Average — CMS composite of the measures below.
The next survey window likely opens around November 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 Mid-town Oaks Post-acute during CMS and state inspections, most recent first.
Resident health information was entered into the wrong chart when an NP documented one resident’s progress note in another resident’s EHR. The note included the resident’s name, DOB, medical history, diagnoses, physical exam information, and treatment plan. The DON and MRD confirmed the error, and the other resident said she found the note after requesting copies of her own record.
Failure to Report Allegation of Abuse: A resident told staff that another resident threw a comb at him and struck him in the head during a dispute over the TV. Staff documented the altercation and police involvement, and the DON was notified, but the facility treated the event as a grievance and did not report the abuse allegation to the Department within the required timeframe.
A resident with bilateral knee osteoarthritis and difficulty walking had physician orders and care plan interventions for a restorative nursing ambulation/mobility program, including scheduled sessions several times per week using a FWW and later a quad cane, along with UE/LE exercises. The RNA reported assisting the resident for only two weeks and noted the resident preferred a quad cane, with refusals to be documented. Record review showed only three weekly restorative summaries and a single documented refusal, with no evidence the restorative program was provided or offered during multiple periods despite active orders and care plan directives, contrary to facility policy requiring individualized, resident-centered restorative services.
Staff failed to follow contact isolation requirements and use appropriate PPE for two roommates, one with an active C. diff infection and the other identified as at risk. Despite signage indicating contact precautions and a facility policy requiring gown and gloves based on transmission-based precautions, CNAs entered the shared room without PPE to deliver a meal tray, manipulate the light cord, and reposition a bed, and an LN administered injectable medications while her clothing contacted the bed and linens, all without donning a gown. Staff interviews confirmed lack of PPE use, misunderstanding of when gowns were required, and awareness that both residents were considered under contact isolation, while the DON confirmed the expectation that all staff entering the room and providing care should use gowns and gloves.
A resident with osteoarthritis, anxiety disorder, and moderate cognitive impairment submitted multiple written requests for copies of her medical and therapy records, which were not provided within the required two-business-day timeframe. In the first instance, the request was relayed from rehab to medical records, forwarded to legal, and ultimately fulfilled several days later by email from the DON. In the second instance, the resident emailed medical records directly, was given a facility authorization form, and after she returned the form, the MRA sought legal approval before releasing the records by email several days after the initial request. Both responses exceeded the facility’s two-business-day standard for providing requested records, resulting in delayed access to the resident’s medical information.
A resident with osteoarthritis, anxiety, and moderate cognitive impairment reported left-hand nerve issues and decreased thumb strength, which were documented by a physician, and also had a cracked molar with sharp edges that caused a sizable tongue ulcer. Despite these documented concerns and the resident’s report that no one was monitoring the ulcer’s progression, review of the record showed no monitoring orders or comprehensive care plans addressing either the left-hand weakness or the tongue ulcer. The DON acknowledged the facility was aware of these issues and expected them to be monitored and care planned, but this was not done in accordance with the facility’s comprehensive, person-centered care plan policy.
Two residents with cognitive impairment eloped without staff awareness, demonstrating a failure to provide adequate supervision and prevent accidents. One resident with metabolic encephalopathy, psychotic disorder, and moderate cognitive impairment twice left the facility and went to a nearby hospital ER without staff knowledge, with the facility only learning of his location when contacted by hospital staff. Another resident with dementia, severe cognitive impairment, and difficulty walking eloped and was later found by an LPN outside the front door on the ground near a wheelchair, crying and with visible injuries including facial bruising, a bleeding elbow skin tear, and a knee abrasion. An internal investigation identified an unattended reception area near the front door as a likely contributing factor, despite facility policies requiring identification and implementation of safety interventions for residents at risk of wandering, elopement, and falls.
Advance directives were not available in the medical records for three residents. One resident with cognitive communication deficit, another readmitted with the same diagnosis, and a third resident with schizoaffective disorder and bipolar disorder all had MDS/POLST documentation indicating an advance directive was available and reviewed, but the DON, MDSC, and MRA confirmed the documents could not be located in the chart or EHR.
A resident with psychotic disorder and hallucinations received olanzapine without a GDR attempt, and the pharmacist’s GDR recommendation was not addressed. Another resident had a PRN lorazepam order that exceeded the 14-day limit without a stop date, and sertraline was ordered for depression without a documented manifestation; the pharmacist’s recommendations on both orders were not responded to by the physician.
Pharmacist MRR recommendations were not followed for two residents. One resident with psychotic disorder and hallucinations remained on olanzapine without a GDR attempt, and the pharmacist’s GDR recommendation was not addressed. Another resident had a PRN lorazepam order without a 14-day stop date and sertraline ordered without a manifestation, despite pharmacist comments and no physician response to the MRRs.
Unsafe medication storage and monitoring were identified when an incomplete medication refrigerator temperature log was found, an expired and discontinued nebulizer medication remained in the refrigerator, loose tablets and discontinued bubble packs were stored in a med cart, and four OTC medications were left unsecured in a resident’s room. An LPN confirmed the unsecured and unidentifiable medications, and the DON stated staff should have been checking and recording refrigerator temperatures twice daily and removing expired or discontinued meds from storage.
Improperly Closed Outdoor Dumpster: One of four outdoor dumpsters had lids that did not fully cover the dumpster, leaving a two-inch gap in the middle. The DSS observed the issue and stated the lid should be replaced, and the DON stated dumpsters used for trash disposal should be kept closed to prevent pests and disease spread. The facility policy stated outside dumpsters will be kept closed and food-related garbage will be stored inaccessible to vermin.
Missed Metoprolol Dose Due to Misread Order: An LPN withheld a resident’s scheduled metoprolol succinate after misreading the hold parameters, even though the resident’s BP and HR were within the physician’s ordered limits. The DON confirmed the dose was not given as ordered and noted the resident had hypertensive heart disease with heart failure.
A resident with dementia and wandering behavior was observed pacing and redirecting by staff, but an LPN did not check the wanderguard’s functionality as ordered and was unsure how to properly test it. Another resident with moderate cognitive impairment and an order for PRN oxygen was observed smoking on the patio without staff supervision, despite a smoking assessment indicating supervision was required.
Failure to change a resident's nasal cannula weekly as ordered. A resident with COPD and respiratory failure was receiving continuous O2 via NC, but the NC was observed labeled with an older date and had not been changed as required. An LPN confirmed the NC should be changed weekly, and the DON stated weekly changes were important to prevent lung infection. The facility policy required changing the oxygen cannula and tubing every seven days or as needed.
Expired bread was found stored on the kitchen bread rack and confirmed by the DSS during observation. The DON stated kitchen staff should not store expired food items that could be served to residents and might make them sick. The facility policy stated foods must be received and stored in a manner that complies with safe food handling practices.
Call Light Not Within Reach: A resident with anxiety, inability to sleep, and moderate memory impairment was observed in bed without the call light within reach. The resident stated he could not reach or find it, and the DON confirmed the call light was hanging off the side of the bed instead of being within arm-reach, contrary to facility policy.
Failure to Post Daily Nurse Staffing Information: The facility failed to ensure nurse staffing information was posted daily for a census of 96 residents when the posting was not updated for two days over the weekend. An observation near the main entrance found the staffing sheet dated earlier than expected, and the SC stated the weekend supervisor should have updated it. The DSD/IP stated staffing information should be posted daily to show residents and visitors the facility's compliance with staffing to provide care to residents.
The facility failed to document and replace emergency medication kits (E-Kits) for 95 residents. An IV E-Kit was opened, and dextrose was removed but not replaced, and a refrigerated E-Kit had insulin removed without notifying the pharmacy. The DON expected E-Kits to be replaced within 72 hours, as per policy, which was not followed.
The facility failed to properly label, store, and dispose of medications, leading to deficiencies such as an unlocked medication refrigerator, expired pharmaceutical products, and lack of resident-specific labels. These issues were identified during observations and interviews with nursing staff and the DON, highlighting potential risks of medication misuse and errors.
The facility did not follow the prescribed menu for residents on a pureed diet, serving carrots with a runny consistency due to excess liquid. The Dietary Services Supervisor confirmed the issue, and the Registered Dietician noted that the recipe was altered without using a thickener as suggested in the facility's documentation.
The facility failed to provide pureed food with appropriate textures for 10 residents on a pureed diet, potentially compromising their medical and nutritional status. Observations revealed that pureed carrots were runny and pureed wheat rolls were stiff and lumpy, contrary to the facility's guidelines for pureed foods. The Dietary Services Supervisor and Registered Dietitian confirmed the inappropriate textures, noting potential difficulties in consumption and aspiration risks.
The facility failed to follow professional standards for food service safety, affecting 95 residents. Expired hamburger buns were found in storage, and metal serving containers were improperly stored while still wet. Additionally, sanitizer buckets contained a solution below the required strength for effective decontamination. These deficiencies could lead to contamination and foodborne illness.
The facility failed to maintain infection control by not using PPE in EBP rooms and storing clean linen uncovered. Staff, including a PT and CNAs, did not wear gowns and gloves during high-contact interactions, contrary to facility policy. Additionally, a clean-linen cart was stored uncovered, risking contamination.
A resident with chronic kidney disease and a permanent catheter did not have a comprehensive care plan addressing catheter care. The resident reported no dressing changes or monitoring since admission, and the facility's policies on catheter care were not followed. The absence of a care plan was confirmed by the DON.
A resident receiving apixaban for anticoagulation was not monitored for side effects, as there were no orders or care plan in place. This oversight was confirmed by a licensed nurse and acknowledged by the DON, who stated that monitoring is essential to prevent unmonitored bleeding. Facility policies require medication orders to be supported by care processes, which were not adhered to in this instance.
A resident with malignant breast neoplasm and generalized muscle weakness was unable to receive assistance due to a non-functional call light system. Despite pressing the call button, the light did not activate, leaving the resident at risk of falling. A CNA confirmed the malfunction, and the DON acknowledged the call light should be operational at all times.
A resident's right to self-determination was violated when their medical appointment was canceled by the facility without consulting the resident or their family. The resident, who was capable of making medical decisions, had an appointment necessary for a pre-operation work-up. The Social Services Assistant canceled the appointment due to transportation issues and based on information from a receptionist, without confirming the necessity of the appointment with qualified personnel. The Social Services Director later confirmed the appointment was necessary.
A resident with type 2 diabetes experienced low blood sugar, but the LTC facility failed to follow its hypoglycemia management policy. The resident's blood sugar was not rechecked, and the provider was not notified, leading to signs of unconsciousness. The facility's policy required immediate action, which was not documented.
A resident with severe cognitive impairment was not protected from sexual abuse when another resident, also cognitively impaired, was observed with his hand underneath her shirt. Staff confirmed that the resident could not consent to such contact, and the facility's policy defines this as sexual abuse.
A resident with dementia and osteoporosis was found with a fractured wrist of unknown origin, which the LTC facility failed to report as required. Despite the severity of the injury, staff interviews revealed no clear cause, and the resident could not recall the incident. The facility's policy mandates immediate reporting of such injuries, but this was not followed, delaying the investigation process.
Resident Health Information Entered Into Wrong Chart
Penalty
Summary
The facility failed to protect the privacy of one of six sampled residents when a nurse practitioner entered Resident 1’s progress note into Resident 2’s electronic health record. The note contained Resident 1’s name, date of birth, medical history, medical diagnoses, physical examination information, and treatment plan. Resident 1 had been admitted with diagnoses including brain dysfunction caused by a chemical imbalance, anxiety, depression, back pain, and a urinary tract infection, while Resident 2 had been admitted with degenerative joint disease in the knee and difficulty walking. During interview and record review, the DON confirmed that Resident 1’s information was inaccurately documented in Resident 2’s EHR and stated it was a violation of Resident 1’s privacy. The MRD also confirmed that the NP incorrectly documented Resident 1’s information in Resident 2’s chart and stated it was important to have correct information in a medical record. Resident 2 stated she requested copies of her own health record and found the progress note for Resident 1, which included personal information about Resident 1. The facility’s policy stated that resident personal and medical records would be protected and access limited to authorized staff and business associates.
Failure to Report Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of abuse to the Department after Resident 3 stated that Resident 4 threw a comb at him and struck him in the head. Resident 3 was admitted in early 2025 with diagnoses including major depressive disorder, difficulty walking, and muscle weakness, and his MDS dated 1/29/26 showed a BIMS score of 15/15, indicating no cognitive impairment. Resident 4 was admitted in late 2025 with diagnoses including difficulty walking and deafness, and his MDS showed a BIMS score of 13/15, also indicating no cognitive impairment. Progress notes documented that during morning rounds on 4/9/26, staff observed an altercation between the two residents after Resident 3 asked for the television to be flipped to the news and Resident 4 objected. The note stated Resident 4 grabbed his comb and threw it toward Resident 3, striking him in the head, and that police came and investigated with the DON present. Resident 3 later told staff that he asked for 911 to be called and that a nurse told him it was a minor issue. LN 1 stated she was working at the time, heard Resident 3 screaming that Resident 4 threw a comb at him, and confirmed that an allegation of abuse should be reported to the Department. The DON stated he was notified of the incident and that the facility treated it as a grievance, and the ADM stated the incident was not reported because it was handled as a grievance even though allegations of abuse are to be reported within two hours.
Failure to Follow Restorative Nursing Ambulation Orders
Penalty
Summary
The facility failed to follow physician orders for a restorative nursing ambulation and mobility program for one resident. The resident was admitted in early January 2026 with bilateral primary osteoarthritis of the knees and difficulty walking. Restorative Nursing Assistant (RNA) orders were initiated on 2/27/26 for an ambulation/mobility program 3–5 days per week using a front wheel walker (FWW) for 50–100 feet as tolerated, with subsequent orders on 3/19/26 for upper and lower extremity exercises and ambulation three times a week with FWW/single point cane, on 4/2/26 for ambulation 3–5 days per week with FWW and quad cane, and on 4/14/26 for ambulation one day per week with FWW and quad cane. The resident’s care plan, initiated 1/5/26 and revised 4/15/26, identified risk for ADL and mobility decline related to pain, weakness, balance deficit, decreased strength, and gait difficulty, and included an intervention for RNA ambulation/mobility for 50–100 feet as tolerated with FWW/quad cane. During interview, the RNA reported providing assistance to the resident for only two weeks and stated the resident insisted on using a quad cane instead of the FWW for ambulation, and that refusals of the RNA program would be documented. Review of records with the Director of Rehabilitation showed only three RNA Weekly Summaries dated 3/28/26, 4/4/26, and 4/10/26, and a single Restorative Nursing Note on 3/5/26 documenting that the resident refused the RNA program that day. There was no documented evidence that the resident was seen by RNA from 2/28/26 to 3/4/26 and during the second to third week of March, and the Administrator confirmed there were no RNA Weekly Summaries prior to 3/28/26. The DOR stated that, based on the 2/27/26 RNA order, the program should have been offered the following day and that attempts and refusals should have been documented. The facility’s policy on Restorative Nursing Services stated that residents will receive restorative nursing care as needed to promote optimal safety and independence and that restorative goals are individualized and resident-centered.
Failure to Use Required PPE for Residents on Contact Isolation for C. diff
Penalty
Summary
The deficiency involves the facility’s failure to implement appropriate infection prevention and control practices, specifically contact precautions and PPE use, for two residents placed under contact isolation for Clostridium difficile (C. diff). One resident, admitted in May 2025 with diagnoses including diabetes mellitus and sepsis, had an active order for contact isolation for C. diff requiring staff to don gown and gloves prior to room entry and care. The roommate, admitted in January 2026 with diabetes mellitus and colostomy status, had a care plan indicating potential for C. diff infection and the need to use infection control principles and contact precautions as indicated. A sign posted at the room door instructed staff to apply gown and gloves before entering. Surveyors observed multiple staff entering and providing care in this isolation room without required PPE. A CNA entered the room without gown or gloves to deliver and set up a breakfast tray for the resident on contact isolation and, at the resident’s request, pulled the light cord with bare hands, later confirming he had touched room surfaces and was unsure which resident the isolation applied to. Two other CNAs entered the same room without gowns to reposition the exposed roommate’s bed and stated they believed gowns were only needed for close contact care involving the urinary catheter. A licensed nurse entered the room without a gown to administer two injectable medications to the resident on contact isolation, during which her clothing contacted the bed and linens; she later confirmed she knew the resident was on contact isolation for C. diff and that she should have used gown and gloves. The DON confirmed both roommates were considered under contact isolation precautions and that all staff entering and providing care to either resident were expected to use gowns and gloves, consistent with the facility’s PPE policy that PPE type is based on transmission-based precautions.
Failure to Provide Timely Access to Requested Medical Records
Penalty
Summary
The facility failed to provide a resident with requested medical records within two working days following written requests, as required by regulation and facility policy. The resident, who had osteoarthritis of the knees, an anxiety disorder, and moderate cognitive impairment per the MDS dated 1/9/26, reported emailing multiple requests for medical records that were not fulfilled timely and stated she had to "hold staff's feet to the fire" to get anything done. On 1/22/26 after business hours, the resident emailed the Director of Rehabilitation (DOR) to follow up on previously requested medical records, specifically therapy records. The DOR notified the Medical Records Assistant (MRA) on 1/23/26, and the MRA documented receiving the request around noon that day and forwarding it to the legal department. The legal department responded at 4:37 p.m. on Friday when the MRA was out of the office, and the records were ultimately emailed to the resident by the DON on 1/27/26 at 4:46 p.m., exceeding the two-business-day timeframe. A second written request was emailed directly to the MRA on 2/5/26 at 11:51 a.m., using the resident’s own request format. The MRA documented that on 2/6/26 she went to the resident’s room and provided the facility’s authorization form for release of health information, which the resident accepted but stated she would complete when she had time, while asserting that the facility was violating federal law by not providing the records right away. The resident later emailed the completed authorization form on 2/9/26, backdated to 2/5/26, but the MRA noted it was not properly filled out when received. The MRA emailed the legal team for approval, received a response at 4:28 p.m. that the records could be released, and the records were emailed to the resident on 2/10/26. This second fulfillment also occurred more than two business days after the initial written request. The facility’s policy, revised 5/2017, states that residents may submit oral or written requests and may obtain copies of their records within two business days of such a request and completion of the authorization form, but in both instances the records were provided beyond the two-business-day requirement, resulting in delayed provision of medical records and decreasing the likelihood of the resident making informed medical decisions regarding her care.
Failure to Care Plan for Hand Weakness and Oral Ulcer
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and implement a comprehensive, person-centered care plan with measurable objectives and timetables for a resident’s identified clinical issues. The resident, admitted in early 2026 with osteoarthritis of the knees and an anxiety disorder and assessed as having moderate cognitive impairment on the MDS dated 1/9/26, reported decreased strength and nerve issues in the left hand, with the thumb observed to be overextended backwards. A physician’s note dated 1/7/26 documented the resident’s complaints of left hand thumb weakness. Despite this, review of the resident’s current orders and care plans showed no monitoring orders or care plan addressing the left hand problem. The same resident also had an oral issue involving a cracked molar tooth with sharp edges that caused sores on the tongue. A progress note dated 1/27/26 documented the resident’s ongoing concern with the cracked molar that was bothering her and causing sores on her tongue. During observation and interview, the resident demonstrated an ulcer on the right side of the tongue, approximately 1 cm wide and 2 cm long, and stated that it developed after the tooth broke and that nobody was looking at or monitoring the progression of the ulcer. Review of the care plan and orders revealed no monitoring orders or care plan for the tongue ulcer. The DON confirmed the facility was aware of the resident’s left hand and tongue issues and stated he expected these issues to be monitored and care planned, which was not done, contrary to the facility’s policy requiring comprehensive, person-centered care plans with measurable objectives and timeframes for each resident’s needs.
Failure to Prevent Elopement and Provide Adequate Supervision for Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and prevent elopement for two residents with cognitive impairment. One resident, admitted with metabolic encephalopathy, cognitive communication deficit, and a psychotic disorder with hallucinations, had a BIMS score of 11/15 indicating moderate cognitive impairment. This resident exited the facility without staff authorization on two separate occasions. On both dates, the resident went to a nearby hospital emergency room (ER) during times such as lunch, and facility staff were unaware of the resident’s absence until contacted by hospital staff. The DON confirmed that both elopements occurred without the facility’s knowledge and that an electronic wander guard device was not implemented until after the second elopement. The second resident involved in the deficiency was admitted with unspecified dementia, cognitive communication deficit, and difficulty in walking, and had a BIMS score of 3/15 indicating severe cognitive impairment. This resident experienced an unwitnessed fall after eloping from the facility and was found by staff outside the front door at the top of a sloped walkway, sitting on the ground next to her wheelchair and crying. The resident had visible injuries, including a bluish bump to the left cheek and temporal area, a skin tear to the left elbow with moderate bleeding, and an abrasion to the left knee. A licensed nurse reported seeing the resident on the ground outside, observing the bleeding elbow and the developing facial bump. Record review of an investigation summary for the second resident’s unwitnessed fall and elopement identified that the most likely contributing factor to the elopement was the reception area near the front door being unattended for a brief period. The facility’s own policies on wandering, elopements, and fall risk management state that residents at risk for unsafe wandering or elopement should have care plan strategies and interventions to maintain safety, and that staff will identify interventions related to specific risks and causes to try to prevent falls. Despite these policies and the residents’ documented cognitive impairments and mobility issues, the residents were able to leave or be outside the facility without staff awareness or supervision, resulting in elopements and, for one resident, an unwitnessed fall with injuries.
Advance Directives Not Available in Resident Records
Penalty
Summary
The facility failed to ensure current copies of advance directives were available in the medical records for three sampled residents. Resident 47 was admitted in July 2024 with a diagnosis of cognitive communication deficit. Although the POLST dated 7/2/24 indicated the resident's advance directive was not available, the MDS dated 9/26/25 indicated it was available and reviewed. During a concurrent interview and record review on 12/3/25, the DON confirmed that a copy of Resident 47's advance directive was not in the medical record and stated that if the MDS indicated it was available and reviewed, a copy should have been placed in the chart. Resident 10 was readmitted in June 2025 with a diagnosis of cognitive communication deficit. The POLST dated 6/25/25 indicated an advance directive was available and reviewed by staff, but during a concurrent interview and record review on 12/2/25, the MDSC confirmed the advance directive was unavailable in the medical record. Resident 85 was admitted with diagnoses including schizoaffective disorder and bipolar disorder. The MDS indicated an advance directive was available and reviewed, but during a concurrent interview and record review on 12/2/25, the MRA could not locate the document in either the electronic health record or physical chart. The DON stated that if the MDS indicated the advance directive was available and reviewed, it should have been readily available in the medical record. Facility policies stated advance directive information and copies should be maintained prominently and be readily retrievable in the resident's medical record.
Unnecessary Psychotropic Medication Use and Missing Order Parameters
Penalty
Summary
The facility failed to ensure two residents were free from unnecessary psychotropic medications. One resident, admitted with diagnoses including psychotic disorder with hallucinations and recurrent major depressive disorder with severe psychotic symptoms, had an order for olanzapine 15 mg at bedtime for auditory hallucinations. The record showed no episodes of auditory hallucinations in September 2025, two episodes in October 2025, and seven episodes in November 2025. The consultant pharmacist identified a gradual dose reduction recommendation in November 2025, but the recommendation was left unmarked with no action documented. During interview and record review, the DON confirmed the resident started olanzapine in June 2025 and that a GDR was not attempted, and also confirmed the pharmacist recommendation was not addressed. A second resident, admitted with diagnoses including depression and anxiety, had a PRN lorazepam 0.5 mg order for anxiety manifested by restlessness and inability to relax, started on 9/25/25 with no stop date. The consultant pharmacist reviewed the order in November 2025 and recommended adding a 14-day stop date or documenting the need for extended therapy, but there was no physician response. The same resident also had sertraline 50 mg daily for depression, started on 4/28/25 without a manifestation. The consultant pharmacist recommended adding a manifestation to the order, and the record again showed no physician response. The DON confirmed the lorazepam PRN order should have had an end date after 14 days and stated sertraline should have a manifestation listed in the order.
Pharmacist MRR recommendations were not followed for psychotropic medications
Penalty
Summary
The facility failed to follow monthly pharmacist medication regimen review (MRR) recommendations for two residents. Resident 18, admitted with psychotic disorder with hallucinations and recurrent major depressive disorder with severe psychotic symptoms, had an order for olanzapine 15 mg at bedtime for auditory hallucinations. The record showed no episodes of auditory hallucinations in September 2025, two episodes in October 2025, and seven episodes in November 2025. The November 2025 MRR included a pharmacist recommendation for a gradual dose reduction (GDR) of olanzapine, but the recommendation was left unmarked with no action documented. During interview and record review, the DON confirmed the resident started olanzapine in June 2025, a GDR was not attempted, and the pharmacist recommendation was not addressed. Resident 86, admitted with depression and anxiety, had a lorazepam 0.5 mg PRN order for anxiety manifested by restlessness and inability to relax, started without a stop date, and a sertraline 50 mg daily order for depression started without a manifestation. The pharmacist’s MRR noted the lorazepam PRN order needed a 14-day stop date or provider documentation for extended therapy, but there was no physician response. A separate MRR noted sertraline needed a manifestation added, and there was no physician response. The DON confirmed the lorazepam PRN order had no end date beyond 14 days and stated sertraline should have a manifestation listed in the order.
Unsafe Medication Storage and Incomplete Refrigerator Monitoring
Penalty
Summary
The facility failed to ensure medications were safely stored and secured for a census of 96 residents. During observation and interview in the medication room at station-3, an incomplete medication refrigerator temperature log was found posted at the door, and the Licensed Nurse confirmed the refrigerator temperature had not been recorded for three days on the morning shift. In the same medication refrigerator, a partially used box of formoterol fumarate 20 mcg/2 ml nebulizer vials was found stored beyond its expiration date of 10/22/25, and the nurse confirmed the medication had expired and had been prescribed for a resident who was discharged from the facility on 8/1/25. At medication cart 2 at station-2, eight loose tablets were found in a drawer and three loose bubble packs were found behind the bottom drawer; the Licensed Nurse stated the tablets were unidentifiable and needed to be discarded, and that two of the bubble packs were discontinued and belonged to residents who had been discharged. In addition, four OTC medications were observed stored insecurely on top of Resident 89's cabinet in the resident's room, and the nurse confirmed they needed to be locked up. Resident 89 had been admitted to the facility in 2024. The DON stated staff should have checked and recorded the medication refrigerator temperature twice in 24 hours and expected expired, discontinued, and loose medications to be removed from storage.
Improperly Closed Outdoor Dumpster
Penalty
Summary
The facility failed to provide a clean environment when one of four garbage dumpsters located outside the facility was not closed securely because there was a two-inch gap between the lids. During a concurrent observation and interview with the Dietary Services Supervisor, the dumpster was inspected and found to have lids that did not fully cover the dumpster, and the DSS stated the dumpster lid should be replaced. During a later interview, the DON stated that dumpsters where trash is disposed should always be kept closed by ensuring the lids fit properly and that this practice was necessary to prevent pests from entering and potentially spreading disease. The facility policy titled, Food-Related Garbage and Rubbish Disposal, stated that outside dumpsters will be kept closed and that garbage and rubbish containing food wastes will be stored in a manner that is inaccessible to vermin.
Missed Metoprolol Dose Due to Misread Order
Penalty
Summary
The facility failed to administer metoprolol succinate according to the physician’s order for one resident with hypertensive heart disease with heart failure. The resident was admitted in July 2023 with a diagnosis of hypertensive heart disease with heart failure. During observation, a nurse prepared the resident’s morning medications and withheld metoprolol succinate because the resident’s blood pressure and heart rate were believed to be below the ordered parameters; the nurse stated the resident’s BP was 108/58 and HR was 59. Review of the order summary showed metoprolol succinate 75 mg was ordered once daily and to be held only if BP was less than 90/50 and HR was less than 50. Review of the MAR showed the scheduled 8 a.m. dose was withheld, and the nurse documented that the vital signs were out of parameters. The nurse later confirmed the dose was not given because she misread the physician’s order. The DON confirmed the medication was not administered even though the resident’s BP and HR were within the ordered values and stated the nurse was expected to read the orders correctly to avoid drug errors.
Unsafe Wanderguard Monitoring and Unsupervised Smoking
Penalty
Summary
The facility failed to ensure Resident 61’s environment was free from accident hazards when a Licensed Nurse did not check the resident’s wanderguard functionality as ordered. Resident 61 was admitted with diagnoses including dementia with agitation and a history of falling. During observation, the resident was pacing in the hallway and had to be redirected by staff to keep her from wandering into other residents’ rooms. The nurse confirmed the resident was wearing a wanderguard on her right ankle and stated she checked the placement during the shift, but not the functionality. The resident’s MAR directed staff to check the wanderguard placement and functionality every shift for safety, and the nurse had signed the MAR for the evening shifts. During interview, the nurse confirmed the functionality should have been checked every shift as ordered, but stated she was unsure of the proper method to check it and believed it was functional if the resident passed by a door and the alarm sounded. The facility document on transmitter testing stated transmitters must be tested prior to use and that failure to test can result in system failure or elopement. The facility also failed to ensure Resident 9 was supervised while smoking. Resident 9 was admitted with diagnoses including encephalopathy and respiratory failure, had a BIMS score of 9 indicating moderate cognitive impairment, and stated she kept a lighter and cigarettes in her room and smoked whenever she wanted. An oxygen concentrator was observed at the bedside, and the resident had an order for oxygen as needed. During observation, Resident 9 lit and smoked a cigarette in the smoking patio without staff supervision. The smoking assessment indicated the resident required smoking supervision, and the DON confirmed the resident should not have smoked without supervision.
Failure to Change Nasal Cannula Weekly
Penalty
Summary
Respiratory care was not provided in accordance with professional standards of practice for one resident with COPD and respiratory failure when the resident's nasal cannula was not changed weekly as ordered. Resident 42 was admitted with diagnoses including chronic obstructive pulmonary disease and respiratory failure and had an active order for continuous oxygen at one liter per minute via nasal cannula with instructions to change the nasal cannula every Sunday and as needed. During observation, the resident was wearing a nasal cannula labeled with a date of 11/18, and a licensed nurse confirmed the cannula was supposed to be changed weekly. The Director of Nursing stated it was important to change the nasal cannula weekly and as needed to prevent the risk of lung infection for the resident. The facility policy also stated to change the oxygen cannula and tubing every seven days or as needed.
Expired Bread Stored in Kitchen
Penalty
Summary
The facility failed to safely store food for a census of 96 residents when an expired loaf of bread was available for use in the kitchen. During a concurrent observation and interview with the Dietary Services Supervisor in the kitchen, a loaf of bread with an expiration date of 11/30/25 was observed stored on the bread rack, and the DSS confirmed it was expired. During a later interview, the Director of Nursing stated kitchen staff should not store expired food items that can be served to residents and might make them sick. The facility’s undated policy titled, Food-Related Garbage and Rubbish Disposal, stated that foods shall be received and stored in a manner that complies with safe food handling practices.
Call Light Not Within Reach
Penalty
Summary
The facility failed to ensure that Resident 87’s call light was within reach while the resident was in bed. Resident 87 was admitted in 2025 with diagnoses including anxiety and inability to sleep, and the MDS dated 10/27/25 indicated moderate memory impairment. During a 12/1/25 observation and interview, Resident 87 stated he could not reach the call light and could not find it, and the call light was observed hanging off the left side of the bed. During a concurrent interview, the DON confirmed the call light was hanging off the bed and stated it should have been within arm-reach of the resident. The facility policy titled, Answering the Call Light, stated that when the resident is in bed or in a chair, the call light should be placed within reach.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure staffing information was posted daily for a census of 96 residents when the posted nurse staffing information was not updated for two days during the weekend. During an observation on 12/1/25 at 7:07 a.m. near the main entrance door, the staffing posting was found dated 11/28/25. During an interview on 12/3/25 at 9:35 a.m., the Staffing Coordinator stated the weekend supervisor should have updated the staffing information and that it should be posted daily. During an interview on 12/3/25 at 1:14 p.m., the Director of Staff Development/Infection Preventionist stated staffing information should be posted daily to show residents and visitors the facility's compliance with staffing to provide care to residents. The facility policy, Posting Direct Care Daily Staffing Numbers, revised 8/22, stated the facility will post on a daily basis for each shift nurse staffing data, including the number of nursing personnel responsible for providing direct care to residents.
Failure to Document and Replace Emergency Medication Kits
Penalty
Summary
The facility failed to accurately document and replace emergency medication kits (E-Kits) for a census of 95 residents. During an observation and interview, it was found that an intravenous E-Kit had been opened on October 16, 2024, and a liter of dextrose was removed but not replaced. The Licensed Nurse (LN 3) acknowledged that the medication sticker should have been faxed to the pharmacy for replacement and documented in a binder at the nursing station, which was not done. Additionally, a refrigerated E-Kit was found to have been opened on August 16, 2024, with a vial of insulin removed, but the pharmacy was not notified, and the E-Kit was not replaced. The Director of Nursing (DON) stated that the expectation was for nurses and pharmacy to follow the process to replace E-Kits within 72 hours to ensure availability of emergency medications. The facility's policy required immediate recording of medication use and notification to the pharmacy for replacement, which was not adhered to in these instances.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling, storage, and disposal of medications and medical supplies, leading to several deficiencies. During an observation, a medication refrigerator in the second-floor medication room was found unlocked, which was against the facility's policy. Licensed Nurse 3 acknowledged that the refrigerator should have been locked to prevent unauthorized access to medications. The Director of Nursing confirmed that the expectation was for the refrigerator to be locked at all times. Expired pharmaceutical products were discovered in various locations, including a medication refrigerator, medication carts, and treatment carts. Specific examples included a bottle of lansoprazole with an expiration date of 10/20/24, a bottle of latanoprost expired on 11/3/24, and a bottle of sodium hypochlorite solution expired in August 2024. Licensed nurses acknowledged the presence of expired medications and the potential issues they could cause, such as inaccurate medication strength and ineffectiveness. The Director of Nursing stated that expired medications should have been removed promptly according to the facility's policy. Additionally, prescription pharmaceutical products were found without resident-specific labels, and open date labels were not used to determine expiration dates. This included silver sulfadiazine and lidocaine ointment without resident-specific labels, and semaglutide and blood glucose test strips without open dates. The lack of proper labeling raised concerns about potential cross-contamination and medication errors. The Director of Nursing confirmed that medications should have resident-specific labels and open dates to ensure proper administration and expiration tracking.
Failure to Follow Pureed Diet Recipe
Penalty
Summary
The facility failed to adhere to the prescribed menu for residents on a pureed diet, which is a therapeutic diet modification necessary for certain medical conditions. During lunch, 10 residents were served pureed carrots that did not meet the required consistency as per the recipe. The Dietary [NAME] 1 (DC 1) prepared the pureed diet by adding 1 1/2 cups of chicken broth to the carrots, resulting in a runny mixture. This was observed during the tray line service, where the carrot mixture oozed into other plated food items, indicating that the consistency was not as intended. The Dietary Services Supervisor (DSS) confirmed the runny consistency during a test tray tasting and acknowledged that the extra liquid could have contributed to the issue. The Registered Dietician (RD) noted that the recipe was altered and suggested that a food thickener could have been used to achieve the correct texture. The facility's recipe documentation indicated the appropriate amount of liquid to be used and suggested options for thickening, which were not followed in this instance.
Inadequate Pureed Food Textures for Residents
Penalty
Summary
The facility failed to provide pureed food with appropriate textures for 10 residents on a pureed diet, potentially compromising their medical and nutritional status. During an observation, the Dietary staff member (DC 1) prepared pureed carrots by adding chicken broth, resulting in a runny mixture. DC 1 expected the mixture to thicken on the steam tray but did not add any further ingredients before serving. Similarly, DC 1 prepared pureed wheat rolls by adding milk and butter, resulting in a thick consistency initially, which was then thinned with additional milk and butter. The pureed bread was expected to thicken on the steam tray, but it was served with a stiff and lumpy texture. During the tray line observation, the pureed items served included a watery carrot mixture and stiff bread roll puree, which seeped into other plated food items. The Dietary Services Supervisor (DSS) confirmed the inappropriate textures, noting that the thin carrot puree and lumpy bread puree could make consumption difficult for residents on a pureed diet. The Registered Dietitian (RD) indicated that an approved thickener could have been used for the carrots, and the stiff, lumpy bread posed an aspiration risk. The facility's document on the International Dysphasia Diet Standardization Initiative (IDDSI) Transition outlined that pureed foods should be smooth, free of lumps, and not too firm or sticky, which was not adhered to in this instance.
Deficiencies in Food Storage and Sanitization Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, affecting 95 residents. During an inspection, expired food items, specifically hamburger buns, were found in dry storage. The Dietary Services Supervisor (DSS) acknowledged that the bread was expired and should not have been kept on the bread rack beyond five to seven days from the opening date. Additionally, metal serving containers were improperly stored while still wet, which contradicts the facility's policy and the FDA Food Code that requires air drying before stacking to prevent microorganism growth. A sticky residue was also found on a metal serving container, indicating inadequate sanitization. Furthermore, the facility did not maintain proper sanitizing procedures. Two out of three sanitizer buckets contained quaternary ammonia sanitizer at only 100 parts per million (ppm), below the required 200 ppm for effective decontamination. The Dietary Aide and DSS confirmed that the sanitizer solution was too weak and should be replaced every two hours or when dirty. The Registered Dietician also stated that 100 ppm was insufficient for adequate decontamination. These deficiencies in food storage and sanitization practices had the potential to lead to contamination and foodborne illness among residents.
Infection Control Lapses in PPE Use and Linen Storage
Penalty
Summary
The facility failed to maintain proper infection control practices for a census of 95 residents. Staff members did not adhere to Enhanced Barrier Precautions (EBP) by neglecting to wear gowns and gloves during high-contact interactions in EBP rooms. Multiple staff members, including a physical therapist, certified nursing assistants, and a hospice nurse, were observed not using the required personal protective equipment (PPE) while performing tasks such as transferring residents, changing linens, and assessing residents. These actions were contrary to the facility's policy, which mandates the use of gowns and gloves in EBP rooms to prevent the transmission of communicable diseases. Additionally, a clean-linen cart was found stored uncovered in the basement, which was against the facility's policy that requires clean linen to be protected from environmental contamination. The Infection Preventionist and Director of Nursing confirmed that the uncovered linen was considered contaminated and posed a risk of infection. These lapses in infection control practices had the potential to facilitate the spread of communicable diseases among residents.
Failure to Develop Comprehensive Care Plan for Catheter Care
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident with a permanent catheter, which was not addressed in the care plan. This deficiency was identified during a survey when it was observed that the resident, who was admitted with chronic kidney disease, did not receive any dressing change or monitoring for her right upper chest catheter since her admission a week prior. The resident confirmed this lack of care during an interview, and a review of her order summary report showed no orders for catheter care and dressing monitoring. Further investigation revealed that during the resident's admission assessment, the charge nurse noted the skin was intact without any vascular access, indicating a failure to properly assess and document the presence of the catheter. The Licensed Nurse confirmed the absence of orders for catheter care, and the Director of Nursing acknowledged the lack of a care plan for catheter care. The facility's policies on dressing changes and preventing catheter-related infections were not followed, as there was no daily assessment or routine dressing change for the catheter site.
Failure to Monitor Anticoagulant Therapy
Penalty
Summary
The facility failed to provide services according to professional standards for a resident who was receiving anticoagulant medication, specifically apixaban, without appropriate monitoring in place. The resident was admitted with diagnoses including hemiplegia and cerebral infarction, conditions that necessitate careful management of blood clotting. A review of the resident's Medication Administration Record revealed that there were no orders to monitor for side effects such as excessive bleeding or bruising, which are critical when administering anticoagulants. During an interview and record review, a licensed nurse confirmed the absence of orders or a care plan for anticoagulant monitoring, acknowledging the risk this posed to the resident. The Director of Nursing also stated that residents on anticoagulants should have monitoring orders and a care plan to prevent unmonitored bleeding. The facility's policies on medication therapy and comprehensive person-centered care plans emphasize the need for supporting medication orders with appropriate care processes and establishing measurable objectives and expected outcomes, which were not followed in this case.
Non-Functional Call Light System for Resident
Penalty
Summary
The facility failed to ensure that the call light system was functioning for a resident, identified as Resident 37, which decreased the facility's ability to provide timely assistance. Resident 37, who was admitted in April 2024 with diagnoses including malignant breast neoplasm and generalized muscle weakness, required partial to moderate assistance to roll from side to side in bed. On November 4, 2024, during an observation and interview, Resident 37 was found pressing the call light button without receiving any response, expressing fear of sliding off the bed and falling. Certified Nursing Assistant 4 confirmed that the call light was not working after checking the system, which was securely plugged in but failed to activate the light outside the room. The Director of Nursing later acknowledged that the call light should be operational at all times and that staff should have checked on Resident 37 every two hours or more frequently to ensure the call light's functionality. The facility's policy, dated September 2022, mandates that the resident call system remains functional at all times.
Resident's Right to Self-Determination Violated by Appointment Cancellation
Penalty
Summary
The facility failed to uphold a resident's right to self-determination by canceling a medical appointment without consulting the resident or their family. This incident involved a resident admitted with multiple diagnoses, including a pressure ulcer and type 2 diabetes mellitus. The resident's daughter reported that the facility canceled a necessary pre-operation work-up appointment without prior consultation. The resident's active orders indicated that the resident was capable of making medical decisions and participating in their treatment plan. The Social Services Assistant (SSA) canceled the appointment due to a lack of transportation and based on information from a receptionist at the doctor's office, who stated the appointment was unnecessary. However, the SSA was unsure if the receptionist was qualified to make such a decision. The Social Services Director confirmed the appointment was necessary and had to be rescheduled. The facility's policy on resident rights emphasizes the importance of self-determination and participation in decision-making, which was violated in this case.
Failure to Manage Hypoglycemia in Diabetic Resident
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards for a resident with type 2 diabetes mellitus, who experienced an episode of low blood sugar. The resident was admitted to the facility with multiple diagnoses, including diabetes, and was taking high-risk medications that could cause hypoglycemia. On a specific date, the resident's blood sugar was recorded at 62 mg/dl, which is below the threshold for Level 1 hypoglycemia. The facility's policy required immediate notification of the provider, administration of glucose, and a recheck of blood sugar in 15 minutes. However, there was no documentation indicating that these steps were followed. The resident's progress notes and medication administration record showed no follow-up finger stick to check blood sugar, and the resident later showed signs of unconsciousness. During an interview, a licensed nurse confirmed the absence of documentation for the required follow-up actions. The facility's policy on managing hypoglycemia, dated November 2020, outlined the necessary steps for addressing low blood sugar, which were not adhered to in this case.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from sexual abuse when a staff member witnessed inappropriate contact between two residents. Resident 1, who had severe cognitive impairment and a history of altered mental status and post-traumatic stress disorder, was observed by a Certified Nursing Assistant (CNA) with his hand underneath Resident 2's shirt. Resident 2, also with severe cognitive impairment due to dementia, was unable to consent to such contact. The incident was reported by CNA 2, who heard a scream from Resident 2's room and upon entering, observed the inappropriate contact and noted that Resident 2 appeared scared. Interviews with facility staff, including the Social Service Director and a Licensed Nurse, confirmed that Resident 2 lacked the mental capacity to consent to being touched. The facility's policy on identifying sexual abuse and capacity to consent, revised in September 2022, clearly states that consent is not valid if obtained from a resident who lacks the capacity to consent, and defines sexual abuse as non-consensual sexual contact of any type. The policy further specifies that intimate touching, especially of the breasts, is considered sexual abuse if the resident does not have the cognitive ability to consent or does not want the contact to occur.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an incident of an injury of unknown origin for a resident, which is a requirement under the regulations. The resident, who was admitted with dementia, a history of falling, and osteoporosis, was found to have a swollen and painful right wrist with limited range of motion. An X-ray revealed a fracture involving the distal ulnar shaft with displacement. Despite the severity of the injury, the facility did not report the incident as an injury of unknown origin, delaying the abuse investigation process. The resident's condition was first noted when a licensed nurse observed swelling on the wrist while adjusting the resident's blanket. The resident, due to severe cognitive impairment, was unable to recall or explain the cause of the injury. Interviews with staff, including certified nurse assistants and licensed nurses, revealed that none of them could provide an explanation for the injury, and there was no observed behavior that could have led to the fracture. The Social Services Director confirmed that the cause of the fracture was unknown and acknowledged that the incident should have been reported within two hours if abuse was suspected. The Director of Nursing and the Administrator both conducted investigations but did not conclude that the injury was due to abuse, attributing it instead to a previous fall. However, the facility's policy requires that any injury of unknown origin be reported immediately, which was not done in this case. The delay in reporting and investigating the injury potentially compromised the safety of the resident and hindered a thorough investigation into the cause of the injury.
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Illustrative
What surveyors actually found near you
We read the 680 citations issued within 25 miles in the last 12 months — including the 2 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
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Sacramento
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mckinley Park Care Center | 0.5 mi | ★★★★★ | 31 | 0 |
| Saylor Lane Healthcare Center | 0.7 mi | ★★★★★ | 0 | 0 |
| University Post-acute Rehab | 1.1 mi | ★★★★★ | 0 | 0 |
| Pioneer House | 1.6 mi | ★★★★★ | 22 | 0 |
| Sherwood Healthcare Center | 1.7 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.