Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mirage Post Acute during CMS and state inspections, most recent first.
RP Not Notified Before Podiatry Service: A resident with Alzheimer’s disease, DM, PVD, and no decision-making capacity had a podiatry visit for toenail trimming even though the RP/POA had a documented request that no ancillary consults occur without prior notice and approval. The RP stated she had repeatedly told staff she needed to be informed first, but the podiatrist trimmed the resident’s toenails before she was notified. The SSA, ADON, DON, and an LVN all confirmed the RP was not informed before the service and that the resident’s right to have the RP notified was not followed.
Failure to Notify Conservator of Resident’s Death: A resident with dementia, CVA, dysphagia, and HTN had a court-appointed Conservator and was transferred after the hospital discussed placement with that Conservator. Facility staff treated the resident as a bioethics client, did not contact the Conservator or listed family on admission, and the Conservator first learned of the resident’s death only after calling the facility. Interviews showed staff did not consistently establish conservatorship or document repeated contact attempts.
The facility failed to notify the MD and a conservator of a resident’s death after the resident was found unresponsive and pronounced dead, and failed to notify the MD when another resident had post-surgical pain and ordered oxycodone was not yet available. Records showed the first resident had a court-appointed conservator and lacked decision-making capacity, while the second resident had recent cardiac surgery, documented pain, and missed pain assessments. Staff interviews confirmed confusion about the first resident’s representative status and that the second resident’s pain medication was delayed despite being available in CUBEX.
Failure to Provide Ordered Pain Medication and Pain Assessments: A resident admitted after recent CABG surgery reported severe chest pain on arrival, but the ordered oxycodone was not given until the next morning and pain assessments were not documented across multiple shifts. The resident stated she was in pain, could not sleep, and cried, while the CNA and LVN confirmed the medication was not available when pain was first reported. The DON stated the oxycodone was available in CUBEX and that staff should have obtained authorization to use it when the medication was not yet available.
A resident with cerebral ischemia, muscle weakness, a history of falls, and a daily aspirin order for CVA prevention developed unexplained discoloration to the chin and forehead, documented via SBAR after staff could not identify a fall or clear cause. Nursing leadership, including the ADON and DON, acknowledged the resident was on anticoagulant therapy, had a history of agitation and a tendency to hurt herself, yet there were no care plans addressing anticoagulant/aspirin use or behavioral issues such as agitation, restlessness, or self-injury, contrary to the facility’s comprehensive person-centered care plan policy.
The facility failed to maintain accurate, objective medical records for two residents. For one resident with a history of CVA and falls, a practitioner’s progress note incorrectly documented that the resident had recently fallen and sustained a left shoulder dislocation, chin bruising, and a forehead bump, despite leadership confirming no fall had occurred. For another resident with dementia and severe protein-calorie malnutrition, an SBAR form for a fall inaccurately recorded that a physician recommended an X-ray of the right arm and elbow, when the LPN later admitted this was her own assumption and no X-ray order existed in the physician orders or progress notes. Additionally, the resident’s fall care plan labeled the event as a witnessed fall, while the SBAR described the resident as being found on the floor, creating conflicting documentation about whether the fall was witnessed, contrary to the facility’s policy requiring complete and accurate charting.
Failure to Provide Advance Directive Information and Documentation: The SSD did not provide written information about the right to accept or refuse treatment and to formulate an AD for multiple residents. One resident with stroke-related deficits had no AD in PCC, two residents had incomplete AD/POLST documentation and no evidence they were given AD information, and another resident refused to sign an AD form because family involvement was requested, but the request was not documented and no follow-up with the family representative was noted.
Failure to Document and Assess Physical Restraint Use: Surveyors found that a bed placed against the wall for three residents and a pillow tucked under the sheets for one resident were used as restraints without the required MD order, informed consent, restraint assessment, or care plan. Staff, including RNs, LVNs, the DSD, and the DON, confirmed the positioning and stated these practices limited movement and were considered restraints, while the residents had diagnoses including weakness, impaired mobility, cognitive impairment, vision impairment, dementia, obesity, and other conditions affecting function.
Failure to Care Plan Lorazepam Use and Hot/Cold Gel Pack Self-Administration: A resident with dementia, anxiety, and DM had a PRN lorazepam order, but the ADON stated there was no care plan for the medication or monitoring of adverse effects, black box warning issues, dependence, or withdrawal reactions. Another resident with polyneuropathy, chronic pain, HTN, and COPD was being monitored for self-administration of a hot/cold gel pack, but an LVN stated there was no physician order or comprehensive person-centered care plan for that self-administration.
A resident had Visine and A&D ointment left at the bedside despite no order and no desire to self-administer meds. Another resident’s bed was found in a high position even though the care plan called for the lowest setting. A third resident had a call light cord with frayed, exposed wires, and two fall-risk residents had bedside tables placed on top of floor mats intended to cushion falls.
A resident who was incontinent had an unlabeled urinal at the bedside, another resident with an indwelling catheter had no stat lock or leg strap in place, and a third resident was observed with a 20 Fr Foley despite an order for 16 Fr. Staff and the DON/DSD stated the urinal should have been labeled, the catheter should have been secured, and the ordered catheter size was not followed.
A facility failed to provide respiratory care consistent with orders and infection control practices for four residents. One resident had an unlabeled bedside suction canister, another had NC tubing touching the floor, a third had an incomplete oxygen order and care plan without titration parameters or pulse oximetry frequency, and a fourth was receiving oxygen at a higher flow rate than ordered. Staff and the DON acknowledged the issues during observation and interview.
Bed rails were used for three residents without the required documentation and authorization. One resident with hemiplegia and fluctuating decision-making capacity had bilateral half side rails in use, but RN and DON stated there was no current physician order or care plan for side rail use. Two other residents, including one with Alzheimer's disease and seizures and another with hemiplegia and intact cognition, had orders and assessments for 1/4 rails, but were observed or documented with 1/2 rails instead; the DSD and DON stated the specific 1/2 rail use lacked the proper order, informed consent, assessment, and care plan.
Failure to Rotate Insulin Injection Sites: The DON and DSD identified that insulin injections were repeatedly given in the same subcutaneous sites for multiple residents despite orders and manufacturer guidance to rotate sites. Records showed repeated use of the same abdominal and arm locations for insulin administration, and the facility acknowledged this was not in accordance with the prescriber’s orders, standards of practice, or insulin labeling.
A cook did not follow the fortified diet instructions during lunch trayline service and used a household tsp instead of the required 1 oz measure of melted margarine on potatoes and vegetables. The DS and DON stated the correct scoop or ladle should have been used to ensure residents on fortified diets received the intended calorie density and nutrients.
Unsafe food storage and labeling practices were observed in the kitchen. Wet meal trays and food storage bins were stacked before air drying, spoiled onions and a dented can were mixed with other stored food, and several opened food items, including milk products and bread products, were not labeled with an open date. The DS and DM acknowledged the labeling, storage, and drying issues during the survey.
Antibiotic stewardship monitoring and order deficiencies were identified for three residents. One resident receiving Augmentin had missing q-shift adverse-effect documentation, another resident had Hiprex ordered for UTI prevention without an end date and Cefuroxime ordered with an improper indication, and a third resident receiving Daptomycin had no documented q-shift monitoring for adverse effects. The facility’s records and staff interviews showed that antibiotic orders and monitoring were not consistently completed as required by policy.
Frayed and exposed wires were observed on bed remote controls in the rooms of three residents, including residents with impaired cognition, mobility dependence, and diagnoses such as paraplegia, muscle weakness, and depression. Staff stated the exposed wiring should not have been present because of the risk of electrocution, and one bed remote was also not working when used for care. In a separate room, a resident’s call light did not activate the light outside the door or ring at the nurse’s station, and the resident reported being unable to get help when calling for assistance.
A resident with paraplegia and stool incontinence was left to eat lunch before being cleaned, despite telling CNA staff he could not eat with feces in his brief. In a separate event, an LVN administered meds via G-tube to a severely cognitively impaired resident while the privacy curtain was left fully open, exposing the resident to the hallway. Both events were identified as dignity and privacy failures by facility leadership.
Nonfunctional Closet Drawer: A resident with severe cognitive impairment and dependence for multiple ADLs had a broken closet drawer that was hanging down and had a broken handle, making it nonfunctional. RN observed the issue and stated broken drawers should be addressed promptly to support a homelike environment, dignity, and safe storage of personal belongings; the DON also stated broken furniture should be reported to maintenance immediately.
Unnecessary Psychotropic Medication Monitoring Deficiency: A resident with dementia, anxiety disorder, and fluctuating decision-making capacity received a PRN lorazepam order for anxiety manifested by increased restlessness leading to shortness of breath, with non-pharmacological interventions listed before use. The ADON stated there was no care plan or order for monitoring the medication’s black box warning adverse effects or for behavioral monitoring to show whether the medication was effective or needed adjustment, despite the facility policy requiring monitoring and documentation of response to psychotropic meds.
Failure to Timely Report Unwitnessed Fall With Injury of Unknown Origin: A resident with severe cognitive impairment, osteoporosis, and high fall risk was found on the floor next to the bed with facial bleeding and multiple lacerations requiring sutures after an unwitnessed fall. RN and LVN staff described finding the resident and calling 911 for hospital transfer, and the DON stated no staff directly observed how the injuries occurred. The DON also stated the incident was not reported to the SA as required by policy for suspected abuse, neglect, or injury of unknown source.
A resident with COPD, dysphagia, and generalized weakness had an OSR for oxygen at 2 L/min via N/C, but the care plan still directed continuous oxygen at 4 L via N/C. RN and DON acknowledged the care plan did not match the current physician order, and the facility policy stated care plans are revised as resident conditions change.
Failure to Rotate Insulin Injection Sites: Licensed nursing staff did not rotate SQ insulin injection sites for two residents with DM, despite provider orders, care plan interventions, and facility policy requiring site rotation. Record review showed repeated injections in the same abdominal quadrants for both residents, and the DSD and DON confirmed that staff did not follow the insulin administration policy or manufacturer instructions.
Failure to Follow Up After Ophthalmology Appointment: A resident with DM, impaired vision, and moderate cognitive impairment reported weeks of left eye dryness and pain, saying he had told multiple staff and requested eye drops but felt ignored. Records showed an ophthalmology visit for bilateral eye pain, floaters, and blurry vision, but there was no documentation that the resident returned from the appointment or that any visit note or new orders were received and carried out. Staff confirmed the lack of follow-up documentation and that the resident's eye complaints were not addressed.
Failure to notify the physician and assess repeated splint refusals: A resident with hemiplegia and hemiparesis had orders for a right hand splint and right elbow splint for contracture management, but was observed without the splints and staff reported the resident had long-standing refusals because they were painful. RNA staff and the ADON confirmed there was no SBAR documentation for the refusals, and the physician was not notified.
Failure to Complete Monthly Weight Loss Assessment and Update Care Plan: A resident with GERD, major depressive disorder, a stage 4 sacral pressure ulcer, and impaired cognition had documented significant weight loss and required set-up assistance with eating. The RD identified an 11.4% weight loss over 3 months, but the monthly weight loss assessment was not completed on the first of the month and the care plan was not updated to reflect the resident’s current weight loss, despite existing orders for RD review, weekly weights, and monitoring for significant weight change.
A resident with intact cognition and a need for setup or clean-up assistance with eating requested teeth and was seen by the dentist, who recommended tooth extractions and new dentures/partials. The SSA later acknowledged there was no follow-up after the dental visit and that she overlooked the resident’s dental needs. The DSD and DON stated social services was responsible for dental scheduling and that the lack of timely follow-up delayed denture fitting.
A resident with intact cognition and a history including UTI, bacteremia, and pneumonia poured water from the top of a med cart during med pass while an LVN, another LVN, and an RN were present at Station 2 desk. The staff did not stop or educate the resident at the time, and later stated residents should not touch or pour liquids from medication carts because it is an infection control issue and can contaminate items used for medication administration.
A resident with parkinsonism, aphasia, generalized muscle weakness, and moderately impaired cognition had a hospital CM inquire about discharge back to the facility. The AA spoke with the CM and stated the facility would accept the resident once candida auris test results were available to arrange appropriate isolation, but this conversation was never documented in the resident’s progress notes. The ADON was unaware of the resident’s potential return and stated the communication should have been charted to support IDT communication and an accurate record, and review of the facility’s documentation policy with the DON confirmed that such services and changes must be completely and accurately recorded.
Surveyors found that two emergency exit doors and their egress paths were obstructed by items including a signage board, a wheelchair, and a floor cleaner machine in separate hallways between resident rooms and common areas. An LVN and the Operations Assistant acknowledged that hallways to emergency exits should be kept clear, and the DON confirmed that blocked exits could delay emergency response and endanger staff and residents. Review of the facility’s “Exits or Means of Egress” policy showed it required exits to remain clear at all times and never be blocked, even briefly, which was not followed.
A resident with psychosis and a history of falls received quetiapine for delusions, but nursing staff failed to perform ordered weekly orthostatic BP checks related to this antipsychotic, documenting them as "not applicable" on multiple occasions. The resident’s H&P documented lack of decision-making capacity, yet verbal consent for quetiapine was obtained from the resident rather than the responsible party. Later, the total daily quetiapine dose was increased from 100 mg to 150 mg without obtaining new informed consent from the representative, despite facility policy requiring consent prior to initiating or increasing psychotropic medications. The DON and ADON acknowledged that physician orders and facility policies on psychotropic use, monitoring, and informed consent were not followed.
A resident with orthopedic aftercare, COPD, and respiratory failure had PRN orders for hydrocodone-acetaminophen for moderate pain (4–6) and oxycodone-acetaminophen for severe pain (7–10). Review of the MAR and interviews showed that on multiple occasions nurses administered hydrocodone when the resident’s documented pain level was 7 or 8, instead of giving the ordered oxycodone for severe pain. The ADON and DON confirmed that staff did not follow the physician’s pain management orders, despite facility policies requiring medications to be administered as prescribed.
Two residents did not receive appropriate person-centered care planning and implementation. One resident with COPD and respiratory failure had a continuous oxygen order but was observed asleep with the nasal cannula disconnected while the concentrator was running, and staff and record review confirmed there was no care plan addressing the resident’s removal or refusal of oxygen. Another resident with osteoarthritis, morbid obesity, and high fall risk had a care plan requiring the bed to be kept in a low position, yet was observed asleep with the bed in a high position, and staff confirmed there was no care plan reflecting the resident’s preference for a high bed despite the documented fall risk.
A high fall-risk resident with osteoarthritis, morbid obesity, and right knee pain, who required moderate assistance for toileting and lower body dressing, was found asleep in a bed left in a high position despite a care plan intervention requiring the bed to be kept low with brakes locked. The resident’s fall risk assessment identified them as high risk, and their cognitive skills for daily decisions were documented as intact. During interviews, the ADON and DON acknowledged there was no care plan addressing the resident’s preference for a high bed position and confirmed that the facility’s fall prevention policy required identification of interventions based on assessment, which had not been done in this case.
A resident with COPD and acute and chronic respiratory failure with hypoxia had physician orders for continuous oxygen via nasal cannula, which were revised to 2 L/min. During observation, the oxygen concentrator was found running at 5 L/min while the nasal cannula was not connected to the resident but hanging on nearby equipment. An RN confirmed the oxygen setting and disconnection, and an LVN obtained a pulse oximeter reading of 92% before reconnecting the cannula, noting the resident’s saturations had fluctuated between 80–90% on 5 L/min. The ADON and DON confirmed there was no order to increase or titrate oxygen above 2 L/min and that facility policy requires oxygen, treated as a medication, to be administered according to prescriber orders and with proper flow, which did not occur in this instance.
A resident with orthopedic aftercare needs, psychosis, and a history of falls was admitted and assessed as using antipsychotic medication, with documentation inconsistencies between the H&P and MDS regarding decision-making capacity. Shortly after admission, the resident’s family member reported finding pills in a clear plastic bag and showed a photo of these pills to an SSA, stating the resident had been caught with pills in a GACH. The SSA acknowledged discussing the medications and viewing the photo but did not document this conversation or concern in the resident’s medical record, despite facility policy requiring documentation of events, incidents, and changes in condition to ensure a complete and accurate record.
Surveyors found that a resident with COPD and acute and chronic respiratory failure receiving O2 via concentrator had nasal cannula tubing hanging from a portable emergency light with the tubing touching the floor, while the resident was asleep and not connected to the cannula. Documentation showed the resident lacked decision-making capacity in the H&P but had intact cognitive skills on the MDS and required staff supervision for ADLs. The ADON stated O2 tubing should not touch the floor for infection control, and the DON acknowledged the risk of infection and reported there was no specific written policy, only a facility practice to keep O2 tubing off the floor.
The facility failed to maintain an effective, on-going pest control program that included routine interior inspections and treatment. Two residents with multiple medical conditions and intact cognition reported seeing cockroaches in their rooms and nearby hallways on several occasions, with staff responding by killing the insects on sight and discarding them. Review of pest control logs and interviews with the Maintenance Supervisor and the pest control contractor showed that only the exterior of the building received scheduled monthly inspections and treatment, while the interior was inspected only when specific pest complaints were reported, contrary to the facility’s own pest control policy stating the building would be kept free of insects and rodents.
A resident with paraplegia, osteoarthritis of the hip, a stage 4 sacral pressure ulcer, and fluctuating decision-making capacity was documented on the MDS as fully dependent on staff for hygiene, dressing, and transfers. However, Fall Risk Observation/Assessment forms completed by staff indicated the resident had no neuromuscular or functional conditions or risk factors such as loss of limb movement. During an interview and record review, the DON confirmed these fall risk assessments were incomplete and failed to include the resident’s paraplegia, resulting in a lower fall risk score, contrary to the facility’s policy requiring complete and accurate medical record documentation.
A nurse documented the administration of apixaban for a resident with multiple serious conditions, even though the medication was not actually given and remained in the medication packaging. The resident was out for dialysis at the time, and there was no nursing note explaining the discrepancy. Facility leadership confirmed the documentation was inaccurate and did not align with policy requiring complete and accurate medical records.
A resident with DM II, depression, and CHF had a change in condition with a right abdominal skin fissure and later dermatology findings of pink, erythematous, scaly plaques on both upper and lower extremities. The care plan was not updated to reflect the resident's skin concerns, and both an LVN and the DON stated the plan should have been revised when the skin problems were identified.
Failure to manage Legionella in the water system and report positive findings. Multiple water tests showed Legionella in domestic water, including resident rooms and a bathtub, but the IPN, DON, and maintenance leadership stated the facility did not follow the water management plan, did not document resident monitoring for exposure, and did not ensure communication of the positive results to the current administrator or CDPH. A resident with COPD and DM later had AMS, fever, SOB, was transferred to the hospital, and had a sputum test that detected Legionella.
Leaking Ceiling Left Residents in Unsafe Room: A room shared by three residents had rainwater leaking from the ceiling, and staff left the residents in place with a bucket under the leak instead of moving them. One resident said the leak continued for days and staff did not move him or his roommates; an LVN said the residents stayed in the room without a room change, and the DON stated the facility did not meet the residents' needs by not changing their room. The residents had significant medical and functional needs, including HTN, anemia, ESRD, cirrhosis, seizures, and varying levels of cognitive and ADL impairment.
A resident was left in a room with a leaking ceiling, visible rainwater, and containers placed to catch the water, while staff stated the resident had not yet been moved. Another resident was observed asking for a blanket because the room was too cold, and the MS measured the temperature at 64 degrees Fahrenheit. The DON stated the room was too cold and that the facility's homelike environment policy was not followed.
A resident with a displaced tibia fracture, DM, and dementia remained in a room with a leaking ceiling after refusing a room change, but the care plan was not individualized to address safety in that setting. Surveyors observed active water dripping, makeshift containers and towels placed under the leak, and bulging ceiling paint. RN and MDS staff stated the plan lacked specific monitoring such as hourly rounding, and the DON said the plan should have been person-centered to address the resident's safety in the room.
Staff did not consistently address a resident by their preferred name, with an LVN repeatedly using the term "honey" instead. Additionally, several CNAs and an Occupational Therapist were observed speaking in a non-English dialect in hallways near resident rooms, contrary to facility policy requiring English communication in resident areas. These actions did not align with the facility's policies on dignity and communication courtesy.
A resident with diabetes and hypertension was found with a nasal spray on the bedside table, which had not been assessed for self-administration by the interdisciplinary team. The medication was brought in by family and used by the resident without staff knowledge. Facility staff confirmed the medication was accessible and not stored securely, contrary to policy requiring assessment and secure storage of self-administered medications.
A resident with severe cognitive impairment and multiple medical conditions was not given a prescribed dose of fluconazole on the day of readmission due to miscommunication and lack of order clarification between nursing staff and the discharging hospital. The antibiotic was available, but staff incorrectly assumed the first dose had already been administered, resulting in a delay in treatment.
A resident with a history of falls and requiring moderate ADL assistance was found to have a nonfunctional call light since admission, confirmed by both the resident and an LVN. The resident had to use a roommate's call light to request help, and the DON acknowledged the importance of a working call system for timely staff response. Facility policy requires the call system to be functional and routinely maintained.
RP Not Notified Before Podiatry Service
Penalty
Summary
The facility failed to follow the Responsible Party’s request to be notified before any ancillary services were provided to a resident who lacked decision-making capacity. Resident 1 was admitted with diagnoses including unspecified Alzheimer’s disease, diabetes mellitus, and unspecified peripheral vascular disease. The admission record identified the RP as having POA, and the physician order dated 10/29/2025 stated that no ancillary consults were to be performed without prior notice and approval from the RP. The resident’s H&P dated 4/19/2026 stated the resident did not have the capacity to understand and make decisions, and the MDS dated 4/30/2026 indicated severely impaired cognitive skills for daily decisions and dependence on staff for all ADLs. Despite this documented restriction, the podiatrist trimmed the resident’s toenails on 5/18/2026. The podiatry notes documented debridement and trimming of toenails using a nail clipper and Dreme. During interview, the RP stated she had previously told staff in multiple IDT meetings that she had to be informed first before the resident could be seen by outside services such as podiatry. The RP later noticed that someone had cut the resident’s toenails and stated she had not been notified before the podiatry visit. Facility staff confirmed the RP was not notified before the podiatrist came. The SSA stated she was covering for another SSA, was not familiar with the resident, and did not notice the RP’s request that no ancillary services occur unless she was informed and agreed. The SSA stated the nurse had requested podiatry for long toenails, the referral was emailed, and the podiatrist trimmed the toenails before the RP was notified. The ADON, DON, and LVN 1 all stated the RP’s right to be informed prior to the procedure was not followed, and the DON stated the resident had no capacity to decide for herself and that the RP should have been informed before the podiatrist visit.
Failure to Notify Conservator of Resident’s Death
Penalty
Summary
The facility failed to notify the Conservator of one sampled resident when the resident died. The resident had an Order Appointing Probate Conservator showing the responsible party as the Conservator, and a hospital progress note indicated conservatorship paperwork had been initiated because of impaired decision-making capacity. The resident’s records also showed diagnoses including cerebral infarction, dementia, dysphagia, and essential hypertension, and the resident was admitted with the facility later discharging the resident as deceased. The resident’s hospital discharge summary indicated the hospital discussed placement at SNF 1 with the Conservator, who was agreeable to the transfer. The resident’s history and physical stated the resident did not have the capacity to make decisions. Although the Minimum Data Set indicated the resident had the ability to make self understood and was usually understood, the Conservator stated she was never contacted by SNF 1 when the resident was admitted and did not sign admission documents. She stated she made several attempts to call the facility and only later learned the resident had been processed as a bioethics client because staff believed the resident had no family or next of kin. During interviews, the admission coordinator stated she completed the admission record and determined the resident was a bioethics resident because the hospital case manager said the resident had family members who were not involved; she also stated she did not contact the family despite seeing emergency contacts listed. A social service assistant stated the facility usually tries to reach a conservator, but she only called the county conservatorship office once, left a message, and did not document the calls consistently. The assistant stated that if the facility did not establish the resident’s conservatorship, there would be a lack of communication, and that the facility violated the resident’s wishes because conservators are there to establish and advocate for the resident’s wishes.
Failure to Notify MD and Representative of Resident Condition Changes
Penalty
Summary
The facility failed to inform the attending physician and the resident representative/conservator of significant changes in condition for two residents. For one resident, the record showed a court-appointed conservator had been established, the resident had diagnoses including cerebral infarction, dementia, dysphagia, and hypertension, and the H&P stated the resident did not have capacity to make decisions. On the day of death, the resident was found unresponsive, without a pulse, CPR was initiated, a code blue was called, and the resident was pronounced dead at 1:30 p.m. The conservator stated this was the first time she learned of the resident’s death, and staff interviews did not provide documented evidence that the MD was notified of the death. Facility staff described confusion about the resident’s representative status. The admission coordinator stated she classified the resident as a bioethics resident because she believed family members were not involved, even though the admission record listed family as emergency contacts. The social service assistant stated she was aware of the conservatorship paperwork but only made limited attempts to contact the county conservatorship office and did not document all calls. The DON stated the MD needed to be notified of changes of condition and that failure to notify the MD and RP could delay care and fail to respect the RP’s wishes. For the second resident, the admission record showed recent cardiac surgery-related diagnoses, and the care plan addressed acute pain after surgery. The MAR documented a pain score of 6/10 and the record also showed missed pain assessments on multiple shifts. The resident stated she arrived in pain, reported an 8/10 chest pain level, asked for pain medication, and was told it was being ordered from the pharmacy; she said she did not receive medication until the next morning and cried because of the pain. CNA and LVN interviews confirmed the resident complained of pain while the medication was not yet available, and the DON stated the nurse should have called the doctor right away because oxycodone was available in CUBEX and there was no point in not giving the medication.
Failure to Provide Ordered Pain Medication and Pain Assessments
Penalty
Summary
The facility failed to ensure safe, appropriate pain management for a resident admitted after recent cardiovascular surgery, including CABG and hypertensive heart disease with heart failure. The resident’s orders required pain monitoring every shift and oxycodone HCl 10 mg by mouth every 6 hours as needed for moderate to severe pain, with nonpharmacological interventions before administration and notification of the physician if pain was unrelieved. The resident’s care plan also directed staff to administer medication as ordered and assess pain every shift and as indicated. The record showed the resident reported pain on 5/7/2026 and received oxycodone at 7:50 a.m., but the MAR also showed no pain assessment documented for the night shift on 5/6/2026, the day shift on 5/7/2026, or the evening shift on 5/7/2026. The resident stated she arrived at the facility around 6 p.m. on 5/6/2026 already in pain, asked for pain medication, and was told it was being ordered through the pharmacy. She stated she had chest pain rated 8/10, could not sleep, and cried. Staff interviews confirmed the medication was not available when the resident first complained of pain. The CNA stated the resident was complaining of pain during the night shift and again during morning care, and that the facility did not have pain medications available at that time. The assigned LVN stated the resident’s medications had just arrived and were given around 8:45 a.m. to 9 a.m., and the DON stated the oxycodone was available in CUBEX and that staff should have called the doctor right away to obtain authorization to use it when the medication was not available. The facility policy required pain assessment at admission and ongoing assessment, use of a standardized pain tool, implementation of the medication regimen as ordered, and documentation and communication of intervention results.
Failure to Care Plan for Anticoagulant Use and Self-Injurious Behaviors
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan addressing a resident's use of aspirin and self-injurious behavior. The resident was admitted with diagnoses including cerebral ischemia, muscle weakness, and a history of falling, and had a physician's order for daily aspirin 81 mg for cerebrovascular accident. An MDS assessment showed the resident could understand and be understood and required varying levels of assistance with ADLs such as dressing, toileting, showering, and hygiene. An SBAR communication form documented that the resident was noted with discoloration to the chin and forehead, with no known fall. During interviews, an RN reported being informed of the discoloration by an LVN and completing an SBAR because the cause was unknown, stating it did not appear the resident was hit and suggesting it might have occurred during repositioning or when the resident became combative. The ADON confirmed the discoloration was noted without any known fall, acknowledged the resident was on anticoagulant medication and had a history of agitation, and stated there were no care plans related to agitation, restlessness, behaviors, or aspirin use. The DON similarly stated the resident had a tendency to hurt herself and was on anticoagulant medication, but there were no care plans for behavior or anticoagulant use. This was inconsistent with the facility’s policy requiring a comprehensive, person-centered care plan with measurable objectives and timetables to meet each resident’s physical, psychosocial, and functional needs.
Inaccurate Clinical Documentation for Falls and Physician Orders
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and objective medical records for two residents, resulting in inaccurate documentation in their charts. For one resident with cerebral ischemia, muscle weakness, a history of falling, and a prior CVA treated with daily aspirin, the admission record showed admission and readmission dates and the MDS documented that the resident could understand and be understood and required varying levels of assistance with ADLs. An SBAR form dated 3/30/2026 noted discoloration on the resident’s chin and forehead. However, a medical practitioner narrative progress note dated 4/2/2026 stated that the resident had a recent fall resulting in a left shoulder dislocation, bruising to the chin, and a bump on the forehead, even though facility leadership later confirmed that the resident had not had a fall, making the note inaccurate. For another resident with dementia, difficulty walking, and severe protein-calorie malnutrition, the MDS indicated the resident could understand and be understood and required supervision or assistance with several ADLs while being independent with eating and oral hygiene. An SBAR form dated 4/2/2026 documented that the resident had a fall, was last seen sleeping in bed by a CNA and then found on the floor two minutes later, and that the physician was notified with a recommendation for an X-ray of the right arm and elbow. The nurse who completed the SBAR initially stated that the physician recommended an X-ray but, upon review, acknowledged that she had documented the X-ray recommendation before actually communicating with the physician and that the X-ray recommendation was her own assumption, not the physician’s order. Review of the physician orders confirmed there was no X-ray order, and no progress note was entered to correct the inaccurate SBAR entry. The same resident’s care plan for a witnessed fall, initiated on 4/2/2026, directed staff to keep the bed in a low position with brakes locked and the call light within reach and labeled the event as a witnessed fall. However, the SBAR indicated that the CNA found the resident on the floor after last seeing the resident sleeping in bed, and the DON later stated that the CNA had actually witnessed the fall. The ADON and DON both identified that the SBAR and the care plan did not coincide regarding whether the fall was witnessed or unwitnessed, and that the SBAR inaccurately reflected that the physician had ordered an X-ray. The facility’s charting and documentation policy required that documentation in the medical record be objective, complete, and accurate, which was not followed in these instances.
Failure to Provide Advance Directive Information and Documentation
Penalty
Summary
The facility failed to inform and provide written information to adult residents about the right to accept or refuse medical and surgical treatment and the option to formulate an advance directive. The deficiency involved four sampled residents: Resident 14, Resident 10, Resident 17, and Resident 150. The report states that the Social Services Director (SSD) did not provide written advance directive information, and in several cases the advance directive documentation was incomplete or absent. Resident 14 was admitted with diagnoses including hemiplegia, hemiparesis following cerebral infarction, dysphagia following cerebral infarction, and essential hypertension. The H&P dated 3/5/2026 indicated the resident did not have capacity to understand and make decisions, while the MDS dated 2/18/2026 indicated the resident could make self-understood and understand others and had modified independence with some difficulty in new situations only. During review of the electronic record, RN 3 stated the resident’s advance directive was not seen in PCC. SSA 1 stated the advance directive or acknowledgment form was not completed or not in PCC, and the DON stated the resident should be asked upon admission and, if no advance directive is available, social services offers the resident the opportunity to formulate one. Resident 10 was admitted with diagnoses including generalized muscle weakness, Alzheimer’s disease, depression, and anemia. The H&P dated 2/25/2026 indicated the resident had capacity to understand and make decisions, while the MDS indicated moderate cognitive impairment and substantial or maximal assistance with ADLs. The AD/POLST acknowledgment dated 9/11/2025 was incomplete and indicated the resident did not wish to do an advance directive on the day of admission, but there was no signature showing acknowledgment of the refusal. The SSD stated there was no indication or documentation that Resident 10 was given information about advance directives, and that the resident should have been given that information to clarify appropriate actions if health deteriorated. Resident 17 was admitted with diagnoses including muscle weakness, generalized anxiety disorder, and adult failure to thrive. The H&P dated 4/03/2026 indicated fluctuating capacity to understand and make decisions, and the MDS indicated the resident could understand others and be understood and needed partial to moderate assistance with ADLs. The AD/POLST form dated 9/11/2025 was incomplete, and the SSD stated there was no indication or documentation that Resident 17 was given information about advance directives. Resident 150 was admitted with diagnoses including traumatic hemothorax, difficulty walking, and muscle weakness. The MDS indicated moderate cognitive impairment and substantial/maximal assistance with ADLs. During review, the SSD stated Resident 150 refused to sign an advance directive form upon admission because the resident wanted family involvement, but there was no note documenting that request and no follow-up call to the family representative. The SSD stated Resident 150 did not have an advance directive and that the importance of having one is to ensure clarity regarding appropriate actions if the resident’s health declines or deteriorates.
Failure to Document and Assess Physical Restraint Use
Penalty
Summary
The facility failed to ensure four sampled residents were free from the use of physical restraints without the required documentation and assessment for the restraint methods being used. The report identified restraint use as placing a bed against the wall for three residents and tucking a pillow under the sheets for one resident. For each of these residents, surveyors found missing or incomplete physician orders, informed consent, restraint assessments, and care plans related to the restraint use. Resident 142 was admitted with diagnoses including muscle weakness, difficulty walking, and glaucoma. The resident’s MDS showed moderate cognitive impairment, visual impairment, and need for partial assistance with mobility and ADLs. Surveyors observed the resident’s bed placed against the wall on the right side. The OSR did not show an order for the bed placement, and staff interviews confirmed that the bed against the wall was considered a restraint. RN 7, the DSD, and the DON each stated that a physician’s order, informed consent, restraint assessment, and care plan were required, and the DSD confirmed those elements were not present for this resident. Resident 264 had diagnoses including hemiplegia, hemiparesis, muscle weakness, and age-related nuclear cataract, with fluctuating decision-making capacity, highly impaired vision, moderate cognitive impairment, and dependence to partial assistance with mobility and ADLs. Surveyors observed the resident’s bed placed against the wall. The OSR did not show an order for the restraint, the BRERO did not include an assessment for bed placement against the wall, and staff stated there was no specific assessment for that positioning. The DSD and DON stated the resident did not have the required physician’s order, informed consent, restraint assessment, or care plan for the bed placement. Resident 86 had diagnoses including difficulty walking, cognitive communication deficit, history of falling, and unspecified dementia. The resident’s H&P indicated capacity to understand and make decisions, and the MDS showed the resident could make self-understood and understand others. Surveyors observed the resident’s bed against the wall on one date, and staff later reviewed a photo showing the same positioning. LVN 7 stated there was no assessment, consent, MD order, or care plan for the bed placement. Resident 80 had diagnoses including morbid obesity, depression, and venous insufficiency, with intact cognition and dependence to set-up assistance for mobility and ADLs. Surveyors observed a pillow tucked under the sheet at the right side of the resident, and LVN 1 stated this limited the resident to one side and was a form of restraint. The OSR did not show an order for pillows tucked under the sheets, and the DSD and DON confirmed the absence of a physician’s order, informed consent, restraint assessment, and care plan for that practice.
Failure to Care Plan Lorazepam Use and Hot/Cold Gel Pack Self-Administration
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident 175 related to lorazepam use. Resident 175 was admitted with diagnoses including dementia, anxiety disorder, and type 2 DM, and the H&P noted fluctuating capacity to understand and make decisions. A physician order dated 4/20/2026 directed lorazepam oral concentrate 2 mg/ml, 0.5 ml sublingually every 4 hours as needed for anxiety manifested by increased restlessness leading to shortness of breath for 14 days. During a concurrent interview and record review, the ADON stated there was no care plan developed for the use of lorazepam and no physician order for monitoring the black box warning for lorazepam, including adverse effects. The ADON stated the adverse effects to be monitored included drowsiness, slurred speech, dizziness, nausea, and aggressive/impulsive behavior. The ADON also stated licensed staff should have developed a care plan for the use of lorazepam, its adverse effects, and should have monitored Resident 175 for risks, medication dependence, and withdrawal reactions. The record review and interview showed that these elements were not documented in the resident’s care plan. The facility also failed to develop a comprehensive person-centered care plan for Resident 5 regarding self-administration of a hot/cold gel pack. Resident 5 had diagnoses including polyneuropathy, hypertension, chronic pain syndrome, and COPD, and the H&P indicated the resident had capacity to make decisions. The MDS indicated intact cognitive skills for daily decision making, but also showed dependence with lower body dressing and footwear and substantial/maximal assistance with toileting hygiene and shower self. Progress notes dated 4/20/2026 and 4/21/2026 indicated the resident was being monitored for self-administration of the hot/cold gel pack, yet LVN 3 stated there was no physician order allowing self-administration and no comprehensive, person-centered care plan addressing it.
Unsafe bedside items, bed height, and equipment hazards
Penalty
Summary
The facility failed to keep medications and biologicals from being left at a resident’s bedside. Resident 163 was admitted and later readmitted with diagnoses including metabolic encephalopathy, major depressive disorder, and anxiety disorder. The resident’s record showed intact cognition and that the resident did not want to self-administer medications. The order summary did not include orders for Visine or A&D ointment, yet during observation two bottles of Visine eye drops and multiple packets of A&D ointment were found at the bedside. LVN 8 and the DSD both stated the resident was not desiring to self-administer medications and there was no order for those items, and the DON stated licensed staff should not have left medications at the bedside. The facility also failed to keep a resident’s bed in the lowest position. Resident 159 was admitted and readmitted with diagnoses including dementia, muscle wasting, atrophy, and lack of coordination. The resident’s history and physical noted fluctuating capacity to understand and make decisions, and the MDS indicated severe cognitive impairment and need for substantial to partial assistance with mobility and ADLs. The resident was assessed as a moderate fall risk, and the care plan included keeping the bed in the lowest position. During observation, the bed was found in a high position and measured 27 inches from the floor to the mattress surface. Staff stated the bed was too high and that the care plan called for the lowest position. The facility further failed to maintain safe resident equipment and floor mat interventions. Resident 231, who had dementia, age-related osteoporosis, and a history of falling, was observed with a call light cord that had frayed and exposed wires. CNA 10 and the DON stated exposed wires should not be present because of the potential for electrocution. Resident 239 and Resident 255 were both assessed as fall risks and had care plans that included floor mats on one side of the bed. In both rooms, the bedside table was observed placed on top of the floor mat. CNA 8, RN 5, and the DON stated the table should not be on the mat because the mat is intended to cushion a fall and the table interfered with that purpose.
Urinary catheter and urinal care not followed
Penalty
Summary
The facility failed to ensure appropriate care for residents with urinary catheters and urinary incontinence for three sampled residents. One resident who was always incontinent of urine had an unlabeled urinal sitting on the bedside drawer. The resident’s care plan identified a risk for urinary tract infection, and the Director of Staff Development stated the urinal should have been labeled with the resident’s name, room number, and date it was provided, but it was not. The Director of Nursing stated the unlabeled urinal could be used by another resident and that labeling was used to prevent UTI. A second resident with an indwelling urinary catheter did not have a securement device in place. The resident’s orders required daily catheter care and use of a stabilization device to secure the catheter, and the care plan also directed staff to use a catheter anchor. During observation, the catheter was seen without a stat lock or leg strap. The Director of Staff Development stated the licensed staff did not follow the physician’s orders and facility policies requiring a securement device, and the Director of Nursing stated the catheter should have been secured to prevent tugging and pulling. A third resident with an indwelling catheter order for 16 Fr/10 cc was observed with a 20 Fr catheter. The resident had diagnoses including neuromuscular dysfunction of the bladder, bacteremia, and paraplegia. Staff documented that the resident had bypassing of the Foley catheter, and treatment staff attempted to replace the catheter but met resistance and were unsuccessful. The treatment nurse stated the resident had been found with a 20 Fr catheter and that the order was for 16 Fr. The Assistant Director of Nursing stated there was no documentation showing that a 20 Fr catheter had been ordered or placed, and that the physician order and policy were not followed.
Respiratory Care Errors Involving Suction Equipment, Oxygen Tubing, and Oxygen Orders
Penalty
Summary
Resident 22, who had diagnoses including COPD and dyspnea and was documented as lacking capacity to understand and make decisions, was observed with an unlabeled suction canister at the bedside suction setup. During the observation, RN 8 stated the canister should have been labeled with the date and time it was provided for infection control. The facility’s DSD and DON also stated the canister should have been labeled with the date it was provided and that the canisters should be changed weekly, but the canister observed at the bedside was not labeled as required by the facility policy. Resident 235, who had diagnoses including COPD and CHF and was documented as cognitively intact, was observed asleep in the room with oxygen therapy running at 2 liters per minute via NC while the tubing was touching the floor. CNA 5 stated the tubing should not touch the floor and should be kept off the floor by placing extra tubing inside the plastic storage bag on the side of the oxygen concentrator. LVN 11 and the DON also stated the tubing should not have been touching the floor and that extra tubing should be placed in the storage bag, but the observation showed the tubing on the floor. Resident 5, who had diagnoses including polyneuropathy, hypertension, chronic pain syndrome, and COPD and was cognitively intact, was receiving oxygen at 5 liters per minute via NC. The physician’s order indicated oxygen at 2 to 5 liters per minute via NC continuously every shift, but LVN 3 stated the oxygen therapy care plan and order did not include oxygen titration parameters with a specific target saturation level and did not document pulse oximetry frequency. The DON stated the absence of those details could result in inadequate respiratory monitoring and improper oxygen administration. Resident 212, who had diagnoses including COPD, dysphagia, oropharyngeal phase, and generalized muscle weakness and was documented as having intact cognition, had an order for oxygen at 2 liters per minute via NC continuously every shift. During observation, LVN 10 found the oxygen concentrator set at 4.5 liters per minute. After reviewing the order, LVN 10 stated the resident was receiving the incorrect oxygen level and adjusted it to 2 liters per minute. The DON stated the order was not being followed and that the resident could have had over oxygenation.
Bed rails used without required orders, consent, assessments, and care plans
Penalty
Summary
The facility failed to safely use bed rails for three sampled residents by not ensuring the required physician orders, informed consent, bed rail assessments, and care plans were in place for the specific bed rail use observed. The report states that the facility used bed rails without meeting its own criteria for use, and that staff and leadership acknowledged the need for a resident assessment, entrapment assessment, consent, physician order, and care plan before bed rails are used. Resident 11 was admitted with diagnoses including hemiplegia, hemiparesis following cerebral infarction, type II DM, and generalized muscle weakness. The H&P noted fluctuating capacity to understand and make decisions. The MDS showed the resident needed supervision or touching assistance with toileting, personal hygiene, showering, and lower body dressing, and was independent with rolling and sit-to-lying. During observation, the resident was seen in bed with bilateral side rails elevated, and CNA 4 stated the resident requested the side rails be elevated at all times. RN 5 reviewed the record and stated there was no current physician order for side rail use and no care plan documented for side rail use. The DON stated side rail use required assessment for risks and benefits, entrapment assessment, consent, a physician order, and inclusion in the comprehensive person-centered care plan. Resident 22 had diagnoses including Alzheimer's disease, contracture, and seizures, and the H&P stated the resident did not have capacity to understand and make decisions. The MDS indicated severely impaired cognition and dependence for mobility and ADLs. The OSR contained an order for padded side rails up times 2 top of quarter for mobility/enabler every shift for seizures, and the BRERO assessed quarter rails. However, during observation the resident's bed rails were identified as 1/2 length. The DSD stated the resident had an order for 1/4 padded side rails/bedrails but no order for the 1/2 bed rails actually in use, and that the BRERO and consent were for a 1/4 bed rail. Resident 163 had diagnoses including hemiplegia, hemiparesis following cerebral infarction, and disorders of bone density and structure of the left hand. The MDS showed intact cognition and dependence to partial assistance with mobility and ADLs. The OSR ordered may have 1/4 side rails up x 2 for mobility aid, and the BROA assessed bilateral 1/4 bedrails, but the DSD stated the resident was on 1/2 bed rails without a specific order, informed consent, bed rail assessment, or care plan for that use.
Failure to Rotate Insulin Injection Sites
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors by not rotating subcutaneous insulin administration sites for three of three sampled residents. The report states that the medication error involved preparation or administration of insulin that was not in accordance with the prescriber’s order, manufacturer’s specifications, and accepted professional standards. The deficiency was identified through interview and record review for residents receiving insulin therapy. One resident was admitted with diagnoses including type 2 diabetes mellitus and mild protein-calorie malnutrition. The resident’s orders included insulin with instructions to rotate injection sites, and the care plan also identified a potential for skin discoloration related to insulin injections with an intervention to rotate injection sites regularly. The location of administration record for March 2026 showed insulin was administered subcutaneously, and the Director of Staff Development stated there were multiple instances where licensed staff did not rotate the insulin administration sites. The DSD stated that rotating sites was important to prevent bruising and lipodystrophy and that administering insulin on sites of lipodystrophy could affect absorption and cause hypo- or hyperglycemia. A second resident with diagnoses including DM2 with diabetic neuropathy and morbid obesity had orders for NovoLog and facility-provided manufacturer information that directed injection site rotation within the same region to reduce the risk of lipodystrophy and localized cutaneous amyloidosis. A third resident with diagnoses including DM2 and dementia had orders for Humulin R and insulin glargine that specifically directed rotation of injection sites. Review of the location of administration records showed repeated use of the same abdominal quadrant and repeated use of the left arm without rotation. The DSD and DON both stated that the insulin administration sites were not rotated, that insulin is a significant medication, and that failure to rotate sites was considered a medication error because it did not follow the physician’s order, manufacturer’s guidelines, and standards of practice.
Fortified Diets Not Prepared as Ordered During Lunch Service
Penalty
Summary
The facility failed to meet the nutritional needs of 38 out of 237 residents who received fortified diets when, during lunch trayline service, Cook 2 did not follow the fortified diet instructions posted at the trayline station. The menu spreadsheet for the regular diet listed diced fried potatoes and Capri blend vegetables with 1 teaspoon of margarine, while the fortified diet instructions required adding 1 oz of melted margarine to potatoes, rice, pasta, and hot vegetables to increase calorie density for residents who could not consume adequate calories and/or protein to maintain weight or nutritional status. During trayline observation, Cook 2 was observed using a household teaspoon to add melted margarine to the diced fried potatoes and Capri blend vegetables for residents on fortified diets. In interview, Cook 2 stated she used a household teaspoon and had only used one to two teaspoons of melted margarine for fortified diets. The Dietary Supervisor stated that the fortified diet instructions required 1 oz of melted margarine, equivalent to 30 ml, and that Cook 2 should have used the correct scoop or ladle. The Dietary Supervisor later stated that Cook 2 did not use the correct scoop when adding melted margarine during lunch service and that the residents receiving fortified diets were at risk for weight loss due to decreased calorie density in their food. The DON also reviewed the fortified diet information and stated that kitchen staff were supposed to follow and prepare residents' meals as indicated in the menu, and that using the appropriate scoops or ladles would ensure residents received the correct number of calories and nutrients they needed.
Unsafe Food Storage and Labeling Practices
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen. During an initial kitchen tour, eight meal trays were observed stacked and still wet in the drying area next to the dishwashing area, and two clear food storage bins were observed stacked and still wet in the dried food storage bins area. The Dietary Supervisor stated that dishes, meal trays, food storage bins, pots, and pans should not be stacked while still wet and should be air dried before stacking. In the dry food storage room, four onions with green sprouts and four onions with brown and dark gray discoloration that were soft to touch were observed inside a brown box. One dented can of fruit cocktail was also observed mixed in with non-dented cans. The Dietary Manager stated that the sprouted and discolored onions should have been discarded and that the dented can should have been removed from the non-dented cans and placed in the designated area for dented cans. In the walk-in refrigerator, one container of soy milk, one container of almond milk, and one container of liquid non-dairy creamer were observed without open dates. In the tray area, four plastic bags of hotdog buns and two plastic bags of hamburger buns had stickers showing the received date, but no open date was indicated. The Dietary Supervisor stated that opened food items should be labeled with the date they were opened so staff would know they were not old. Facility policies and food storage guidance reviewed by surveyors indicated that food items in storage and refrigeration should be labeled and dated, and that reusable dishware and equipment should be air dried only.
Antibiotic Stewardship Monitoring and Order Deficiencies
Penalty
Summary
The facility failed to implement its antibiotic stewardship program for three sampled residents by not consistently monitoring antibiotic use and adverse effects, and by not ensuring antibiotic orders contained complete and appropriate information. The report states that the facility’s policies required antibiotic orders to include the drug name, dose, frequency, route, and indication, and that residents receiving antibiotics were to be monitored for adverse effects every shift and documented in the progress notes. For one resident admitted with chronic pulmonary edema and emphysema, Augmentin was ordered for bacterial pleural effusion for 10 days. The care plan identified possible adverse effects such as diarrhea, nausea, vomiting, anorexia, and hypersensitivity/allergic reactions, with monitoring every shift. During record review, the Director of Staff Development found missing progress note monitoring on multiple dates while the resident was receiving the antibiotic, and stated the monitoring was not consistently completed every shift. For another resident with obstructive and reflux uropathy and chronic embolism/thrombosis, Hiprex was ordered for UTI prevention without an end date, and Cefuroxime Axetil was ordered for left hand swelling. The care plan included monitoring for adverse effects every shift, but the progress notes did not consistently show this monitoring. The DSD and DON stated the Hiprex order lacked a duration, the Cefuroxime indication was a symptom rather than a diagnosis, and there was no evidence of consistent adverse-effect monitoring. For a third resident admitted with MRSA infection in the blood, Daptomycin was ordered intravenously every 24 hours for 8 weeks. The care plan directed staff to monitor for adverse reactions every shift, but the progress notes from the start of therapy through the review period did not show monitoring for adverse side effects. The IP and DON both stated that licensed nurses were supposed to monitor residents on antibiotics every shift and document those observations in the progress notes.
Frayed bed remotes and nonfunctioning call light
Penalty
Summary
The facility failed to maintain resident care equipment in safe operating condition when bed remote controls for three residents were observed with frayed and exposed wires near the control pad. Resident 49 was admitted with diagnoses including difficulty walking, muscle weakness, and spondylopathy of the lumbosacral region. The resident’s record showed the resident had the capacity to understand and make decisions at admission, while the MDS later indicated severe cognitive impairment and dependence for mobility and ADLs. During observation in the resident’s room, the bed remote control had peeling wires that were frayed and exposed, and the RNA stated the remote should have no exposed wires to prevent electrocution. Resident 136 was admitted with diagnoses including major depressive disorder, generalized anxiety disorder, and restlessness and agitation. The resident’s H&P indicated the resident did not have the capacity to understand and make decisions, and the MDS showed severe cognitive impairment, dependence for mobility and ADLs, and high fall risk. During observation in the resident’s room, the bed remote had peeling and exposed wires near the control pad. The CNA stated there should be no exposed electrical wires in the resident’s environment because of the risk of accidents such as electrocution. Resident 3 was admitted and later readmitted with diagnoses including a stage four sacral pressure ulcer, paraplegia, and major depressive disorder. The resident’s H&P indicated the resident did not have the capacity to understand and make decisions, and the MDS showed moderately impaired cognition and dependence for mobility and ADLs. During observation in the resident’s room, the bed remote control had frayed and exposed wires near the control pad, and the CNA stated there should be no exposed electrical wires to prevent accidents such as electrocution. The CNA also attempted to use the bed remote to elevate the bed for care, but the remote was not working. The facility also failed to maintain the resident call system in functional condition for Resident 41, who was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction, essential hypertension, and morbid obesity. The MDS showed the resident could make self-understood and understand others, had moderate cognitive impairment, and needed maximal assistance with mobility and ADLs. The resident stated the resident had been calling to be changed but no one would go to the room. When the resident pressed the call light, the light outside the room did not illuminate or ring at the nurse’s station. CNA 7 and ADON 2 observed the same malfunction, and CNA 7 stated the resident would not be able to call for assistance if the call light was not working.
Dignity and Privacy Failures During Meal and G-Tube Care
Penalty
Summary
Resident 3 was observed eating lunch in bed while his incontinence brief had not been changed and he had stool in the brief. During the lunch observation, the resident told CNA 3 that he needed to be cleaned before eating and stated that he could not eat with feces in his brief. CNA 3 told him to eat first and said he would be cleaned after he had eaten, while continuing to reposition him, elevate the head of the bed, and prepare the lunch tray. The DSD later observed the resident eating with the brief still unchanged and stated the brief should have been changed first because it was a dignity issue. Resident 3’s record showed diagnoses including paraplegia, a stage 4 pressure ulcer of the sacral region, and major depressive disorder. The H&P stated he did not have the capacity to understand and make decisions, while the MDS indicated he could make himself understood and understand others, had moderate cognitive impairment, was dependent or needed set-up assistance with mobility and ADLs, was frequently incontinent of stool, and was at risk for pressure injuries with one unhealed pressure injury. His care plan included a bowel/bladder program to improve or maintain continence if needed. Resident 287 was observed in the room while LVN 4 administered medications via G-tube with the privacy curtain fully open, leaving the resident exposed and visible from the hallway. LVN 4 stated that leaving the curtain open exposed the resident and violated privacy and dignity. Resident 287’s record showed diagnoses including hydrocephalus, hypertension, encephalopathy, and dysphagia, and the MDS indicated severely impaired cognition, dependence with all ADLs, and use of a feeding tube. The DON stated the privacy curtain must be closed during G-tube medication administration to protect privacy and dignity.
Nonfunctional Closet Drawer
Penalty
Summary
The facility failed to provide a homelike environment for one sampled resident by not maintaining functional closet drawers. Resident 2 was admitted on 2/21/2025 and readmitted later, with diagnoses including metabolic encephalopathy, type 2 DM, and dysphagia. The resident's MDS dated 3/2/2026 indicated severely impaired cognitive skills for daily decision making and dependence on staff for toileting hygiene, showering, lower body dressing, footwear, chair/bed-to-chair transfer, and tub/shower transfer. During a concurrent observation and interview on 4/22/2026, RN 1 observed that Resident 2's closet drawer was broken and hanging down, and stated the drawer had a broken handle and was nonfunctional. RN 1 stated broken drawers should be addressed promptly to ensure residents maintain a homelike environment, dignity, and the ability to safely store and access personal belongings. During an interview on 4/24/2026, the DON stated that broken furniture needs to be addressed to maintenance immediately and that nonfunctioning furniture can negatively affect a resident's mood and psychosocial wellbeing, potentially leading to frustration, decreased independence, and reduced quality of life. The facility's Homelike Environment policy stated that residents are provided with a safe, clean, comfortable, and homelike environment and encouraged to use personal belongings to the extent possible.
Unnecessary Psychotropic Medication Monitoring Deficiency
Penalty
Summary
The facility failed to ensure that one sampled resident with dementia, anxiety disorder, and Type II diabetes mellitus was free from unnecessary psychotropic medication use and chemical restraint concerns. Resident 175 was admitted with fluctuating capacity to understand and make decisions, and a physician order later directed lorazepam oral concentrate 2 mg/ml, 0.5 ml sublingually every 4 hours as needed for anxiety manifested by increased restlessness leading to shortness of breath for 14 days, with non-pharmacological interventions to be provided before administration. During a concurrent interview and record review, the ADON stated there was no care developed for the use of lorazepam and monitoring for its black box warning adverse effects. The ADON stated there was no order for monitoring adverse effects or behavioral monitoring for anxiety manifested by increased restlessness leading to shortness of breath, and that behavior and adverse effect monitoring should be used to determine whether the medication was effective or needed adjustment. The facility policy on psychotropic medication use stated residents do not receive psychotropic medications that are not clinically indicated and necessary to treat a specific condition documented in the medical record, and that residents receiving psychotropic medication are monitored and the response to treatment is documented.
Failure to Timely Report Unwitnessed Fall With Injury of Unknown Origin
Penalty
Summary
The facility failed to report an unwitnessed fall with injuries of unknown origin to the State Survey Agency immediately, and no later than two hours after the allegation, for one resident. Resident 23 was admitted with diagnoses including a displaced comminuted fracture of the left fibula, Alzheimer’s disease, and osteoporosis. The resident’s MDS showed a BIMS score of 00, indicating severe cognitive impairment, and the resident required assistance with multiple activities of daily living. The fall risk assessment identified the resident as high risk for falls. On 4/11/2026, staff found Resident 23 lying on the floor on her back next to the bed with blood on her face. RN 3 documented a bump, skin discoloration, and a skin tear on the left forehead, a skin tear on the bridge of the nose, and a skin tear above the right eyebrow. Staff called 911, and EMTs transferred the resident to the hospital. The hospital ED note identified the event as an unwitnessed fall and documented laceration repairs with sutures to the forehead, bridge of the nose, and right eyebrow. During interviews, RN 3 stated she responded to the room after being paged and found the resident on the floor with blood on her face. LVN 5 stated CNA 11 called her after observing the resident on the floor while passing by the room, and LVN 5 then found the resident on the floor and notified the RN supervisor and PCP. The DON stated the resident sustained an unwitnessed fall with lacerations requiring stitches, that no staff directly observed how the injuries occurred, and that the incident was not reported to the SA. The facility policy reviewed by the DON stated suspected abuse, neglect, exploitation, misappropriation, or injury of unknown source must be reported immediately according to state law.
Care Plan Did Not Match Current Oxygen Order
Penalty
Summary
The nursing staff failed to revise Resident 212’s care plan to reflect a change in the physician’s oxygen order. Resident 212 was admitted with diagnoses including COPD, dysphagia, and generalized muscle weakness, and the H&P indicated the resident had the capacity to understand and make decisions. The MDS showed the resident could make self understood and understand others, had intact cognitive function, and required partial to moderate assistance with several activities of daily living. A review of the OSR showed an order for oxygen at 2 liters per minute via nasal cannula continuously, every shift. However, the care plan still listed continuous oxygen at 4 liters via nasal cannula related to COPD, with a goal of effective airway exchange and an intervention to administer oxygen at 4L via nasal cannula. During interview and record review, RN 5 stated the care plan needed to match the OSR and that it did not, and the DON stated a care plan needed to follow the OSR and if incomplete could not meet resident needs. The facility policy stated care plans are revised as residents’ conditions change.
Failure to Rotate Insulin Injection Sites
Penalty
Summary
Licensed nursing staff failed to rotate subcutaneous insulin administration sites for two residents, despite orders and care plan interventions directing that injection sites be rotated. The deficiency was identified during record review and interviews with the Director of Staff Development (DSD) and Director of Nursing (DON), who both stated that the staff did not follow the facility’s insulin administration policy or the manufacturers’ instructions for the insulin products used by the residents. One resident had diagnoses including type 2 DM and mild protein-calorie malnutrition, and the record showed orders for Basaglar, insulin lispro, and sliding-scale insulin with instructions to rotate injection sites. The care plan also identified a potential for skin discoloration related to insulin injections and included an intervention to rotate injection sites regularly. The location of administration record showed repeated insulin injections in the same abdominal areas on multiple occasions, including the LLQ, LUQ, and RUQ, rather than consistent rotation across sites. The second resident had diagnoses including DM with diabetic neuropathy, morbid obesity, and disease of spleen, and the record showed orders for NovoLog and Lantus with instructions to rotate insulin sites. The care plan again identified a potential for skin discoloration related to insulin injections and directed regular rotation of injection sites. The location of administration record showed repeated NovoLog injections in the same abdominal quadrants on multiple dates, including multiple injections in the LLQ, LUQ, and RLQ. The DSD stated there were multiple instances where licensed staff did not rotate the insulin administration sites for both residents, and the DON stated the staff did not follow the facility policy and manufacturer specifications.
Failure to Follow Up After Ophthalmology Appointment
Penalty
Summary
The facility failed to ensure that Resident 53 received proper treatment after an ophthalmology appointment. Resident 53 was admitted with diagnoses including diabetes mellitus, difficulty walking, and depression, and the record also noted fluctuating capacity to understand and make decisions and moderate cognitive impairment. The care plan identified impaired vision and eye-related concerns, including the need to monitor for irritation, redness, dryness, and to arrange consultation with an eye care practitioner as required. During observation and interview, Resident 53 reported dryness in the left eye for 7 weeks and described it as feeling like a scratch on the skin. The resident stated he had eye surgery in the past, had used eye drops previously, and had complained to multiple staff about the dryness and requested eye drops, but felt ignored. On concurrent interview, the resident again stated that he had informed multiple staff that nothing had been done and requested eye drops for relief. Record review and staff interviews showed that Resident 53 had an ophthalmology appointment, but there was no documentation that he returned from the appointment or that any visit note or new orders were received and carried out. LVN staff stated that the appointment result was not available in the chart and that there was no order for eye drops. The visit note from the ophthalmology appointment documented complaints of pain in both eyes, floaters, blurry vision, and pain for 6 months, with the resident using over-the-counter dry eye drops. Staff interviews also confirmed that documentation was required when residents left for and returned from appointments, and that the resident's needs were not addressed.
Failure to Notify Physician and Assess Repeated Splint Refusals
Penalty
Summary
The facility failed to provide restorative nursing services for a resident with limited ROM and mobility related to hemiplegia and hemiparesis following a cerebral infarction, seizure, and anemia. The resident was admitted with fluctuating capacity to understand and make decisions, and later assessments showed clear speech and the usual ability to understand others, with substantial/maximal assistance needed for mobility and ADLs. The resident had orders for a right resting hand splint and a right elbow splint to be applied by RNA 5 times per week for 4 to 6 hours per day or as tolerated for contracture management of the right upper extremity, with monitoring for redness, skin irritation, or discomfort. During observation, the resident was seen without the right hand and right elbow splints in place. RNA staff stated the resident had already completed ROM exercises and that the resident refused to wear the splints because they were painful. One RNA stated the resident had refused the splints for a long time and that charge nurses were aware of the refusals. The Assistant DON reviewed nursing progress notes, RNA weekly summaries, and eINTERACT SBAR documentation and stated there was no SBAR documentation for the resident's refusal to wear the splints. The ADON stated the SBAR should include assessment information such as pain, body system, mental and functional status, change in condition, notification of the clinician/doctor, notification of the family or resident representative, and any intervention orders. The ADON also stated there should have been an SBAR completed when the resident refused the splints, but there was none. The report also states the physician was not notified when the resident had constant refusals for the right hand and right elbow splints.
Failure to Complete Monthly Weight Loss Assessment and Update Care Plan
Penalty
Summary
The facility failed to recognize, evaluate, and address the nutritional needs of a resident at risk for impaired nutrition and hydration by not completing the monthly weight loss assessment as established by the interdisciplinary team. The resident was admitted with diagnoses including GERD, major depressive disorder, and a stage 4 sacral pressure ulcer, and the H&P stated the resident did not have the capacity to understand and make decisions. The MDS later indicated the resident had moderately impaired cognition, required set-up assistance with eating, and had experienced 5% or more weight loss in the last month or 10% or more in the last 6 months without a physician-prescribed weight-loss regimen. The resident’s weight record showed fluctuations, including weights of 166.2 lbs., 151.7 lbs., 151 lbs., and 162 lbs. The care plan identified the resident as at risk for weight loss and documented actual significant weight loss related to dialysis with accompanying fluid shifts. The care plan goal was to avoid significant weight change, with interventions including RD evaluation as indicated, weekly weights, and reporting significant weight changes to the physician. A dietary note later documented that the IDT reviewed the resident for a 19 lb. weight loss over 3 months, equal to 11.4%, with a height of 69 inches, weight of 151.5 lbs., BMI of 22.4, and multiple diet orders including CCHO, renal, double portions, IDDSI level 7 easy-to-chew texture, thin liquids, a sugar-free renal HS snack, and a 1200 ml/day fluid restriction. During interview, the RD stated she completed the weight loss calculation and identified the 11.4% loss but did not update the prior care plan to reflect the current weight loss. The RD stated monthly weight loss assessments should be done on the first of the month and that the care plan should have been updated after 72 hours. The DON also stated the RD should have performed the monthly assessment on the first of April and updated the care plan immediately.
Failure to Follow Up on Dental Needs and Denture Fitting
Penalty
Summary
The facility failed to follow up on a resident’s request for dentures after the resident was seen by the dentist and the dentist recommended new dentures/partials and tooth extractions. Resident 80 was admitted on 8/3/2021 and readmitted on 8/16/2023 with diagnoses including morbid obesity, type 2 DM, and disease of spleen. The resident’s H&P dated 12/5/2025 indicated the resident had the capacity to understand and make decisions, and the MDS dated 2/23/2026 indicated the resident could make self-understood and understand others, had intact cognition, and needed setup or clean-up assistance with eating. The record showed an order for dental consultation as needed, and an Onsite Mobile Dental form dated 11/21/2025 documented that the resident wanted teeth and that the dentist recommended teeth extractions and new dentures/partials. A later OMB form dated 12/12/2025 documented 12 PA x-rays but did not include a patient chief complaint or treatment recommendations. During interview and record review, the SSA stated there was no follow up after the 12/12/2025 dental visit and that she overlooked the resident’s dental needs. The DSD stated social services was responsible for scheduling dental services, that the SSA should have followed up the extraction and x-ray results to facilitate denture fitting, and that it was not appropriate to wait four months for denture fitting. The DON stated the SSA should have followed up within the same month the x-rays were done.
Resident Touched and Poured Water From Medication Cart During Med Pass
Penalty
Summary
The facility failed to implement and maintain its infection control program when Resident 153 poured a cup of water from the top of Med Cart 1 during a medication pass observation in front of Station 2 desk. Resident 153 had been admitted with diagnoses including UTI, bacteremia, and pneumonia, and the H&P and MDS indicated the resident had intact cognition, could understand and make decisions, and was able to make needs known. During the observation, Med Cart 1 and Med Cart 2 were positioned in front of Station 2 desk with LVN 2, LVN 12, and RN 1 present. Resident 153 poured water from Med Cart 1, drank from the cup, discarded it in the trash bin on the cart, and left. The staff did not educate Resident 153 at the time about not pouring or touching items on top of the medication cart. During interviews, LVN 2 stated she did not see the resident pour the water because the computer screen blocked her view, while LVN 12 and RN 1 stated they did not notice the act and could not explain why it was not observed. All three staff stated residents are not supposed to pour liquids from medication carts because it is an infection control issue and could contaminate items on top of the carts; they also stated residents may have fluid restrictions or may not be appropriate to consume thin liquids. The IP and DON both stated residents should not touch anything on top of medication carts and that the licensed nurses should have called the resident’s attention and educated him not to touch the items used for medication administration. The facility’s IPCP policy stated the program is established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.
Failure to Document Hospital Discharge Communication in Resident Medical Record
Penalty
Summary
The facility failed to maintain an accurate and complete medical record for one of three sampled residents by not documenting a key communication regarding the resident’s potential return from a general acute care hospital. The resident had been admitted with diagnoses including unspecified parkinsonism, aphasia, and generalized muscle weakness, and had documented fluctuating capacity to understand and make decisions, with an MDS indicating moderately impaired cognitive skills for daily decisions. On the day in question, the Admissions Assistant (AA) spoke with the hospital Case Manager (CM) about the resident’s discharge back to the facility and informed the CM that the facility would accept the resident once candida auris test results were received so that appropriate isolation room arrangements could be made. During interviews and record review, surveyors found no documentation of this conversation in the resident’s progress notes for that date. The AA acknowledged that the discussion with the CM was not documented and stated she had time to document it before leaving the facility but did not do so. The Assistant Director of Nursing (ADON) reported having no knowledge of whether the resident was returning and stated that the AA should have documented the conversation to ensure timely communication among departments and to maintain an accurate and complete medical record. Review of the facility’s Charting and Documentation policy with the Director of Nursing (DON) showed that all services and changes in a resident’s condition must be documented, and that documentation must be objective, complete, and accurate to facilitate communication among the IDT, underscoring that the missing entry was inconsistent with facility policy.
Obstructed Emergency Exit Doors and Egress Paths
Penalty
Summary
The deficiency involves the facility’s failure to keep designated emergency exit doors and their egress paths free from obstruction. During an observation, surveyors noted that Exit Door 2, located in Station 5’s hallway between the dayroom and the Director of Staff Development classroom, was blocked by a signage board that indicated “emergency exit only,” and there were no staff present in that hallway at the time. In a separate observation with an LVN, Exit Door 1, located in Station 2’s hallway between two resident rooms, was found blocked by a wheelchair and a floor cleaner machine. The LVN stated that the hallway leading to the emergency exit door should be clear of any equipment. In a concurrent observation and interview with the Operations Assistant, Exit Door 1 was again observed blocked by a floor cleaner machine, and the Operations Assistant stated that equipment should be kept on one side of the hallway to allow full access to emergency exit doors. During an interview and review of the facility map with the DON, the DON acknowledged that the blocked emergency exit doors had the potential to delay emergency response and pose a danger to staff and residents, and stated that emergency exit doors should be clear and open to the outside for safety during an emergency. Review of the facility’s policy titled “Exits or Means of Egress,” last reviewed on 1/27/2026, showed that the policy required all personnel to keep exits clear at all times and that exit doors are never to be blocked, even briefly, which was not followed in these instances.
Failure to Monitor Antipsychotic Side Effects and Obtain Valid Informed Consent
Penalty
Summary
The deficiency involves the facility’s failure to prevent unnecessary chemical restraint and to adequately monitor and obtain informed consent for the use of the antipsychotic medication quetiapine for one resident. The resident was admitted with diagnoses including orthopedic aftercare, unspecified psychosis, and a history of falls. The admission History and Physical dated 12/19/2025 documented that the resident did not have the capacity to understand and make decisions, while a subsequent MDS dated 12/25/2025 indicated intact cognitive skills for daily decisions and that the resident was receiving an antipsychotic. On 12/22/2025, the physician ordered quetiapine 100 mg by mouth at bedtime for psychosis manifested by delusions. The facility failed to follow physician orders for monitoring orthostatic blood pressure related to quetiapine use. An order dated 1/15/2026 required orthostatic blood pressure checks (lying and then sitting within three minutes) every Sunday, with instructions to call the physician if the systolic blood pressure changed by more than 20 mmHg or the diastolic by more than 10 mmHg. Review of the January 2026 MAR showed that on 1/18/2026 and 1/25/2026, the assigned LVN documented orthostatic blood pressure as “not applicable” for both lying and sitting positions, meaning the ordered monitoring was not performed. The ADON and DON both stated that quetiapine can cause orthostatic hypotension, that the order required weekly orthostatic blood pressure monitoring, and that failure to complete and document these assessments could delay physician notification and delay care. Facility policies on Adverse Consequences and Medication Errors and on Psychotropic Medication Use required monitoring residents for adverse consequences and documenting responses to psychotropic medications. The facility also failed to obtain appropriate informed consent for the initiation and subsequent dose increase of quetiapine. An informed consent form dated 12/19/2025 documented that the resident verbally consented to quetiapine 50 mg twice a day for agitation and aggression, verified by an RN. However, the H&P from the same date indicated the resident lacked capacity to understand and make decisions. The ADON stated the facility should have followed the H&P and clarified with the physician and informed the responsible party. On 12/22/2025, the order was clarified to quetiapine 100 mg at bedtime, and on 12/28/2025, an additional order for quetiapine 50 mg in the evening was added, resulting in a total daily dose of 150 mg from 12/28/2025 to 1/4/2026. The ADON and DON stated that when the dose of a psychotropic medication is increased, a new informed consent is required, and acknowledged that no new consent was obtained when the dose was increased to a total of 150 mg. The DON further stated that, because the resident did not have capacity, the responsible party should have provided consent, and that without valid informed consent, the responsible party’s rights were violated. Review of the facility’s Psychotropic Medication Use and Antipsychotic Medication Use policies showed requirements to inform residents or representatives of the recommendation, risks, benefits, purpose, and potential adverse consequences of antipsychotic use and to obtain documented consent prior to initiating or increasing psychotropic medications, which the DON stated were not followed.
Failure to Follow PRN Pain Medication Orders for Severe Pain
Penalty
Summary
The deficiency involves the facility’s failure to administer pain medication according to physician orders for one resident. The resident was admitted with diagnoses including orthopedic aftercare, unspecified COPD, and acute and chronic respiratory failure with hypoxia. An H&P dated 12/19/2025 indicated the resident did not have capacity to understand and make decisions, while an MDS dated 12/25/2025 documented intact cognitive skills for daily decisions, a need for supervision with hygiene, toileting, and showering, and occasionally moderate pain. Physician orders dated 1/15/2026 directed that hydrocodone-acetaminophen 5-325 mg be given every four hours as needed for moderate pain rated 4–6, and oxycodone-acetaminophen 7.5-300 mg be given every six hours as needed for severe pain rated 7–10. Review of the MAR for January 2026 showed that LVN 2, LVN 3, and LVN 4 administered hydrocodone instead of the ordered oxycodone when the resident’s pain was documented at levels 7 or 8 on four separate occasions (1/21/2026 at 2:27 a.m., 1/25/2026 at 6:28 a.m., 1/26/2026 at 1:10 a.m., and 1/29/2026 at 3:10 a.m.). During interviews, the ADON confirmed that the physician’s order specified hydrocodone for pain levels 4–6 and oxycodone for pain levels 7–10, and acknowledged that the nurses should have administered oxycodone instead of hydrocodone on those dates. The DON also stated that nurses are expected to follow physician orders and that the resident’s pain could not be completely relieved because the orders were not followed. Review of facility policies on Pain Assessment and Management and Administering Medications showed that medications are to be implemented and administered as ordered, including required time frames.
Failure to Develop and Implement Person-Centered Care Plans for Oxygen Use and Fall Risk
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered care plans with measurable objectives and timetables for identified resident needs. For one resident admitted with diagnoses including orthopedic aftercare, unspecified COPD, and acute and chronic respiratory failure with hypoxia, the physician ordered continuous oxygen at two liters per minute via nasal cannula every shift. The resident’s H&P documented that the resident did not have capacity to understand and make decisions, while the MDS indicated intact cognitive skills for daily decisions and a need for supervision with hygiene, toileting, and showering. Despite these findings and the continuous oxygen order, staff interviews and record review confirmed there was no care plan addressing the resident’s noncompliance or refusal related to oxygen use. During an observation at the bedside, the resident was found asleep with the oxygen concentrator running at five liters per minute, but the nasal cannula was not connected and was hanging on a portable emergency light on the rolling table. The RN present verified that oxygen was running at five liters per minute and that the cannula was not in place. A CNA stated that if the cannula was not connected, the resident had removed it. The LVN and ADON both confirmed on review that there was no care plan developed for the resident’s refusal or removal of the oxygen cannula. The DON stated that without a care plan for the resident’s removal of the oxygen cannula, the facility would not be able to provide care and address the resident’s refusal, and that the resident could have hypoxia for not using oxygen. For a second resident admitted with left shoulder primary osteoarthritis, morbid obesity, and right knee pain, the H&P documented fluctuating capacity to understand and make decisions. The resident’s care plan for fall risk, initiated at admission, included an intervention to keep the bed in a low position with brakes locked. The MDS showed intact cognitive skills for daily decisions and a need for moderate assistance with toileting and lower body dressing, and a Fall Risk Observation/Assessment identified the resident as high risk for falls. However, during observation, the resident was found asleep with the bed in a high position. The ADON confirmed there was no care plan addressing the resident’s bed being kept in a high position, even though the resident was at high risk for falls and reportedly preferred the bed high. A CNA stated it was the first time she observed the bed high and acknowledged the resident could fall off if left too high, and an LVN stated he had just learned of the resident’s preference for a high bed and that a care plan should have been developed for this preference to prevent falls. The DON confirmed that the resident was high risk for falls, had no care plan for a high bed position, and that the resident put the bed up high and this should have been care planned as a resident preference.
Failure to Maintain Low Bed Position for High Fall-Risk Resident
Penalty
Summary
The facility failed to ensure a high fall-risk resident’s environment was free from accident hazards and that care-planned fall-prevention interventions were implemented. The resident was admitted with diagnoses including left shoulder primary osteoarthritis, morbid obesity, and right knee pain, and had a history and physical noting fluctuating capacity to understand and make decisions. The resident’s care plan for fall risk, initiated shortly after admission, specified that the bed should be kept in a low position with brakes locked. A subsequent MDS assessment documented that the resident’s cognitive skills for daily decision-making were intact and that the resident required moderate assistance for toileting and lower body dressing. A Fall Risk Observation/Assessment identified the resident as being at high risk for falls. During an observation outside the resident’s room, surveyors found the resident asleep in bed with the bed in a high position, contrary to the care-planned intervention. In interviews and concurrent record reviews, the ADON confirmed there were no care plan interventions addressing the bed being in a high position and acknowledged that the resident could fall and be injured if the bed were high. CNA 1 reported it was the first time she observed the bed too high and stated the resident could fall off the bed if left in that position. The DON reviewed the Fall Risk Observation/Assessment and confirmed the resident was high risk for falls, that there was no care plan developed for use of a high bed position, and that the resident raised the bed and this preference had not been care planned. The facility’s Falls/Accident/Fall Management Prevention policy stated that, based on assessment, staff and the physician will identify pertinent interventions to prevent falls and address fall risks, but this was not followed in relation to the resident’s high bed position.
Failure to Follow Oxygen Orders and Ensure Proper Oxygen Administration
Penalty
Summary
The deficiency involves the facility’s failure to provide respiratory care consistent with professional standards and physician orders for a resident with COPD and acute and chronic respiratory failure with hypoxia. The resident was admitted with diagnoses including unspecified COPD, orthopedic aftercare, and acute and chronic respiratory failure with hypoxia. An H&P dated 12/19/2025 documented that the resident did not have capacity to understand and make decisions, while an MDS dated 12/25/2025 indicated intact cognitive skills for daily decisions and a need for staff supervision with hygiene, toileting, and showering. Initial physician orders on 12/19/2025 directed oxygen at 4 L/min via nasal cannula, continuous with humidification for COPD and shortness of breath every shift, and a subsequent order dated 1/14/2026 changed the oxygen to 2 L/min via nasal cannula continuously every shift. On observation on 1/29/2026 at 9:19 a.m., the resident was found asleep at bedside with an oxygen concentrator running at 5 L/min via nasal cannula, but the nasal cannula was not connected to the resident and was instead hanging on a portable emergency light on top of the resident’s rolling table. A concurrent observation and interview with an RN confirmed that the oxygen was running at 5 L/min and that the nasal cannula was not attached to the resident. The RN called an LVN to obtain a pulse oximeter reading. At 9:25 a.m., the LVN placed the pulse oximeter on the resident’s left index finger, which showed an oxygen saturation of 92%, then reconnected the nasal cannula to the resident. The LVN stated that the resident’s oxygen saturation fluctuated between 80% and 90% while on 5 L/min, and the resident subsequently awoke, coughed up white phlegm, and the oxygen saturation increased to 91%. During interviews and record reviews, the ADON confirmed that the physician’s order dated 1/14/2026 specified oxygen at 2 L/min via nasal cannula and stated that a physician order was required to increase or titrate the oxygen, and there was no such order in place. The ADON stated that a resident not connected to ordered oxygen could experience shortness of breath. The LVN reported having observed the resident’s oxygen set at 5 L/min and acknowledged that the resident had a history of COPD and that giving high oxygen can cause shortness of breath. The DON stated that nurses should follow the physician’s order for continuous oxygen at only 2 L/min and that higher oxygen administration could result in hyperventilation. Review of facility policies showed that medications, including oxygen, must be administered in accordance with prescriber orders and that oxygen administration procedures require ensuring the proper flow of oxygen is being administered, which was not followed in this case.
Failure to Document Family Medication Concern in Resident Medical Record
Penalty
Summary
The facility failed to maintain an accurate and complete medical record for a resident by not documenting a family member’s report and related discussion about the resident’s medications. The resident was admitted with diagnoses including orthopedic aftercare, unspecified psychosis, and a history of falls. The admission History and Physical documented that the resident did not have capacity to understand and make decisions, while the subsequent MDS assessment indicated intact cognitive skills for daily decisions, a need for staff supervision with hygiene, toileting, and showering, and use of antipsychotic medication. On the second day after admission, the resident’s family member reported finding pills in a clear plastic bag and communicated this concern, including a photo, to the Social Service Assistant. The Social Service Assistant later confirmed that the family member had spoken with her about the resident’s medications and had shown her a picture of a clear plastic bag with pills, reporting that the resident had been caught with pills in the general acute care hospital. The Social Service Assistant acknowledged that she did not document this conversation or the concern in the resident’s medical record. Review of the facility’s Charting and Documentation policy showed that all changes in a resident’s medical, physical, functional, or psychosocial condition, as well as events or incidents involving the resident, must be documented in the medical record to facilitate communication among the interdisciplinary team. The DON stated that the Social Service Assistant should have documented the concerns and conversation with the family member and that the absence of this documentation rendered the resident’s medical record incomplete, contrary to facility policy.
Failure to Maintain Oxygen Tubing Off the Floor for Infection Control
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control practices related to the handling of oxygen tubing for one resident. The resident was admitted with diagnoses including orthopedic aftercare, unspecified COPD, and acute and chronic respiratory failure with hypoxia. The resident’s History and Physical dated 12/19/2025 indicated the resident did not have the capacity to understand and make decisions, while the MDS dated 12/25/2025 documented that the resident’s cognitive skills for daily decisions were intact and that the resident required supervision from staff for hygiene, toileting, and showering. During an observation at the resident’s bedside, the resident was asleep with an oxygen concentrator set at five liters per minute via nasal cannula. The nasal cannula was not connected to the resident and was hanging on a portable emergency light on top of the resident’s rolling table, with the oxygen tubing touching the floor. In interviews, the ADON stated that oxygen tubing should not be touching the floor for infection control, and the DON stated the resident could get an infection if oxygen tubing was touching the floor. The DON also stated that the facility did not have a specific written policy stating that oxygen tubing should not touch the floor, but that the facility’s practice was to keep oxygen tubing off the floor for infection control.
Failure to Maintain Effective Interior Pest Control Program
Penalty
Summary
The facility failed to maintain an on-going, effective pest control management program that monitored, identified, controlled, and prevented pest infestations throughout the building, including interior areas. One resident with DM II, depression, COPD, and fluctuating capacity, but assessed as cognitively intact and requiring maximal assistance with toileting and showers and total assistance with chair-to-bed transfers, reported seeing cockroaches in her room and in the hallway outside her room on multiple occasions over the prior several months. She stated she informed facility staff, who responded by killing the cockroaches by stepping on them and discarding them in the trash. Another cognitively intact resident with asthma, anxiety disorder, and muscle weakness, who required moderate assistance with toileting and transfers and was dependent for chair-to-bed transfers, reported seeing cockroaches in her room two to three weeks prior and expressed worry that the cockroaches would crawl onto her bed. Record review and staff and contractor interviews showed that the facility’s pest control program focused on monthly exterior inspections and treatments conducted by a pest control management company, while the interior of the facility was not included in routine monthly inspections. The Maintenance Supervisor confirmed that the pest control company only inspected the exterior monthly and that interior inspections were done only when specific pest issues were identified and reported, and further stated there was no documented record indicating that the facility’s interior was routinely inspected as part of the pest control program. The facility’s pest control policy, last revised on 11/6/2025, stated that the facility would maintain an effective, on-going pest control program to keep the building free of insects and rodents. The Maintenance Supervisor acknowledged that the lack of an on-going, effective pest control program, including routine interior inspections, had the potential for pest infestation that could lead to infection and illness among residents.
Incomplete Fall Risk Documentation for Dependent Resident With Paraplegia
Penalty
Summary
The facility failed to maintain an accurate and complete medical record for one resident by not correctly documenting the resident’s fall risk status on Fall Risk Observation/Assessment forms. The resident was admitted with diagnoses including paraplegia, osteoarthritis of the hip, and a stage 4 sacral pressure ulcer, and the H&P documented fluctuating capacity to understand and make decisions. An MDS assessment indicated the resident was dependent on staff for toileting hygiene, personal hygiene, showers, dressing, and transfers. Despite these conditions, the Fall Risk Observation/Assessment forms dated 10/20/2025 and 11/24/2025 indicated the resident did not have neuromuscular or functional health conditions and risk factors for falls such as loss of arm or leg movement. During a concurrent interview and record review, the DON confirmed that the Fall Risk Observation/Assessment form is one of the tools used to evaluate residents’ fall risk and provide necessary care and interventions, and that the form generates a score based on the answers provided. The DON stated that the resident’s Fall Risk Observation/Assessment forms were incomplete and did not indicate the diagnosis of paraplegia, which resulted in a lower fall risk score. The facility’s Charting and Documentation policy required that all services, progress toward care plan goals, and any changes in the resident’s condition be documented in an objective, complete, and accurate manner to facilitate communication among the interdisciplinary team, but this standard was not met for this resident’s fall risk documentation.
Failure to Accurately Document Medication Administration
Penalty
Summary
A deficiency occurred when a Licensed Vocational Nurse (LVN) failed to accurately document the administration of apixaban, an anticoagulant, for a resident with diagnoses including sepsis, end stage renal disease, and diabetes mellitus type II. The resident was admitted with an order for apixaban to be given twice daily for deep vein thrombosis prophylaxis. On the morning in question, the LVN marked the medication as administered on the Medication Administration Record (MAR), despite the medication still being present in the bubble pack and not actually given to the resident. The LVN was unable to explain why the medication was documented as given when it had not been administered. Further review by facility leadership confirmed that the resident was out for dialysis at the time the medication was marked as given, and there was no nursing note explaining the discrepancy. The Assistant Director of Nursing (ADON) and Director of Nursing (DON) both acknowledged that the MAR should accurately reflect medication administration and that signing for a medication not given creates a discrepancy in the medical record. Facility policy requires all services and changes in condition to be documented completely and accurately to facilitate communication among the care team.
Care Plan Not Updated for New Skin Problems
Penalty
Summary
The facility failed to review and revise a comprehensive care plan for one sampled resident to reflect newly identified skin problems. The resident was admitted with diagnoses including DM II, depression, and combined systolic and diastolic heart failure, and the H&P noted fluctuating capacity to understand and make decisions. The MDS dated 10/8/2025 indicated moderately impaired cognitive functioning and dependence on staff for toileting hygiene, personal hygiene, showers, and upper and lower body dressing. The record showed a change of condition form dated 10/10/2025 identifying a right abdominal skin fissure, and a dermatology progress note dated 11/18/2025 describing pink, erythematous, scaly plaques involving bilateral upper and lower extremities. During a concurrent interview and record review, LVN 1 stated the care plan was not updated to reflect the resident's skin concerns and that care plans need to be updated when residents develop new skin issues. The DON stated the resident's care plan should have been updated when the skin problems were initially identified, and that the care plan should reflect long-term and short-term goals and interventions.
Failure to Manage Legionella in Water System and Report Positive Findings
Penalty
Summary
The facility failed to provide and implement its infection prevention and control program in relation to Legionella bacteria found in the water system. Multiple Annual Analytical Validation Viable Legionella Bacteria Reports dated from 2/26/2024 through 3/17/2025 showed detectable Legionella in domestic water samples, including samples from resident rooms and Bathtub 1. The reports included recommendations to flush positive fixtures and adjacent taps, verify hot water temperature, replace affected showerheads and hose lines, descale or disinfect fixtures, re-test positive locations after corrective actions, and consider additional control measures when repeated positives continued. The facility’s Water Management Program Water Safety Plan also stated that affected fixtures could be isolated and that water should be re-sampled after corrective actions, but the report states the facility did not follow or act on these recommendations and there was no documented evidence that the actions were implemented. The Infection Preventionist Nurse stated she did not carry out her role in managing Legionella and did not maintain logs showing whether residents were monitored for potential exposure. She also stated she was not aware the facility’s water tested positive on 2/26/2024 and only learned of later results after the previous administrator informed her. The DON stated she was not aware of the 3/17/2025 positive water test and that there was no documented evidence the facility monitored residents for Legionella exposure. The DON and IP Nurse also stated the facility failed to implement and follow the water management plan recommendations, and the DON stated the presence of Legionella in the water system was not reported to CDPH. Resident 1 was admitted with COPD and type 2 DM and was severely impaired in thought processes and dependent for ADLs. On 10/25/2025, Resident 1 had a change in condition with altered mental status, fever, shortness of breath, and unresponsiveness, and was transferred to a GACH. The hospital record showed Resident 1 underwent a Legionella pneumoniae sputum procedure that detected Legionella bacteria. The report also states the facility failed to ensure communication between the previous and current administrators regarding the positive Legionella findings, and the current administrator stated he was not aware of the water test results because they had been reported to the previous administrator.
Leaking Ceiling Left Residents in Unsafe Room
Penalty
Summary
The facility failed to ensure resident safety for three sampled residents when the ceiling in their shared room was leaking rainwater and the residents were not moved from the room. Resident 2 was admitted with diagnoses including hypertension and anemia, and his MDS indicated intact thought process and supervision assistance with ADLs. Resident 3 was admitted with diagnoses including end stage renal failure and hypertension, and his MDS indicated moderate impairment with thought process and substantial assistance with ADLs. Resident 4 was admitted with diagnoses including cirrhosis and seizures, and his MDS indicated severe impairment with thought process and substantial assistance with ADLs. Resident 2 stated that the room ceiling had been leaking since Saturday, that staff placed a bucket under the leak, and that he and his two roommates stayed in the room the whole time because staff did not move them. LVN 1 stated the previous shift reported the leak and that the residents remained in the room without a room change, and she stated the residents should have been moved because of safety concerns from water on the floor. HK 1 stated she was assigned to the room during the weekend and placed a bucket under the dripping water. The ADON stated residents could fall if the floor was wet and it could possibly cause an accident, and the DON stated the facility did not provide proper care or meet the residents' needs by not changing their room when the ceiling was leaking with rainwater. The facility policy stated residents are to be provided with a safe, clean, comfortable, and homelike environment.
Unsafe Room Conditions and Inadequate Temperature Control
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for two residents by leaving one resident in a room with a leaking ceiling and another resident in a room that was too cold. Resident 7 was admitted with diagnoses including a displaced left tibia fracture, diabetes mellitus, and unspecified dementia. Her H&P described her as confused with minimal communication but able to follow commands, and her care plan included modifying the environment as needed to meet current needs, including keeping floors even and free from spills and clutter. Her MDS indicated moderately impaired cognitive skills for daily decisions. During observation, Resident 7 was found in her room with an open yellow container and blanket on the floor under a section of ceiling with visible drops of rainwater, along with a towel on the floor and a trash bin placed on it beneath bulging ceiling paint. LVN 2 stated there was a leak in the ceiling by the window and by the foot of other beds in the room, and that residents had been moved out except Resident 7. CNA 1 stated Resident 7 was left in the room with the leaking ceiling and had no plan to be moved yet. LVN 3 stated the leak could result in mold and that the ceiling could fall if it became soft from water damage. The MS stated he was not aware of the leak, and later stated the facility did not have a policy for leaking ceiling and comfortable room temperature. Resident 8 was admitted with diagnoses including metabolic encephalopathy, unspecified anxiety disorder, and essential hypertension. Her care plan included an intervention to ensure a comfortable and safe environment, and her H&P noted fluctuating capacity to understand and make decisions. During observation, Resident 8 was calling for assistance and asking for a blanket because the room was too cold. The MS measured the room temperature at 64 degrees Fahrenheit, while stating room temperature should be between 72 and 77 degrees Fahrenheit. LVN 3 stated cold room temperature could start cough, colds, or arthritis pain, and the DON stated 64 degrees was too cold for Resident 8 and could affect her vital signs and comfort. The DON also stated the facility's policy was not followed.
Failure to Individualize Care Plan for Resident Safety in Leaking Room
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for Resident 7 to address safety concerns after the resident refused a room change while the room had a leaking ceiling from rainwater. Resident 7 was admitted on 11/12/2025 with diagnoses including a displaced left tibia fracture, diabetes mellitus, and unspecified dementia. The history and physical dated 11/12/2025 described the resident as confused with minimal communication but able to follow commands, and the MDS dated 11/18/2025 indicated moderately impaired cognitive skills for daily decisions. On 11/21/2025, surveyors observed Resident 7 lying in bed in the room where there was visible water dripping from an open part of the ceiling near the window, a yellow container placed under the leak with a blanket on the floor beneath it, and a trash bin on a towel under bulging ceiling paint in the middle of the room. During interview, LVN 2 stated there was a leak in the ceiling by the window and that other residents had already been moved out of the room. LVN 3 stated a leaking ceiling could result in mold and that softened ceiling material could fall onto Resident 7. The Maintenance Supervisor stated he was not aware of the leak and said that if informed, he would have moved all residents out of the room, opened the ceiling, patched it dry, inspected for mold, and used a fan and humidifier. RN 1 stated she did not develop a care plan to address Resident 7's safety after refusing room change and said there should have been a care plan with interventions such as monitoring the resident every shift for safety in the room with the leaking ceiling. The MDSA reviewed the care plan dated 11/21/2025 and stated it was generalized and did not include hourly rounding to observe whether the leak was progressing or whether Resident 7 was safe and felt safe in the room. The DON stated the care plan should have been person-centered and individualized to address Resident 7's safety in the room with the leaking ceiling, and that without such a plan there might be a delay in room change.
Failure to Maintain Resident Dignity and Communication Standards
Penalty
Summary
Staff failed to uphold resident dignity and respect by not addressing a resident by their preferred name and by using inappropriate terms of endearment. Specifically, a Licensed Vocational Nurse (LVN) was observed calling a resident "honey" on multiple occasions when the resident was requesting medication. The resident had an intact thought process and required moderate assistance with activities of daily living. The LVN acknowledged using the term and admitted that it was not appropriate unless it was care planned and the resident's preference. The Director of Nursing confirmed that staff should always address residents by their names as a matter of dignity, as outlined in the facility's policy. Additionally, several Certified Nursing Assistants (CNAs) and an Occupational Therapist were observed conversing in a dialect other than English in the hallways near resident rooms. The CNAs admitted that they should communicate in English in resident areas to ensure all residents feel included and respected, as not all residents understand their dialect. The Director of Nursing reiterated that staff are expected to speak English in resident areas, in accordance with the facility's communication courtesy policy.
Medication Storage and Self-Administration Assessment Deficiency
Penalty
Summary
A deficiency was identified when a bottle of nasal spray was found on a resident's bedside table without proper assessment for self-administration of medication. The resident, who had been admitted with diagnoses including diabetes mellitus and hypertension, was observed to have an intact thought process and required supervision for activities of daily living. The nasal spray had been brought in by the resident's daughters, and the resident reported using it that morning. Both a CNA and an LVN confirmed the presence of the nasal spray at the bedside, with the LVN stating she was unaware of the medication being there and acknowledging that medications should not be kept at the bedside due to the risk of access by other residents. Further review and interviews revealed that the facility's policy required an interdisciplinary team assessment before allowing residents to self-administer medications, and that such medications must be stored securely and not accessible to other residents. The Director of Nursing confirmed that the resident had not been assessed for self-administration and emphasized the importance of secure storage to prevent potential accidents. The failure to assess the resident and to store the medication securely constituted a breach of facility policy and created a situation where other residents could potentially access and misuse the medication.
Failure to Administer Ordered Antibiotic Upon Readmission
Penalty
Summary
A deficiency occurred when a resident was not administered an antibiotic, fluconazole, as ordered by the physician following readmission from a general acute care hospital. The resident, who had significant cognitive impairment and required total assistance with activities of daily living, was readmitted with diagnoses including attention to a gastrostomy and chronic obstructive pulmonary disease. The hospital discharge summary and subsequent physician order specified that fluconazole 200 mg should be given once daily for seven days, starting on the day of readmission. Upon review, it was found that the resident did not receive the first dose of fluconazole on the day of readmission. Nursing staff assumed the initial dose had been administered at the hospital, but there was no confirmation or communication from the hospital to verify this. The medication was available in the facility’s emergency kit, and both nursing staff and the DON acknowledged that the order should have been clarified and the medication administered within four hours of receipt, as per facility policy and standard practice. The failure to administer the antibiotic as ordered was attributed to miscommunication and lack of order clarification regarding whether the first dose had been given prior to transfer. The facility’s policies on medication reconciliation and physician orders emphasized the importance of timely administration and verification of medication history upon admission or readmission, but these procedures were not followed in this instance.
Nonfunctional Call Light in Resident Room
Penalty
Summary
A deficiency was identified when a resident's call light was found to be nonfunctional since their admission. The resident, who had a diagnosis of hypertension and a history of falls, required moderate assistance with activities of daily living and had an intact thought process. During an observation and interview, the resident demonstrated that their call light did not activate the visual indicator outside the room, and reported having to rely on their roommate's call light to request assistance. This issue was confirmed by a Licensed Vocational Nurse, who also observed that the call light did not work and acknowledged the importance of a functioning call system for timely response to resident needs. Further review of facility policy indicated that the resident call system is required to remain functional at all times and should be routinely maintained and tested by the maintenance department. The Director of Nursing confirmed the importance of a working call light system for communication between staff and residents, noting that a malfunction could result in staff being unable to meet residents' needs immediately. The deficiency was based on direct observation, resident and staff interviews, and review of facility records and policies.
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 129 citations issued within 25 miles in the last 12 months — 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 Lancaster
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Desert Canyon Post Acute, Llc | 0.1 mi | ★★★★★ | 41 | 0 |
| Antelope Valley Care Center | 0.1 mi | ★★★★★ | 67 | 0 |
| The Ellison John Transitional Care Center | 0.9 mi | ★★★★★ | 21 | 0 |
| Santa Clarita Post-acute Care Center | 30.1 mi | ★★★★★ | 8 | 0 |
| Mountain View Conv Hosp | 30.2 mi | ★★★★★ | 41 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Mirage Post Acute.
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.