Average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
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 Montrose Springs Skilled Nursing & Wellness Center during CMS and state inspections, most recent first.
Failure to Complete Significant Change in Status Assessment: A resident with DM, cerebral infarction, and vascular dementia had significant weight loss and lost the ability to ambulate, but the facility completed a quarterly MDS instead of an SCSA. A CNA stated the resident was non-ambulatory and needed two-person assist for transfers, and the MDSC and DON both confirmed the resident met criteria for a significant change assessment.
Failure to Update Care Plan After Diet Texture Change: A resident with DM, cerebral infarction, and vascular dementia had a diet order changed to a level 5 minced and moist texture with mildly thick liquids, but the care plan was not revised and still listed a level 6 soft and bite-sized texture. During observation, the resident was eating the new texture, and the family member stated the resident did not like the food texture and did not know why it had been changed. The MDSC and DON stated the care plan should have been updated to reflect the resident's current condition and diet needs.
Failure to Monitor Blood Glucose Before Insulin Administration: A resident with DM, cerebral infarction, and vascular dementia had an order for lispro twice daily with instructions to hold the insulin if blood glucose was less than 70. The MAR showed insulin was given twice a day without documented blood glucose checks before administration, and RN and DON interviews confirmed the glucose should have been monitored prior to giving insulin.
A resident with an indwelling Foley catheter and diagnoses including DM, CVA, and vascular dementia had a physician order for a urology consult, but the consult was not obtained. The CM said several attempts were made to contact a urologist, but they were not documented because of insurance issues. The DON stated physician orders should always be followed and that staff should notify the physician if they cannot carry out an order.
A resident with DM, cerebral infarction, and vascular dementia was placed on a no added salt, CCHO diet with level 5 minced and moist texture and level 2 mildly thick liquids after staff reported difficulty eating, but ST did not complete an evaluation before the diet change. The family member said the resident disliked the food texture and was unaware why the diet had been changed without testing, and the DOR and DON stated the resident should have been evaluated by ST after the texture change.
A resident with capacity, osteoarthritis, muscle wasting, and a history of refusing care was transferred from bed to the shower room with a Hoyer lift even though he repeatedly said no, yelled for staff to stop, and complained of back pain and discomfort. CNAs and an LVN acknowledged the resident refused the shower and transfer, but staff continued anyway. The record did not show the resident agreed to the shower or was offered a choice to refuse. Afterward, the resident had severe low back pain, was sent to the hospital, and was found to have acute compression fractures.
A resident with muscle wasting, bilateral knee OA, and pain refused to be moved and showered, but staff still used a Hoyer lift to transfer him from bed to a shower chair and took him to the shower room despite repeated objections and complaints of discomfort. The care plan called for staff to listen, return later if care was refused, medicate for pain before care, and notify the DON to help negotiate care, but the record did not show that happened. Afterward, the resident developed severe low back pain, was sent to the hospital, and was found to have acute lumbar compression fractures requiring kyphoplasty.
Failure to Communicate Ordered Skin Scraping to Lab A resident with suspected advanced scabies had a dermatologist order a skin scraping along with scabies medications, but the specimen was not documented as sent to the lab and no result was found in the chart. The TN stated she performed the scraping and placed the specimen in the treatment cart, but forgot to enter the order into the EMR, so the lab was not notified unless staff called. The record showed the order was later entered and backdated, while the resident received ivermectin, prednisone, permethrin, and betamethasone for scabies.
Two residents receiving IV antibiotics for sepsis, UTI, and pneumonia had missing documentation on their IV therapy records for scheduled early-morning doses of meropenem and ampicillin. Physician orders required specific IV antibiotic regimens, but the IVT records did not show that these doses were administered, and the RN supervisor confirmed the lack of documentation and stated they should have been recorded. Facility policy required licensed nurses to follow the 6 rights of medication administration, including immediate documentation of time and dose on the MAR/IVT record, which was not followed in these instances.
A resident with diabetes and a left below-knee amputation, who required assistance with ADLs but had intact cognition, experienced an unwitnessed fall resulting in a facial abrasion. Facility policy required 72-hour neurochecks after an unwitnessed fall with suspected head injury, on a defined schedule from every 15 minutes to every 4 hours. Record review and staff interviews showed multiple required neurochecks were missing and two were performed late, with no physician order to discontinue the monitoring. A family member reported being told the resident did not hit their head, later observed a facial abrasion, and expressed concern about the accuracy of the post-fall assessment.
A resident with hepatic encephalopathy, dysphagia, and moderate cognitive impairment experienced a fall resulting in a forehead laceration; EMS was called and the wound was treated, but there was no documentation that the physician or family were notified of the fall and injury. Subsequently, a physician ordered ROM and ambulation with a front wheel walker three times weekly, yet the restorative treatment record showed no treatments provided over several consecutive days. The RNA stated the resident had not been feeling well and refused the exercises, but there was no documentation that the physician was informed of these refusals.
Two residents with limited English proficiency and documented preferences for interpreter services did not have person-centered care plans addressing their communication needs, despite MDS assessments and facility policies requiring identification and care planning for communication requirements. One resident with DM, muscle weakness, and colorectal cancer reported not being fluent in English and needing help to communicate needs, while another resident with hepatic encephalopathy, dysphagia, and cognitive communication deficit could not effectively express concerns, including that his television was not working and available programming was not in a language he understood. The MDS coordinator confirmed that no communication-focused care plans were developed for either resident.
A resident with DM and cognitive impairment had physician orders for Glipizide and Metformin, with fasting blood sugar checks required before breakfast and at bedtime, and instructions to notify the physician if levels were below 70 or above 400. On one morning, the ordered fasting blood sugar was not obtained or documented before the resident received the scheduled oral hypoglycemic medications. The DON confirmed the blood sugar should have been checked prior to administration and that lack of documentation indicated it was not done. This failure was inconsistent with the resident’s diabetes care plan and the facility’s medication administration policy requiring completion and recording of ordered testing, such as point-of-care blood glucose, before giving medications dependent on such results.
A resident with multiple cardiac conditions and diabetes was ordered numerous oral medications and a clonidine patch but persistently refused all medications except the patch over an extended period. The existing care plan for medication refusal contained only basic interventions such as assessing reasons for refusal, documenting refusals, encouraging compliance, and notifying the MD for complications, and it was not updated with new, specific, or measurable interventions despite continued noncompliance. IDT meetings did not reassess or address the ongoing refusals, nursing staff limited their response to repeated education and documentation, the RN supervisor did not involve the pharmacist and had minimal documented MD communication, and the administrator was unaware of the persistent refusals, contrary to the facility’s own person-centered care planning policy.
A nurse administered seven scheduled morning medications, including an antiepileptic, antihypertensive, antidepressant, vitamin D, iron supplement, stool softener, and multivitamin, to a resident more than one hour after the ordered 9:00 AM time, outside the facility’s 8:00–10:00 AM administration window. The RN supervisor reported that nurses typically have about 30 residents and roughly 5 minutes per resident for the morning med pass, which can extend beyond the 2-hour window, and the LVN involved acknowledged the medications were late due to unforeseen events on the unit, contrary to the facility’s policy requiring adherence to the “Right Time” for medication administration.
Surveyors observed that several opened dry food items in the kitchen, including powdered cheese, gelatin mix, cake mix, breadcrumbs, and coconut flakes, were not labeled with opened dates or were stored beyond recommended timeframes. The Registered Dietitian confirmed that facility policy requires labeling and timely disposal of such items, but these procedures were not followed, resulting in improper food storage practices.
A resident with significant physical and cognitive impairments was assisted with feeding by a CNA who stood over the resident instead of sitting at eye level, as required by facility policy. The CNA reported not using a chair due to its unavailability, and both the CNA and an RN confirmed that proper feeding assistance should be provided while seated to maintain resident dignity and comfort.
A resident with dementia and anxiety disorder was prescribed Ativan, a psychotropic medication, without documented informed consent as required by facility policy. Despite the resident's capacity to make decisions, staff confirmed that no signed consent form was present in either the paper or electronic health records, constituting a violation of resident rights and facility procedures.
A resident with multiple medical conditions and intact cognition repeatedly raised concerns about poor Wi-Fi connectivity affecting personal device use. Despite facility acknowledgment and some steps toward resolution, there was a lack of timely follow-up and communication with the resident, and no clear explanation for the delay in installing Wi-Fi extenders. This resulted in the resident's grievance remaining unresolved and affected their quality of life.
A resident with severe cognitive impairment and fluctuating decision-making capacity did not have an Advance Directives Acknowledgement Form or POLST present in their hard copy medical record. Multiple staff, including the SSD, RN Supervisor, and DON, confirmed the absence of these documents, despite facility policy requiring their provision and accessibility.
Two residents did not receive comprehensive, person-centered care plans following significant changes in their conditions and medication regimens. One resident with abdominal pain and moderate cognitive impairment was not provided a care plan after a change in condition, and another resident prescribed Depakote for behavioral issues did not have a care plan addressing medication use, monitoring, or side effects. Staff and leadership confirmed these omissions, which were not in accordance with facility policy.
A resident with quadriplegia and severe cognitive impairment was left without required supportive devices, such as pillows or wedges, after morning care. The resident was observed in an uncomfortable position, and staff interviews confirmed that proper positioning and support were not provided as outlined in the care plan and facility policy.
Surveyors found that appropriate care was not consistently provided to residents who were continent or incontinent of bowel and bladder, including improper catheter care and insufficient measures to prevent UTIs. These failures resulted in a deficiency related to resident care.
A resident with severe cognitive impairment, dysphagia, and malnutrition, who required moderate assistance with eating, did not receive proper mealtime support from a CNA. The resident was left to manage a mechanical soft diet tray without necessary help, such as cutting food or ensuring items were within reach, contrary to care plan and facility policy requirements. Staff interviews and observations confirmed the lack of appropriate assistance.
The facility did not provide necessary medically-related social services to a resident, resulting in the resident not achieving the highest possible quality of life.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
A deficiency was cited when it was found that a working call system was not available in each resident's bathroom and bathing area, preventing residents from being able to request assistance as needed.
Two residents experienced deficiencies in fall prevention when staff failed to follow established care plan interventions and facility policies. One resident with severe cognitive impairment was left unattended during toileting, resulting in an unwitnessed fall and injury requiring hospital treatment. In another case, after a resident's fall and readmission, there was no documentation of an IDT review as required by policy. These failures led to inadequate supervision and lack of proper post-fall evaluation.
Surveyors found that several rooms in the facility housed more than four residents per room, with some rooms containing five or six beds and being fully occupied. Although residents reported no concerns about space and rooms were equipped with necessary furniture and equipment, the facility did not comply with federal regulations limiting room occupancy.
Eighteen resident rooms were found to be below the required 80 square feet per resident in multiple occupancy rooms, as confirmed by the ADM and documented in facility records. Despite the deficiency, no concerns were raised by residents or observed by surveyors, and the facility continues to seek a waiver for these rooms.
A resident with adult failure to thrive and Alzheimer's disease was admitted with an NPO order due to inability to swallow, but the care plan did not reflect this dietary restriction. Both an RN and the DON confirmed the omission, despite facility policy requiring care plans to include physician and dietary orders within 48 hours of admission.
A resident with severe cognitive impairment and total dependence for care was subjected to rough perineal care by a CNA, resulting in pain and distress. Despite reports from the responsible party and a roommate who witnessed and heard the resident in distress, facility staff did not immediately remove the CNA from the assignment or report the incident as potential abuse. The resident's care plan interventions were not followed, and mandated reporting procedures were not implemented, leading to further distress for the resident and fear for another resident.
A resident with severe cognitive impairment and multiple medical conditions was allegedly treated roughly by a CNA during peri care, as witnessed by the responsible party and corroborated by a roommate. Despite the allegation being reported to facility staff, required notifications to CDPH, the Ombudsman, and Law Enforcement were not made within the mandated timeframe, and the CNA continued to provide care to the resident. Staff failed to recognize and escalate the incident as abuse, and the facility did not initiate an investigation or remove the CNA from duty until after law enforcement was contacted.
A resident with severe contractures and arthritis was roughly handled by a CNA during care, resulting in a fracture and hospitalization. Despite the resident's complaints and visible injuries, the facility failed to promptly report the abuse allegation or suspend the CNA. The DON initiated an investigation but did not interview the CNA or follow the facility's abuse prevention and reporting policies.
A facility failed to ensure proper discharge planning for a resident with Parkinson's Disease and Dementia, resulting in the resident not receiving necessary home health services and durable medical equipment after discharge. The Social Service Director and Case Manager did not coordinate effectively, leading to a lack of follow-up on required services and equipment.
The facility failed to complete and document the Annual Certified Nurse Assistant (CNA) Core Clinical Competencies (ACCC) for eight CNAs. The DON admitted there was no system to track performance evaluations, and CNAs could not recall their last skills assessment. A review of employee files showed no ACCC documentation, and only partial skills competencies were evidenced, contrary to facility policy.
A facility failed to inform a resident about medications before administration, violating their rights. An LVN administered medications, including laxatives, without informing the resident, who had expressed a preference against laxatives. Additionally, the facility failed to account for six doses of controlled substances for four residents, with discrepancies found in medication records. The LVN admitted to administering these medications but did not document them, violating facility policy and increasing the risk of medication errors.
A facility failed to maintain a medication error rate below five percent, resulting in a rate of 5.71% due to two errors affecting two residents. One resident received the wrong form of calcium, and another received a multivitamin with minerals instead of the prescribed type. LVNs acknowledged the errors, and the DON confirmed the medications were not administered as ordered.
The facility failed to remove expired medications from stock in one of its medication rooms. An open vial of Aplisol was found without a label indicating when it was opened, and 15 expired Afluria syringes were stored in the refrigerator. Interviews with staff confirmed these medications should have been discarded according to facility policies.
A kitchen staff member was inadequately trained on the proper use of sanitizer test strips, leading to incorrect testing of a QUAT sanitizer solution. The staff member initially used the wrong test strip and did not follow the correct procedure, resulting in an inaccurate reading. The issue was identified during an observation, and it was noted that the facility's training did not cover the correct testing procedure.
The facility failed to follow the prescribed portion sizes for residents on pureed and mechanical soft diets during a lunch service. Residents on a pureed diet received less chicken than required, and those on a mechanical soft diet received less zucchini. The error was due to the use of incorrect scoop sizes by the cooks, as confirmed by the RD.
Two residents with severe cognitive impairments were fed by CNAs standing over them, violating their dignity. The CNAs admitted they should have been at eye level, as confirmed by facility staff and policy.
The facility failed to ensure call lights were within reach for two residents, both with severe cognitive impairments and mobility issues. One resident had the call light tied to the bedrail, out of reach, while another had it placed on the side of the bed inaccessible to their functional hand. Staff interviews confirmed the importance of having call lights accessible, as per facility policy.
A resident with a history of hypertension, obesity, and diabetes exhibited redness in both eyes, which was not reported to the physician by the LTC facility staff. Despite the redness being observed by an LVN for several days, it was assumed to have been documented, leading to a delay in care. The facility's policy requires notifying the physician of such changes, but this was not adhered to, resulting in a deficiency.
A resident with severe cognitive impairment was left exposed during personal care when a CNA failed to pull the privacy curtain, despite the presence of a roommate. The facility's policy requires privacy to be maintained to preserve resident dignity.
The facility failed to develop comprehensive care plans for two residents, leading to potential inadequate care. One resident with multiple diagnoses, including diabetes and cataracts, had no care plan for eye redness despite physician orders. Another resident with an inguinal hernia lacked a care plan for its management, affecting his eating due to abdominal discomfort. The absence of care plans was confirmed by nursing staff and contradicted facility policy requiring updates for new problems or changes in condition.
A facility failed to update a care plan for a resident who experienced bladder incontinence after a urinary catheter was removed. The resident, with dementia and psychosis, was at risk of UTIs due to inconsistent care. Staff interviews confirmed the care plan should have been revised to address the incontinence.
A resident with morbid obesity and hemiplegia was at risk for pressure ulcers due to the facility's failure to set the Low Air Loss (LAL) mattress according to the physician's order. The mattress was set for a lower weight than the resident's actual weight, as confirmed by staff observations and interviews. This oversight could lead to skin breakdown, contrary to the facility's policy requiring proper mattress settings based on weight.
A resident with an indwelling catheter was found with the catheter unsecured and the catheter bag touching the floor, contrary to the facility's policy. An LVN confirmed the bag should not touch the floor, and the DON acknowledged the issue, stating that RNs were informed to secure the catheter and keep the bag off the floor.
The facility failed to provide proper respiratory care for two residents. One resident's nasal cannula was improperly placed, and another resident received incorrect oxygen flow and lacked proper labeling of the nasal cannula. Additionally, the second resident's oxygen saturation was not documented, and they were without oxygen for 15 minutes during ADL assistance.
Failure to Complete Significant Change in Status Assessment
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) for one resident after significant changes in condition were identified, including significant weight loss and loss of the ability to ambulate. The resident’s admission record showed diagnoses including DM, cerebral infarction, and vascular dementia, and the H&P stated the resident did not have the capacity to make medical decisions. The Quarterly MDS dated 11/28/2025 documented that the resident had lost 10% or more of body weight in the last six months and did not walk 50 feet with or without an assistive device. During interview, a CNA stated the resident was not ambulatory and required two-person assistance for transfers, with staff performing most ADLs. The MDSC stated the resident should have had a SCSA rather than a quarterly assessment because the resident experienced two significant changes in condition that met SCSA criteria. The DON stated that when a change of condition affects more than one area of the resident’s health status, it is considered a SCSA and requires a care plan revision and the MDS to be revised and updated. The facility policy stated a new MDS is to be completed within 14 days when there is a significant change in condition.
Failure to Update Care Plan After Diet Texture Change
Penalty
Summary
The facility failed to revise and update the care plan for one resident after a change in diet texture. The resident had diagnoses including DM, cerebral infarction, and vascular dementia, and the MDS indicated moderately impaired cognition, dependence for footwear, substantial to maximal assistance with personal hygiene, dressing, showering/bathing, toileting hygiene, and supervision with eating. The resident's order summary showed an order for a NAS CCHO diet with level 5 minced and moist texture and mildly thick liquids. During observation, the resident was seen eating a level 5 minced and moist diet, while the family member present stated the resident did not like the texture of the food and was unaware why the food texture had been changed. The resident's care plan, last revised on 12/2/2025, still reflected a NAS CCHO level 6 soft and bite-sized texture with interventions for dietary evaluation and explaining the rationale of the diet. The MDS Coordinator stated that when there is a change in a resident's plan of care, the care plan should be revised to reflect the resident's current condition, and the DON stated the care plan should have been revised following the diet texture change. The facility policy stated the IDT would review and revise the care plan following each quarterly and comprehensive assessment.
Failure to Monitor Blood Glucose Before Insulin Administration
Penalty
Summary
The facility failed to monitor blood glucose levels for a resident with DM who had orders for lispro 3 units subcutaneously twice a day with instructions to hold the insulin if blood glucose was less than 70. The resident’s record showed diagnoses including DM, cerebral infarction, and vascular dementia, and the MDS indicated moderately impaired cognition with dependence for several activities of daily living. The care plan for diabetes stated the resident would be free from signs and symptoms of hypoglycemia and directed fasting serum blood sugar as ordered by the physician. Review of the MAR showed insulin was administered twice daily at 11:30 AM and 4:30 PM without documented glucose monitoring before administration. The MAR did not show a blood glucose result prior to insulin administration, although blood glucose values were documented on some dates. During interview, RN 2 stated the physician order required holding insulin if blood glucose was less than 70 mg/dL and that glucose levels should be monitored to prevent hypoglycemia or hyperglycemia. The DON stated the glucose should have been monitored as ordered and that the resident’s blood sugar should have been obtained prior to insulin administration.
Failure to Follow Up on Ordered Urology Consult
Penalty
Summary
The facility failed to ensure a resident with an indwelling urinary catheter received care and services in accordance with physician orders by not following up on a physician-ordered urology consultation. Resident 1 was admitted and later readmitted with diagnoses including DM, cerebral infarction, and vascular dementia, and the MDS indicated moderately impaired cognition with dependence for footwear and substantial to maximal assistance needed for personal hygiene, dressing, bathing, and toileting hygiene. The order listing showed a physician order for a urology consult, but the case manager stated several attempts were made to contact a urologist and that, because of the resident’s insurance, a urologist was not obtained. The case manager also stated these attempts were not documented.
Failure to Obtain ST Evaluation Before Diet Texture Change
Penalty
Summary
The facility failed to obtain a speech therapy evaluation for a resident after speech therapy staff identified difficulty eating and before the resident's diet consistency was downgraded. The resident had diagnoses including DM, cerebral infarction, and vascular dementia, and the MDS indicated moderately impaired cognition, dependence for several activities of daily living, and supervision with eating. The order summary showed the resident was on a no added salt, consistent carbohydrate diet with level 5 minced and moist texture and level 2 mildly thick liquids. During observation, the resident was seen eating the minced and moist diet, and the resident's family member stated the resident did not like the texture of the food and did not know why the diet consistency had been changed without any tests being done. The DOR stated the diet was changed after staff informed ST 2 that the resident was having difficulty eating, but the resident did not receive an evaluation by ST 2 after the change. The DON stated speech therapists should have evaluated the resident after the diet texture was changed and that the family should have been notified. The facility policy stated residents with potential changes in condition should receive timely assessment and skilled therapy services as clinically indicated.
Resident’s refusal of shower care was ignored
Penalty
Summary
The facility failed to protect and promote a resident’s right to self-determination and freedom from interference when staff transferred the resident from bed to the shower room using a Hoyer lift despite repeated verbal objections. The resident had diagnoses including muscle wasting, osteoarthritis of both knees, and a history of psychological trauma, and the record indicated he had the capacity to understand and make decisions. His care plans documented multiple refusals of care, including refusal to get out of bed, refusal of restorative nursing activities, refusal to be cleaned, and refusal of weight monitoring, with interventions directing staff to listen to the resident, be slow and gentle, respect his decisions, and address pain before care. On the day of the event, staff moved the resident from his bed to the shower room during a shift change even though he repeatedly said no, yelled for staff to stop, and stated he did not want to be moved because of back pain and discomfort. CNA 1, CNA 2, and LVN 1 all acknowledged in interviews that the resident refused the transfer and shower, and they described continuing the shower anyway. The resident’s family member stated that he screamed and pleaded not to be moved, and the roommate stated he heard the resident shouting at staff to stop moving him and to put him back in bed. The record did not include documented evidence that the resident agreed to be showered or was given an option to refuse the shower and transfer. After the shower event, the resident reported severe low back pain, and later requested transfer to the hospital because the pain medication was not effective. The medical record showed hydrocodone-acetaminophen was given for severe pain, a change-in-condition evaluation documented uncontrolled lower back pain, and the resident was transferred to the hospital with an order for severe low back pain. Hospital records later showed acute L1, L3, and L4 compression fractures and discharge diagnoses of acute lower back fractures, with kyphoplasty performed. Interviews with nursing staff confirmed that if a resident complains of pain or discomfort during care, the procedure should stop, and the DON stated staff should step away and re-approach when a resident refuses care. The facility’s Resident Rights and Refusal of Treatment policies stated residents have freedom of choice, may refuse treatment, and are not to be forced to accept care.
Failure to Honor Refusal of Care During Hoyer Lift Transfer and Shower
Penalty
Summary
The facility failed to follow Resident 1’s care plan for refusal of care and failed to honor the resident’s repeated objections during a transfer and shower. Resident 1 had diagnoses including muscle wasting, osteoarthritis of both knees, and a history of psychological trauma. The record also showed that the resident had capacity to understand and make decisions, mildly impaired cognition, dependence for some mobility tasks, and moderate pain. The care plan directed staff to listen to the resident’s instructions, be slow and gentle, return later if care was refused, medicate for pain before care, and notify the DON to help negotiate care when the resident refused to be changed or had a bowel movement. On 5/15/2026, staff transferred Resident 1 from bed to a shower chair using a Hoyer lift and took the resident to the Shower Room even though the resident repeatedly refused, yelled at staff, and complained of pain and discomfort. CNA 1, CNA 2, and LVN 1 stated that the resident did not want to be moved and continued to object during the transfer and shower. The record did not show that the resident agreed to be showered or was given an option to refuse the shower and transfer. The DON stated he was not recalled being contacted when the resident refused care, and RN 1 stated she was not informed that the resident refused to be brought to the Shower Room. After the transfer and shower, Resident 1 complained of severe lower back pain and later requested transfer to a GACH because the pain medication was not effective. The hospital record documented that the resident reported severe low back pain after being lifted by facility staff and felt a crack. MRI findings showed acute L1, L3, and L4 compression fractures with height loss, and the resident underwent kyphoplasty. The facility record did not include a PT or OT recommendation for use of a Hoyer lift, and RN 2 stated the therapy summaries did not indicate the resident had been assessed for the appropriateness of a Hoyer lift. The facility’s refusal-of-treatment policy stated that residents may refuse treatment and that the charge nurse or DON interviews the resident when care is refused, but the documented events showed the resident’s objections were not honored before the transfer and shower proceeded.
Failure to Communicate Ordered Skin Scraping to Laboratory
Penalty
Summary
The facility failed to ensure that a physician-ordered skin scraping and specimen collection for a resident suspected of scabies was communicated to the laboratory on 6/18/2026. Resident 3 was admitted with diagnoses including muscle weakness, difficulty walking, and hepatitis, and the history and physical indicated the resident had the capacity to understand and make decisions. The MDS dated 6/8/2026 indicated moderately impaired cognition. On 6/18/2026, the dermatologist’s physician order sheet included diagnoses of dermatitis and medication orders for betamethasone, ivermectin, permethrin, and prednisone, along with an instruction to perform a skin scraping. The interdisciplinary progress note documented that the resident was assessed by the dermatologist with confirmed advanced scabies, with widespread scaling, erythematous lesions, and pruritus, and noted the resident was high risk for transmission due to advanced scabies. Medication and treatment records show ivermectin, prednisone, permethrin, and betamethasone were administered beginning 6/19/2026. The resident’s record did not contain documented evidence that the skin scraping specimen was sent to the laboratory on 6/18/2026 as ordered, and there were no documented results of the skin scrape in the medical record. The order audit report later showed a skin scrape order created on 6/23/2026 and backdated to 6/19/2026 by the treatment nurse. During interview, the treatment nurse stated she performed the skin scraping on 6/19/2026 and placed the specimens in the treatment cart, but was not sure whether laboratory staff collected them. She also stated she forgot to input the order into the medical record on 6/19/2026 and that, because the order was not entered, the laboratory would not have been notified unless staff called. She further stated there was no documented evidence that the laboratory was informed, and that when she called the laboratory, she was told there were no orders for a skin scraping specimen to be collected on 6/19/2026.
Failure to Accurately Document IV Antibiotic Administration for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate clinical records for two residents receiving IV antibiotics. For the first resident, who had sepsis due to E. coli, UTI, ESBL, pneumonia, fluctuating decision-making capacity, and moderate cognitive impairment, the physician’s order directed meropenem 1 g IV three times daily until a specified end date. Review of the IV Therapy Administration Record for the month showed no documentation that the meropenem dose scheduled for 6 AM on 3/24/2026 was administered. The Registered Nurse Supervisor (RNS) stated that after a medication is administered, the licensed nurse must document it to prove it was given, and that without documentation there is no proof the dose was not missed. For the second resident, who was admitted with sepsis, E. coli, and UTI and was documented as alert, oriented, and with normal cognition, the physician’s order directed ampicillin sodium 2 g IV every six hours for six days for sepsis secondary to E. coli UTI. Review of this resident’s IV Therapy Administration Record for the month showed no documentation that the ampicillin dose scheduled for 6 AM on 4/15/2026 was administered. During concurrent interview and record review, the RNS confirmed that the IVT Medication Record did not show documentation of the 6 AM dose and stated it should have been documented. The facility’s medication administration policy required that all medications be administered by licensed nursing staff according to provider orders and that the “right documentation” be completed immediately after administration. The policy specified that the time and dose of medication or treatment administered must be recorded in the resident’s individual medication record by the person who administers it. In both residents’ cases, the IVT records lacked documentation for ordered IV antibiotic doses at specific times, contrary to the facility’s policy and accepted standards for complete and accurate medical records. The RNS stated that if the full antibiotic course is not received and documented, follow-up diagnostics such as chest x‑ray may not show resolution of infection.
Failure to Complete and Document Required 72-Hour Neurochecks After Unwitnessed Fall
Penalty
Summary
The deficiency involves the facility’s failure to consistently perform and document 72-hour neurological checks as required by its Fall Management Program policy after an unwitnessed fall with suspected head injury. The resident involved had a history of type 2 diabetes mellitus and a left below-knee amputation, was originally admitted in 2017 and later readmitted, and had intact cognition and memory per a recent MDS. The MDS also showed the resident required supervision or touching assistance with eating and oral hygiene, and partial/moderate assistance with toileting, bathing, lower body dressing, and transfers. On the date of the incident, progress notes documented an unwitnessed fall in the early morning and a change in condition evaluation confirmed the fall. Later that morning, progress notes documented an abrasion on the right side of the resident’s face following the fall. Review of the neurological check lists and interviews with the MDS nurse and an RN showed that the required 72-hour neurocheck schedule was not followed or fully documented. The facility’s policy required neurochecks every 15 minutes for one hour, every 30 minutes for two hours, every hour for four hours, and then every four hours for 65 hours after an unwitnessed fall with suspected head injury. However, there was no documentation of neurochecks at specific required times, including on one date at 1 PM and on the following date at 1 AM and 5 AM. The RN also identified that two neurochecks due at 5 PM and 9 PM were instead performed and documented at 5:46 PM and 10:53 PM, indicating delays. There was no physician order to discontinue the 72-hour neurochecks, and the MDS nurse stated that if a neurocheck was not documented, it was considered not done. A family member reported being told the resident did not hit his head, but later observed an abrasion on the resident’s face and was concerned about the accuracy of the assessment after the fall.
Failure to Notify Physician/Family After Fall and to Provide Ordered Restorative Therapy
Penalty
Summary
The deficiency involves the facility’s failure to notify the attending physician and the responsible party after a resident sustained a fall with a resulting laceration, and failure to carry out and report refusals of ordered restorative treatments. The resident was admitted with hepatic encephalopathy, dysphagia, and a cognitive communication deficit, and an MDS dated 2/19/2026 documented moderately impaired cognition and a need for supervision or partial/moderate assistance with multiple ADLs, including toileting hygiene, bathing, dressing, eating, oral hygiene, and personal hygiene. On 2/18/2026, progress notes documented that the resident was found on the floor with a forehead cut measuring 2.0 x 0.1 cm, 911 was called, EMS determined there were no significant injuries requiring hospital transport, and the wound was cleansed and monitored. However, in the change in condition fall note for that date and time, there was no documentation that the physician or family were notified of the fall and injury. On 2/23/2026, a telephone/verbal physician order was obtained for a Restorative Nurse Assistant to perform active ROM to both upper extremities and ambulation with a front wheel walker three times weekly for three months. Review of the restorative treatment record from 2/23/2026 through 2/26/2026 showed blanks, indicating that no restorative treatments were provided during that four-day period. During interviews, the resident reported wanting to get out of bed but feeling that his legs were heavier and that he felt tired, and the RN supervisor stated the resident was being monitored for fluid retention. The RNA reported that she had not performed the ROM and ambulation treatments because the resident had not been feeling well on those days, and there was no documentation that the physician was notified of the resident’s refusals of the ordered restorative exercises.
Failure to Care Plan for Non‑English Communication Needs
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement person-centered care plans addressing communication needs in residents whose preferred language was not the dominant language used in the facility. For one resident admitted with diagnoses including diabetes mellitus, muscle weakness, and malignant neoplasm of the large intestine and rectum, the admission record and MDS identified a preferred non-dominant language and a desire for an interpreter to communicate with doctors and health care staff. During interview, this resident reported understanding only some English words, not being fluent, and needing assistance to communicate needs. Observation showed a RN Supervisor using another licensed nurse to translate in the resident’s primary language, and the resident stated he could not communicate his needs in English. Despite this, the MDS coordinator confirmed there was no person-centered care plan developed to address this resident’s communication limitations and need for services in the preferred language. The second resident was admitted with hepatic encephalopathy, dysphagia, and a cognitive communication deficit, and the MDS documented moderately impaired cognition and the need for supervision or assistance with multiple ADLs. Progress notes indicated this resident also needed and wanted an interpreter to communicate with doctors or health care staff. During interview conducted in the resident’s primary language, the resident stated he could not make himself understood and could not fluently understand the language spoken in the facility, and he was unable to explain to staff that his television did not work and that the only audible channel was not in a language he understood. The MDS coordinator acknowledged that, based on the MDS information, both residents should have had person-centered care plans reflecting their communication limitations and language needs, but no such care plans existed. This failure occurred despite facility policies on accommodation of residents’ communication needs and resident rights, which required identification of communication requirements, documentation of preferences, and inclusion of these needs and interventions in the plan of care.
Failure to Check Blood Glucose Prior to Administering Hypoglycemic Medications
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with a physician’s order for monitoring blood glucose prior to administering hypoglycemic medications. A resident with diagnoses including Diabetes Mellitus, muscle weakness, and malignant neoplasm of the large intestine and rectum was admitted on 2/6/2026. The resident’s MDS dated 2/13/2026 documented moderately impaired cognition and the need for varying levels of assistance with activities of daily living. Telephone/verbal orders dated 2/7/2026 directed that the resident receive Glipizide 2.5 mg and Metformin 500 mg twice daily with meals, with fasting blood sugar checks ordered before breakfast at 6:30 AM and at bedtime at 9:00 PM, and instructions to call the physician if blood sugar was less than 70 or greater than 400. The resident’s care plan for diabetes, dated 2/7/2026, indicated the resident would be free from signs and symptoms of hypoglycemia. Review of the Medication Administration Record for 2/7/2026 showed that the fasting blood sugar ordered for 6:30 AM was not documented as completed prior to medication administration, and the DON confirmed that if it was not marked on the MAR, it was not done. The MAR further showed that the resident received Metformin 500 mg twice daily with meals and Glipizide 2.5 mg at 9:00 AM on 2/7/2026 without a recorded blood glucose check beforehand. The DON stated that the blood sugar should have been checked in the morning prior to medication administration as ordered and explained that when the order was entered, it was timed to begin at 9:00 PM and not before breakfast. The facility’s medication administration policy, revised 6/26/2025, stated that when medication administration is dependent on vital signs or testing, such as point-of-care blood glucose, the testing must be completed and recorded prior to administration, which did not occur in this instance.
Failure to Revise Care Plan for Ongoing Medication Refusal
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, resident-centered care plan with specific, measurable objectives and interventions for a resident who persistently refused medications. The resident had multiple significant cardiac and metabolic diagnoses, including atherosclerotic heart disease, hypertensive heart disease with heart failure, cardiomyopathy, and type 2 diabetes mellitus, and was ordered 15 active medications (14 oral and 1 clonidine transdermal patch). Despite this complex regimen, the resident repeatedly refused most medications over an extended period, taking only the clonidine patch, while remaining alert, oriented, and frequently going out on pass with a family member. The resident’s care plan for medication refusal, initiated on 6/30/25 and revised on 7/29/25 and 10/14/25, contained only four original interventions: assess the reason for refusal, document refusals and actions taken, encourage medication compliance with explanation of risks and benefits, and notify the physician for complications. No new or modified interventions were added despite ongoing, documented noncompliance with medications. Physician notes over several months documented that the resident was noncompliant with blood pressure medications except the clonidine patch and remained noncompliant with medications and care despite education on risks. The electronic MAR for January 2026 showed the resident refused all medications except the clonidine patch for the entire review period. Interdisciplinary team (IDT) meeting notes showed that while the resident’s medication refusal was noted on 6/30/25, subsequent IDT meetings did not include discussion or reassessment of this issue. Nursing staff reported that when the resident refused medications, they provided education, documented the refusal, and informed the nursing supervisor, but the RN supervisor acknowledged there were no additional interventions or assessments beyond re-education and documentation. The RN supervisor also stated she had not contacted the pharmacist to investigate potential medication-related issues contributing to the refusals and had limited documented communication with the physician, with the last recorded contact several months earlier. The administrator stated she was not aware of the resident’s ongoing medication refusals. The facility’s own person-centered care planning policy required the IDT to prepare, review, and revise the comprehensive care plan and to implement interventions designed to meet resident objectives, which was not carried out in this case.
Late Administration of Scheduled Morning Medications Beyond Allowed Time Window
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were administered within the facility’s required time window for one resident. During an observation, an LVN was seen preparing and administering a group of seven scheduled medications for a resident, including docusate sodium 100 mg, escitalopram 10 mg, levetiracetam (Keppra) 500 mg, losartan 50 mg, a multivitamin with minerals, vitamin D3 125 mcg (5000 IU), and ferrous sulfate 325 mg. The resident was seated in a wheelchair while the LVN measured the resident’s blood pressure and then prepared and administered the medications. The administration occurred at approximately 11:00 AM, even though the medications were scheduled for 9:00 AM, placing the administration more than one hour after the scheduled time. Interviews with staff confirmed that the facility’s policy required medications to be administered within one hour before or one hour after the scheduled time, and that nurses were to follow the “Right Time” as part of the six rights of medication administration. The RN supervisor stated that morning medications were scheduled at 9:00 AM with an 8:00 AM to 10:00 AM administration window, and acknowledged that with an average assignment of 30 residents per nurse and approximately 5 minutes per resident, some medication passes could extend beyond the 2-hour window. The LVN who administered the medications acknowledged awareness that the medications for this resident were late and attributed the delay to unforeseen events on the unit. The facility’s written policy confirmed the requirement to administer medications within the ordered time window, which was not met in this instance.
Failure to Properly Label and Store Dry Food Items in Kitchen
Penalty
Summary
The facility failed to adhere to its own policies and procedures regarding the storage and labeling of dry food items in the kitchen's dry storage area. During an observation with the Registered Dietitian (RD), several food items, including a bag of powdered cheese, gelatin mix, chocolate cake mix, breadcrumbs, and coconut flakes, were found either without an opened date or stored beyond the recommended storage period. Specifically, a bag of dried cheese powder dated 3/28/2025 was found to have exceeded its storage period, and multiple opened food items lacked labels indicating when they were opened. The RD confirmed that these items should have been dated upon opening to ensure proper rotation and timely disposal. Additionally, inconsistencies were noted between the delivery/received dates on storage bins and the individual food packages inside the bins, such as with pasta. The facility's policy requires that opened products be placed in containers with tight-fitting lids, labeled, and dated, and that stock be rotated according to specific timeframes for each product. The RD acknowledged the importance of correct dating for maintaining food quality and knowing when to discard items. These lapses in following established food storage guidelines had the potential to affect 113 out of 117 residents who receive food from the kitchen.
Failure to Maintain Resident Dignity During Mealtime Assistance
Penalty
Summary
A deficiency occurred when a certified nurse assistant (CNA) provided feeding assistance to a resident while standing over the resident, rather than sitting at eye level as required by facility policy. The resident, who had contractures in both hands, dysphagia, unspecified dementia, and was on a mechanically altered, pureed, nectar thick diet, was observed lying in bed with the head of the bed elevated during the feeding. The CNA stated that a chair was not used because one could not be found, resulting in the CNA feeding the resident while standing. The CNA acknowledged that staff are expected to sit at eye level with residents during feeding to avoid making them feel rushed and to maintain dignity. Interviews with the CNA and a registered nurse confirmed that the standard practice is for staff to be seated and at eye level with residents during meals to promote communication, ensure comfort, and uphold the resident's dignity. Facility policy also requires staff to interact with residents in a manner that accommodates their physical limitations and maintains their dignity. The failure to follow these procedures during mealtime assistance for this resident constituted a lack of respect and dignity, as required by resident rights regulations.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
A deficiency occurred when the facility failed to obtain informed consent for the administration of a psychotropic medication, Ativan, for a resident diagnosed with dementia and anxiety disorder. The resident was assessed as having the capacity to understand and make decisions, with moderately impaired cognition noted in the Minimum Data Set. Despite a physician's order for Ativan to be administered twice daily for anxiety, a review of both the paper and electronic health records revealed that no informed consent form for the use of Ativan was present for the relevant period. Both the Medical Records staff and the Registered Nurse Supervisor confirmed the absence of the required documentation, and the Director of Nursing also verified that the consent form could not be located in the resident's records. Facility policy required that informed consent be obtained and documented before administering psychoactive medications, with written consent to be renewed every six months. The lack of a signed and dated consent form for the psychotropic medication was acknowledged by staff as a violation of resident rights and a failure to follow established procedures. The deficiency was identified through interviews, record reviews, and policy examination, all confirming that the necessary informed consent process was not completed or documented as required.
Failure to Resolve Resident Grievance Regarding Wi-Fi Connectivity
Penalty
Summary
The facility failed to promptly address and resolve a grievance raised by a resident regarding the need for Wi-Fi extenders to improve connectivity for personal devices, such as a phone and television. The resident, who had diagnoses including congestive heart failure, hypertension, and anemia, and was cognitively intact, repeatedly brought up the issue during Resident Council Meetings and directly to the administrator. Documentation showed that the facility acknowledged the request and initiated discussions with IT and maintenance, including obtaining equipment and seeking vendor quotes for installation. However, there was a lack of timely follow-up and communication with the resident about the status of the installation, and no rationale was provided to the resident for the delay. Interviews with the resident and staff confirmed ongoing difficulties with Wi-Fi connectivity, affecting both residents and staff operations. The administrator was unable to provide documentation of interactions with maintenance or evidence of follow-up with the resident regarding the unresolved grievance. The facility's policy required the administrator, as the Grievance Official, to ensure timely follow-up and provide written decisions upon request, but this process was not completed, resulting in the resident's grievance remaining unresolved and impacting the resident's quality of life.
Failure to Maintain Accessible Advance Directives and POLST in Resident Record
Penalty
Summary
The facility failed to ensure that the Advance Directives Acknowledgement Form and the Physician Orders for Life-Sustaining Treatment (POLST) were obtained and readily accessible in the hard copy medical record for one resident. During a review of the resident's admission record, it was noted that the resident had diagnoses including bipolar disorder and paranoid schizophrenia, with documentation indicating fluctuating capacity to understand and make decisions. The resident's Minimum Data Set assessment also showed severely impaired cognition. Despite these factors, both the Social Services Designee and the Registered Nurse Supervisor confirmed during interviews and record reviews that the advance directive acknowledgement form and POLST were not present in the resident's medical record. The Director of Nursing also acknowledged that these documents must be readily accessible in the resident’s hard copy medical record to guide licensed nurses in providing care according to the resident’s wishes during emergencies. The facility’s policy and procedures require that written information about advance directives be provided upon admission, but this was not reflected in the resident’s record. The absence of these critical documents was directly observed and confirmed by multiple staff members during the survey.
Failure to Develop Comprehensive Care Plans for Residents with New Conditions and Medications
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents, resulting in deficiencies related to individualized care. For one resident with a history of abdominal pain, GERD, and Type 2 Diabetes Mellitus, the facility did not create a care plan to address new onset abdominal pain, despite documentation of moderate pain and a physician's order for hospital transfer. The resident had moderate cognitive impairment and required significant assistance with daily activities. Staff interviews confirmed that a care plan should have been implemented following the change in condition, but none was created, and the facility's policy requiring care plan updates after changes in condition was not followed. Another resident, admitted with diagnoses including Type 2 Diabetes Mellitus, diabetic neuropathy, depression, and bipolar disorder, was prescribed Depakote for poor impulse control and verbal aggression. Physician orders required monitoring for medication side effects and target behaviors. However, no care plan was initiated to address the use of Depakote, its intended purpose, or the monitoring of its effectiveness and side effects. Staff interviews confirmed the absence of a care plan for this medication, despite facility policy mandating comprehensive care plans for each resident that include measurable objectives and timeframes for meeting medical, nursing, mental, and psychosocial needs. The facility's failure to develop and update care plans in response to changes in condition and new medication orders resulted in incomplete documentation and a lack of individualized interventions for the residents involved. Staff and leadership acknowledged these omissions and confirmed that facility policies and procedures were not followed in these instances.
Failure to Provide Supportive Devices for Resident with Limited Mobility
Penalty
Summary
A deficiency occurred when staff failed to provide necessary supportive devices, such as pillows or wedges, for a resident with quadriplegia and multiple sclerosis, as required by the resident's care plan and the facility's policy. The resident, who was severely cognitively impaired and dependent on staff for all mobility and positioning, was observed lying in bed with the upper and lower body facing opposite directions and without any supportive devices in place. After morning ADL care, the CNA left the room without ensuring the resident was positioned comfortably or with proper support. Interviews with the LVN and Director of Nursing confirmed that the resident was not in a comfortable or appropriate position and that supportive devices were necessary due to the resident's limited mobility and inability to reposition independently. The facility's policy required staff to maintain good body alignment and provide proper equipment to redistribute pressure and support extremities and the head, which was not followed in this instance.
Deficient Bowel/Bladder and Catheter Care Leading to UTI Risk
Penalty
Summary
The report identifies a deficiency related to the provision of care for residents who are continent or incontinent of bowel and bladder, as well as the management of catheter care and the prevention of urinary tract infections (UTIs). Surveyors found that appropriate care was not consistently provided to residents in these areas. Specific failures included inadequate attention to the needs of residents with incontinence, improper catheter care practices, and insufficient measures to prevent UTIs. These lapses were observed during the survey and contributed to the deficiency cited.
Failure to Provide Adequate Mealtime Assistance for Resident Requiring Moderate Support
Penalty
Summary
A deficiency occurred when a certified nurse assistant (CNA) failed to provide adequate nutritional care and services to a resident who required moderate assistance with eating. The resident, admitted with diagnoses including dysphagia, severe protein-calorie malnutrition, and dementia, was assessed as having severely impaired cognition and needing moderate assistance for activities of daily living, including eating. The care plan and physician orders specified a mechanical soft diet and interventions such as monitoring and anticipating the resident's needs. Despite these documented requirements, observations showed that the resident's breakfast tray was placed in front of her without necessary assistance, such as cutting bread into smaller pieces or ensuring all items were within reach. The resident was seen struggling to cut her food and unable to access her snack and water without help. Interviews with staff confirmed that the CNA did not provide the required assistance, such as cutting food and setting up the tray appropriately, as outlined in the resident's care plan and facility policy. The facility's policy required nursing staff to provide assistance to residents who have difficulty feeding themselves, but this was not followed in the case of this resident. The failure to provide the necessary support was directly observed and corroborated by staff interviews and record reviews.
Failure to Provide Medically-Related Social Services
Penalty
Summary
The facility failed to provide medically-related social services necessary to help each resident achieve the highest possible quality of life. This deficiency was identified based on observations and findings that indicated the required social services were not made available or delivered to residents as needed. The lack of these services directly impacted the residents' ability to attain or maintain their optimal well-being.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report does not specify particular actions or inactions by staff, nor does it mention specific residents or incidents, but it clearly notes the absence or inadequacy of an infection prevention and control program.
Non-Functioning Call System in Resident Bathrooms and Bathing Areas
Penalty
Summary
A deficiency was identified due to the lack of a working call system in each resident's bathroom and bathing area. This observation indicates that residents did not have access to a functioning means to request assistance while in these locations. The report specifically notes the absence of a working call system, but does not provide additional details about individual residents, their medical history, or their condition at the time of the deficiency.
Failure to Follow Fall Management Policies and Provide Adequate Supervision
Penalty
Summary
The facility failed to follow its own policies and procedures regarding fall prevention and management for two residents, resulting in deficiencies related to accident hazards and inadequate supervision. For one resident with Alzheimer's disease and severe cognitive impairment, the care plan required that the resident not be left unattended during toileting. However, a CNA left the resident alone in the restroom with the door closed for privacy, contrary to the care plan. This lack of supervision led to an unwitnessed fall, resulting in a laceration to the right brow bone, abrasions, and the need for transfer to an acute care hospital for further treatment, including sutures. The facility also failed to update the resident's fall risk assessment after the incident and did not document all interventions recommended by the interdisciplinary team (IDT) following the fall. In the case of another resident with a history of sepsis, diabetes with neuropathy, and muscle weakness, the facility did not ensure that an IDT meeting was conducted after the resident sustained a fall and was readmitted to the facility. The resident was assessed as high risk for falls, and the care plan included frequent safety monitoring and fall risk precautions. Despite this, there was no documentation of an IDT meeting or review of the fall, as required by the facility's fall management policies. The absence of this review meant that the circumstances of the fall and the effectiveness of the care plan interventions were not evaluated by the IDT. Both cases demonstrate that the facility did not adhere to its established fall management programs, which require timely updates to care plans, post-fall assessments, and IDT reviews after falls. The failure to implement and document these interventions and reviews resulted in residents being left at risk for further accidents and injuries, as evidenced by the unwitnessed fall and subsequent injury in one resident and the lack of post-fall IDT review in another.
Resident Rooms Exceed Maximum Occupancy Requirements
Penalty
Summary
The facility failed to ensure that resident bedrooms accommodated no more than four residents per room, as required by federal regulations. During a recertification survey, it was observed that eight rooms contained either five or six beds, with several of these rooms fully occupied. The Client Accommodation Analysis and direct observations confirmed that these rooms exceeded the maximum occupancy limit. The surveyors noted that all rooms in question had individualized beds, bedside tables, overbed tables, and resident care equipment, and residents did not report concerns about room size or space during interviews. Despite the presence of adequate space for beds and equipment, the facility's practice of housing more than four residents per room in multiple-resident rooms did not comply with federal requirements. The facility had submitted a waiver letter and had policies in place for management to observe and ensure rooms met residents' needs without adversely affecting health and safety. However, the survey findings indicated that the number of beds and occupants in these rooms exceeded the regulatory limit, constituting a deficiency.
Resident Rooms Below Minimum Square Footage Requirement
Penalty
Summary
The facility failed to ensure that 18 out of 41 resident rooms met the minimum required space of 80 square feet per resident in multiple occupancy rooms. This was identified through observation, interviews, and record review during a recertification survey. The Administrator confirmed that these rooms did not meet the required square footage and stated the facility's intention to continue applying for a room waiver for these rooms. The Client Accommodation Analysis documented the specific square footage per resident for each deficient room, all of which fell below the regulatory requirement. During the survey, the rooms were observed and no immediate issues related to room size were identified. A review of the facility's Room Waiver Request Letter confirmed the ongoing deficiency and stated that the room sizes did not adversely affect residents' health and safety. Additionally, a group interview with the resident council revealed no concerns from residents regarding room sizes. The California Department of Public Health recommended continuation of the facility's room waiver.
Failure to Initiate NPO Care Plan for Resident
Penalty
Summary
The facility failed to initiate a care plan reflecting a resident's current therapeutic diet order of nothing by mouth (NPO), as required by facility policy. The resident was admitted with diagnoses including adult failure to thrive and Alzheimer's disease, and a physician's order was in place for NPO status due to the resident's inability to swallow food or medications. Despite this, a review of the resident's active care plans showed no documentation or care plan addressing the NPO order. Interviews with both a registered nurse and the Director of Nursing confirmed that the resident's NPO status was not included in the care plan, even though the resident was at high risk for aspiration if given food or fluids by mouth. The facility's policy required that a comprehensive, person-centered care plan, including physician and dietary orders, be developed and implemented within 48 hours of admission, but this was not done for the resident in question.
Failure to Protect Resident from Physical Abuse During Perineal Care
Penalty
Summary
A deficiency occurred when a certified nurse assistant (CNA) was observed by a resident's responsible party (RP) being rough during perineal care, causing the resident to experience pain and distress. The RP reported the incident to the facility's Infection Preventionist (IP) nurse, who then informed a licensed vocational nurse (LVN). Despite this report, the CNA continued to be assigned to the resident for the remainder of the shift and the following day. The resident, who had severe cognitive impairment and was dependent on staff for all activities of daily living, was unable to effectively communicate her needs or discomfort due to a language barrier and her medical condition. The resident's care plan required staff to be gentle, explain procedures, and not rush care, but these interventions were not followed during the incident. On the following day, the RP again found the resident in distress, and the resident's roommate, who spoke the same language, reported hearing the resident screaming in pain while the CNA performed care. The CNA did not stop or seek assistance despite the resident's verbalizations of pain. The roommate expressed feeling scared and uncomfortable after witnessing the incident. Other staff members, including the LVN and registered nurse (RN), did not immediately recognize the rough care as potential abuse, did not report the incident to the abuse coordinator or administrator, and did not remove the CNA from caring for the resident until later in the day. Documentation and mandated reporting procedures were not followed at the time of the initial and subsequent complaints. The resident's medical history included traumatic subdural hemorrhage, type 2 diabetes, and major depressive disorder, with documentation indicating severe cognitive impairment and total dependence for mobility and personal care. The facility's policies required prompt reporting and investigation of abuse allegations, as well as protection of residents' rights and dignity. However, the failure to act on the initial and subsequent reports of rough care resulted in the resident being subjected to further distress and pain, and another resident experiencing fear and discomfort.
Failure to Timely Report and Investigate Alleged Abuse
Penalty
Summary
The facility failed to notify the California Department of Public Health (CDPH), the Ombudsman, and Law Enforcement within two hours of an allegation of abuse, as required by both regulation and the facility's own policy. The allegation involved a certified nurse assistant (CNA) being rough during perineal care with a resident who was cognitively impaired and unable to make decisions. The responsible party (RP) observed the incident, reported it to the facility's Infection Preventionist (IP) nurse, and later to a registered nurse (RN), but the required notifications to authorities were not made until approximately 33 hours after the initial report. The CNA in question continued to be assigned to the resident after the allegation was reported, contrary to facility policy which requires immediate suspension of the accused staff member pending investigation. Documentation and interviews confirmed that the CNA provided care to the resident on both the day of the incident and the following day. The facility did not initiate an investigation or remove the CNA from resident care until after law enforcement was contacted by the RP and arrived at the facility. Multiple staff members, including the IP nurse, LVN, and RN, failed to recognize the incident as a reportable allegation of abuse and did not escalate or document the concern appropriately. The resident involved had a history of traumatic subdural hemorrhage, type 2 diabetes, and major depressive disorder, and was assessed as severely cognitively impaired and dependent for activities of daily living. The incident was witnessed by the RP and corroborated by the resident's roommate, who reported hearing the resident in distress and screaming during care. Despite these observations and the resident's inability to advocate for herself, the facility did not follow its own policies for reporting, investigation, and protection of the resident from further potential abuse.
Failure to Prevent and Investigate Abuse Leads to Resident Injury
Penalty
Summary
The facility failed to implement its policy and procedure to prevent, protect, report timely, and thoroughly investigate any allegation of abuse for a resident who reported rough handling by a certified nursing assistant (CNA) during activities of daily living. The resident, who had severe contractures and required careful handling, sustained an acute impacted fracture of the left upper arm, which was displaced, causing unbearable pain and discomfort, leading to hospitalization. The resident had a history of hypertension, weakness, polyarthritis, muscle wasting, and atrophy, and was admitted to the facility with these diagnoses. The resident's care plan indicated the need for careful handling to prevent trauma to the joints, but the CNA dismissed the resident's request for gentler care. The resident reported that the CNA was rough, ignored his pleas for gentleness, and handled him forcefully, causing significant pain. The resident's roommate corroborated the account, stating that the CNA handled the resident roughly and did not seek assistance from other staff. Despite the resident's complaints and visible injuries, the facility did not promptly report the abuse allegation or suspend the CNA involved. The Director of Nursing (DON) initiated an investigation but failed to interview the CNA or suspend him from work immediately. The facility's policy and procedure on abuse prevention and reporting were not followed, as the incident was not reported to the Department of Public Health in a timely manner, and the resident's allegation of abuse was not included in the Facility Reported Incident. The facility's failure to adhere to its policies resulted in the resident's injury and subsequent hospitalization.
Failure in Discharge Planning and Coordination
Penalty
Summary
The facility failed to provide appropriate discharge planning and assistance for a resident's safe discharge by not ensuring that home health services and durable medical equipment (DME) were arranged and confirmed for delivery prior to the resident's discharge. The resident, who had diagnoses including Parkinson's Disease, Dementia, and Difficulty in Walking, required substantial assistance with daily activities and was supposed to be discharged with home health services for physical and occupational therapy, medication management, and specific DME including a front-wheeled walker and a compact wheelchair. Interviews revealed a lack of coordination and communication among the facility's staff. The Social Service Director discussed discharge planning with the family but was not responsible for arranging home health services. The Case Manager, who was responsible for coordinating with the insurance company for authorizations, did not request or follow up on the necessary services and equipment. The Administrator confirmed that both the Social Service and Case Manager were responsible for ensuring discharge readiness and arrangements. As a result, the resident did not receive the required rehabilitation therapy or DME after being discharged home.
Failure to Complete and Document CNA Competency Assessments
Penalty
Summary
The facility failed to provide evidence that the Annual Certified Nurse Assistant (CNA) Core Clinical Competencies (ACCC) were completed for eight sampled CNAs. The Director of Nursing (DON) acknowledged that there was no system in place to track the CNAs' performance evaluations, which should have included a spreadsheet listing all active CNAs with their hire dates and last ACCC dates. Interviews with CNAs revealed that they could not recall when their last annual skill competencies were evaluated, indicating a lack of consistent assessment and training. During a review of the CNAs' employee files, no ACCC documentation was found for the sampled CNAs. The DON confirmed that only partial evidence of skills competencies, such as showering/bathing and donning and doffing gloves, was available, which did not account for the complete annual skills checks required. The facility's policy stated that competency assessments should be retained in employee files, but this was not adhered to, leading to a deficiency in ensuring CNAs' skills and competencies were up to date.
Medication Administration and Documentation Deficiencies
Penalty
Summary
The facility failed to provide the name and indication of medications to a resident before administration, affecting one of the seven residents observed for medication administration. During an observation, a Licensed Vocational Nurse (LVN) administered 11 medications, including two docusate sodium tablets, to a resident without informing them of the medication names and their purposes. The resident expressed a preference not to receive laxatives that morning, but the LVN had already administered the docusate tablets. The LVN acknowledged forgetting to inform the resident, which is a violation of the resident's rights to be informed and make decisions about their medication regimen. Additionally, the facility failed to account for six doses of controlled substances for four residents, leading to discrepancies in the medication accountability records. During an inspection of a medication cart, it was found that doses of oxycodone with acetaminophen, Lacosamide, lorazepam, and clonazepam were missing from the medication bubble packs compared to the counts on the Individual Narcotic Record accountability logs. The LVN admitted to administering these medications but failed to document the administrations on the accountability logs, which is against the facility's policy. The Director of Nursing confirmed that the LVN should have informed the resident of the medication details and that the failure to document controlled substance administrations could lead to potential medication errors and diversion. The facility's policies require immediate documentation of controlled substance administrations to ensure accountability and prevent errors. The failure to adhere to these policies resulted in a violation of resident rights and increased the risk of medication errors.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a rate of 5.71% due to two medication errors out of twenty-four opportunities. These errors affected two residents during medication administration. One resident received a different form of calcium than what was prescribed by their physician, while another resident received a multivitamin with minerals instead of the prescribed multivitamin without minerals. During observations, it was noted that a Licensed Vocational Nurse (LVN) administered the incorrect multivitamin to a resident, and another LVN administered calcium with Vitamin D instead of the prescribed calcium without Vitamin D. These actions were confirmed through interviews with the LVNs, who acknowledged the errors and recognized them as medication errors. The Director of Nursing also confirmed that the medications were not administered as ordered by the physicians. The residents involved had specific medical conditions that required precise medication management. One resident had a history of kidney disease and was prescribed calcium for hypocalcemia, while the other resident had hypomagnesemia and was prescribed a multivitamin. The facility's policies and procedures for medication administration emphasize the importance of administering medications as prescribed, but these were not followed in these instances, leading to the medication errors.
Expired Medications Not Removed from Stock
Penalty
Summary
The facility failed to properly manage and dispose of expired medications in one of its medication rooms, specifically Medication Room Station 1 South West. During an observation, an open vial of Aplisol, used for tuberculosis diagnosis, was found in the refrigerator without a label indicating when it was opened, contrary to the manufacturer's guidelines which require it to be used or discarded within 30 days of opening. Additionally, 15 prefilled syringes of the Afluria influenza vaccine, which expired on June 30, 2024, were found stored in the refrigerator. These medications were not removed from stock as required by the facility's policies. Interviews with the LVN and the DON revealed that the lack of labeling on the Aplisol vial made it impossible to determine its expiration, and the expired Afluria syringes should have been discarded to prevent accidental use. The facility's policies stipulate that expired medications should be immediately removed from stock and stored in a designated area for disposal. The failure to adhere to these policies increased the risk of administering ineffective or potentially harmful medications to residents.
Inadequate Training of Kitchen Staff on Sanitizer Use
Penalty
Summary
The facility failed to ensure that a kitchen staff member, identified as Dishwasher 1 (DW 1), was routinely trained and evaluated for competency in their duties. During an observation, DW 1 was found using a chlorine sanitizer test strip in a quaternary ammonium (QUAT) sanitizer solution, which is incorrect. The test strip did not change color, indicating a lack of understanding of the proper procedure. The Dietary Supervisor (DS) intervened, providing the correct test strip and instructing DW 1 on the proper method, which involves immersing the strip for 10 seconds. Initially, DW 1 dipped the strip for only one second, resulting in no color change. Upon following the correct procedure, the sanitizer was found to be at an acceptable concentration of 200 parts per million (PPM). Further investigation revealed that the facility's in-service training did not include instructions on testing sanitizer solutions, and the dishwasher's job description emphasized maintaining a safe and sanitary environment. The Registered Dietitian (RD) confirmed that the QUAT solution should be at least 200 PPM and noted a recent change in the test strip product, which may have contributed to the confusion. The manufacturer's instructions for the QUAT sanitizer test strips clearly stated the need for a 10-second immersion to obtain an accurate reading, highlighting a gap in staff training and competency evaluation.
Deficiency in Adhering to Prescribed Portion Sizes
Penalty
Summary
The facility failed to adhere to the prescribed portion sizes for residents on pureed and mechanical soft diets during the lunch service on 7/9/2024. Specifically, 12 residents on a pureed diet received 4 ounces of chicken oregano instead of the required 5 and 1/3 ounces, and 46 residents on a mechanical soft diet received 2 and 2/3 ounces of zucchini instead of the prescribed 4 ounces. This discrepancy was observed during the tray line service, where the cooks used incorrect scoop sizes, leading to the serving of smaller portions than indicated in the facility's food portion and serving guide. Interviews with the cooks revealed that they mistakenly used smaller scoops, resulting in the under-serving of chicken and zucchini. The Registered Dietician (RD) confirmed the error and emphasized the importance of following the menu and spreadsheet to ensure residents receive the correct portions to meet their nutritional needs. The facility's policy and procedure on menus, revised in 2014, mandates adherence to the written menu to meet the nutritional requirements set by the food and nutrition board of the national research council.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to promote dignity and respect for two residents during meal assistance. Certified Nursing Assistants (CNAs) were observed standing over the residents while feeding them breakfast, which violated the residents' rights to dignity and respect. Resident 16, who was severely cognitively impaired and required substantial assistance with eating, was fed by CNA 1 while lying in bed with the head elevated. Similarly, Resident 80, who also had severe cognitive impairment and required moderate assistance with eating, was fed by CNA 3 in the same manner. Both CNAs acknowledged that they should have been at eye level with the residents to maintain their dignity. Interviews with facility staff, including a Registered Nurse (RN) and the Director of Nurses (DON), confirmed that the CNAs should have been seated at eye level with the residents during feeding to uphold their dignity. The facility's policy on resident rights emphasizes care that promotes dignity and prohibits demeaning practices. The observations and interviews indicate a failure to adhere to these standards, compromising the residents' dignity during meal times.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call light was within reach for two residents, as required by the facility's policy and procedure. Resident 357, who has major depression, aphasia, and Parkinsonism, was observed with the call light tied to the right bedrail, out of reach. Despite the care plan indicating the need for the call light to be within easy reach, the resident was unable to use it to call for assistance. The Director of Nursing acknowledged the importance of having the call light accessible to the resident. Similarly, Resident 26, who has Parkinsonism, hypertensive heart disease, diabetes, and right hemiparesis, was found with the call light attached to the right upper corner of the bed, inaccessible to the resident's functional left hand. The care plan for Resident 26 also required the call light to be within easy reach, especially given the resident's fall risk and communication deficit. The Licensed Vocational Nurse and Occupational Therapist both confirmed that the call light should be accessible to the resident's left hand. The facility's policy, dated 1/1/2012, mandates that call cords be placed within the resident's reach to enable them to alert nursing staff. The failure to adhere to this policy for both residents was confirmed through observations and interviews with staff, including the Director of Nursing, who emphasized the necessity of having the call light within reach to accommodate residents' needs and ensure their safety.
Failure to Report Change in Condition for Resident's Eye Redness
Penalty
Summary
The facility failed to report a significant change in condition for a resident, identified as Resident 48, who exhibited redness in both eyes. This deficiency was identified through observation, interview, and record review. Resident 48, who has a medical history including hypertension, obesity, type 2 diabetes mellitus with diabetic nephropathy, and bilateral age-related cataract, was observed with reddened eyes. Despite the redness being noted by staff, it was not reported to the attending physician in a timely manner, resulting in a delay in receiving necessary care and treatment. On the morning of the incident, Resident 48 was observed with redness in the sclera of both eyes and reported that the redness had been present since the previous morning. The resident expressed discomfort and a need for eye drops, which had not been administered. Licensed Vocational Nurse (LVN) 6 acknowledged noticing the redness for two to three days but did not report it, assuming it had already been documented. LVN 3, responsible for the resident's care on the day shift, did not assess the eyes, as assessments were scheduled weekly, and no report was received from the Certified Nurse Assistant (CNA). Interviews with the Director of Nurses (DON) and Registered Nurse (RN) 2 confirmed that the redness should have been reported to the physician for monitoring and potential intervention. The facility's policy on Change in Condition Notification requires notifying the attending physician of any sudden and marked adverse change in a resident's condition. However, this protocol was not followed, leading to a delay in addressing the resident's eye condition.
Failure to Maintain Resident Privacy During Personal Care
Penalty
Summary
The facility failed to maintain the privacy and dignity of a resident during personal care. A certified nurse assistant (CNA) was observed cleaning a resident without clothes in their room without pulling the privacy curtain, leaving the resident exposed. This incident occurred while the resident's roommate was present, further compromising the resident's privacy. The CNA admitted to forgetting to pull the curtain, which is a necessary step to ensure privacy during such procedures. The resident involved had severe cognitive impairment and required substantial assistance with personal hygiene. The facility's policy mandates that privacy must be provided to all residents, including those who are cognitively impaired, to preserve their dignity. Interviews with the registered nurse and the director of nurses confirmed that the privacy curtain should have been used to prevent exposure and maintain the resident's dignity, as outlined in the facility's policy on resident rights and quality of life.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, leading to potential inadequate care. Resident 48, who was readmitted with multiple diagnoses including hypertension, obesity, type 2 diabetes with diabetic nephropathy, and bilateral cataracts, was observed with redness in both eyes. Despite having physician orders for eye health and artificial tears, there was no care plan addressing the intervention for the eye redness. The lack of a care plan was confirmed by RN 2 and the Director of Nurses (DON), who acknowledged the importance of a care plan to communicate necessary interventions and monitor the resident's condition. Similarly, Resident 99, admitted with an inguinal hernia and weight loss, did not have a care plan for the management of the hernia. The resident, who had intact cognition, reported abdominal discomfort affecting his eating. RN 1 confirmed the absence of a care plan for the hernia, and the DON stated that a care plan should have been in place. The facility's policy requires care plans to be updated with new problems or changes in condition, which was not adhered to in these cases.
Failure to Update Care Plan for Resident's Incontinence Post-Catheter Removal
Penalty
Summary
The facility failed to review and revise a resident-centered care plan for a resident, identified as Resident 93, who experienced occasional bladder incontinence following the removal of a urinary catheter. The comprehensive care plan, initially developed upon admission and revised months later, did not address the resident's incontinence after the catheter was removed. This oversight resulted in inconsistent care and services for the resident, who was at risk of urinary tract infections. Resident 93 was admitted with diagnoses including dementia and psychosis, and had a urinary catheter due to urinary retention. The care plan aimed to prevent urinary infections and trauma related to catheter use. However, after the catheter was removed, the care plan was not updated to reflect the resident's incontinence. Interviews with facility staff, including a registered nurse and the Director of Nurses, confirmed that the care plan should have been revised to include interventions for the resident's incontinence, but this was not done.
Failure to Set LAL Mattress Correctly for Resident
Penalty
Summary
The facility failed to implement appropriate care and services to prevent the development of pressure ulcers for a resident, identified as Resident 15, by not ensuring the Low Air Loss (LAL) mattress was set according to the physician's order. The physician had ordered the LAL mattress to be set at a level suitable for a body weight of 275 pounds, but it was observed to be set at a level for 150 pounds, which was too soft for the resident's actual weight of 281 pounds. This discrepancy was noted during observations and interviews with facility staff, including a Certified Nursing Assistant and the Director of Staff Development, who acknowledged the incorrect setting. Resident 15 had a history of morbid obesity and hemiplegia following a cerebral infarction, with severely impaired cognitive skills requiring substantial assistance for daily activities. The facility's policy required that air mattresses be set according to the resident's weight and checked routinely to ensure proper functioning. However, the LAL mattress was not set correctly, potentially putting the resident at risk for skin breakdown. The Director of Nursing confirmed the physician's order and the resident's weight, acknowledging that the mattress setting was incorrect and could lead to discomfort and failure to prevent skin breakdown.
Failure to Secure Indwelling Catheter and Maintain Hygiene Standards
Penalty
Summary
The facility failed to provide appropriate care for a resident with an indwelling catheter, which is a flexible tube inserted into the bladder for continuous urinary drainage. The deficiency was identified when the catheter was observed to be unsecured and the catheter bag was touching the floor. This was noted during an observation and interview with an LVN, who acknowledged that the urinary bag should not be in contact with the floor, even if the bed is in a low position. Another LVN confirmed that the catheter tubing should be anchored to the resident's leg to prevent pulling or dislodgement. The Director of Nurses (DON) was interviewed and acknowledged the issue, stating that they had spoken to the RNs about securing the catheter and ensuring the urinary bag is kept off the floor. The facility's policy on catheter care, dated June 10, 2021, specifies that the catheter should be anchored to prevent excessive tension and that the catheter tubing, bag, or spigot should not touch the floor. This failure to adhere to the policy placed the resident at risk for potential accidental dislodgement of the catheter and urinary tract infection.
Deficient Respiratory Care for Two Residents
Penalty
Summary
The facility failed to provide proper oxygen therapy and necessary respiratory care services for two residents, Resident 31 and Resident 50. For Resident 31, who was using a nasal cannula for continuous oxygen therapy, the device was improperly placed on the resident's right cheek instead of the nostrils. This was observed during a general observation and confirmed by a Licensed Vocational Nurse (LVN) who noted the nasal cannula was not correctly positioned. The Director of Nursing (DON) acknowledged that the nasal cannula should have been properly placed to ensure effective oxygen treatment as ordered by the physician. For Resident 50, the facility failed to label the nasal cannula with the date of the last change, as required by the physician's order. Additionally, Resident 50 was observed receiving oxygen at 4 liters per minute (LPM) instead of the prescribed 2 LPM. The lack of proper labeling and incorrect oxygen flow rate were confirmed by LVN 3 and the DON. Furthermore, Resident 50's oxygen saturation and respiratory rate were not documented on the day of observation, and the resident was found without oxygen for 15 minutes during assistance with activities of daily living (ADL), which led to fluctuating oxygen saturation levels. The facility's policy and procedure for oxygen therapy, issued in November 2017, indicated that oxygen should be administered per physician orders under safe and sanitary conditions. However, the observations and interviews revealed that the facility did not adhere to these procedures, resulting in deficiencies in the respiratory care provided to Residents 31 and 50.
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What surveyors actually found near you
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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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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Montrose
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| La Crescenta Healthcare Center | 0.9 mi | ★★★★★ | 15 | 0 |
| Usc Verdugo Hills Hospital Dp/snf | 1.2 mi | — | 0 | 0 |
| Montrose Healthcare Center | 1.2 mi | ★★★★★ | 20 | 0 |
| Oakpark Healthcare Center | 2.5 mi | ★★★★★ | 24 | 0 |
| Golden Haven Care Center | 3.6 mi | ★★★★★ | 16 | 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.