan to maximize recruitment and retention of direct care staff, and a contingency plan for staffing needs. The report states that the Facility Assessment dated [DATE] did not show direct care staff members, direct care representatives, residents, residents' representatives, or residents' family members were actively involved in developing the assessment. During an interview and concurrent document review on 9/18/25 at 1032 hours, the Administrator reviewed the Facility Assessment dated 2/6/25 and acknowledged being unaware of the CMS update to the Facility Assessment requirements. The Administrator verified there were no direct care staff, direct care representatives, residents, resident representatives, or family members actively involved in developing the Facility Assessment, and confirmed there was no plan to maximize recruitment and retention of direct care staff, no resources necessary to care for residents including weekends, and no contingency plan for staffing needs.
Incomplete and Inaccurate MAR Documentation
Penalty
Summary
The facility failed to ensure the medical record for one resident was complete and accurate. For Resident 28, the MAR documented an oxygen saturation rate of 137% during the day shift on 9/1/25, which RN 1 later verified was a typographical error. The resident also had an order to check oxygen saturation every shift, and the facility’s P&P required licensed caregivers performing pulse oximetry to be in-serviced on the standards of its use and performance of the procedure. The medical record was also incomplete for Resident 28’s meal intake documentation. The resident had a physician’s order to monitor meal percentage with meals, but the MAR for August 2025 did not include the dinner meal percentage entry for 8/22/25. During interview and concurrent record review, RN 1 acknowledged the missed documentation and stated the MAR should have been completed. The DON was informed of and acknowledged these findings.
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 Ensure Safe and Individualized Transfer/Discharge
Penalty
Summary
The facility failed to ensure that the transfer or discharge process met the resident's needs and preferences, and did not adequately prepare the resident for a safe transfer or discharge. The report identifies that the necessary steps to assess and address the resident's individual requirements and preferences during the transfer or discharge process were not followed, resulting in a deficiency related to resident care planning and transition.
Medications Improperly Stored and Accessible in Resident Rooms
Penalty
Summary
The facility failed to ensure that medications and biologicals were stored securely and not kept at the bedside, as required by facility policy and professional standards. In one instance, a bubble pack of metformin prescribed for a resident with diabetes was found hidden in another resident's closet for ten days. The investigation revealed that a CNA, who also had diabetes, took the medication from the medication room when the door was left slightly open and hid it in the resident's room with the intention of taking it home, but forgot about it until it was discovered by the resident's family. The resident whose closet was used to hide the medication had no capacity to understand or make decisions, as documented in their medical record. Additionally, another resident's side table drawer was found to contain a medication cup filled with thick white cream and a tongue depressor, which the DON identified as zinc oxide cream prescribed for a pressure injury. This medication was not stored securely as required. Both incidents were acknowledged by facility leadership and were in direct violation of the facility's medication storage policy, which mandates that medications be accessible only to authorized personnel and not stored at the bedside.
Improper Discharge Process for a Resident with Diabetes
Penalty
Summary
The facility failed to ensure a proper discharge process for Resident 1, who was diagnosed with type two diabetes mellitus with hyperglycemia. The resident was discharged without the necessary documentation and communication of critical information. The discharge planning review form indicated that the resident was going home with a friend and would have a caregiver after discharge. However, the facility could not provide the discharge/transfer report, which should have included evidence of teaching or training provided to the resident and the caregiver, as well as a list of medications. Interviews with LVN 1 and the DON revealed that the discharge protocol was not followed. LVN 1 confirmed that no teaching or training was provided to the resident or the caregiver, and the caregiver was not present or contacted during the discharge. The DON acknowledged that Resident 1 required assistance with medication administration and could not self-administer insulin injections. The DON confirmed that the discharge was unsafe due to the lack of education and training provided to the resident and caregiver, and the absence of the responsible person during the discharge.
Failure to Document Home Health Referral for Discharged Resident
Penalty
Summary
The facility failed to ensure a safe and orderly discharge for Resident 1, who was discharged with home health services. The medical record review revealed that there was no documentation indicating that a referral to a home health agency was arranged prior to the discharge. This oversight placed Resident 1 at risk of not receiving the necessary care after leaving the facility. The Order Summary Report for Resident 1 included an order for discharge to home with current medications and follow-up by home health PT/OT/RN, with a subsequent follow-up with the PCP in one to two weeks. A progress note indicated that the SSD had discussed the discharge with Resident 1 and intended to arrange home health services as ordered. However, further review of the medical record did not show evidence of a referral being sent to the home health provider. During an interview, the SSD was unable to provide documentation for the home health services referral, and the Administrator and DON acknowledged these findings.
Failure to Obtain Proper Consent for Vaccination
Penalty
Summary
The facility failed to obtain the appropriate consent prior to administering COVID-19 and influenza vaccines to a resident who lacked capacity to make healthcare decisions. The resident, who was readmitted to the facility, had a family member designated as the surrogate decision maker according to a Durable Power of Attorney for Healthcare. Despite this, the resident personally signed the informed consent for immunizations, which was not valid due to their lack of capacity. The vaccines were administered without the consent of the designated family member. During an interview, the Director of Nursing confirmed that the facility did not inform or obtain consent from the resident's responsible party before administering the vaccines.
Inaccurate Medical Records for Two Residents
Penalty
Summary
The facility failed to maintain accurate and complete medical records for two residents, leading to potential care issues. For the first resident, the History and Physical examination document had a section where a decision-making capacity entry was struck through without a date or initials, making it unclear when and by whom the correction was made. This lack of proper documentation could lead to misunderstandings about the resident's ability to make medical decisions. For the second resident, there was a discrepancy in the medical records regarding a fall. The resident experienced an unwitnessed fall, which was documented in a Post Fall Evaluation note. However, a subsequent Long Term Care Evaluation note incorrectly stated that the resident had not experienced any falls since the last evaluation. This error was confirmed by the DON, who acknowledged that the record should have reflected the fall, indicating a failure in maintaining accurate records.
Failure to Assess Residents for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that residents were properly assessed for the ability to self-administer medications, as evidenced by the cases of two residents. Resident 23 was observed self-administering insulin without a physician's order permitting self-administration, and the resident's care plan did not document the ability to self-administer medications. Despite the resident's history and physical examination indicating the capacity to understand and make decisions, the most recent assessment showed the resident was not capable of self-administering subcutaneous injections, and all medications were to be administered by a nurse. LVN 1, who was responsible for the resident's care, was unaware of the lack of documentation supporting the resident's ability to self-administer insulin. Similarly, Resident 18 was not assessed for the ability to self-administer medications, despite a physician's order for unsupervised self-administration of an antibiotic. The resident's history indicated fluctuating capacity to understand and make decisions, and the assessment showed that all medications were to be administered by a skilled nurse. RN 1 confirmed that the resident was not capable of self-administration and acknowledged the transcription of the physician's order into the MAR, which had the potential for the resident to self-administer the antibiotic without proper assessment or documentation.
Failure to Ensure Call Light Accessibility and Timely Response
Penalty
Summary
The facility failed to promote dignity and respect for several residents by not ensuring that call lights were within reach and not responding to call lights in a timely manner. Specifically, Residents 18, 22, and 62 were observed with their call lights on the floor, out of reach, which prevented them from calling for assistance when needed. This was verified by staff members who acknowledged the issue. Resident 18, who had limited mobility and quadriplegia, was unable to reach the call light, and this was confirmed by an LVN. Similarly, Resident 22, who had multiple health issues including dementia and impaired communication, was also found with the call light on the floor, as verified by another LVN. Additionally, the facility did not ensure timely responses to call lights for Residents 4, 23, and 60. Resident 4 reported that staff would hide the call light during the night shift and that there were instances where the call light was turned off without attending to her needs. This resident, who was dependent on staff for toileting hygiene, expressed concerns about waiting over an hour for assistance. Resident 23, who required moderate assistance, also reported long wait times during the night shift and mentioned that staff cited insufficient staffing as a reason for delays. Resident 60's family member corroborated these issues, stating that the resident had to wait for hours for assistance, which caused agitation due to incontinence. The facility's policy and procedure on the communication-call system, dated 1/1/12, stated that call cords should be within the resident's reach and that nursing staff should answer call bells promptly and courteously. However, the observations and interviews conducted during the survey revealed that these policies were not being followed, leading to deficiencies in the care provided to the residents. These failures posed a risk to the residents' physical and emotional well-being, as they were unable to receive timely assistance for their needs.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, leading to deficiencies in addressing their specific medical needs. Resident 423, who was admitted with a central venous access device (CVAD) for intravenous antibiotic treatment, did not have a care plan problem developed to address the use of the CVAD. This oversight was confirmed through interviews and medical record reviews with the RN and the Director of Nursing (DON), who verified the absence of a care plan for the CVAD. Similarly, Resident 17, who required a cervical collar and a thoracic-lumbar-sacral orthosis (TLSO) brace following an accident, did not have a care plan addressing the application and noncompliance with these devices. Despite physician orders for the use of these devices, the resident was observed not wearing them, and staff interviews revealed a lack of awareness and documentation regarding the resident's refusal to comply. The DON and MDS Coordinator acknowledged the absence of a care plan for Resident 17's needs and noncompliance.
Failure to Apply Cervical Collar as Ordered
Penalty
Summary
The facility failed to provide necessary treatment and services for a resident who required a cervical collar (c-collar) as ordered by a physician. The resident, who had been hit by a car while in a wheelchair, was observed without the c-collar on multiple occasions. The physician's order specified that the c-collar should be worn at all times, but the resident was non-compliant with this order. The facility's plan of care did not address the application of the c-collar or the resident's noncompliance. Interviews with various staff members, including the Director of Rehabilitation (DOR), Registered Nurse Assistant (RNA), and Licensed Vocational Nurses (LVNs), revealed a lack of awareness and action regarding the resident's need for the c-collar. The DOR acknowledged the resident's non-compliance and the need for a follow-up with an orthopedic specialist, but there was no documented evidence of notifying the physician or specialist about the resident's refusal. The Director of Nursing (DON) and MDS Coordinator confirmed the findings and acknowledged that the resident had not been seen by an orthopedic specialist during their admission.
Failure to Securely Store Smoking Materials
Penalty
Summary
The facility failed to provide a safe environment free from potentially serious accident hazards for a resident who was reviewed for smoking. The facility's policy and procedure for smoking residents required the interdisciplinary team to develop an individualized plan of care for the safe storage and use of smoking materials. However, during an observation and interview, it was found that the resident had a box of cigarettes stored inside a bag on the ground in his room. The resident stated that he kept the cigarettes in his room because the facility would forget about them, despite the facility's policy that smoking materials should be securely stored. Further investigation revealed that the resident's plan of care included an intervention for cigarettes and a lighter to be stored in a designated box. However, both an LVN and an RN confirmed that the resident was allowed to keep his smoking materials in his room, contrary to the facility's policy. The RN acknowledged that the cigarettes should not have been kept in the resident's room and proceeded to store them in a locked container at the nurse's station. This oversight posed a risk of fire and serious injuries to the residents in the facility.
Improper Catheter Care Leads to UTI Risk
Penalty
Summary
The facility failed to provide appropriate care and services to prevent a urinary tract infection (UTI) for a resident with a suprapubic catheter and a history of recurrent UTIs. The deficiency was identified when the resident's urinary drainage bag was observed laying on the floor during an initial tour of the facility. This improper positioning of the drainage bag posed a risk for the resident to develop a catheter-associated urinary tract infection (CAUTI), as it allowed urine to potentially flow back into the bladder. The resident, who had the capacity to understand and make decisions, admitted to placing the urinary drainage bag on the floor himself and sometimes putting it in a trash bag. He stated that the facility did not educate him about the risks associated with placing the drainage bag on the floor. Observations and interviews with facility staff, including an LVN and the MDS Coordinator, confirmed that the urinary drainage bag should not be placed on the floor for infection control reasons. The MDS Coordinator acknowledged the findings and confirmed the resident's history of recurrent UTIs and the need for proper catheter care.
Improper Storage and Labeling of Respiratory Equipment
Penalty
Summary
The facility failed to provide appropriate respiratory care for four residents, as observed during a survey. For two residents, the nasal cannula was not dated or labeled, and the nebulizer mask was improperly stored. One resident's CPAP mask was not stored correctly, and another resident's nasal cannula was left on top of a wheelchair instead of being stored properly. These actions were not in compliance with the facility's policies and procedures, which require respiratory equipment to be stored in labeled bags and changed regularly. The medical records of the residents involved showed that they had various respiratory conditions requiring specific treatments, such as oxygen therapy and nebulization. Interviews with facility staff, including LVNs and the DON, confirmed the improper storage and labeling of respiratory equipment. The staff acknowledged the deficiencies and verified that the equipment should have been stored according to the facility's policies to ensure safe and sanitary conditions for the residents.
Failure to Provide Appropriate Dialysis Care
Penalty
Summary
The facility failed to provide appropriate dialysis care for a resident, identified as Resident 29, who required dialysis services. The deficiency was observed in the lack of proper assessment and monitoring of the resident's dialysis access site. Specifically, the licensed staff did not assess Resident 29's dialysis access site after returning from the dialysis clinic, nor did they document any assessment of the site upon the resident's return. This oversight was contrary to the facility's policy and procedure, which required licensed staff to inspect the dialysis access site for functionality and signs of complications, and to document pre- and post-dialysis assessments. Resident 29, who received dialysis on Tuesdays, Thursdays, and Saturdays, was observed with a dry dressing on the left upper arm dialysis access site, which should have been removed four hours post-dialysis for an accurate assessment. Interviews with LVN 3 and RN 1 confirmed that the necessary assessments were not conducted or documented. Additionally, a review of the resident's medical records revealed a lack of documentation regarding a post-dialysis assessment on a specific date, further indicating a failure to adhere to the required care protocols.
Failure to Document Controlled Medication Administration
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of two residents, specifically in the administration and documentation of controlled pain medications. For Resident 17, the Individual Narcotic Record indicated that an oxycodone 10 mg tablet was removed from the supply on May 23, 2024, at 1400 hours. However, this administration was not documented in the resident's Medication Administration Record (MAR) for May 2024. This discrepancy was confirmed during an interview and medical record review with LVN 1, who acknowledged the missing documentation. Similarly, for Resident 23, the Individual Narcotic Record showed that a Norco 5-325 mg tablet was removed on June 3, 2024, at 2140 hours, but this was not recorded in the MAR for June 2024. LVN 1 verified the removal of the medication and confirmed the absence of documentation on the MAR. The facility's policy and procedure for controlled medications require immediate documentation of administration details in both the accountability record and the MAR, which was not adhered to in these cases.
Failure to Act on Pharmacy Consultant's Recommendations
Penalty
Summary
The facility failed to ensure that the Pharmacy Consultant's recommendations were acted upon for a resident reviewed for unnecessary medications. The resident was admitted to the facility and had a physician's order to administer buspirone HCL, an antianxiety medication, for anxiety manifested by restlessness. The Consultant Pharmacist's Medication Regimen Review noted that agitation or restlessness was too subjective to be used as a diagnosis or behavior and recommended updating the order with a specific and quantifiable behavior. However, there was no documented evidence that the resident's physician was notified or that the Pharmacy Consultant's recommendation was acted upon. During an interview, an RN stated that she had followed up with the physician and changed the manifested behavior to resisting care, but was unable to provide documentation to support this claim.
Expired Medications Found in Medication Carts
Penalty
Summary
The facility failed to ensure the removal of expired and potentially deteriorated medications from two of its three medication carts, specifically Medication Carts A and B. During an inspection of Medication Cart B, two 10 ml vials of injectable sterile water with past expiration dates were found. RN 1 confirmed the vials were expired and acknowledged they should have been removed. Similarly, an inspection of Medication Cart A revealed a box of budesonide inhalation solution with an open foil package containing two ampules, which should have been used within two weeks of opening. LVN 1 verified that the remaining medication should have been removed from the cart, as per the instructions on the medication box. These findings indicate a failure to adhere to the facility's policy and procedure for medication storage, which mandates the immediate removal and disposal of outdated or deteriorated medications. This oversight had the potential to result in the administration of expired or deteriorated medications to residents.
Failure to Follow Menu and Portion Control Guidelines
Penalty
Summary
The facility failed to adhere to the prescribed menu and portion control guidelines, which could potentially impact the nutritional needs of the residents. During the preparation of pureed Spinach Au Gratin, the cook did not follow the recipe as outlined in the facility's documents. Instead of using margarine and cheese as specified, the cook boiled the spinach with soup base and added a thickener, omitting the required ingredients. This deviation from the recipe was confirmed during an observation and interview with the cook and the Dietary Services Supervisor (DSS). Additionally, the facility did not follow the portion control guidelines for serving Spinach Au Gratin. The facility's portion control chart specified using a #8 scoop for a 1/2 cup serving size, but the cook used a #12 scoop instead. This discrepancy was observed during a trayline inspection, where trays prepared for residents on regular and mechanical soft diets contained incorrect portion sizes. The DSS acknowledged the error and confirmed that the serving size did not match the facility's guidelines.
Sanitary Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to meet sanitary requirements in the kitchen, as evidenced by several observations during a survey. Foods in the kitchen were not properly labeled and dated, which is a violation of the FDA Food Code 2022, Section 3-501.17. During an inspection, a bag of frozen egg omelets, cookies, donuts, and blueberries were found without opened dates inside Freezer #2. Additionally, the refrigerator designated for residents' food brought in from outside contained a box of chimichangas labeled with a resident's name and due date, but also had four unlabeled bags of ice. Unlabeled food containers and fruits were also found in a resident's room, indicating a lack of adherence to the facility's policy on food brought in by visitors. The facility's kitchen equipment and environment were not maintained in a sanitary condition. The ice machine was found with a yellowish slimy residue, and the kitchen exhaust hood had brownish black residue, which had not been cleaned since December 2023. The oven and heated plate dispenser were observed with food debris, and the blender machine had food debris as well. These conditions violate the FDA Food Code 2022, which requires non-food contact surfaces to be kept clean to prevent microorganism growth and pest harborage. Furthermore, the facility did not ensure proper air drying of kitchen items, as required by the FDA Food Code 2022. A blender container was found with water residue, and a dietary staff member was observed using a paper towel to dry a blender container and measuring cup after washing. Additionally, two green cutting boards were heavily marred with knife marks, making them difficult to clean and sanitize. These deficiencies in maintaining sanitary conditions in the kitchen had the potential to cause foodborne illnesses among the medically vulnerable resident population who consumed food prepared in the facility's kitchen.
Failure to Follow Food Storage Policy for Resident
Penalty
Summary
The facility failed to adhere to its policy and procedures (P&P) regarding the handling and storage of food brought in by visitors for a resident. Specifically, the facility did not ensure that food containers brought by the resident's family were labeled with the resident's name and date received, nor were they stored in a designated refrigerator. Instead, several fruits and unlabeled food containers were observed on the resident's bedside table, overbed table, floor, and bed. The facility's P&P required that residents and their families be provided with guidelines about the use and storage of food brought in by visitors as part of their admission packet, which was not done in this case. The medical records for the resident indicated a care plan problem related to the storage of extra food brought from home, with interventions including education on infection control and offering storage solutions. However, there was no documentation of continued communication with the resident and family about these issues, nor was there follow-up on the family's compliance with the storage guidelines. Interviews with facility staff, including a CNA, LVN, MDS Coordinator, and Admissions Director, confirmed awareness of the issue but revealed a lack of consistent communication and enforcement of the facility's P&P.
Improper Trash Disposal
Penalty
Summary
The facility failed to properly dispose of trash, as observed during a survey. One of three dumpsters located outside the facility was found overflowing with boxes, which prevented the lid from fully closing. This observation was made on 6/4/24 at 0755 hours. The issue was confirmed during a concurrent observation and interview with the Director of Maintenance at 0803 hours, who verified that the dumpster was indeed overflowing and the lid was not fully closed. This situation was in violation of the FDA Food Code 2013, 5-501.113, which requires receptacles and waste handling units for refuse to be kept covered with tight-fitting lids, thus potentially attracting pests and/or rodents.
Confidentiality Breach and Inaccurate Record-Keeping
Penalty
Summary
The facility failed to maintain accurate and confidential resident records, as evidenced by two specific incidents. Firstly, a binder labeled 'CDPH Annual Survey Binder' was observed on a table in the lobby for public review, containing confidential resident rosters with names and identifiers from various dates in 2021. During an interview and document review, the Administrator confirmed that these confidential rosters were mistakenly included in the binder, making protected information accessible to the public. Secondly, the facility did not accurately document Resident 29's monthly weight. A review of the resident's medical records showed inconsistent weight entries over the past six months, with a significant discrepancy in the June weight, which was recorded in kilograms instead of pounds. The Director of Nursing (DON) acknowledged the error during an interview and confirmed that the incorrect entry was due to a failure to convert the weight from kilograms to pounds, resulting in inaccurate medical records for the resident.
Inappropriate Infection Control Practices
Penalty
Summary
The facility failed to implement appropriate infection control practices, compromising the safety and sanitation of the environment and increasing the risk of infection spread. On June 5, 2024, at 0410 hours, multiple briefs and blue chucks were observed stacked on top of an isolation cart in front of room A. Later, at 0515 hours, a CNA was seen distributing these items to rooms A, B, and another resident's room. During an interview at 0520 hours, the CNA admitted to placing the briefs and chucks on the isolation cart for distribution purposes, acknowledging that this practice could lead to contamination and infection spread. The CNA verified the findings, confirming the inappropriate handling of these items.
Deficiencies in Equipment Maintenance and Documentation
Penalty
Summary
The facility failed to maintain essential equipment in safe operating condition, specifically the ice machine and glucometer. The ice machine was not cleaned and sanitized according to the manufacturer's specifications and the facility's policies and procedures. An incorrect ratio of nickel-safe cleaner was used, hot water was used instead of a sanitizing solution, and an unidentified spray bottle was used to sanitize the panels. These actions could potentially lead to the equipment not functioning as intended, posing a risk of food-borne illnesses for residents. During an inspection, yellowish slime was observed on a paper towel after wiping the inside of the ice machine, indicating improper cleaning. The Director of Maintenance admitted to using a capful of nickel-safe cleaner diluted with a little water, which did not align with the manufacturer's instructions. Additionally, the Director used hot water for sanitizing instead of the correct sanitizing solution, and the spray bottle used for sanitizing the panels was unlabeled and of unknown brand. The facility also failed to ensure the glucometer's serial number matched the one listed on the Quality Control Record. This discrepancy was discovered during an inspection of Medication Cart A, where the glucometer's serial number did not match the one documented in the quality control log. The LVN and DON confirmed that the serial numbers should match, indicating a lapse in proper documentation and equipment management.
Deficiency in Bed Rail Entrapment Assessments
Penalty
Summary
The facility failed to ensure accurate and complete entrapment assessments for residents using bed rails, which could lead to potential entrapment, serious injury, or death. The report highlights that the facility did not record measurements during bed inspections to identify areas of possible entrapment for three residents using side rails. The facility's policy requires that bed frames, rails, and mattresses leave no gaps wide enough to entrap a resident's head or body, and that maintenance staff routinely inspect beds to identify risks, including entrapment. For Resident 50, observations showed the resident lying in bed with both upper side rails elevated. The medical record indicated that the resident lacked the capacity to make decisions, and the bed rail assessment noted the use of bilateral side rails for mobility and safety. However, the maintenance director could not provide documentation of bed inspection or entrapment risk assessment for the resident's bed. Similarly, Resident 423 was observed with elevated side rails, and although a physician's order was in place for side rails, the maintenance director again failed to provide documentation of an entrapment assessment. Resident 18 was observed with elevated bed rails, and the medical record indicated fluctuating capacity to understand and make decisions. The plan of care included the use of side rails for ADL changes, mobility, and positioning. However, the maintenance director acknowledged not performing any entrapment assessment. Measurements taken by the environmental services staff revealed a gap that could potentially entrap a resident's arm or hand, confirming the deficiency in the facility's bed inspection and entrapment assessment process.
Failure to Properly Label Tube Feeding for a Resident
Penalty
Summary
The facility failed to provide necessary gastrostomy tube (GT) care and services for a resident, identified as Resident 45, who was reviewed for GT care. The deficiency was observed when the label on Resident 45's tube feeding bottle did not include the start time of the feeding and the initials of the nurse who hung the tube feeding. This omission was noted during observations conducted on two separate days. The facility's policy and procedure for enteral feedings, dated 9/7/23, required that the bag and tubing be labeled with the date and time hung, with a hang time of no more than 24 hours. Interviews with facility staff, including the Infection Preventionist (IP), a Licensed Vocational Nurse (LVN), and the Director of Nursing (DON), confirmed that the labeling process was not followed as per the facility's policy. The staff acknowledged that the label should have included the resident's name, date, start time, room number, and the nurse's initials. Resident 45, who lacked the capacity to understand and make decisions, had a physician's order for Jevity 1.2 feeding formula to be administered via pump. The failure to properly label the tube feeding had the potential to lead to complications related to tube feedings and/or risk for infections, as noted in the report.
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 2,876 citations issued within 25 miles in the last 12 months — including the 8 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 Costa Mesa
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Newport Nursing And Rehabilitation Center | 0.8 mi | ★★★★★ | 11 | 0 |
| Pelican Ridge Post Acute | 0.9 mi | ★★★★★ | 62 | 0 |
| Crystal Cove Care Center | 1 mi | ★★★★★ | 6 | 0 |
| Victoria Healthcare And Rehabilitation Center | 1.4 mi | ★★★★★ | 1 | 0 |
| Newport Subacute Healthcare Center | 2.2 mi | ★★★★★ | 50 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Mesa Verde Post Acute Care Center.
100% money-back within 48 hours.
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.