Average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Morning Star Post Acute during CMS and state inspections, most recent first.
Expired chicken was found in the kitchen refrigerator during an observation with the DSM. The DSM stated the chicken had been thawed and was supposed to be used the day before, but it remained stored in the refrigerator after its used-by date. The DSM, RD, and facility policy all indicated that dietary staff were responsible for checking dates, rotating stock, and discarding food past expiration.
Open and Overflowing Dumpsters: Two of three outdoor dumpsters were observed with lids open, and one was overflowing with garbage that prevented the lid from closing securely. The DSM stated the garbage should have been placed so the lid could close, and the EVS stated dumpster lids were his responsibility to keep closed at all times. Facility policy required garbage containers to be kept covered and outside dumpsters to remain closed and free of surrounding litter.
Failure to Develop Care Plans for Change in Condition and Fall A resident with a cough and new orders for cough medication, steroids, antibiotics, and a chest x-ray did not have a comprehensive, person-centered care plan developed after the change in condition. Staff stated the care plan should have guided monitoring and care, and the DON said it should have been initiated when the change was identified. A second resident with a left lower leg fracture and external fixator had a fall from a wheelchair in the facility, but no care plan was found for the fall. The ADON/IP and DON confirmed a change of condition report was completed, but no care plan had been initiated.
A resident with COPD and heart failure received oxygen at 2.5 LPM without a physician order, while another resident receiving an HHN treatment was not properly monitored when a CNA turned off the machine before the nurse verified the medication was fully delivered. In a separate issue, a resident with a discontinued HD history still had a soiled, lifting permacath dressing, and the record lacked clear documentation and care planning for the access after treatments stopped.
Expired meds and wound solution were found in the medication room, including unopened bottles of Fexofenadine, Dextromethorphan HBr/Guaifenesin, and Vashe wound solution with past expiration dates. In a separate observation, a resident had two medication bottles and an MDI on the over-bed table after the resident’s partner brought them from home. Staff interviews confirmed residents are not allowed to keep meds at bedside and that home meds require an order before use.
Failure to Test Symptomatic Resident for COVID-19 and Follow EBP During G-Tube Care: A resident with a new cough was not tested for COVID-19 despite facility policy listing cough as a testing criterion and a PRN test order already being in place. In a separate event, an LVN handled another resident’s G-tube during enteral feeding while wearing gloves but not the required gown under EBP. The DON, IP/DSD, and LVN acknowledged the policy requirements and that they were not followed.
A resident with anxiety and intact cognition was given clonazepam after the order changed from PRN to scheduled q12h, but the chart did not show a new informed consent before administration. RN and DON interviews confirmed the consent on file matched the prior PRN order, the resident had not signed the updated consent before receiving two doses, and the resident said she was unaware the change had taken effect.
Failure to document and notify for an AMA discharge: A resident with hip effusion, spinal stenosis, weakness, and gait impairment left after being unhappy with her room situation. Staff said the resident signed the AMA form and was told the meaning and consequences, but the RN did not notify the MD or ADM, the LVN did not remember doing so, and the DON confirmed the chart did not show required notification. The SSD also found no documentation of resident discussions and did not notify the ombudsman.
A resident with MRSA foot wounds, chronic heel wounds, DM, and IV antibiotic treatment had an MDS assessment that did not mark infection of the foot in Section M. During observation, the resident was in bed with facial grimacing and reported right foot pain, while records and staff interviews confirmed ongoing wound care, isolation precautions, and IV vancomycin for MRSA.
Surveyors observed that 3 of 16 rooms exceeded the maximum allowed occupancy, with rooms 11, 12, and 14 each housing more than four residents. The report notes that the rooms had adequate storage, accessible wheelchair and toilet facilities, sufficient space for nursing care and ambulation, and bedside stands for each resident.
Nursing staff did not recognize or appropriately act on a resident's clinical decline, including failing to notify the physician of abnormal lab results, low blood pressure, and elevated heart rate. The resident's condition worsened to altered mental status and low oxygen saturation, with action only taken after a family member intervened. This resulted in emergency hospital transfer and a diagnosis of sepsis and acute kidney injury.
A resident with multiple chronic conditions was not given several prescribed medications due to unavailability, and the nurse did not notify the physician or document the missed doses as required by facility policy. The resident had no cognitive impairment and required these medications for ongoing health issues, but the necessary communication and documentation were not completed.
The facility failed to maintain sanitary conditions in the kitchen, with debris found on ventilator fans, vents, cabinet shelves, and food carts, leading to potential cross-contamination. Additionally, a toaster and a beef roast in the freezer were not properly maintained, risking bacterial growth. Staff acknowledged these issues, and the facility's sanitation and storage policies were not followed.
The facility failed to implement its Water Management Program to reduce Legionella risk, placing residents at risk for undetected waterborne pathogens. Additionally, two residents' oxygen nasal cannulas were found on the floor, and an LPN did not sanitize a resident's inhaler mouthpiece after use, both actions risking cross-contamination and infection. The facility's infection control policies were not followed in these instances.
A facility failed to ensure resident dignity and privacy during medical procedures. An LVN checked a resident's blood sugar without closing the privacy curtain, while another LVN administered medications and checked blood pressure for multiple residents without ensuring privacy. These actions were acknowledged by the staff involved, and the DON confirmed the expectation for privacy during such procedures.
The facility failed to ensure the expiration dates of medications in the emergency kit were checked and updated, resulting in expired lorazepam being available for use. The DON and LVN acknowledged the oversight, and the pharmacist did not notice the expired medication during her monthly visit, contrary to the facility's policy.
The facility failed to properly store and label medications, leaving a treatment cart unlocked and unsupervised, and not labeling inhalers and nasal sprays with open or expiration dates for two residents. Discontinued medications were also improperly stored without labels or identifiers. These actions violated the facility's policies, posing potential health risks.
The facility was found to have three bedrooms each accommodating eight residents, exceeding the regulatory limit of four residents per room. Despite this, the rooms met the required needs, including adequate space, privacy, and accessibility, and the facility requested a waiver to maintain this setup.
The facility failed to ensure call lights were within reach for three residents, leading to potential harm. A resident's call light was under the bed, while two others had call lights on the floor, making them inaccessible. Staff interviews confirmed the failure to follow the facility's policy, which requires call lights to be within easy reach.
A resident with COPD and asthma was allowed to self-administer inhaler medications without the required assessment, physician's order, or care plan, contrary to the facility's policy. The LVN permitted this action, which was confirmed by interviews with the Infection Preventionist and DON, highlighting a lapse in following established procedures for medication administration.
A resident with severe cognitive deficits did not receive necessary assistance with personal hygiene, resulting in long, dirty fingernails and food particles in her mouth. Staff interviews revealed inconsistencies in providing nail and oral care, despite facility policies requiring regular maintenance. The resident's refusal of care was not consistently reported to licensed nurses, contributing to the deficiency.
Expired Chicken Left in Refrigerator
Penalty
Summary
Food was not prepared and stored in accordance with professional food safety standards when a five-pound bag of chicken with a used-by date of 2/16/26 was found in the refrigerator during an initial kitchen tour. During the concurrent observation and interview on 2/17/26 at 8:22 a.m., the Dietary Service Manager stated the chicken was supposed to have been used the day before and that dietary staff had defrosted more chicken than was needed. During later interviews, the Dietary Service Manager stated the cook was responsible for pulling food to thaw for use and that refrigerators and freezers were monitored daily for expiration dates so food past the used-by date would not remain in the refrigerator. The Dietary Service Manager stated the expired chicken should have been removed to avoid use. The Registered Dietitian stated thawed meat was required to be served and any unused portions discarded, and that all dietary staff were responsible for checking daily for expired food and discarding it as needed. The facility policy titled Food Storage required food items to be labeled, rotated so the oldest were used first, and discarded after the expiration date.
Open and Overflowing Dumpsters
Penalty
Summary
Garbage and refuse were not stored and disposed of in a manner that prevented unsanitary conditions when two of three outdoor dumpsters were observed with lids open and one dumpster was overflowing. During a concurrent observation and interview on 2/18/26 at 8:15 a.m. with the Dietary Service Manager (DSM), the dumpster behind the building was seen with two lids in the open position, and one dumpster contained overflowing garbage in a plastic bag that prevented the lid from closing securely. The DSM stated the garbage should have been placed in the back first so the lid could close. During later interviews, the DSM stated the dumpster was everybody’s responsibility and that leaving it open attracts vermin and causes odor. The Environmental Supervisor (EVS) stated it was his responsibility to ensure dumpster lids remained closed at all times and that the facility’s dumpsters contained dirty briefs, food, and other garbage. A review of the facility policy titled Food-Related Garbage and Refuse Disposal, revised 10/17, indicated all garbage and refuse containers must be kept covered, food waste must be stored in a manner inaccessible to pests, and outside dumpsters must be kept closed and free of surrounding litter.
Failure to Develop Care Plans for Change in Condition and Fall
Penalty
Summary
The facility failed to ensure a comprehensive, person-centered care plan was developed and implemented for Resident 5 after a change in condition. Resident 5 was admitted with diagnoses including a right lower leg fracture and muscle weakness, and had a BIMS score of 14, indicating cognitive intactness. On 2/14/26, Resident 5 reported developing a productive cough and later received new physician orders for guaifenesin, dextromethorphan-benzocaine lozenges, prednisone, azithromycin, and a chest x-ray. The chest x-ray showed bilateral lower lung field atelectatic changes. During interview, Resident 5 stated he had been receiving cough syrup and throat lozenges and had undergone the x-ray, with results pending at the time. Staff interviews and record review showed no care plan was in place for the cough and related change in condition. CNA 1 stated care plans were her guide for resident care and that new developments should be care planned so staff know what to monitor. RN 1 reviewed the orders and stated there should have been a care plan in place when Resident 5 complained of a cough, and that care plans are important to ensure care is provided according to the established plan. The DON stated it was her expectation that the nurse would initiate a care plan as soon as a change in condition was identified. The facility policy stated assessments are ongoing and care plans are revised when information or condition changes, and the interdisciplinary team reviews and updates the care plan when there has been a significant change in condition. The facility also failed to develop a care plan for Resident 10 after a fall in the facility. Resident 10 was admitted with diagnoses including left lower leg fracture, muscle weakness, and difficulty walking, and had an external fixator on the left ankle/leg. Resident 10 stated she had fallen at home, and also had another fall in the facility when she slipped out of her wheelchair. LVN 2 reviewed the record and stated Resident 10 had a fall in the facility on 2/15/26 but no care plan was found. CNA 4 stated Resident 10 had fallen off her wheelchair while reaching out and required assistance with turning and repositioning. The ADON/IP confirmed a change of condition report was completed for the fall but no care plan was found, and the DON stated no care plan had been initiated after the change of condition was completed.
Oxygen without order, incomplete nebulizer monitoring, and permacath care issues
Penalty
Summary
Resident 12 was observed receiving oxygen therapy at 2.5 LPM through a nasal cannula connected to an oxygen concentrator, but the resident had no active, discontinued, or expired physician order for oxygen therapy in the record. The resident had diagnoses including COPD, hypertensive heart disease, and heart failure, and had a BIMS score of 12, indicating moderate cognitive impairment. During record review and interviews, the LVN, another LVN, and the DON all stated that oxygen is a medication requiring a physician order, and the DON stated the resident was at risk of being over oxygenated when oxygen was administered without physician oversight. The facility policy stated oxygen is administered under physician orders except in an emergency. Resident 49 was observed sitting at the edge of the bed holding a handheld nebulizer while receiving albuterol sulfate inhalation treatment. During the observation, a CNA turned off the nebulizer machine after the resident stated the treatment was completed, and the licensed nurse did not verify that the medication in the nebulizer chamber had been fully administered. The CNA stated CNAs are not allowed to turn on or off resident machines and are not allowed to touch resident medications, and the LVN later stated she should have stayed with the resident while the HHN was still on because there was still medication in the chamber. The DON and DSD/IP stated CNAs are not allowed to turn on or off HHN machines and oxygen, and the facility policy required the resident to be monitored until the medication was fully nebulized. Resident 29 had a right upper chest permacath that was observed covered with a bordered gauze dressing that was discolored, partially lifting, and had visible yellow-brown staining, with the central gauze pad appearing soiled. The resident stated he last received hemodialysis one month earlier. Record review showed he had previously been receiving hemodialysis, but treatments had been discontinued, and staff were still maintaining the permacath dressing. RN 1 stated staff cleaned and reinforced the dressing, but she did not see documentation of the task on the TAR and was not sure when the dressing was last changed. The SSD stated the facility was working on having the permacath removed, but the IDT notes did not address the discontinuation of hemodialysis or a plan of care moving forward. The facility policy required ongoing communication with the dialysis facility, comprehensive care planning, and dressing changes when the dressing was damp, loosened, or visibly soiled.
Expired Medications Stored in Medication Room and Home Medications Left at Bedside
Penalty
Summary
Expired medications and wound care solutions were found in the medication room during observation with the DON. Four unopened bottles of Fexofenadine Hydrochloride 180 mg had a manufacturer expiration date of 1/2026, one unopened bottle of Dextromethorphan HBr 20 mg/Guaifenesin 400 mg had an expiration date of 11/2025, and two unopened 8.5 fluid ounce Vashe wound solution bottles had an expiration date of 2/2025. The DON stated the items were expired and acknowledged that the medication room should not contain expired medications or wound treatment solutions. The DON also stated licensed nursing staff and the consultant pharmacist were expected to review expiration labels and remove expired items. During interviews, the Pharmacist Consultant and Pharmacist Consultant Supervisor stated expired medications needed to be removed to prevent accidental administration and that efficacy could not be guaranteed past the expiration date. The facility’s pharmacy services and procedures manual stated medications and biologicals with expired dates, or those retained longer than recommended, should be stored separate from other medications until destroyed or returned, and that storage areas should be inspected regularly for compliance. Another facility policy stated the pharmacy and medication rooms are routinely inspected for discontinued, outdated, defective, or deteriorated medications, and that these items are destroyed in accordance with facility policy. A separate observation in Resident 32’s room showed two medication bottles and one metered dose inhaler on top of the resident’s over-the-bed table and available for use. Resident 32 stated her partner brought the medications from home, including a lotion bottle, a bottle containing a white powder she said was for constipation, and an inhaler she used at home for breathing. Resident 32 stated she was not sure when she last used the inhaler and believed staff had seen the bottles on her table. Staff interviews confirmed residents are not allowed to keep medications at bedside, that home medications are not to be used without an order, and that medications brought from home should be stored in the medication room. The DON stated the facility does not allow medications to be kept at bedside and that the partner brought the medications without notifying nursing staff.
Failure to Test Symptomatic Resident for COVID-19 and Follow EBP During G-Tube Care
Penalty
Summary
The facility failed to ensure Resident 5 was tested for COVID-19 after he developed a productive cough. Resident 5 was admitted with diagnoses including a right lower leg fracture and muscle weakness, and his MDS showed a BIMS score of 14, indicating he was cognitively intact. During observation and interview, Resident 5 stated the cough began on 2/14/26 and that he had received cough syrup, throat lozenges, and a chest X-ray with results pending. RN 1 stated she was the nurse assigned to Resident 5 when the cough developed and that the facility's COVID-19 protocol required residents with signs or symptoms of COVID-19 to be tested, but Resident 5 was not tested. The MAR showed a PRN order for COVID-19 testing that had not been administered. The Infection Preventionist/Director of Staff Development reviewed the record and stated Resident 5 had developed a cough and that she was unsure why the nurse did not test him for COVID-19. She stated testing was important to determine the resident's COVID-19 status and that COVID-19 spreads rapidly. She also stated the nurse assesses residents and determines if they meet criteria for testing, and that testing would have been beneficial because results are available within 15 minutes. The DON reviewed the facility policy titled COVID-19, which listed cough as a clinical criterion for testing, and stated Resident 5 should have been tested according to the policy because he already had a PRN order for testing. The facility also failed to ensure Enhanced Barrier Precautions were followed when LVN 1 handled Resident 4's G-tube during enteral feeding administration. Resident 4 had diagnoses including cerebral infarction, gastrostomy status, type 2 diabetes mellitus, and dysphagia, and his MDS showed a BIMS score of 3 with a feeding tube. His OSR indicated an active order for enteral feed every 4 hours via G-tube and that he was on Enhanced Barrier Precautions for enteral feeding via G-tube. During observation, LVN 1 was seen handling Resident 4's G-tube with gloves but without a gown. The IP/DSD, LVN 1, and DON all stated that gown and gloves were required for this high-contact care activity and that the facility policy for Enhanced Barrier Precautions was not followed.
Incomplete informed consent for scheduled clonazepam
Penalty
Summary
The facility failed to ensure a complete and accurate informed consent was obtained before administering clonazepam, a psychotherapeutic medication, to one resident who was her own representative party and had a BIMS score of 15. The resident was admitted with diagnoses including rhabdomyolysis, spinal stenosis, chronic pain syndrome, and anxiety disorder. Her medical record showed an order for clonazepam 0.5 mg every 12 hours as needed for anxiety, and an informed consent dated 2/5/26 for that PRN order. The resident’s clonazepam order was changed on 2/17/26 to 0.5 mg every 12 hours scheduled for 14 days. The record did not show that a new informed consent was obtained for the revised scheduled order before the medication was given. The medication was administered on 2/17/26 at 9:00 p.m. and on 2/18/26 at 9:00 a.m. before the resident signed an informed consent for the scheduled order. During interviews, RN 1 stated the current informed consent did not match the current clonazepam order and that a new informed consent was required when a psychotherapeutic medication changed, including frequency. The resident stated she was unaware the medication had been changed from PRN to scheduled every 12 hours and said she requested the change so she could receive it at 9 a.m. and 9 p.m., but did not know it had gone into effect yet. The DON stated she signed the informed consent as the receiving licensed nurse of the verbal order, that the resident did not sign it on 2/17/26, and that the resident received two doses before signing the informed consent on 2/18/26. The DON also stated she could not locate a policy, in-service, or education supporting the resident not being able to sign informed consent if the provider was not at bedside, and acknowledged facility policy had not been followed.
Failure to Document and Notify for AMA Discharge
Penalty
Summary
The facility failed to follow its policy for an against medical advice (AMA) discharge for one resident who left the facility on 2/6/26. The resident had been admitted with diagnoses including right hip effusion, spinal stenosis, muscle weakness, and abnormalities of gait and mobility. Her MDS assessment showed a BIMS score of 13 out of 15, indicating no cognitive deficit. During interviews, the LVN who assisted with the AMA process stated the resident was unhappy and wanted to leave, that he explained the meaning and consequences of AMA, and that the resident signed the AMA form, but he did not remember notifying the MD or ADM. The RN who was the resident’s nurse stated she sent a message to the DON but did not notify the resident’s MD or ADM, and said she assumed the DON would notify the ADM. The SSD stated there was no documentation that she had spoken with the resident about wanting to go home or about a room change, and she acknowledged she should have notified the ombudsman but did not. The DON stated the resident had threatened to leave multiple times, but there were no documentations, and she was not sure about the facility’s AMA policy. The DON also stated the nurse progress note did not indicate that the MD and ADM were notified or made aware of the resident’s decision to leave AMA. The facility policy titled Transfer and Discharge (Including AMA) stated the physician should be notified of the intended AMA discharge, encouraged to speak with the resident, and that documentation of the notification should be entered in the nurses’ notes; it also stated the SSD should document discussions with the resident or family in the social service progress notes.
MDS Assessment Did Not Reflect Foot Infection
Penalty
Summary
The facility failed to ensure Resident 58’s MDS assessment accurately reflected his health and functional status when Section M did not indicate an infection of the foot. During observation, Resident 58 was lying in bed with facial grimacing and stated he had pain in his right foot. His right foot was covered with a kerlix roll dressing from above the left ankle to the toes, and the left foot was covered with an elastic bandage. Resident 58 stated that the nurse said it was too soon for another pain medication. Record review showed Resident 58 was re-admitted with diagnoses including MRSA infection, DM, and absence of other right toes. The OSR documented wound care orders for the right plantar foot and right heel, along with IV vancomycin for MRSA to bilateral lower extremity wounds. The IP stated Resident 58 was on isolation precautions due to MRSA to wounds on his feet and was currently receiving IV antibiotics. The ADON/IP stated Resident 58 had chronic wounds to the heel area and had been re-admitted with IV antibiotic treatment for MRSA until 3/3/26. During review of the Admission/Medicare MDS assessment, the MDSC stated Resident 58 was on antibiotic for MRSA to wounds on his foot but Section M was not marked to show infection of the foot, and she stated, "I made a mistake, I should have marked it yes."
Excessive Room Occupancy Observed in Multiple Bedrooms
Penalty
Summary
The facility failed to ensure each bedroom accommodated no more than four residents, with 3 of 16 rooms exceeding the allowed occupancy. During the initial tour, surveyors observed rooms 11, 12, and 14 each containing more than four residents, with room 11 having 8 beds, room 12 having 7 beds, and room 14 having 8 beds. The report states that although these bedrooms accommodated more than four residents, each room met the particular needs of each resident, had adequate closet and storage space, accessible wheelchair and toilet facilities, sufficient room for nursing care and resident ambulation, and bedside stands for each resident.
Failure to Recognize and Respond to Change in Condition
Penalty
Summary
Nursing staff failed to recognize and appropriately act on a significant clinical change in condition for a resident with multiple complex medical diagnoses, including hemiplegia, hemiparesis, cerebral infarction, dysphagia, and diabetes mellitus. The resident exhibited abnormal laboratory results, specifically an elevated white blood cell count and blood urea nitrogen, which were not communicated to the physician as required by facility policy. Additionally, daily resident assessments were not completed on two consecutive days, which could have detected early signs of decline. On subsequent days, the resident presented with low blood pressure and elevated heart rate, yet these abnormal vital signs were not reported to the physician. The resident's condition further deteriorated, with altered mental status, increased weakness, decreased communication, shortness of breath, and distress, accompanied by a critically low oxygen saturation. Despite these significant changes, nursing staff did not promptly notify the physician or take appropriate action until the resident's family member intervened and insisted on emergency medical attention. The lack of timely assessment, failure to report abnormal findings, and inadequate response to the resident's clinical decline resulted in the resident being transferred to an acute care hospital, where she was diagnosed with sepsis and acute kidney injury, requiring intensive care. Interviews and record reviews confirmed that staff did not follow facility protocols for assessment, notification, and escalation of care in response to abnormal findings and changes in the resident's condition.
Failure to Administer and Report Missed Medications as Ordered
Penalty
Summary
A deficiency occurred when a resident was not administered multiple prescribed medications, including Allopurinol, Duloxetine, Empagliflozin, Linagliptin, and Rifaximin, as ordered by the physician. The Medication Administration Record (MAR) indicated that these medications were not given due to their unavailability, coded as 'code 11.' The licensed nurse did not document any notification to the prescribing physician regarding the missed doses, nor was there evidence that the provider was informed of the situation. The resident involved had a medical history that included encephalopathy, diabetes mellitus type 2, liver cirrhosis, chronic gout, anxiety disorder, and recurrent major depressive disorder. The resident was assessed as having no cognitive impairment according to the Brief Interview for Mental Status (BIMS) score. Despite the resident's complex medical needs, the required medications were not administered, and the necessary communication with the physician was not documented. Facility policy required that nursing staff notify the attending physician when medications are unavailable, explain the circumstances, and obtain new orders or alternative therapies. The policy also required documentation of this communication and timely administration of medications. Both the Licensed Vocational Nurse and the Director of Staff Development confirmed that these procedures were not followed, and the nurse failed to adhere to professional standards and facility policy regarding missed medication doses.
Sanitation and Food Storage Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain safe and sanitary food preparation and storage practices in the kitchen, as observed during a survey. Multiple areas in the kitchen, including a ventilator fan in the milk refrigerator, vents above the dishwasher, and a vent in front of the milk refrigerator, were found to have brown, grey, and black debris. The Dietary Manager (DM) acknowledged that these areas should have been cleaned, and the drinks stored underneath the ventilator fan were ready for resident consumption. The Infection Preventionist (IP) and other staff members confirmed that the debris could lead to cross-contamination and potential gastrointestinal infections for residents. Additionally, black and brown debris was found on cabinet shelves next to stored clean bowls, and brown debris was present on every shelf inside a food cart. The DM and other staff members recognized that these areas should have been cleaned or replaced to prevent cross-contamination. The presence of debris on nonfood-contact surfaces was noted as a potential environment for the growth of microorganisms, which could be transferred to food, leading to food-borne illnesses among residents. Further observations revealed brown debris on top of and inside a toaster, and a beef roast inside a plastic bag covered in ice stored in the meat freezer. The DM and other staff members stated that the toaster should have been clean and the roast should not have had ice buildup, as these conditions could lead to bacterial growth and food-borne illnesses. The facility's policies and procedures for sanitation and freezer storage were not followed, contributing to the deficiencies observed during the survey.
Infection Control Deficiencies in Water Management and Equipment Handling
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies. Firstly, the Water Management Program (WMP) was not implemented since April 8, 2022, to reduce the risk of Legionella and other waterborne pathogens. The Maintenance Director, who was responsible for Legionella oversight, had not been part of an annual review or committee for Legionella since taking the position in April 2024. The Infection Preventionist and the Administrator also confirmed that they had not participated in an annual review for Legionella, and the facility did not follow the WMP policy and procedure. This lack of review and implementation placed residents at risk for undetected Legionella in the water system. Additionally, the facility failed to ensure proper infection control practices concerning oxygen nasal cannulas for two residents. Observations revealed that the nasal cannulas for these residents were on the floor while their oxygen concentrators continued to deliver oxygen. Licensed Vocational Nurse (LVN) 2 acknowledged that the nasal cannulas should not be on the floor and recognized the potential for cross-contamination. The Infection Preventionist and the Director of Nursing confirmed that the facility's policy and procedure for Oxygen Administration were not followed, and the residents were at risk of acquiring bacteria and germs from cross-contamination. Furthermore, the facility did not adhere to proper infection control practices regarding the use of inhalers for another resident. LVN 2 failed to wipe or sanitize the mouthpiece of the resident's inhalers after use, which could lead to bacterial growth and infection. The Infection Preventionist and the Director of Nursing emphasized the importance of cleaning the inhaler's mouthpiece after each use to prevent infection. The facility's policy and procedure for administering medications, which includes infection control procedures, were not followed in this instance.
Failure to Provide Privacy During Medical Procedures
Penalty
Summary
The facility failed to ensure residents were treated with dignity and respect, as evidenced by multiple instances where privacy was not provided during medical procedures. Licensed Vocational Nurse (LVN) 1 checked a resident's blood sugar level without closing the privacy curtain or door, despite the presence of another resident, facility staff, and a visitor in the room. This action was acknowledged by LVN 1, who admitted that privacy should have been provided. Similarly, LVN 3 was observed checking another resident's blood pressure without ensuring privacy by closing the curtain or door. This occurred while staff and other residents were walking by in the hallway. LVN 3 admitted to not providing the necessary privacy and acknowledged the oversight. Furthermore, LVN 3 administered medications to several residents without closing the privacy curtains, despite the presence of other residents, staff, and visitors in the vicinity. This was confirmed by LVN 3, who recognized the violation of residents' rights to privacy. The Director of Nursing (DON) also confirmed that the expectation was for licensed nurses to provide privacy during medication administration, emphasizing the importance of maintaining resident dignity and respecting their rights.
Failure to Monitor Expiration Dates in Emergency Kit
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for 54 residents by not ensuring the expiration dates of medications in the emergency kit (E-kit) were checked and updated. During an observation and interview, it was found that the E-kit contained two vials of lorazepam with an expiration date of 11/30/24, which had not been replaced. The Director of Nursing (DON) acknowledged that the E-kit should have been replaced before the medication expired, and a resident could have needed the medication after its expiration, leaving no available medication to administer. Interviews with the Licensed Vocational Nurse (LVN) and the pharmacist revealed that the pharmacist, who visits the facility monthly, did not notice the expired lorazepam during her last visit. The LVN admitted to not checking the expiration dates of medications in the E-kit, assuming it was the pharmacist's responsibility. The facility's policy indicated that the pharmacy should inspect the condition and expiration dates of medications stored in the dispensing machine regularly, but this was not adhered to, resulting in the potential risk of administering expired medication during emergencies.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications, as observed during a survey. A treatment cart was found unlocked and unsupervised in front of the nursing station, which contained medicated ointments and other medications. This oversight was confirmed by an LVN, who acknowledged that the cart should have been locked to prevent unauthorized access by residents or staff, potentially leading to serious health conditions. The Director of Nursing (DON) also stated that the expectation was for licensed nurses to ensure the treatment cart was locked when not supervised. Additionally, the facility did not label medications with open dates or expiration dates for two residents. Resident 14's inhalers and nasal spray, used for treating COPD and asthma, lacked these critical labels. An LVN admitted not knowing when the medications were opened, emphasizing the importance of labeling to avoid administering expired medications, which could be less effective. Similarly, Resident 18's inhaler also lacked an open date or expiration date, with an LVN noting that the medication would not be effective after 30 days of being opened. Furthermore, discontinued medications were improperly stored in a clear plastic container in the medication room without labels or resident identifiers. The DON acknowledged that medication labels should not have been removed and that these medications should have been destroyed or returned to the pharmacy. The facility's policies and procedures require that medications be stored in locked compartments and properly labeled, but these were not followed, leading to the potential for adverse reactions if medications were administered incorrectly.
Exceeding Resident Capacity in Bedrooms
Penalty
Summary
The facility failed to comply with the regulation that limits the number of residents per bedroom to a maximum of four. During the survey conducted from December 3, 2024, to December 10, 2024, it was observed that three resident bedrooms each housed eight residents, exceeding the allowed capacity. Despite this non-compliance, the facility ensured that each room met the required needs of the residents, including adequate square footage, privacy, storage space, and accessibility for wheelchairs and other devices. The health and safety of the residents were not adversely affected, and the facility requested a waiver to continue this arrangement.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that call lights were within reach for three residents, leading to potential harm. Resident 104's call light was found under the bed and not accessible, despite the resident's severe cognitive deficit and medical conditions such as heart failure and end-stage renal disease. Observations and interviews with staff, including an LVN and CNAs, confirmed that the call light was not within reach, which is against the facility's practice and policy. Similarly, Resident 19's call light was observed hanging off the bedframe and touching the ground, making it inaccessible. This resident also had a severe cognitive deficit and was diagnosed with generalized muscle weakness. Staff interviews revealed that the call light should have been within reach to ensure the resident could call for assistance when needed. Resident 30's call light was found on the floor, out of reach, despite the resident's ability to communicate and understand. The resident had medical conditions such as acute respiratory failure and morbid obesity, which limited mobility. Staff acknowledged the safety issue and the failure to follow the facility's policy, which requires call lights to be clipped to the bed and within easy reach of residents.
Failure to Follow Self-Administration Policy for Inhaler Medications
Penalty
Summary
The facility failed to adhere to its own policy and procedure regarding the self-administration of medication for one resident, identified as Resident 14. Resident 14, who was admitted with diagnoses of Chronic Obstructive Pulmonary Disease (COPD) and asthma, was observed self-administering her inhaler medications without having undergone the required self-administration assessment, physician's order, or care plan. The Licensed Vocational Nurse (LVN) 2 allowed Resident 14 to self-administer her inhalers, despite the facility's policy requiring an interdisciplinary team assessment to determine the resident's capability to safely self-administer medications. Interviews with the Infection Preventionist, LVN 2, and the Director of Nursing (DON) confirmed that Resident 14 did not have the necessary assessment, physician's order, or care plan in place. The facility's policy, dated 2/2021, mandates that residents must be assessed by an interdisciplinary team to ensure they are capable of safely self-administering medications, and this must be documented in the medical record and care plan. The failure to follow these procedures had the potential to result in Resident 14 not receiving the correct medication dose as ordered by the physician.
Failure to Provide Adequate ADL Assistance
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for a resident, identified as Resident 22, who was unable to maintain personal hygiene and grooming independently. Observations revealed that Resident 22 had long, jagged, and dirty fingernails with dark particles underneath, and food particles were present in her mouth and between her teeth. The resident expressed a need for assistance with nail trimming and oral care, which she had not received. Interviews with staff, including the Director of Staff Development (DSD), Certified Nurse Assistants (CNAs), and a Licensed Vocational Nurse (LVN), confirmed that the facility's practice was to provide nail care on scheduled shower days and oral care twice daily. However, staff admitted to not remembering when they last provided these services to Resident 22. The CNAs noted that Resident 22 sometimes refused care, but they did not consistently report refusals to licensed nurses as required by facility policy. The facility's policies on nail and oral care emphasized the importance of regular maintenance to prevent health issues. Despite these guidelines, the staff failed to ensure that Resident 22 received the necessary care, resulting in poor personal hygiene. The Director of Nursing (DON) acknowledged the potential health risks associated with inadequate nail and oral care, such as infections, but the deficiency persisted due to lapses in staff adherence to care protocols.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 322 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Clovis
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Horizon Health & Subacute Center | 2.2 mi | ★★★★★ | 5 | 0 |
| Willow Creek Healthcare Center | 2.3 mi | ★★★★★ | 4 | 0 |
| The Terraces At San Joaquin Gardens Village | 3.9 mi | ★★★★★ | 0 | 0 |
| North Point Healthcare & Wellness Centre Lp | 3.9 mi | ★★★★★ | 0 | 0 |
| Keystone Post-acute | 4 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.