Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Monte Vista Healthcare Center during CMS and state inspections, most recent first.
Failure to develop comprehensive person-centered care plans for two residents. One resident had repeated falls, impaired cognition, and significant mobility and ADL assistance needs, but no CPs addressed the falls. Another resident had acute respiratory failure with hypoxia, heart failure, impaired decision-making, and continuous O2 at 3 LPM, but no CP addressed the supplemental O2 therapy. The DON and RNS confirmed the missing CPs during record review.
Medication, restorative care, and post-fall assessment failures: An LVN gave an unmeasured amount of Lidocaine ointment instead of the ordered 2 grams for a resident with chronic pain, while another resident with hemiplegia and contractures missed ordered RNA ambulation and brace-assist sessions needed to maintain function. A third resident with repeated falls did not have post-fall risk assessments completed after multiple falls, despite facility policy requiring assessment and documentation after each fall.
One bag of breaded fish in Freezer 1 was found with an undated label during a kitchen tour. The DM stated the bag did not have a received date or use-by date, which was required by the facility’s Food Receiving and Storage P&P for safe food handling.
Infection control practices were not implemented for multiple residents and areas. In a shared restroom used by several residents, an unlabeled emesis basin, toothpaste, and toothbrushes were found on the sink counter, even though staff stated these items should be labeled and stored at the bedside for infection control. In the laundry room, a commercial dryer had a thick buildup of lint on the lint screen/trap, and staff stated the lint trap had not been properly cleaned. For a resident with a foley catheter on EBP, the room doorway lacked the required EBP sign, despite the DON and IP confirming the resident needed EBP and that signage should be posted.
Failure to Maintain Privacy During Toileting: A resident with COPD and dementia was observed using the toilet with the shared room and restroom doors left open while a CNA stood outside. The CNA acknowledged the restroom door should have been closed for privacy, and the RNS stated toilet use should be private to preserve dignity. The resident’s record showed severe cognitive impairment, substantial to maximal ADL assistance needs, and frequent urinary and bowel incontinence.
A resident admitted with bacteremia and chronic diastolic CHF did not have a BCP created within 48 hours of admission. The DON acknowledged the BCP was completed almost a week after admission, and the RNS reviewed the late-dated plan and stated it is used to help staff know the resident and the care plan. The resident's H&P also indicated the resident lacked capacity to understand and make decisions.
Failure to maintain a low bed and bedside floor mats for a resident at high fall risk. A resident with repeated falls, impaired cognition, cerebellar ataxia, and gait/mobility problems was observed lying in bed with the bed not in the lowest position and bilateral floor mats folded against the wall instead of placed beside the bed. The DON then lowered the bed and positioned the mats on the floor.
GT site care was not provided as ordered for a resident with a GT, cerebral palsy, dysphagia, and severe cognitive impairment. The resident was observed without the ordered abdominal binder, with an undated soiled dressing and GT site redness, inflammation, and dried drainage. Staff stated the binder was needed to prevent the resident from pulling out the GT, and the RN supv reviewed records showing the site redness and irritation should have been monitored and the dressing changed.
A resident with acute respiratory failure with hypoxia and COPD had an order for continuous O2 at 3 LPM via N/C, but was observed receiving 2.5 LPM with only one nasal prong in place. The TN and RNS both acknowledged the resident was not receiving the ordered dose when both prongs were not in the nostrils, and the resident stated they always used O2 and did not know who had placed the N/C.
A facility failed to post nurse staffing information showing the actual hours worked by licensed and unlicensed nursing staff responsible for resident care, instead posting projected DPHHD for each shift. The DSD stated actual direct care hours were calculated the following day and kept in a binder in the front office, and were not posted for public viewing; the DON stated actual nursing hours should be posted for patient care ratios and resident safety.
A resident with Alzheimer's disease and moderate cognitive impairment had two home medication bottles in the med cart that were brought in by family, but the contents were not verified by a licensed pharmacist as required by facility P&P. The LVN did not know whether the bottles had been checked, and the DON confirmed the pharmacist had not verified the contents.
Missing Consent for COVID-19 Vaccine: A resident with COPD and sepsis, who was documented as unable to make medical decisions and severely impaired in daily decision making, received the COVID-19 vaccine without a recorded consent. The IP confirmed there was no consent on file, noted the vaccine was given by an outside contracted pharmacy, and the facility policy required a signed consent form before vaccination.
Surveyors found that the facility did not develop comprehensive, person-centered care plans for two residents related to vaccination refusal and influenza status. One resident with sepsis and a UTI, documented as having moderately impaired cognition and needing assistance with several ADLs, formally declined COVID-19, RSV, influenza, and pneumococcal vaccines, but this refusal was not addressed in the care plan despite facility policy. Another resident with a healing femur fracture and hemiplegia, severely impaired decision-making, and high ADL dependence tested positive for influenza, yet no care plan addressed the influenza diagnosis. The IP and DON confirmed that individualized care plans for these issues were missing, contrary to the facility’s written care plan policy.
Surveyors found that an LVN reported receiving an influenza vaccine from an outside provider but never submitted proof of vaccination, and the facility did not obtain or document this information in the employee file. Review of the personnel records confirmed there was no influenza vaccination record for this LVN, despite facility policy requiring that employees be offered the vaccine within a specified timeframe and that all vaccination details or outside vaccination documentation be maintained in the employee medical record. The DSD and DON both acknowledged the importance of having this documentation on file and confirmed that the missing record did not comply with the facility’s influenza vaccine policy.
A resident with dementia, UTI, and moderately impaired cognition, who was dependent on staff for toileting and bathing, alleged that a CNA grabbed and injured the resident’s arm during incontinence care. CNAs and the IPN reported the allegation to an LVN and assessed the resident, with documentation noting both a small area of redness and later no new marks or scratches, and inconsistent statements by the resident. Despite a written policy requiring immediate reporting of abuse allegations within two hours and removal of any accused employee from resident contact, the allegation was not reported within the required timeframe, and the CNA accused of abuse was not removed from resident care and returned to the resident’s room after the allegation.
A resident with DM, hemiplegia, and hemiparesis, who was dependent for ADLs and transfers, was found via hip X-ray to have a suspected acute right femur fracture and was later confirmed at a GACH to have an acute femur fracture. Despite facility policy requiring that injuries of unknown origin be promptly reported to the Ombudsman, Police, and State Survey Agency and thoroughly investigated, the DON acknowledged that no investigation was conducted to determine how the fracture occurred and that the required external reports were not made within the mandated 2-hour timeframe.
A resident with DM, hemiplegia, and hemiparesis, who was dependent for ADLs and transfers, had a bilateral hip X-ray showing a suspected acute right femur fracture and was transferred to a GACH, where imaging confirmed an acute right femur fracture. Despite these findings, the DON reported that no investigation was conducted to determine how the fracture occurred and that the injury of unknown origin was not reported to the Ombudsman, police, or State Survey Agency within the required two-hour timeframe, contrary to facility policy requiring prompt reporting and thorough investigation of all suspected abuse and injuries of unknown origin.
A resident with DM and post-stroke hemiplegia/hemiparesis, dependent for ADLs and transfers but able to make decisions, was sent to an outside pain specialist appointment accompanied by a spouse. The assigned LVN did not obtain or document assessments or VS when the resident left for or returned from the appointment, and the DON could not locate any related nurse’s notes or VS in the medical record. Both the LVN and DON acknowledged that facility policy requires licensed staff to complete and document assessments and VS around outside appointments, and the facility’s charting policy requires documentation of services provided and changes in condition to support IDT communication.
The facility failed to maintain a clean, safe, and homelike environment, as evidenced by a clogged toilet in a resident's bathroom that went unaddressed for two days despite being reported. Additionally, multiple bathrooms and resident rooms exhibited maintenance issues such as unpainted plaster, cracked caulking, and chipped paint. The Maintenance Director acknowledged that these issues were not properly reported by staff, posing a potential risk to residents' health.
A facility failed to follow a physician's order for a resident's Losartan Potassium administration, which required holding the medication if the resident's SBP was below 140 mmHg or HR was below 85. Despite these parameters, the medication was administered on several occasions when the resident's readings were below the specified thresholds. The LVN and RNS acknowledged the oversight, which was contrary to the facility's policy for safe medication administration.
Two residents in an LTC facility received inadequate pressure ulcer care. One resident's low air loss mattress was incorrectly set, potentially delaying healing of a stage 4 ulcer. Another resident, with severe cognitive impairment, was not repositioned as per care plan, leading to open scratch marks. These deficiencies highlight failures in adhering to care protocols and professional standards.
The facility failed to provide appropriate respiratory care for three residents, including untimely changes of nebulizers and unlabeled oxygen tubing. A resident's nebulizer was not changed weekly as required, and two residents had unlabeled oxygen equipment, with one lacking a physician's order for oxygen therapy. These deficiencies were observed during a survey, highlighting lapses in infection control and equipment management.
A resident with severe cognitive impairment and multiple diagnoses, including diabetes, did not receive full doses of medications via a gastrostomy tube, resulting in a 9.68% medication error rate. The LVN failed to ensure complete administration, leaving significant medication residue in cups. The RN Supervisor confirmed the resident did not receive full therapeutic doses, violating the facility's medication administration policy.
The facility failed to label two medications, Senna and Docusate Sodium, with the date they were opened, as required by policy. This oversight was discovered during an observation of Med Cart 2, where the LVN confirmed the medications were part of the house supply and should have been dated to ensure effectiveness. The RN Supervisor reiterated the importance of labeling to maintain medication potency.
The facility failed to provide fortified diets as ordered for two residents, one with cerebral infarction and hemiplegia, and another with metabolic encephalopathy and diabetes. Despite the diet roster and menu indicating the need for fortified diets, meal trays lacked the required super soup. The Dietary Supervisor confirmed the oversight, which could impact the residents' caloric intake.
The facility failed to discard expired food items in the kitchen's dry storage, posing a risk of food-borne illnesses. An open package of corn meal and baking powder were found expired during an observation. The Dietary Supervisor acknowledged the need for immediate disposal but could not explain the oversight, and the facility lacked a specific policy for handling expired items.
The facility failed to manage a norovirus outbreak effectively, as isolation precautions were prematurely discontinued for symptomatic residents. Staff did not consistently wear appropriate PPE, and personal care items were not properly labeled or stored, increasing the risk of cross-contamination.
A facility failed to maintain a functional call light for a resident, leading to frustration and potential risk. Bathrooms and rooms were found in disrepair, posing health risks. Additionally, a resident's bed control was intermittently non-functional, causing discomfort, and the issue was not promptly reported or logged for maintenance, highlighting lapses in the facility's maintenance processes.
A facility failed to maintain a resident's dignity and privacy during care. A CNA exposed a resident's lower body while washing their face and neck, contrary to the facility's policy requiring covered care to ensure privacy. The resident had severe cognitive impairment and required maximum assistance with personal hygiene.
A resident with end-stage renal disease and diabetes was found with an unauthorized bottle of Pepto Bismol Ultra in their room, without a physician's order or consent for self-administration. The resident, with moderately impaired cognition, admitted to using the medication for indigestion. The facility failed to assess the resident's ability to self-administer safely, as required by policy.
A resident tested positive for C. diff, but the facility failed to develop a care plan from the time of the positive result until several days later. Despite receiving treatment orders, no care plan was created to address the resident's condition, and appropriate isolation measures were initially lacking.
A resident with dementia and a history of falls did not have a toileting schedule as per their care plan, leading to potential fall risks. The resident was observed getting up unassisted and feeling dizzy, and had previously fallen while attempting to pick up pants. The DON acknowledged that a toileting schedule could prevent such incidents, but it was not in place.
A resident with severe cognitive impairment and recurrent UTIs experienced a deficiency in catheter care when the facility failed to follow the physician's order for daily irrigation of the Foley catheter. Observations revealed sediments on the catheter tubing, and the last recorded irrigation was several days prior, despite the resident's care plan indicating a need for monitoring and maintenance. The facility's policy required immediate reporting of unusual findings, which was not adhered to, contributing to the resident's ongoing issues.
A resident with a G-Tube was administered medications mixed with apple sauce instead of water, contrary to facility policy and without a physician's order. The LVN involved stated this was their usual practice, but the RN Supervisor and Director of Staff Development confirmed it could lead to tube occlusions and decreased medication potency.
The facility failed to serve food at safe and appetizing temperatures, with observations showing food items like chicken and green beans below the recommended temperature range. Resident Council Minutes also documented complaints about cold food. The Dietary Supervisor noted that unappetizing food could lead to residents not eating and potential weight loss.
A resident with hemiplegia and other conditions experienced a non-functional call light, leading to potential delays in care. The resident reported the issue, and a CNA confirmed the malfunction, stating the importance of a working call light, especially in emergencies. The facility's policy requires call lights to be operational and defects reported promptly.
The facility failed to maintain a pest-free environment in Kitchen 1, where two dead cockroaches were found near the walk-in freezer. A Dietary Aide confirmed the presence of the cockroaches and used a broom with dust and green beans to sweep them away. The Dietary Supervisor noted that the cockroaches might have appeared after a recent pest control visit. The facility's policy requires kitchen areas to be clean and pest-free, which was not followed.
Failure to Develop Comprehensive Person-Centered Care Plans
Penalty
Summary
The facility failed to ensure comprehensive person-centered care plans were developed for two sampled residents in accordance with its Care Plans, Comprehensive Person-Centered and Fall Risk Assessment policy. Resident 36 was admitted with diagnoses including intervertebral disc displacement of the lumbar region, cerebellar ataxia, repeated falls, lack of coordination, and abnormalities in gait and mobility. The H&P stated the resident did not have the capacity to understand and make decisions, and the MDS showed moderately impaired cognition, dependence with toilet hygiene and lower body dressing, and maximal assistance with upper body dressing. Fall risk assessments identified the resident as at risk for falls, and the COC documented falls on 1/30/2026, 2/9/2026, 2/15/2026, 3/1/2026, and 3/23/2026. During interview and record review, the DON stated there were no care plans addressing these falls. Resident 14 was originally admitted and later readmitted with diagnoses including acute respiratory failure with hypoxia and heart failure, unspecified. The H&P stated the resident did not have the capacity to understand or make medical decisions, and the MDS showed moderately impaired cognitive skills for daily decision making, dependence to partial/moderate assistance with ADLs, and continuous O2 therapy. The OSR showed a physician order for O2 at 3 LPM via nasal cannula continuously, but during interview and record review the RNS stated there was no care plan addressing the resident's supplemental O2 therapy. The facility policy stated comprehensive person-centered care plans with measurable objectives and timetables are to be developed and implemented for each resident and revised as conditions change.
Medication, restorative care, and post-fall assessment failures
Penalty
Summary
Resident 20 had diagnoses including spondylosis and type 2 diabetes mellitus with chronic kidney disease. The care plan for acute/chronic pain directed staff to administer pain medication as ordered. A physician order dated 3/11/2026 directed staff to apply 2 grams of Lidocaine external ointment 5% to the right upper arm twice daily for right arm pain. During a concurrent observation and interview on 4/23/2026, an LVN administered an unmeasured amount of the ointment and stated she was not sure how much was applied because the medication label did not indicate how much ointment was 2 grams. The DON stated correct dosages should be given to ensure residents are not over dosed or under dosed, and the facility policy required medications to be administered in accordance with prescriber orders. Resident 24 had diagnoses including hemiplegia and hemiparesis following cerebral infarction, contractures of the left knee, left elbow, and left hip, lack of coordination, and generalized muscle weakness. The resident’s H&P indicated capacity to understand and make decisions, and the MDS indicated cognitive intactness with impairment on one side of the upper and lower extremities and use of a walker and manual wheelchair. The care plan and physician order directed an RNA program to assist with ambulation using a hemi walker and left HKAFO application four times per week to maintain current level of function. The RNA medical record for April 2026 showed missed RNA services on 4/5/2026, 4/7/2026, and 4/19/2026. The resident stated not all RNA therapy sessions were received as ordered, and RNA staff and facility leadership stated the missed treatments were important because they helped maintain mobility and function. Resident 36 had diagnoses including lumbar intervertebral disc displacement, cerebellar ataxia, repeated falls, lack of coordination, and abnormalities in gait and mobility. The H&P indicated the resident did not have capacity to understand and make decisions, and the MDS showed moderately impaired cognition with dependence for some ADLs and maximal assistance for others. The resident’s COC documented falls on 1/30/2026, 2/19/2026, 3/1/2026, 3/23/2026, and 4/15/2026. During interview and record review, the DON stated post-fall risk assessments were not completed after those falls. The facility’s fall-related policies stated residents must be assessed after a fall and that a falls risk assessment should be completed and documented in the medical record.
Undated Frozen Fish in Freezer
Penalty
Summary
One bag of breaded fish in Freezer 1 was observed during a kitchen tour to have an undated label. During the concurrent observation and interview, the Dietary Manager stated that the bag did not contain a label showing a received date and a use-by date, which was required for resident food safety. Review of the facility’s policy and procedure titled, Food Receiving and Storage, dated 11/2022, showed that foods are to be received and stored in a manner that complies with safe food handling practices, and that all foods stored in the refrigerator or freezer are to be covered, labeled, and dated with a use-by date.
Infection Control Failures With Personal Items, Dryer Lint Trap, and EBP Signage
Penalty
Summary
The facility failed to implement infection prevention and control practices in multiple areas. In a shared restroom used by Residents 54, 9, 39, and 45, surveyors observed an unlabeled gray emesis basin with a personal-size toothpaste and two toothbrushes stored on the sink counter. CNA 2 identified these as personal care items and stated they should be labeled and stored at the resident’s bedside for infection control. The Infection Preventionist later stated that emesis basins, toothpaste, and toothbrushes were personal care items that should be labeled with the resident’s room number and initials and stored at the bedside, and that proper labeling and storage were important because the rooms were on EBP. Resident 54 was admitted and readmitted to the facility with diagnoses including a history of poliomyelitis and heart failure. Resident 54’s H&P indicated the resident had capacity to make medical decisions, and the MDS indicated intact cognitive skills for daily decision making, with partial/moderate assistance needed for oral hygiene. Resident 9 was admitted with diagnoses including type 2 DM and an unstageable sacral pressure ulcer; the HPI indicated the resident had capacity to understand and make decisions, and the MDS indicated intact cognitive skills for daily decision making with supervision or touching assistance needed for oral hygiene. Resident 39 was admitted with diagnoses including type 2 DM with other complication and essential HTN; the H&P indicated the resident did not have capacity to understand and make decisions, and the MDS indicated substantial/maximal assistance was required for oral hygiene. Resident 45 was admitted and readmitted with diagnoses including COVID-19 and UTI; the H&P indicated the resident did not have capacity to understand and make decisions, and the MDS indicated intact cognitive skills for daily decision making with supervision or touching assistance needed for oral hygiene. The facility also failed to maintain the lint screen/trap of one commercial laundry dryer. During observation in the laundry room, the dryer had a thick accumulation of lint on the lint screen/trap, and clumps of lint fell off onto the floor. The Daily Cleaning Lint Trap record showed the lint traps were cleaned every 2 hours, with the last cleaning documented at 11 AM, but the Maintenance Supervisor stated the lint trap had been cleaned about forty-five minutes earlier. The Housekeeping staff stated they cleaned the dryer every 2 hours but only cleaned the floor and did not know how to clean the lint screen/trap. The Housekeeping staff and Maintenance Supervisor stated cleaning the lint trap was important to prevent fires. The facility also failed to post Enhanced Barrier Precaution signage for Resident 70. Resident 70 was admitted with diagnoses including bacteremia and chronic diastolic congestive heart failure, had no capacity to understand and make decisions, and had a foley catheter. The physician order recap showed an order for EBP due to an indwelling medical device, and the care plan initiated on 4/21/2026 directed staff to place EBP signage at the resident’s door entry. During observation, the doorway to Resident 70’s room was without EBP signage, and the DON stated the resident had a foley catheter and was on EBP. The Infection Preventionist stated that residents with indwelling medical devices required EBP and that signage near the door indicated caregivers needed to wear gown and gloves for high-contact care.
Failure to Maintain Privacy During Toileting
Penalty
Summary
The facility failed to ensure Resident 44 was treated with dignity when CNA 1 did not close the door to the resident’s shared room and/or the shared restroom while the resident was using the toilet on 4/21/2026. During the observation, Resident 44 was on the toilet and occasionally groaned, while CNA 1 stood outside the restroom and both doors were open. CNA 1 stated the doors were open because the roommate was not in the room, and acknowledged that the restroom door should have been closed for the resident’s privacy. Resident 44’s record showed the resident was originally admitted and later readmitted to the facility with diagnoses including COPD with acute exacerbation and unspecified dementia, with severe impairment in cognitive skills for daily decision making. The MDS also indicated the resident required substantial to maximal assistance with ADLs and was frequently incontinent of urine and bowel. The Registered Nurse Supervisor stated that when a resident used the toilet, the restroom door should be closed to provide privacy and dignity. The facility’s dignity policy stated residents are treated with dignity and respect at all times and that staff promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care.
Failure to Create Baseline Care Plan Within Required Timeframe
Penalty
Summary
The facility failed to create a Baseline Care Plan for Resident 70 within 48 hours of admission. Resident 70 was admitted with multiple diagnoses, including bacteremia and chronic diastolic congestive heart failure. The admission History and Physical dated 4/17/2026 indicated that Resident 70 did not have capacity to understand and make decisions. During interview and record review on 4/24/2026, the DON stated that Resident 70's Baseline Care Plan was created on 4/23/2026, almost one week after admission, and acknowledged that it should have been created upon admission. The RNS reviewed the Baseline Care Plan dated 4/23/2026 and stated that its purpose was to get to know the resident better and let staff know the plans for care. The facility policy titled Care Plans - Baseline stated that a baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within 48 hours of admission.
Failure to Maintain Low Bed and Floor Mats for a Resident at High Fall Risk
Penalty
Summary
The facility failed to implement safety measures for a resident with a history of multiple falls and identified fall risk. Resident 36 was admitted with diagnoses including intervertebral disc displacement of the lumbar region, cerebellar ataxia, repeated falls, lack of coordination, and abnormalities in gait and mobility. The resident’s H&P stated the resident did not have the capacity to understand and make decisions, and the MDS showed moderately impaired cognition, dependence with toilet hygiene and lower body dressing, and maximal assistance needed with upper body dressing. The resident’s care plan, initiated for low bed use, directed staff to keep the bed in the lowest position at all times when the resident was resting unless care was being provided. The resident also had a physician’s order for bilateral floor mats at the bedside. During observation with the DON, the resident was lying in bed with the bed not in the lowest position and the floor mats folded vertically and leaning against the wall rather than placed on both sides of the bed. The DON then lowered the bed and placed the mats on the floor. The resident’s record also showed multiple falls on 1/30/2026, 2/9/2026, 2/15/2026, 3/1/2026, and 3/23/2026, and a fall risk assessment dated 4/4/2026 indicated the resident was at risk for falls.
GT Site Care Not Provided as Ordered
Penalty
Summary
Resident 32, who had cerebral palsy, dysphagia, severe cognitive impairment, and dependence for activities of daily living, was admitted with a gastrostomy tube and a history of displacement of gastrointestinal prosthetic devices. The care plan identified that the resident required tube feeding and included interventions to provide local GT site care, monitor for signs and symptoms of infection, and apply an abdominal binder at all times because the resident was at risk for pulling out the GT. The physician's orders also directed staff to cleanse the GT site with normal saline, apply a dry dressing as needed for a soiled or dislodged GT, and use an abdominal binder related to a history of pulling out the GT every shift. On 4/23/2026, during a concurrent observation and interview, Resident 32 did not have the abdominal binder wrapped around the GT area. The GT site had an undated soiled dressing, and the site showed redness, inflammation, light brown dried drainage, and crusty dried skin around the GT site. The LVN stated that checking the GT site, providing GT care, and reporting to the treatment nurse were important to prevent skin irritation, MASD, and infection, and that the abdominal binder was important to prevent the resident from pulling out the GT. During interviews and record review, the treatment nurse stated GT site care and dressing changes were done daily and as needed, and that the dressing should have been changed and the abdominal binder should have been on to prevent the resident from pulling out the GT. The registered nurse supervisor reviewed the records and stated the GT site redness and irritation should have been monitored, the dressing changed, and the physician notified. The facility policy for gastrostomy/jejunostomy site care required assessment for redness, pain, swelling, or drainage and immediate reporting of signs of infection to the supervisor and physician.
Improper Oxygen Delivery for Resident with Respiratory Failure
Penalty
Summary
The facility failed to ensure proper respiratory care for one sampled resident who had diagnoses including acute respiratory failure with hypoxia and heart failure. The resident’s record showed an order for oxygen at 3 LPM via nasal cannula continuously, and the resident’s MDS indicated continuous oxygen therapy, moderate impairment in cognitive skills for daily decision making, and dependence to partial/moderate assistance with ADLs. During observation, the resident was receiving 2.5 LPM oxygen via nasal cannula, and only one nasal prong was in the left nostril. During interview, the resident stated they always used oxygen and did not know who placed the nasal cannula. The Treatment Nurse acknowledged that only one nasal prong was in the resident’s nostril and stated both prongs were important for the resident to receive the correct oxygen dose because of COPD. The Registered Nurse Supervisor also stated the resident was not receiving the ordered dose when both nasal prongs were not in place and noted the resident had a tendency to remove the nasal cannula and should be monitored. The facility policy on oxygen administration stated the nasal cannula should be placed approximately one-half inch into the resident’s nose.
Nurse Staffing Information Not Posted as Actual Hours Worked
Penalty
Summary
The facility failed to post nurse staffing information showing the actual hours worked by licensed and unlicensed nursing staff who were directly responsible for resident care, per shift daily, in a prominent location and readily accessible to residents and visitors on 4/21/2026, 4/22/2026, 4/23/2026, and 4/24/2026. During observation on 4/24/2026 at 12:35 PM, the posted document titled Projected Census and Direct Service Hours Per Patient Day (DPHHD) showed projected hours for direct care staff for the 7 AM to 3 PM, 3 PM to 11 PM, and 11 PM to 7 AM shifts, but it did not show the actual hours worked per shift. During interview and record review with the DSD on 4/24/2026 at 12:41 PM, the DSD stated projected nursing hours were posted at the beginning of the day, while actual worked direct care hours were not calculated or generated until the following day and were kept in a binder inside the front office. The DSD stated the actual worked nursing hours were not posted for public viewing and said it was important for actual nursing hours to be posted to ensure the facility tracked the actual nursing hours provided to residents. During interview with the DON on 4/24/2026 at 2:35 PM, the DON stated actual nursing hours should be posted for patient care ratios and for resident safety. The facility policy titled Staffing, Sufficient and Competent Nursing, revised 8/2022, stated direct care daily staffing numbers are posted in the facility for every shift.
Home Medication Bottles Not Verified by Pharmacist
Penalty
Summary
The facility failed to ensure that two home medication bottles for Resident 48 were verified by a licensed pharmacist, as required by the facility's policy and procedure for medications brought to the facility by the resident or family. Resident 48 was admitted with multiple diagnoses including Alzheimer's disease and generalized muscle weakness. The Minimum Data Set dated 3/2/2026 indicated the resident's cognition was moderately impaired and that the resident was dependent for toileting and bathing. Resident 48's active physician orders included glucosamine hydrochloride 1500 mg by mouth daily and a men's 50+ multivitamin by mouth daily. During observation on 4/24/2026, two medication bottles were seen in medication cart #2: a 220-tablet bottle of glucosamine HCl with chondroitin/MSM complex and a 275-tablet bottle of men's 50+ multivitamin. The LVN stated the bottles were not from the facility pharmacy and had been brought in by the resident's family, and did not know whether the pharmacist had checked them. The DON stated the contents of the bottles had not been verified by the facility's pharmacist, and the facility's policy required that the contents of each container be verified by a licensed pharmacist.
Missing Consent for COVID-19 Vaccine
Penalty
Summary
The facility failed to ensure that Resident 4 had a consent for the COVID-19 vaccine before the vaccine was administered, as required by the facility’s policy and procedure titled, Coronavirus Disease (COVID-19) - Vaccination of Residents. Resident 4 was originally admitted to the facility and later readmitted with diagnoses including COPD and sepsis. The resident’s H&P dated 4/19/2026 indicated the resident could make needs known but could not make medical decisions, and the MDS dated 4/23/2026 indicated severely impaired cognitive skills for daily decision making and that the resident’s COVID-19 vaccination was not up to date. During interview and record review on 4/24/2026, the Infection Preventionist reviewed the Residents Immunization record and confirmed Resident 4 received the COVID-19 vaccine on 9/17/2025, but there was no record of consent for the vaccine. The Infection Preventionist stated the facility did not provide the COVID-19 vaccine directly and that an outside contracted pharmacy administered it to residents. The Infection Preventionist also stated the contracted pharmacy did not have a COVID-19 consent for Resident 4, and that obtaining consent was important to get permission from Resident 4 to administer the vaccine. The facility policy stated residents must sign a consent to vaccinate form prior to receiving the vaccine and that the medical record must include, at a minimum, a signed consent.
Failure to Care Plan Vaccine Refusal and Influenza Diagnosis for Two Residents
Penalty
Summary
The facility failed to develop comprehensive, person-centered care plans addressing vaccination refusal and influenza status for two residents. One resident was originally admitted with sepsis and a urinary tract infection and had documented capacity to understand and make decisions, with an MDS showing moderately impaired cognitive skills and a need for supervision or assistance with several ADLs. Vaccine consent forms dated shortly after admission showed this resident declined COVID-19, RSV, influenza, and pneumococcal vaccines. However, review of the resident’s care plan with the Infection Prevention Nurse (IP) revealed there was no care plan addressing the resident’s refusal of these vaccines, despite facility policy requiring a care plan when a resident declines vaccine administration upon admission. Another resident, admitted with a right femur fracture and hemiplegia/hemiparesis following cerebral infarction, also had documented capacity to understand and make decisions, but an MDS indicated severely impaired cognitive skills for daily decision making and dependence or high assistance needs for toileting, showering, dressing, hygiene, and eating. The IP reported being informed that this resident tested positive for influenza, yet concurrent review of the resident’s care plan showed there was no care plan addressing the resident’s influenza diagnosis. Both the IP and the DON acknowledged the absence of individualized care plans for these current medical conditions, despite a written policy requiring comprehensive, person-centered care plans with measurable objectives and timetables, including for services not provided due to a resident’s exercise of the right to refuse treatment.
Failure to Document Staff Influenza Vaccination per Facility Policy
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to implementation of its influenza vaccination policy for staff. An LVN reported in interview that they had received an influenza vaccine in August 2025 but had not provided proof of vaccination to the facility. Review of the LVN’s Personnel Action Form, dated with a hire date in early December 2025, and the employee file showed there was no documentation of influenza vaccination. The Director of Staffing Development confirmed that the facility’s practice was to obtain a copy of each employee’s influenza vaccination documentation and place it in the employee file, and acknowledged that this documentation was missing for the LVN. The DON stated it was important to have the LVN’s influenza vaccine documentation on file because it would indicate whether the LVN had received the vaccine and was important for resident safety. Review of the facility’s written P&P titled “Influenza Vaccine,” revised March 2022, showed that all employees without medical contraindications were to be offered the influenza vaccine annually, and that employees hired between October 1 and March 31 were to be offered the vaccine within five working days of job assignment. For those who received the vaccine, the policy required documentation of the vaccination details in the employee’s medical record, and stated that staff could obtain vaccines from personal physicians but must provide documentation of previous vaccination to the facility. The absence of any influenza vaccination record for the LVN in the employee file was inconsistent with these policy requirements.
Failure to Timely Report Abuse Allegation and Remove Accused CNA From Resident Contact
Penalty
Summary
The deficiency involves the facility’s failure to follow its abuse, neglect, exploitation, and misappropriation reporting and investigation policy for a resident who alleged abuse by a CNA. The resident had dementia, a UTI, moderately impaired cognition, and was dependent on staff for toileting hygiene and bathing. On the date of the incident, two CNAs reported that the resident complained a CNA had grabbed the resident’s upper arm, with documentation in the progress note that there was a small area of redness, although the CNAs stated the redness was present before they assisted the resident. A change in condition evaluation documented that a CNA grabbed the resident’s upper arm, resulting in a small area of redness, and that the resident did not know the current location, situation, or date/time. A post-event review later documented that the resident alleged a CNA scratched or ripped the resident’s arm and that the resident, who had dementia and an active UTI, provided inconsistent statements. Staff interviews showed that the allegation was reported internally but not handled in accordance with the facility’s written policy. CNA 1 reported the allegation to LVN 1 and the infection prevention nurse (IPN), and both LVN 1 and the IPN assessed the resident’s skin and reported finding no new marks, scratches, or redness. The incident time was variably recalled as around early to mid-afternoon. Despite the facility policy requiring that suspicions of abuse be reported immediately to the administrator and other officials within two hours and that any employee accused of abuse be placed on leave with no resident contact, the allegation was not reported within the required two-hour timeframe, and CNA 1 was not removed from resident contact and re-entered the resident’s room after the allegation. The DON confirmed that staff should have reported the allegation immediately and that CNA 1 should have been suspended from resident contact in accordance with the policy.
Failure to Report and Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to timely report and investigate an injury of unknown origin for one of ten sampled residents, as required by its abuse, neglect, exploitation, or misappropriation reporting and investigating policy. The resident was admitted with diagnoses including diabetes mellitus, hemiplegia, and hemiparesis following a cerebral infarction, and was documented as dependent on staff for ADLs and transfers. A bilateral hip X-ray obtained on 12/21/2025 at 9:14 a.m. showed a suspected acute right femur fracture. A Change in Condition Evaluation completed at 1:56 p.m. the same day documented the suspected right femur fracture and a physician recommendation to transfer the resident to an acute care hospital for further evaluation. Nursing documentation indicated the resident was transported by ambulance to the hospital at 4:20 p.m. Subsequent hospital imaging on 12/22/2025 at 9:11 a.m. confirmed an acute right femur fracture. The DON stated during interview that the facility did not conduct an investigation to determine how the resident sustained the right femur fracture and did not report this injury of unknown origin to the local Ombudsman, the Police, or the State Survey Agency within two hours of obtaining the X-ray results, as required by the facility’s policy. Review of the written policy dated 9/2022 showed that all reports of resident abuse, including injuries of unknown origin, were to be reported to local, state, and federal agencies as required by regulations and thoroughly investigated, with findings documented and reported. The DON acknowledged the facility did not follow this policy regarding the resident’s injury of unknown origin.
Failure to Investigate and Report Injury of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to investigate and report an injury of unknown origin for one sampled resident. The resident was admitted with diagnoses including diabetes mellitus, hemiplegia, and hemiparesis following a cerebral infarction, and was documented on the MDS as dependent on staff for ADLs and transfers. A History and Physical dated 4/19/2026 indicated the resident had capacity to understand and make decisions. On 12/21/2025 at 9:14 am, a bilateral hip X-ray showed a suspected acute right femur fracture. A Change in Condition Evaluation completed at 1:56 pm the same day documented the suspected right femur fracture and the primary physician’s recommendation to transfer the resident to an acute care hospital for further evaluation. Nursing notes show the resident was picked up by ambulance and transferred out at 4:20 pm. Subsequently, an X-ray at the acute care hospital on 12/22/2025 at 9:11 am confirmed an acute right femur fracture. Despite these findings, the DON stated during interview that the facility did not conduct an investigation to determine how the resident sustained the right femur fracture and did not report this injury of unknown origin to the local Ombudsman, police, or State Survey Agency within two hours of obtaining the X-ray results. The DON acknowledged the facility did not follow its policy, dated 9/2022, which requires that all reports of resident abuse, including injuries of unknown origin, be reported to local, state, and federal agencies as required and be thoroughly investigated by facility management, with findings documented and reported.
Failure to Assess and Document Resident Status Before and After Outside Appointment
Penalty
Summary
The facility failed to ensure that a licensed nurse completed and documented required assessments and vital signs before and after an outside medical appointment for one resident. The resident had been admitted with diagnoses including diabetes mellitus, hemiplegia and hemiparesis following a cerebral infarction, and was dependent on staff for ADLs and transfers. The resident’s history and physical indicated that the resident had the capacity to understand and make decisions. On the day in question, the resident left the facility with their spouse for an appointment with a pain specialist. Record review with the DON showed there was no nurse’s note, assessment, or vital signs documented in the medical record related to the resident’s departure for, or return from, the pain management appointment. In an interview, the LVN assigned to the resident that day confirmed that no assessment or vital signs were taken when the resident left for or returned from the appointment, despite acknowledging that facility policy requires assessments and vital signs in these circumstances. The DON also stated that the assigned licensed nurse should document vital signs and an assessment when a resident leaves and returns for a doctor’s appointment. The facility’s charting and documentation policy required that all services provided and any changes in the resident’s condition be documented to facilitate communication among the interdisciplinary team.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, safe, sanitary, and homelike environment, as evidenced by several deficiencies observed in resident bathrooms and rooms. One significant issue involved a clogged toilet in a resident's bathroom, which had been unusable for two days. Despite the resident reporting the issue to both nurses and certified nursing assistants, the problem was not addressed promptly. The Maintenance Director (MTD) was only informed of the issue on the day of the survey, indicating a breakdown in communication and reporting procedures within the facility. In addition to the clogged toilet, multiple resident bathrooms were found to have various maintenance issues, including unpainted plaster, cracked and peeling caulking, chipped paint, and exposed wood. These conditions were observed in bathrooms used by several residents, indicating a widespread problem with the facility's maintenance and upkeep. The MTD acknowledged that these issues had not been reported through the proper channels, as staff failed to log maintenance requests in the designated binder. Resident rooms also exhibited similar deficiencies, with observations of unpainted plaster, black marks, chipped paint, and exposed wood. These conditions were noted in rooms occupied by multiple residents, further highlighting the facility's failure to provide a homelike environment. The MTD confirmed that these areas required repair and acknowledged that the lack of proper reporting by staff contributed to the ongoing maintenance issues, posing a potential risk to residents' health.
Failure to Follow Physician's Orders for Medication Administration
Penalty
Summary
The facility failed to ensure that a resident received proper care by not adhering to the physician's order regarding the administration of Losartan Potassium, a medication used to treat hypertension. The physician's order specified that the medication should be held if the resident's systolic blood pressure (SBP) was less than 140 mmHg or if the heart rate (HR) was less than 85. Despite these parameters, the medication was administered on multiple occasions when the resident's SBP and HR were below the specified thresholds. The resident, who was admitted with multiple diagnoses including acute respiratory failure with hypoxia and essential hypertension, had intact cognition according to a Minimum Data Set assessment. However, a History and Physical report indicated the resident did not have the capacity to understand and make decisions. The Licensed Vocational Nurse (LVN) and Registered Nurse Supervisor (RNS) acknowledged the failure to follow the physician's parameters, which was important to prevent potential side effects such as hypotension. The facility's policy and procedure for administering medications emphasized the importance of administering medications as prescribed, which was not adhered to in this case.
Deficient Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care for two residents, leading to deficiencies in treatment and prevention. Resident 41, who was admitted with a stage 4 pressure ulcer on the right buttock and paraplegia, had a low air loss (LAL) mattress that was not set correctly according to the resident's weight. The mattress was set at 2 light bars instead of the required 3 light bars for a resident weighing 167 pounds. This incorrect setting was observed during an interview with the resident and confirmed by the treatment nurse, who adjusted the setting to the correct level. The facility's policy and procedure, as well as the LAL mattress user manual, indicated the importance of setting the mattress correctly to provide the necessary pressure relief and benefits. Resident 22, who had severe cognitive impairment and was dependent on assistance for personal hygiene and bed mobility, was not repositioned according to the care plan. The care plan required turning and repositioning at least every 2 hours to prevent skin breakdown. However, observations revealed that the resident was left lying on his back for extended periods, and the certified nursing assistant (CNA) did not attempt to reposition the resident due to anticipated resistance. The resident had open scratch marks on the buttocks and small scabs on the back, indicating a lack of compliance with the repositioning protocol. The facility's policy emphasized the need to reposition residents at risk of pressure injuries. These deficiencies in care could potentially delay the healing of existing pressure ulcers and increase the risk of developing new ones. The facility's failure to adhere to professional standards of practice and care plans for pressure ulcer management and prevention was evident in the observations and interviews conducted during the survey.
Deficient Respiratory Care and Equipment Management
Penalty
Summary
The facility failed to provide appropriate respiratory care for three residents, as observed during a survey. Resident 21's nebulizer was not changed in a timely manner, as it was found unlabeled and unwrapped, dated from 2/6/2025, despite the facility's policy requiring weekly changes. This oversight occurred even though Resident 21 was in contact isolation, which necessitates strict infection control measures. The Director of Staff Development acknowledged that the nebulizer should have been changed and stored according to protocol. For Resident 52, the facility did not have a physician's order for the administration of oxygen, despite the resident receiving oxygen therapy via nasal cannula. Additionally, the oxygen tubing was not labeled with a date, which is necessary to ensure timely changes and prevent infection. Resident 52 had a history of bone cancer and chemotherapy, requiring careful management of respiratory treatments. Resident 111, who was admitted with pneumonia and acute respiratory failure, also had issues with unlabeled respiratory equipment. The nasal cannula and humidifier used for oxygen therapy were not labeled with a date, contrary to the facility's policy. The Registered Nurse Supervisor confirmed that labeling is essential for tracking when equipment needs to be changed, highlighting a lapse in adherence to infection control protocols.
Medication Administration Errors Lead to High Error Rate
Penalty
Summary
The facility failed to ensure that the medication error rate was below 5 percent, resulting in a 9.68 percent error rate during medication administration for one of the sampled residents. This was observed during a medication administration session where three errors were noted out of 31 opportunities. The errors involved the incomplete administration of medications via a gastrostomy tube for a resident, which could potentially affect the efficacy and benefits of the medications. The resident involved, identified as Resident 28, was admitted with multiple diagnoses, including type 2 diabetes mellitus with diabetic polyneuropathy and required attention to a gastrostomy tube. The resident's cognitive abilities were severely impaired, and they were dependent on a feeding tube for medication administration. During the medication administration process, the Licensed Vocational Nurse (LVN) failed to ensure that the full dose of medications was delivered, as evidenced by leftover medication residue in the medicine cups used for administration. The LVN admitted to not being able to identify the medications by sight and acknowledged that more water should have been added to ensure complete dissolution and administration of the medications. The Registered Nurse Supervisor confirmed that the leftover medication residue was significant and that the resident did not receive the full dose, which was necessary for therapeutic effectiveness. The facility's policy on administering medications, which requires safe and timely administration as prescribed, was not adhered to in this instance.
Failure to Label Medications Properly
Penalty
Summary
The facility failed to ensure that medications were labeled in accordance with professional principles, specifically concerning two medications, Senna and Docusate Sodium, used to treat constipation. During an observation and interview, it was found that these medications, stored in Med Cart 2, did not have an opened date label. The Licensed Vocational Nurse (LVN) acknowledged that these were part of the facility's house supply and should have been dated upon opening, as they expire 28 days after being opened. The absence of labeling could lead to the administration of ineffective medications. The Registered Nurse Supervisor confirmed that staff are required to label house supply medications with the date they are opened to maintain their potency. The facility's policy and procedure, titled 'Administering Medications,' mandates that the expiration or beyond-use date on the medication label is checked before administration and that the date of opening is recorded on multi-dose containers. The failure to adhere to this policy resulted in the potential for residents to receive ineffective and possibly contaminated medications, compromising their health, safety, and well-being.
Failure to Provide Fortified Diets as Ordered
Penalty
Summary
The facility failed to provide fortified diets as ordered by the physician for two residents, Resident 29 and Resident 112. Resident 29, admitted with diagnoses including cerebral infarction and hemiplegia, required a fortified/high protein diet with aspiration precautions. Resident 112, admitted with metabolic encephalopathy and type 2 diabetes mellitus, also required a fortified/high protein diet. The facility's diet roster confirmed these dietary needs, and the facility's menu for the specified date included 6 ounces of super soup for residents on fortified diets. However, during an observation, it was noted that the meal trays for both residents did not include the super soup, indicating a failure to follow the prescribed diet orders. The Dietary Supervisor acknowledged that the fortified diet was intended to provide extra calories and confirmed that the diet orders for Residents 29 and 112 needed to be followed. This oversight had the potential to prevent the residents from receiving the necessary caloric intake as ordered by their physician.
Expired Food Items Found in Kitchen Storage
Penalty
Summary
The facility failed to ensure that expired food items were not present in the kitchen's dry storage, which could potentially lead to food-borne illnesses among residents. During an observation and interview with the Dietary Aide, it was found that an open package of corn meal and an open package of baking powder were expired but still kept in the storage area. The Dietary Aide acknowledged that these items needed to be discarded immediately. In an interview with the Dietary Supervisor, it was stated that expired food items should be discarded right away to prevent their use. However, the Dietary Supervisor could not provide a reason for the presence of expired items despite the responsibility of all kitchen staff to check for them. The facility lacked a specific policy and procedure regarding expired food items, although staff were expected to follow various storage guidelines. A review of the facility's Dry Goods Storage Guidelines confirmed the storage duration for corn meal and baking powder, emphasizing the need to check expiration dates.
Infection Control Lapses During Norovirus Outbreak
Penalty
Summary
The facility failed to adhere to infection control practices, particularly in managing a norovirus outbreak. Two residents, who were still exhibiting symptoms of norovirus, had their contact isolation precautions prematurely discontinued based on a recommendation from a Public Health Nurse. The Infection Prevention Nurse removed the isolation signs without confirming the residents were symptom-free for the required 48 hours. This oversight was confirmed when both residents reported ongoing symptoms, such as diarrhea and nausea, during interviews. Additionally, staff members did not consistently wear appropriate personal protective equipment (PPE) when interacting with residents under contact precautions. Observations revealed that CNAs and other staff entered rooms with only surgical masks, despite the presence of contact precaution signage and PPE carts. This lack of adherence to PPE protocols was acknowledged by the Director of Nursing and the Infection Preventionist, who emphasized the importance of proper PPE use to prevent the spread of infection. The facility also failed to ensure personal care items were properly labeled and stored, which is crucial for infection control. Unlabeled items such as wash basins, toothbrushes, and toiletries were found in shared restrooms, increasing the risk of cross-contamination. These deficiencies were observed in multiple shared rooms, where residents were under contact precautions due to the norovirus outbreak. The facility's policies on infection control and norovirus prevention were not effectively implemented, contributing to the potential spread of infection among residents and staff.
Deficiencies in Call Light, Bathroom Maintenance, and Bed Control Functionality
Penalty
Summary
The facility failed to ensure the functionality of a call light for a resident, which was not working since the previous night. The resident expressed frustration at having to yell for assistance, and a Certified Nursing Assistant confirmed the call light was non-functional. This deficiency was observed during an interview and concurrent observation, highlighting a lapse in the facility's adherence to its policy of ensuring call lights are operational at all times. Additionally, the facility did not maintain seven bathrooms and several rooms in good repair, as observed during an inspection with the Maintenance Director. The bathrooms and rooms had issues such as chipped paint, scratches, and cracked caulking, which were acknowledged by the Maintenance Director as potential health risks. This observation pointed to a failure in maintaining a clean, safe, and homelike environment as per the facility's policy. Another deficiency involved a resident's bed control, which was intermittently non-functional, causing discomfort due to being stuck in one position. Despite the resident informing multiple CNAs, the issue was not reported to maintenance until much later. The Maintenance Director confirmed that the bed control was only fixed after it was reported, and there was no record of the repair request in the Maintenance Log, indicating a breakdown in the facility's process for tracking and addressing maintenance issues.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to promote dignity and privacy during patient care for Resident 22, who was admitted with diagnoses including malignant neoplasm of the left lung and retention of urine. According to the Minimum Data Set dated 10/31/2024, Resident 22 had severe cognitive impairment and required maximum assistance with personal hygiene. During an observation on 2/21/2025, Certified Nursing Assistant 4 (CNA 4) was seen removing the sheet covering Resident 22's body, leaving the resident's lower body exposed while washing the resident's face and neck. This action was contrary to the facility's policy and procedure on dignity, which requires staff to cover other areas of the body while providing care to ensure privacy. CNA 4 acknowledged during an interview that care should be provided by washing the resident's body by area, ensuring other areas remain covered to prevent exposure. The facility's policy, dated February 2021, emphasizes the importance of promoting, maintaining, and protecting resident privacy, including bodily privacy during personal care and treatment procedures.
Failure to Assess Self-Administration of Medication
Penalty
Summary
The facility failed to conduct a proper assessment for the self-administration of Pepto Bismol Ultra for a resident with multiple diagnoses, including end-stage renal disease and type 2 diabetes mellitus with diabetic polyneuropathy. The resident, whose cognition was moderately impaired, was found with an almost empty bottle of Pepto Bismol Ultra in their room, without a physician's order or consent for self-administration, as required by the facility's policy and procedures. The resident admitted to purchasing and using the medication for indigestion without staff intervention or guidance. The Registered Nurse Supervisor confirmed that there was no order or consent for the resident to self-administer the medication and acknowledged that the facility's practice required an assessment of the resident's ability to self-administer safely, followed by obtaining a physician's order. The facility's policy indicated that residents could self-administer medications only if deemed safe and appropriate by the interdisciplinary care planning team. The presence of unauthorized medication at the bedside, especially for a dialysis patient, posed a potential risk due to possible contraindications and the need for careful monitoring.
Failure to Develop Care Plan for C. diff Positive Resident
Penalty
Summary
The facility failed to develop a care plan for a resident who tested positive for Clostridium difficile (C. diff), a highly contagious bacteria causing severe diarrhea. The resident, who was admitted with multiple diagnoses including atherosclerotic heart disease, type 2 diabetes mellitus, gastro-esophageal reflux disease, and dependence on renal dialysis, received a positive lab result for C. diff. Despite the positive result and subsequent orders for Vancomycin treatment, no care plan was created to address the resident's condition from the time of the positive result on February 2nd until February 10th. The absence of a care plan was confirmed during an interview with the Registered Nurse Supervisor, who acknowledged that a care plan for active C. diff was only initiated on February 19th after the resident reported having diarrhea on February 16th. Observations noted that the resident's room initially lacked appropriate contact isolation signage, which was later corrected. The facility's policy requires comprehensive, person-centered care plans with measurable objectives and timetables, which were not adhered to in this case.
Failure to Implement Toileting Schedule for Resident at Risk for Falls
Penalty
Summary
The facility failed to ensure that a toileting schedule was implemented for a resident, identified as Resident 14, who was at risk for falls. Resident 14 was admitted with diagnoses including dementia and a history of repeated falls. The care plan for Resident 14, initiated on July 14, 2024, included an intervention to meet the resident's toileting needs every two hours. However, during observations and interviews, it was noted that Resident 14 did not have a toileting schedule in place, and items were stored on top of the bedside commode, obstructing its use. This lack of adherence to the care plan had the potential to result in falls and injury to the resident. On February 18, 2025, Resident 14 was observed getting up from bed unassisted and reported feeling dizzy. A change of condition report from February 15, 2025, documented an incident where Resident 14 fell while attempting to pick up pants after entering the wrong room. The Director of Nursing acknowledged that a toileting schedule could help prevent falls by ensuring the resident's needs were met, reducing the likelihood of the resident attempting to toilet independently. The facility's policy on falls indicated that staff should try various interventions to reduce or stop falls, but this was not effectively implemented for Resident 14.
Failure to Follow Catheter Care Protocol
Penalty
Summary
The facility failed to ensure that the licensed nurse followed the physician's order for indwelling catheter care for a resident with severe cognitive impairment and a history of urinary retention and lung cancer. The resident was admitted with bladder incontinence and recurrent urinary tract infections (UTIs). During an observation, brown sediments were noted on the resident's Foley catheter tubing, and the RN Supervisor confirmed the presence of light-colored sediments. Treatment Nurse 1 acknowledged that there was an order to flush the Foley catheter with acetic acid once a day for maintenance, but the last recorded irrigation was several days prior, on 2/16/2025. The resident's care plan indicated a need to monitor for signs and symptoms of UTIs, including urine cloudiness. Despite this, the resident continued to experience chronic sediments and recurrent UTIs. The facility's policy required immediate reporting of unusual findings to the physician or supervisor, but the report does not indicate that this was done in a timely manner. The resident was on a course of Ciprofloxacin for a UTI, but the persistent sediments and lack of adherence to the catheter care protocol suggest a failure in following the prescribed care plan and facility policies.
Improper Medication Administration via G-Tube
Penalty
Summary
The facility failed to ensure appropriate care and services during medication administration via a gastrostomy tube (G-Tube) for a resident. The resident, who was admitted with multiple diagnoses including type 2 diabetes mellitus with diabetic polyneuropathy and dysphagia, had a care plan goal to remain free of complications related to tube feeding. However, during a medication administration observation, a Licensed Vocational Nurse (LVN) mixed the resident's medications with apple sauce instead of using water, as required by the facility's policy. This practice was not supported by a physician's order and contradicted the facility's procedures for administering medications through an enteral tube. The LVN stated that the tablets were not crushed because they were coated and that this method was how they were taught. The Registered Nurse Supervisor confirmed that a physician's order was necessary to mix medications with apple sauce for G-Tube administration. The Director of Staff Development also stated that using apple sauce could lead to clogging the G-Tube and decrease the potency of the medication. The facility's policy indicated that medications should be diluted with warm, purified water, and did not mention using apple sauce. This deficient practice had the potential to cause tube-associated complications such as feeding tube occlusions for the resident.
Failure to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to ensure that food served to residents was at a safe and appetizing temperature. During an observation, it was noted that the last cart sent out from the kitchen contained food items that were not at appropriate temperatures. Specifically, the chicken was measured at 103 degrees Fahrenheit, green beans at 104 degrees Fahrenheit, and mashed potatoes at 134 degrees Fahrenheit. According to the facility's policy, the danger zone for food temperatures is between 41 and 135 degrees Fahrenheit, which promotes the rapid growth of pathogenic microorganisms that can cause foodborne illness. The deficiency was further supported by the facility's Resident Council Minutes from December 2024 and January 2025, which documented resident complaints about receiving cold food. The Dietary Supervisor acknowledged that the chicken was not cold but not warm either, and expressed concern that cold food would not be appetizing to residents, potentially leading to them not eating and experiencing weight loss. This practice had the potential to result in food that was not palatable or appetizing, thereby affecting residents' caloric intake and nutritional goals.
Non-Functional Call Light in Resident's Room
Penalty
Summary
The facility failed to provide a functioning call light for a resident, identified as Resident 7, which had the potential to delay care and services necessary for the resident's needs. Resident 7 was admitted with diagnoses including hemiplegia, hemiparesis following cerebral infarction, epilepsy, and muscle weakness. During an interview, Resident 7 reported that the call light had not been working since the previous night, and a Certified Nursing Assistant (CNA) had instructed him to yell for assistance. This situation caused distress to Resident 7, who expressed a desire for the call light to be repaired. An observation confirmed that the call light in Resident 7's room was non-functional, as pressing the button did not activate the light inside the room or above the door. CNA 6 acknowledged the importance of a working call light, especially in emergencies, and stated that she would inform the maintenance director about the issue. The facility's policy on answering call lights, revised in September 2022, emphasizes the need for call lights to be plugged in and functioning at all times, with defective call lights to be reported promptly to the nurse supervisor.
Pest Control Deficiency in Kitchen
Penalty
Summary
The facility failed to maintain a pest-free environment in Kitchen 1, as evidenced by the presence of two dead cockroaches found during a tour. The cockroaches were located at the back of the walk-in freezer, visible in a 3-inch gap between the freezer and the wall. A Dietary Aide used a broom, which had dust and green beans on it, to sweep the dead cockroaches from the area. During an interview, the Dietary Aide confirmed the presence of the dead cockroaches. The Dietary Supervisor suggested that the cockroaches might have emerged after a recent pest control visit conducted more than a week prior. The facility's Policy and Procedure on Sanitization, dated October 2008, requires all kitchen and dining areas to be kept clean and free from pests, which was not adhered to in this instance.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 5,325 citations issued within 25 miles in the last 12 months — including the 22 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Duarte
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Monrovia Post Acute | 0.3 mi | ★★★★★ | 26 | 0 |
| Royal Oaks Manor-bradbury Oaks | 0.6 mi | ★★★★★ | 11 | 0 |
| Royal Terrace Healthcare | 0.7 mi | ★★★★★ | 16 | 0 |
| Community Care Center | 1.6 mi | — | 1 | 0 |
| Monrovia Gardens Healthcare Center | 1.9 mi | ★★★★★ | 31 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Monte Vista Healthcare Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.