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 October 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.
Ativan was administered to a resident with respiratory failure, DM, and anxiety disorder without the respiratory rate being counted and documented before each dose, and the order to hold the medication if the respiratory rate was above 12 breaths per minute was not followed. The MAR showed multiple doses, but the vital sign record documented respiratory rates before only some administrations. The ADON and an LVN stated the order was unusual, should have been clarified, and that the respiratory rate should have been checked and documented before giving the medication.
A resident’s chart contained the wrong last name for the RP/POA across multiple records, including admission, consent, IDT, and transfer documents, even though hospital paperwork listed the correct contact information. The chart also lacked documented evidence that the RP was informed about the purpose of IV hydration, and a CIC note recorded physician and RP notification with an incorrect date that predated the event. RN, MDSN, ADON, and DON interviews confirmed the documentation errors and the lack of clear record evidence.
Delayed Notification of Responsible Party After Acute Decline: A resident with respiratory failure, DM, and dementia had a significant change in condition with crackles, cyanosis, cold clammy skin, and O2 sat of 66% on NC. 911 was called and the resident was transferred to the hospital, but the RP was not notified until after the transfer, with no documented attempts to call earlier. The physician was notified earlier, and the DON stated family should be informed before hospital transfer.
A resident with a hx of cerebral infarction, HTN, and generalized muscle weakness had an inaccurate MDS mobility assessment. The MDS documented use of a walker and wheelchair, while rehab, RNA, IDT notes, and staff interviews showed the resident ambulated with a single point cane and was highly functioning. The DON and ADON stated the MDS was not accurate, and the MDSN confirmed the cane use was not reflected.
The facility failed to develop person-centered care plans for two residents. One resident with cerebral infarction, HTN, and depression had a CIC noting fabrication of stories, but no care plan was created. Another resident with respiratory failure, DM, and dementia had orders for peripheral IV access and IV hydration, but nursing notes documented repeated refusal of IV insertion and no care plan was developed to address the refusal. The ADON and DON both stated the care plans should have been developed.
IV Hydration Provided Without Supporting Dehydration Diagnosis: A resident received IV Lactated Ringers for hydration even though hospital records showed normal BUN and creatinine and no documented dehydration diagnosis. The resident was also documented as drinking orally, with the FM stating the resident only needed encouragement to drink. RN and MDS staff confirmed IV fluids were given or ordered, while the DON stated IV hydration was unnecessary when labs were normal and the resident drinks, and could cause fluid overload.
Failure to Provide Ordered Pressure Ulcer Treatment: A resident with DM, dementia, and respiratory failure had a sacrococcyx pressure ulcer on admission, and the ordered wound care was not documented as provided on the TAR. The TN confirmed no wound treatment was given, while the DON stated treatment should begin right away after a physician order; the resident also had severely impaired cognitive skills and required staff supervision for toileting and transfers.
A resident with DNR status, severe cognitive impairment, and a poor prognosis had a change in condition with weakness and poor intake, then was transferred to GACH before the legally recognized decisionmaker was clearly notified and agreed to the transfer. RN, SSD, ADON, and DON interviews and the record showed no documented evidence that Family Member 1 confirmed or approved the transfer, and a voicemail was left only after the resident had already left.
Failure to Coordinate Hospice Transfer With Family and Hospice Agency: A resident receiving hospice care had a change in condition with weakness and poor intake, then was transferred to GACH without documented agreement from the FM or notification/authorization from the hospice agency. The resident lacked decision-making capacity, had a surrogate decision maker, and the chart showed orders and a hospice agreement requiring hospice contact before transfer, but staff could not provide evidence that those steps occurred.
Unsafe Room Temperatures in Resident Rooms: A facility failed to maintain comfortable and safe room temperatures for three residents. One resident with UTI, MS, and GBS said her room was so hot, while two other residents in the same room also reported excessive heat; one resident with respiratory failure, hypothyroidism, and DM said the heat made her uncomfortable and caused sweating, and another resident with a humerus fracture, DM, and UTI said the room was too hot and had been reported without action. Staff measured multiple rooms in Station A above the stated target range, and the DON said room temperatures should be between 71 F and 74 F unless requested otherwise.
A resident with an indwelling urinary catheter and EBP orders was observed receiving incontinent care from three CNAs without gowns, and no EBP signage was posted outside the room. The resident’s care plan and facility policy required gown and glove use during high-contact care activities such as brief changes and device care, and the LVN, RN, and DON all confirmed that gowns and posted precaution signage were required.
Failure to Hold BP Medications per Physician Orders: Two residents had BP medication orders to hold if SBP was below 110 mmHg, but an LPN administered losartan to one resident with BP 101/68 and multiple doses of clonidine and hydralazine to another resident despite low BP readings. The ADON, DSD, DON, and involved LPNs acknowledged the orders were not followed, and the facility policy required medications to be given in accordance with prescriber orders and vital signs to be checked before administration when necessary.
A resident with impaired decision-making capacity, malnutrition, failure to thrive, and a stage 4 sacral pressure ulcer was served a breakfast tray without utensils. A CNA delivered the tray, the tray remained unopened during observation, and an LPN noted the missing utensils could delay food intake. The ADS and DON stated the resident should have received regular silverware unless disposable utensils were preferred, and the resident’s meal ticket did not indicate a disposable utensil preference.
A resident with Alzheimer’s disease and schizophrenia had a significant change in condition with unmanageable behavior, nausea/vomiting, and coffee ground emesis, and was transferred to the hospital after the MD was notified. The RP said she was not told about the coffee ground emesis before the transfer, and the RN stated she intended to call again but the resident was picked up before that happened, despite facility policy requiring prompt notification of the resident representative for significant changes and hospital transfer.
Failure to provide written transfer notice to RP: A resident with Alzheimer’s disease and schizophrenia, who lacked decision-making capacity and had severely impaired cognition, was transferred to the hospital after unmanageable behavior and coffee ground emesis. Staff gave conflicting accounts about the transfer notice, and the RP reported she was not given the written notice or informed of the full reason for transfer before the resident left. The notice was completed after the transfer process had started, and the form did not consistently document the required information.
A resident with a sacral stage 4 PU, malnutrition, and adult failure to thrive was observed on an LALM set at 180 lbs even though the resident weighed about 100 to 103 lbs and the care plan and order summary directed staff to set the mattress to the resident’s weight. The ADON, TN, and DON stated the LALM should be based on weight, and the manufacturer’s guidelines said the pressure setting should be adjusted according to the patient’s weight and height.
A resident with Alzheimer’s disease and schizophrenia received PRN Ativan for anxiety/restlessness, but the MAR and progress notes did not document the required behavior episodes to justify multiple doses. The ADON and DON stated staff should have documented the resident’s restlessness and the number of episodes before giving the medication, but the record did not show that this was done.
Incomplete dialysis communication documentation was found for a resident dependent on renal dialysis. The HD forms were left blank for several required items before transport to the dialysis center, and one form also lacked post-dialysis pain information. The DON stated the forms should be complete and used for communication between the facility and the dialysis center, and the facility policy required documentation to be objective, complete, and accurate.
A resident on EBP for high-contact care related to a wound and GT received mobility assistance from an LVN who wore gloves but no gown while turning the resident and helping the resident sit on the edge of the bed. The LVN later stated a gown should have been worn, and the DSD/IP and DON confirmed that gown and gloves were required for this type of mobility assistance under the facility’s EBP guidance.
Failure to Monitor Antibiotic Adverse Effects: A resident with a sacral stage 4 pressure ulcer and DM was prescribed levofloxacin for a wound infection, with orders to monitor for adverse reactions every shift. The MAR and progress notes showed the antibiotic was given, but required monitoring was not documented for multiple shifts after the first doses, and the IP confirmed the monitoring did not begin until later. The DON stated residents on antibiotics are monitored every shift from the start of therapy.
A resident with CVA, dysphagia, a g-tube, hemiplegia, HTN, and cognitive impairment was discharged after a g-tube dislodgement and subsequent ER visit. The discharge plan listed a lower-level care home with HH services and DME, but the resident was later dropped off at GACH by that home and left there alone. Interviews showed the POA expected a placement that could meet the resident’s needs, while SSA relied on verbal assurances and did not verify that the boarding care was licensed or appropriate.
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.
Ativan Given Without Documented Respiratory Rate and Contrary to Hold Order
Penalty
Summary
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist was deficient for one resident when Ativan was administered without the respiratory rate being counted and documented before administration, and the physician order to hold Ativan for a respiratory rate above 12 breaths per minute was not followed. The resident was admitted with diagnoses that included unspecified acute and chronic respiratory failure, diabetes mellitus, and generalized anxiety disorder. The resident’s MDS indicated severely impaired cognitive skills for daily decisions and anxiety and depression disorder. The physician order dated 4/18/2026 directed Ativan 0.5 mg by mouth every six hours as needed for anxiety manifested by verbalization of nervousness for 14 days, with instructions to hold if respiratory rate was above 12. The MAR showed Ativan was administered on four occasions, but the Weights and Vital Summary documented respiratory rates only before three of those administrations. During interview, the ADON stated the order should have been clarified because Ativan is usually held if respiratory rate is below 12, and nurses should have checked and documented the respiratory rate and called the physician for clarification before administration. An LVN stated she administered Ativan when the resident was agitated and believed the respiratory rate was above 12, but did not notice the hold parameter and might have forgotten to document the respiratory rate.
Inaccurate resident record documentation and missing notification documentation
Penalty
Summary
The facility failed to maintain an accurate and complete medical record for one sampled resident by documenting the wrong last name for the resident’s responsible party in multiple records. The resident was admitted with diagnoses including unspecified acute and chronic respiratory failure, diabetes mellitus, and unspecified dementia, and the resident’s records identified the responsible party as the person to notify and as the emergency contact. However, the admission record, informed consents, consent to treat forms, change in condition evaluations, interdisciplinary team conference notes, and hospital transfer form all listed the responsible party’s first name with a different last name than the one used in the hospital registration and resident administration records. During interviews, the family member stated the responsible party was the resident’s power of attorney and that the facility had documented a different person by using the wrong last name. The admission director stated she assumed the responsible party’s last name was the same as the resident’s and did not verify it against the hospital records or by calling the responsible party. The responsible party later stated his last name was different from the resident’s and that no one from the facility had called to verify his full name or notify him about changes in condition, interdisciplinary team meetings, care plans, or consents. The assistant director of nursing and the director of nursing stated admission staff should have verified and accurately documented the responsible party’s name, and that using a different last name could cause confusion and make it appear to be a different person. The facility also failed to document that the responsible party was notified of the purpose of IV hydration. The resident had an order for Lactated Ringers IV solution at 75 ml per hour for hydration for three days, and progress notes showed an order was obtained for IV fluids with multivitamins added. RN 1 stated there was no documented evidence that the responsible party was informed of the purpose of the IV fluids, although she later recalled calling him. The responsible party stated he was not informed why IV fluids were ordered, while MDSN 2 stated RN 1 spoke to him at the bedside but she did not hear the explanation. The ADON and DON stated there was no documented evidence of notification and that nurses should document when family is notified of a resident procedure or treatment. In addition, the facility inaccurately documented the date of physician and responsible party notification on a change in condition record. The change in condition note described abnormal lung sounds, chest pain, accessory muscle use, rales, diminished left lung sounds, respiratory rate of 20, oxygen saturation of 93 percent, and oxygen at two liters per minute, but it listed physician and responsible party notification as occurring four days earlier than the change in condition itself. The ADON stated the date was inaccurately documented, and the DON stated the nurses should have updated the current change in condition with the correct date and time of notification. The facility policy on charting and documentation stated that documentation in the medical record will be objective, complete, and accurate.
Delayed Notification of Responsible Party After Resident’s Acute Decline
Penalty
Summary
The facility failed to promptly notify Resident 2’s responsible party of a change in condition on 4/21/2026. Resident 2 was admitted on 4/15/2026 with diagnoses including unspecified acute and chronic respiratory failure, diabetes mellitus, and unspecified dementia. The change in condition evaluation showed that between 11 p.m. on 4/20/2026 and 1 a.m. on 4/21/2026, Resident 2 had noticeable crackles without shortness of breath and was on oxygen via nasal cannula. At 4:08 a.m., Resident 2 became cyanotic with cold, clammy skin, was visibly struggling to breathe, and had an O2 saturation of 66% on 2 liters per minute via nasal cannula. A breathing treatment was given at 4:10 a.m., 911 was called at 4:12 a.m., and paramedics arrived at 4:20 a.m. to transfer Resident 2 to the hospital. The physician was notified at 12 midnight, but the responsible party was not notified until 6 a.m., after Resident 2 had already been transferred. The ADON stated there were no documented attempts to call the responsible party from 1 a.m. when the change in condition began, and the DON stated attempts should be made to call and inform the family before a resident is transferred out to the hospital.
Inaccurate MDS Mobility Assessment
Penalty
Summary
The facility failed to ensure an accurate assessment for one resident when the 6/16/2026 MDS documented the resident as using a walker and a wheelchair, while other records showed the resident was ambulating with a single point cane. The resident was admitted on 3/10/2026 with diagnoses including cerebral infarction, essential HTN, and generalized muscle weakness, and the H&P dated 3/11/2026 stated the resident had the capacity to understand and make decisions. Record review showed the resident’s Rehabilitation-Screening Form dated 4/21/2026 indicated the resident was safe after PT screening to ambulate using a single point cane, and RNA orders were updated to include ambulation with a single point cane daily five times a week. A later Rehabilitation-Screening Form dated 6/5/2026 and IDT Conference Notes dated 6/16/2026 also indicated ambulation with a single point cane daily five times a week as tolerated. During interviews, RNA 1, the RD, the MDSN, the ADON, and the DON all acknowledged the resident used a single point cane and that the MDS assessment was not accurate.
Failure to Develop Person-Centered Care Plans for Behavioral Change and IV Refusal
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for Resident 1 after a change in condition on 6/18/2026 documented fabrication of stories. Resident 1 was admitted on 3/10/2026 with diagnoses including cerebral infarction, essential hypertension, and unspecified depression. The H&P dated 3/11/2026 indicated the resident had the capacity to understand and make decisions, and the MDS dated 6/16/2026 indicated cognitive skills for daily decisions were intact. During a concurrent interview and record review on 6/30/2026, the ADON reviewed Resident 1’s CIC dated 6/18/2026 and the care plans and stated there was no care plan developed for the fabrication of stories. The ADON stated the care plan should have been developed and that care plans are interventions provided to residents and provide communication between providers. The DON later stated the care plan should have been developed for Resident 1’s fabrication of stories to provide the right care and services, and that without a care plan the facility would not be able to meet Resident 1’s needs. The facility also failed to develop and implement a care plan for Resident 2’s refusal of IV insertion for hydration. Resident 2 was admitted on 4/15/2026 with diagnoses including unspecified acute and chronic respiratory failure, DM, and unspecified dementia. The order summary dated 4/16/2026 included orders for peripheral IV insertion every 72 hours and Lactated Ringers IV solution at 75 ml per hour every shift for hydration for three days. Progress notes on 4/17/2026 documented that RN 4, RN 5, and RN 6 each recorded that Resident 2 refused the new peripheral IV insertion three times, and the MDS dated 4/21/2026 indicated severely impaired cognitive skills for daily decisions and peripheral IV access.
IV Hydration Provided Without Supporting Dehydration Diagnosis
Penalty
Summary
The facility failed to ensure Resident 2 received care consistent with professional standards of practice when it initiated IV hydration without documentation supporting a diagnosis of dehydration and despite evidence that the resident was drinking. The resident’s hospital history and physical dated 3/31/2026 showed BUN 17 mg/dl and creatinine 0.7 mg/dl, and the hospital progress note dated 4/13/2026 showed BUN 9 mg/dl and creatinine 0.4 mg/dl. The admission record showed the resident was admitted on 4/15/2026 with diagnoses including unspecified acute and chronic respiratory failure, diabetes mellitus, and unspecified pulmonary hypertension. After admission, the resident’s intake and output record showed 240 ml of fluid intake on the night shift of 4/15/2026, 1,630 ml on 4/16/2026, 1,580 ml on 4/17/2026, and 1,400 ml on 4/18/2026. The order summary dated 4/16/2026 directed Lactated Ringers IV at 75 ml per hour every shift for hydration for three days. The MDS dated 4/21/2026 indicated the resident’s cognitive skills for daily decisions were severely impaired, that the resident had peripheral IV access, and that the resident had an average fluid intake of 501 ml per day or more. During interviews, the resident’s family member stated the facility gave IV fluids even though the resident drank on her own and only needed encouragement to drink. RN 1 stated the resident received Lactated Ringers IV for hydration on 4/16/2026 and 4/18/2026, and refused IV insertion on 4/17/2026. MDSN 2 stated she reviewed the hospital records, noted a diagnosis of dehydration and elevated BUN and creatinine, and called the PMD to recommend IV fluids, but the hospital records reviewed at the time did not show a dehydration diagnosis and the BUN and creatinine were within normal limits. The DON stated that if laboratory results were normal and the resident drinks, there is no need for IV hydration and that administering IV fluids could cause fluid overload.
Failure to Provide Ordered Pressure Ulcer Treatment
Penalty
Summary
The facility failed to ensure a resident received pressure ulcer treatment consistent with professional standards of practice when the ordered treatment was not administered on 4/16/2026. Resident 2 was admitted on 4/15/2026 with diagnoses including acute and chronic respiratory failure, DM, and dementia. The admission skin assessment documented a stage 2 pressure ulcer on the sacrococcyx, and the order summary on 4/16/2026 directed staff to clean the sacral DTI with normal saline, pat dry, apply zinc oxide, and leave open to air daily and as needed for 30 days. The TAR for 4/16/2026 did not show that the treatment was provided. During interview and record review, the Treatment Nurse stated there was no documented wound treatment provided on that date and acknowledged the resident could have further skin integrity issues and worsening of the wound. The MDS dated 4/21/2026 indicated the resident had severely impaired cognitive skills for daily decisions, required supervision for toileting and transfer, and had one unstageable pressure ulcer present on admission. The DON stated treatment should be started right away after obtaining a physician order and that delay in treatment could potentially result in worsening pressure ulcers.
Failure to Notify Legal Decisionmaker Before Hospital Transfer
Penalty
Summary
The facility failed to promptly notify Family Member 1, the resident’s responsible party and legally recognized decisionmaker, regarding a change in condition before the resident was transferred to General Acute Care Hospital 1. The resident was admitted with diagnoses including type 2 diabetes mellitus, mild protein-calorie malnutrition, and age-related osteoporosis, and the admission record identified Family Member 1 as the responsible party and substitute decision maker. The resident’s POLST, dated 3/17/2026, indicated DNR status and showed Family Member 1 signed as the legally recognized decisionmaker. The resident’s MDS, dated 5/24/2026, indicated severely impaired cognitive skills for daily decision making and a prognosis of less than six months. On 6/4/2026, the resident had a change in condition with weakness, increased assistance needed during mealtime, and poor food intake with periods of refusing to eat. The COC evaluation documented that the attending physician and Family Member 1 were notified at 6 p.m., but it did not show whether staff spoke with Family Member 1 or left a voicemail. Progress notes later documented that the resident left for GACH 1 at 10:25 p.m. and that a voicemail was left for Family Member 1 while staff waited for a callback. RN 1 stated she did not speak with or confirm with Family Member 1, and the SSD stated he did not speak with Family Member 1 before 6/5/2026. The ADON and DON both acknowledged there was no documented evidence that Family Member 1 agreed to the transfer, and the DON stated the resident’s rights were not honored by ensuring Family Member 1 was notified and agreed with the plan of care regarding the transfer.
Failure to Coordinate Hospice Transfer With Family and Hospice Agency
Penalty
Summary
The facility failed to ensure necessary hospice-related coordination when Resident 1 was transferred to General Acute Care Hospital 1. Resident 1 was admitted with diagnoses including type 2 diabetes mellitus, mild protein-calorie malnutrition, and age-related osteoporosis, and the record showed the resident was terminally ill, receiving hospice services, lacked capacity to make decisions, and had FM 1 as the responsible party and surrogate decision maker. The resident’s MDS also documented severely impaired cognitive skills for daily decision making and a prognosis of less than six months. On 6/4/2026, a change in condition evaluation documented weakness, increased assistance needed during mealtime, and poor food intake with periods of refusing to eat. The evaluation noted the attending physician and FM 1 were notified at 6:00 p.m. Later that night, RN 1 documented that Resident 1 left for GACH 1 and that a phone message was left for FM 1, with a callback pending. RN 1 stated she did not speak with FM 1, the hospice attending physician, or HA 1 regarding the transfer. During interviews and record review, the SSD stated he was told FM 1 was upset that Resident 1 had been taken to GACH 1 without approval, and the DON could not provide documented evidence that HA 1 was notified of the change in condition or transfer, or that FM 1 agreed to the transfer. The physician orders directed staff to contact HA 1 for any change in condition and not to transfer the resident to GACH without prior authorization from HA 1. The hospice and nursing facility services agreement also required the facility to notify hospice when a significant change occurred or when a transfer from the SNF was needed so hospice could make arrangements for necessary continuous or inpatient care related to the terminal illness and related conditions.
Unsafe Room Temperatures in Resident Rooms
Penalty
Summary
The facility failed to provide a comfortable and safe temperature level for three sampled residents by not ensuring the room temperature remained between 71 F and 81 F. Resident 1 was admitted with diagnoses including UTI, unspecified MS, and GBS, and her MDS indicated moderately impaired cognitive skills for daily decisions. During an interview, Resident 1 stated she was in Room A and that the room was so hot, noting that two other residents were also in that room. Resident 2 was admitted with diagnoses including unspecified respiratory failure, unspecified hypothyroidism, and DM. Her H&P stated she did not have the capacity to understand and make decisions, while her MDS indicated her cognitive skills for daily decisions were intact. During observation and interview, a window fan and a table fan were present in her room, and Resident 2 stated the room was very hot and that this was why she did not want any clothes on. She stated it became uncomfortable and she sweated a lot when the room was hot. Resident 3 was admitted with diagnoses including an unspecified fracture of the upper end of the left humerus, DM, and UTI. Her H&P and MDS indicated she had the capacity to understand and make decisions and that her cognitive skills for daily decisions were intact. During observation and interview, a table fan was clipped to a rolling table in her room, and Resident 3 stated the room was too hot and had been reported, but nothing had been done. Maintenance staff later checked the rooms and found temperatures including 77 F in the room shared by Residents 2 and 3, while other rooms in Station A were observed at 78 F, 80 F, 82 F, 82 F, 78 F, 78.2 F, 80 F, and 77 F. The DON stated room temperatures should be between 71 F and 74 F unless there is a resident request, and the facility policy required comfortable and safe temperatures.
Failure to Use EBP PPE and Post Precaution Signage
Penalty
Summary
The facility failed to implement infection control measures for one sampled resident who was on enhanced barrier precautions (EBP). The resident was admitted with diagnoses including UTI, unspecified multiple sclerosis, and Guillain Barre Syndrome. The resident’s MDS indicated moderately impaired cognitive skills for daily decisions. Physician orders dated 6/11/2026 included an indwelling catheter for neuromuscular dysfunction of the bladder and EBP during high-contact resident care activities every shift. The care plan for EBP directed staff to use PPE such as a gown, gloves, and face shield as indicated during high-contact care activities including hygiene, linen changes, brief changes, toileting assistance, device care, and wound care. During an observation on 6/13/2026, the resident was in bed with an indwelling catheter secured to the left thigh. At 3:36 p.m., three CNAs were observed providing incontinent care and changing the resident’s incontinent brief without gowns. During a concurrent interview, LVN 1 confirmed there was no precaution signage posted on the door and stated the three CNAs should have worn gowns when changing the resident’s brief. RN 1 stated staff should wear a gown when providing incontinent care for a resident with an indwelling catheter and that EBP signage should be posted on the door. The DON stated residents with indwelling catheters should be on EBP and that staff providing incontinent care and/or indwelling catheter care should wear a gown for infection control. The facility policy stated EBPs apply to residents with indwelling medical devices such as urinary catheters, require targeted gown and glove use during high-contact resident care activities, and require signs posted on the door or wall outside the resident’s room.
Failure to Hold BP Medications per Physician Orders
Penalty
Summary
The facility failed to provide pharmaceutical services by not following physician orders to hold blood pressure medications when residents’ systolic blood pressure was below 110 mmHg. For one resident admitted with essential HTN and cerebral infarction, the record showed losartan 50 mg daily was ordered to be held if systolic blood pressure was below 110 mmHg, yet on 5/14/2026 at 9 a.m. LVN 4 administered the medication when the resident’s blood pressure was 101/68 mmHg. The resident’s MDS indicated severely impaired cognitive skills for daily decisions. For a second resident admitted with diagnoses including hypertensive chronic kidney disease and an unspecified nontraumatic subdural hemorrhage, the record showed orders for clonidine 0.2 mg twice daily and hydralazine 50 mg every six hours, both to be held if systolic blood pressure was below 110 mmHg. The MAR showed LVN 5 administered hydralazine on 5/14/2026 at 6 a.m. when blood pressure was 94/60 mmHg, LVN 3 administered hydralazine on 5/14/2026 at 12 noon when blood pressure was 103/64 mmHg, LVN 3 administered clonidine on 5/14/2026 at 1 p.m. when blood pressure was 103/64 mmHg, and LVN 6 administered hydralazine on 5/16/2026 at 6 a.m. when blood pressure was 109/89 mmHg. The resident’s H&P noted fluctuating capacity to understand and make decisions, while the MDS indicated cognitive skills for daily decisions were intact. During interviews, the ADON, DSD, DON, and the involved LVNs acknowledged the orders were not followed and that the medications should have been held based on the documented blood pressures. The DSD stated the resident could develop hypotension, the ADON stated the resident could develop orthostatic hypotension, and LVN 3 and LVN 5 stated that giving blood pressure medication when blood pressure was already low could cause further drops in blood pressure. The facility policy stated medications are to be administered in accordance with prescriber orders and that vital signs are checked/verified prior to administration when necessary.
Missing Silverware on Breakfast Tray
Penalty
Summary
The facility failed to provide care in a manner that maintained dignity for one resident by not ensuring silverware was provided with the breakfast tray. The resident was admitted with a sacral stage 4 pressure ulcer, mild protein-calorie malnutrition, and adult failure to thrive. The H&P stated the resident did not have the capacity to understand and make decisions, and the MDS indicated the resident’s cognitive skills for daily decisions were moderately impaired. The order summary showed the resident was on a controlled carbohydrate regular textured diet. During observation, a CNA delivered the breakfast tray to the resident’s room and the tray had no utensils. The tray remained unopened during a later observation. An LVN stated the breakfast tray was missing utensils and that this could delay the resident’s food intake. The ADON stated kitchen staff should check for tray completeness, and the CNA stated it was the kitchen staff’s responsibility to ensure residents had utensils. The ADS reviewed the meal ticket and stated the facility provides silverware to residents, that disposable utensils would be indicated if preferred, and that this resident’s meal ticket did not show a preference for disposable utensils. The DON stated the resident should have been provided regular silverware unless it was the resident’s preference, and that disposable utensils could affect dignity.
Failure to Promptly Notify Responsible Party of Significant Change in Condition
Penalty
Summary
The facility failed to promptly notify Resident 3’s responsible party of a significant change in condition before the resident was transferred to the hospital. Resident 3 was admitted with diagnoses including unspecified Alzheimer’s disease and unspecified schizophrenia, and the record showed the resident did not have capacity to understand and make decisions. The MDS also indicated the resident’s cognitive skills for daily decisions were severely impaired. On 6/1/2026, the Change in Condition Evaluation documented behavioral symptoms, nausea and vomiting, unmanageable behavior disturbing other residents, and two episodes of coffee ground emesis. The physician was notified and ordered transfer to the GACH. Although the record indicated the responsible party was notified at 7:00 p.m., the responsible party stated she was not informed about the coffee ground emesis before the transfer and learned of it only after arriving at the facility. RN 1 stated she had called the responsible party about the unmanageable behavior and intended to call again about the coffee ground emesis, but the resident was transported before that occurred. The facility policy required prompt notification of the resident, physician, and resident representative for significant changes and when transfer to a hospital was necessary.
Failure to Provide Written Transfer Notice to RP
Penalty
Summary
The facility failed to notify Resident 3’s Responsible Party in writing of the transfer and the reasons for the move before the resident was sent to the hospital. Resident 3 was admitted with diagnoses including unspecified Alzheimer’s disease and unspecified schizophrenia, and the record showed the resident did not have capacity to understand and make decisions. The resident’s MDS later documented severely impaired cognitive skills for daily decisions and maximum assistance needed for eating, oral hygiene, and personal hygiene. On 6/1/2026, Resident 3 had unmanageable behavior disturbing other residents and two episodes of coffee ground emesis. The physician was notified and ordered transfer to a General Acute Care Hospital. The record showed the RP was notified before the physician order, but the Notice of Proposed Transfer/Discharge was timed after the transfer process had already begun, and the resident left the facility before 9 p.m. The transfer form listed behavioral symptoms as the reason for transfer and did not include coffee ground emesis. Interviews showed conflicting accounts about the notice and signature. RP 1 stated no transfer form was provided when she arrived and that she was told only that the resident would be transferred for unmanageable behavior, not for coffee ground emesis. LVN 7 stated she completed the notice, faxed a copy to the Ombudsman, and called RP 1 before the transfer, but also stated there was no RP signature when she completed the form. RN 1 stated she called RP 1 about the transfer, wrote RP 1’s name on the notice because she forgot to obtain a signature, and did not provide a copy when RP 1 came to the facility. The facility policy required residents or representatives to be notified in writing of the impending transfer or discharge, the reasons for the move, and other required information before transfer when practicable.
LALM Set Incorrectly for Resident With Stage 4 Pressure Ulcer
Penalty
Summary
The facility failed to ensure Resident 4 received pressure ulcer care consistent with professional standards of practice when the low air loss mattress (LALM) was not set according to the resident’s weight as ordered. Resident 4 was admitted with a sacral stage 4 pressure ulcer, mild protein-calorie malnutrition, and adult failure to thrive. The care plan and order summary both directed staff to set the LALM to the resident’s weight. The resident’s H&P stated the resident did not have the capacity to understand and make decisions, and the MDS documented moderately impaired cognitive skills for daily decisions and a weight of 100 lbs. During observation, Resident 4 was lying on the LALM, which was set at 180 lbs, while the machine’s arrow pointed close to 90 lbs. In a concurrent interview, the ADON reviewed the resident’s weight as 103 lbs and stated the mattress should be set close to 90 lbs and at the resident’s weight level. The TN, ADON, and DON each stated the LALM setting should be based on the resident’s weight to prevent skin breakdown and for comfort. The manufacturer’s guidelines stated the pressure setting should be adjusted according to the patient’s weight and height and that higher pressure output supports heavier weight patients.
PRN Ativan Given Without Required Behavior Documentation
Penalty
Summary
The facility failed to ensure that one resident’s drug regimen was free from unnecessary drugs by not adequately monitoring and documenting the resident’s behavior before administering PRN antianxiety medication. Resident 3 was admitted with diagnoses including unspecified Alzheimer’s disease and unspecified schizophrenia, and the H&P stated the resident did not have the capacity to understand and make decisions. The MDS indicated the resident’s cognitive skills for daily decisions were severely impaired and that the resident was on antianxiety medications. A physician ordered Ativan 0.5 mg by mouth every six hours as needed for anxiety manifested by restlessness, evidenced by yelling and rocking back and forth aggressively, for 14 days. The order recapitulation report also directed staff to monitor behavior episodes of antianxiety use manifested by restlessness as evidenced by yelling and rocking back and forth aggressively. The MAR showed behavioral episodes of restlessness on 5/4/2026 and 5/10/2026 from 3 p.m. to 11 p.m., and also showed Ativan administration by LVN 8 on 5/5/2026, 5/6/2026, 5/10/2026, 5/11/2026, 5/12/2026, 5/13/2026, 5/14/2026, and 5/17/2026, and by LVN 9 on 5/9/2026 at 7:45 p.m. During interviews, the ADON stated the MAR did not indicate the behavior on the dates Ativan was given and that the nurses should have documented the behavior to justify the need for the medication. The ADON also stated there were no documented episodes of behavior in the progress notes. The DON stated the nurses should document why they administered Ativan and the number of behavioral episodes of restlessness in the MAR or progress notes, and stated that because the behavior was not documented, the nurses did not follow the physician order to medicate the resident only if the resident had a behavior of restlessness.
Incomplete Dialysis Communication Documentation
Penalty
Summary
The facility failed to maintain accurate and complete medical records for one of three sampled residents by not ensuring dialysis communication forms were completed before transfer to the dialysis center and after return to the facility. Resident 2 was admitted with diagnoses including unspecified nontraumatic subdural hemorrhage, a sacral stage four pressure ulcer, and dependence on renal dialysis. The resident’s H&P noted fluctuating capacity to understand and make decisions, while the MDS later indicated the resident’s cognitive skills for daily decisions were intact and that the resident was on dialysis. Review of the resident’s dialysis-related documentation showed that the facility’s Nursing: Hemodialysis Communication Observation/Assessment forms were incomplete. On one form, the pre-dialysis pain level, pain location, and time of last meal were left blank. On another form, the pre-dialysis pain level, pain location, time of last meal, diet, and sack meal were left blank, and the post-dialysis pain level and pain location were also left blank. The DON stated the HD forms should be complete and should be completed as part of communication between the facility and the dialysis center. The facility policy stated documentation in the medical record should be objective, complete, and accurate.
Failure to Use Gown During EBP Mobility Assistance
Penalty
Summary
The facility failed to implement infection control measures for one sampled resident who was on enhanced barrier precautions (EBP) for high-contact resident care activities related to wound and gastrostomy tube management. Resident 4 was admitted with diagnoses including a stage 4 pressure ulcer and a gastrostomy tube, and the resident’s H&P indicated the resident did not have the capacity to understand and make decisions. The MDS showed the resident’s cognitive skills for daily decisions were moderately impaired and that the resident was dependent on staff for rolling from side to side. During observation, Resident 4 was in bed on the left side and LVN 1 assisted the resident to turn onto the back and sit on the edge of the bed while wearing gloves but no gown. LVN 1 held the resident’s forearms, assisted with turning, held the resident’s lower legs, and slid them down to the edge of the bed. LVN 1 later stated she should have worn a gown to help the resident get up and sit on the edge of the bed because the resident was on EBP. The DSD, who was also the IP, stated staff providing direct high-contact care needed PPE such as gown and gloves, and the facility’s EBP signage and policy identified mobility assistance and bed mobility as activities requiring gown and gloves.
Failure to Monitor Antibiotic Adverse Effects
Penalty
Summary
The facility failed to implement its antibiotic stewardship policy for one sampled resident who was prescribed levofloxacin for a wound infection. The resident was admitted with diagnoses including an unspecified nontraumatic subdural hemorrhage, a sacral stage four pressure ulcer, and diabetes mellitus. The resident’s H&P noted fluctuating capacity to understand and make decisions, while the MDS dated 3/4/2026 indicated the resident’s cognitive skills for daily decisions were intact. On 5/9/2026, the resident was ordered levofloxacin 250 mg by mouth daily for seven days. The order also required monitoring for adverse reactions to antibiotic therapy, including rash, itching, swelling, shortness of breath, nausea, vomiting, and diarrhea, with physician notification every shift until 5/20/2026 at 11:59 p.m. The MAR showed levofloxacin was administered on 5/10/2026 and 5/11/2026 at 9 a.m. by LVN 2, and on 5/12/2026 at 9 a.m. by LVN 3. Record review and interview showed the required monitoring was not documented for the shifts after the first doses were given. Progress notes documented no adverse effects for 7 a.m. to 3 p.m. on 5/10/2026 and 5/11/2026, and on 5/12/2026 from 7 a.m. to 3 p.m., but the MAR did not show monitoring beginning until 5/12/2026 at 3 p.m. to 11 p.m. During interview, the IP stated there was no documented monitoring in the MAR from 5/10/2026 at 3 p.m. through 5/11/2026 at 7 a.m., and from 5/11/2026 at 3 p.m. through 5/12/2026 at 7 a.m., and no documented monitoring in progress notes for the 3 p.m. to 11 p.m. and 11 p.m. to 7 a.m. shifts on 5/10/2026 and 5/11/2026. The DON stated residents are monitored every shift from when antibiotics are started.
Unsafe discharge to an inappropriate placement
Penalty
Summary
The facility failed to ensure a safe discharge for a resident with significant medical and behavioral needs, including cerebral infarction, dysphagia with a gastrostomy tube, hemiplegia, hypertension, and documented cognitive impairment. The resident’s record showed dependence for multiple activities of daily living, enteral feeding orders, NPO status at times, and a wandering/elopement risk score of 12, with notes indicating the resident required monitoring for safety and function and had a 1:1 sitter because of aggressive behavior and pulling at the g-tube. After the resident dislodged the g-tube and was sent to the ER for replacement, the discharge plan changed from transfer to a GACH to discharge to a lower-level care home. Social services documented that the family requested discharge to a private home and that a lower-level care home evaluated the resident and was said to be agreeable to accepting him. The discharge summary and post-care instructions indicated discharge to the lower-level care home with home health services and DME, and the resident was discharged from the facility on 5/28/2026. On 6/1/2026, GACH 1 staff contacted the facility and reported that the lower-level care home had dropped the resident off at GACH 1 and left him there by himself. During interviews, the resident’s POA stated she agreed to the boarding care only if it was properly equipped to meet the resident’s needs, but the resident was instead left at GACH 1. The DBD stated he believed the resident was going to a licensed boarding care but did not verify the address, and the SSA stated she relied on verbal information, did not ensure the boarding care was licensed, and did not check the license before discharge. The DON stated social services were responsible for ensuring residents were sent to a licensed boarding care facility prior to discharge.
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.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near 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 | ★★★★★ | 43 | 0 |
| Antelope Valley Care Center | 0.1 mi | ★★★★★ | 21 | 0 |
| The Ellison John Transitional Care Center | 0.9 mi | ★★★★★ | 39 | 0 |
| Santa Clarita Post-acute Care Center | 30.1 mi | ★★★★★ | 21 | 0 |
| Mountain View Conv Hosp | 30.2 mi | ★★★★★ | 39 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.