Average — CMS composite of the measures below.
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Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at New Bethany Skilled Nursing during CMS and state inspections, most recent first.
A resident with significant mobility limitations and a high fall risk was transferred by a CNA using a stand-up lift instead of the required Hoyer lift, and without the mandated two-person assistance. The resident, who had a history of spinal stenosis, neuropathy, morbid obesity, and lower extremity edema, slid out of the lift and fell, resulting in discomfort and a subsequent emergency department evaluation. Staff interviews and documentation confirmed that the care plan and physician's order specified the use of a Hoyer lift with two staff members, but these protocols were not followed.
A resident with a significant change in condition, hospice admission, poor intake, and major weight loss did not receive an RD nutritional assessment tied to the change. In a separate event, an LVN gave PRN acetaminophen without assessing pain first and administered metoprolol without checking BP or HR beforehand, despite the resident being cognitively intact and having cardiac and HTN diagnoses.
Medication labeling and storage were deficient when resident-specific OTC meds and supplements were marked only with room numbers instead of patient identifiers, including name and DOB. Staff confirmed this was the facility’s practice for resident-brought medications, and the DON stated patient-specific meds should have patient labels. The medication room was also observed wide open and unattended, despite staff and policy stating it must remain locked when not in use.
Improper food handling and sanitation were observed when chicken was thawing under running water without being fully submerged and the kitchen dishwasher had visible residue, dirt, and debris on its surface. Dietary staff, the DSS, and the RD stated the meat should have been fully submerged during thawing and the dishwasher should have been kept clean to prevent contamination of clean dishes and food.
QAPI recommendations were not followed when the RD’s request to participate in IDT weight meetings was not implemented. The RD reported that monthly weight meetings were not occurring, she was not included in IDT meetings, and skin reports were only provided when requested. The ADM and DON acknowledged the RD’s reports were sent by email for QAPI review, but no documented attempt was made to involve the RD in IDT meetings.
An LPN stored personal belongings and drinks on the medication counter, and two residents’ NCs were found improperly stored outside protective packaging. Staff and the DON stated the medication room counter was not for personal items and that opened NC tubing should be dated and kept sealed or enclosed to prevent contamination. One resident had diagnoses including heart failure, CKD, and interstitial pulmonary disease, and the other had cerebral infarction, CKD, and acute respiratory failure with hypoxia.
A resident who primarily spoke Russian and had dementia-related diagnoses was not consistently provided the communication support identified in her care plan; staff relied on a phone translation app and did not use the communication card listed for her preferred language. Another resident with dementia, aphasia, and other conditions was observed waiting to be fed while a resident at the same table was already eating, despite needing one-on-one meal assistance. Staff and the DON acknowledged that residents needing feeding assistance should be helped at the same time and that the resident should not have been watching another resident eat.
A resident who primarily spoke Russian had a care plan calling for a communication card, but staff instead relied on a phone translation app and did not use the card. The DON stated the facility had no translator service and no Russian-speaking staff, while the resident’s care plan and language-barrier policy called for language assistance and documented communication preferences. In a separate issue, another resident’s fall care plan required floor mats on both sides of the bed, but repeated observations found the mats stored against the wall instead of in place, despite the resident’s high fall risk and history of falls.
Missing nurse signatures on controlled drug receipt records. Two residents had controlled substance delivery records that were not completed by the receiving nurse: one for hydrocodone-acetaminophen and one for lorazepam. The DON and CP stated that the nurse should sign the controlled drug record when medications are received, and the facility policy required the receiving nurse and delivery person to count controlled substances together and both sign the record.
Failure to Provide Written Transfer Notification: A resident with HF, atrial flutter, and cardiomegaly had a sudden change in baseline and was sent by ambulance to an acute hospital for further evaluation. The RP received verbal notice and agreed to the transfer, but the LVN/DSD and DON stated the facility did not provide written notice of the transfer or reason for the hospital send-out, despite policy requiring resident/representative notification for emergent transfers.
Failure to Update Care Plans After Significant Change of Condition: A resident with dementia, DM, HTN, anemia, CKD, and other diagnoses had a significant change of condition after hospice admission, with poor PO intake, meal refusals, weight loss, and increased weakness. The RD stated the IDT did not notify her and the nutritional assessment was not completed, while the MDSC and AD stated the nutritional and activities care plans were not reviewed or revised to reflect the resident’s current status, including that the resident was now staying in bed and no longer wandering.
Failure to Provide Nail Care for a Dependent Resident A resident with dementia, DM, HTN, anemia, TIA, hypertensive heart disease, and CKD was observed with long, dirty fingernails and brownish dirt built up under the nails. CNA staff later confirmed the nails were dirty and long, and stated CNAs and activity staff were responsible for weekly nail care. The DON stated the resident's fingernails should have been trimmed and cleaned, and the facility policy called for daily cleaning and regular trimming to prevent infection and skin scratches.
Failure to maintain a resident’s hearing device use: A resident with a left ear implant had difficulty hearing during conversations with staff and other residents, and staff had to speak close to the resident’s ear to communicate. The implant was documented in nurses’ notes, but it was not included in the care plan initially, and staff were not aware of the device. The DON stated the implant should have been identified on admission and communicated to CNAs, while the SSD/MR was unaware of the resident’s hearing difficulty and implant.
Failure to honor food preferences and fortified diet orders: Two residents were served meals that did not match documented preferences or diet requirements. One resident on a fortified mechanical soft diet refused the tray and was given a regular, non-fortified chicken noodle soup instead of a fortified substitute. Another resident who disliked gravy was served lunch with gravy, ate only a small amount, and was not offered a substitute meal. Staff and records confirmed the residents’ diet orders, dislikes, and the expectation that substitutes be provided within the ordered diet.
A resident’s POLST was not signed by the current RP. The SSD/MR, an LVN, and the DON stated the POLST must be complete and signed by the RP to be valid, but the record showed the resident’s spouse signed as the legally recognized decision maker even though the son was the current RP. The resident had Type 2 DM with ketoacidosis without coma, Huntington’s disease, and COPD, and the POLST indicated DNR, selective treatment, hospital transfer only if comfort needs could not be met, and no artificial nutrition.
Unmonitored Portable Heater in IP Office: A personal portable electric heater was observed in the IP's room, turned on and unattended, while the IP was not present. The SSD said the heater belonged to the IP and was being used because the room was hot and the IP was always cold. The MTNS stated he was unaware of the heater, there was no temperature monitoring, and the heater should not be allowed except in an emergency. The IADM stated he had no knowledge of the heater's use and the facility had no policy for personal portable electric heaters.
The facility failed to employ a full-time qualified person for food and nutrition services, as both the RD and DSS were part-time. This resulted in inadequate oversight, with staff not adhering to food safety protocols. Observations showed improper use of hair restraints and personal items in the kitchen, risking cross-contamination. Interviews highlighted the need for a full-time supervisor to ensure proper management and adherence to standards.
The facility failed to meet food service safety standards, with expired food products found in storage and personal items in the kitchen, risking cross-contamination. Staff were observed with improper hair restraints, exposing food to potential contamination. The part-time Dietary Services Supervisor was deemed insufficient for proper oversight.
A resident was transferred to a hospital for diabetic ketoacidosis, and the facility failed to provide a written Bed-hold notice to the responsible party at the time of transfer, as required by federal regulations. The facility's process involved providing a written Bed-hold policy during admission only, with subsequent notifications made by phone. Interviews with staff confirmed that the responsible party did not receive the required written notice, and the facility's policy was not followed.
A resident was not permitted to return to the facility after hospitalization due to unpaid bills and an expired bed-hold, despite being medically cleared. The facility cited concerns about the resident's behaviors and the need for a higher level of care, although staff noted the behaviors were not dangerous. This decision caused hardship for the resident's spouse, who had to reduce visit frequency.
Two residents were not treated with dignity in a facility. A resident with severe cognitive impairment was fed without communication or focus by a CNA, while another resident's urinary catheter bag was left uncovered, violating facility policy. Both incidents reflect a failure to maintain resident dignity.
The facility failed to meet professional standards by not explaining medications to residents during administration and not verifying meal trays against dietary orders. An LVN administered medications without explanation, and CNAs distributed meals without licensed staff verification, risking resident safety.
A long-term care facility failed to maintain effective infection control practices. A resident on contact precautions did not have isolation gowns available, and a CNA did not use alcohol-based hand rubs (ABHR) when distributing breakfast trays or feeding residents. These actions were contrary to the facility's policies, as confirmed by staff interviews and observations.
Failure to Follow Transfer Protocols Results in Resident Fall
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) transferred a resident using a stand-up lift instead of the Hoyer lift as required by the resident's care plan and physician's order. The resident, who had a history of intervertebral disc stenosis, neuropathy, morbid obesity, osteoarthritis of the knee, and significant lower extremity edema, was assessed as high risk for falls and unable to bear weight safely. Despite clear documentation and staff awareness that the resident required a Hoyer lift and two-person assistance for transfers, the CNA proceeded alone with the stand-up lift. During the transfer from a shower chair to bed, the resident slid out of the stand-up lift and fell to the floor. The resident reported discomfort and pain, particularly in her shoulders, which had previously been replaced. She stated that the stand-up lift caused pressure and discomfort, and that she had warned the CNA she was falling. The incident was witnessed by an ultrasound technician present in the room. The resident was later transported to the emergency department for evaluation due to shoulder pain, but imaging showed no acute fracture or dislocation. Interviews with staff, including other CNAs, the Director of Staff Development, and the Director of Nursing, confirmed that the resident's care plan and physician's order specified the use of a Hoyer lift with two staff members for all transfers. The CNA involved acknowledged awareness of these requirements but stated she used the stand-up lift at the resident's request and performed the transfer alone. Facility policy also required two staff for mechanical lift transfers. The failure to follow established protocols and orders resulted in the resident's fall and subsequent discomfort.
Failure to complete RD assessment and medication checks
Penalty
Summary
The facility failed to complete a nutritional assessment by the RD for a resident with a significant change of condition. Resident 9 was observed sleeping in bed, weak, and later refusing most of the meal while accepting liquids. CNA 2 stated the resident had been refusing meals, liked to drink liquids, was always thirsty, was getting weak, could no longer get up in her wheelchair, and had a decline in condition. The RD stated she was not aware the resident had a significant change in condition and had been admitted to hospice, and that the interdisciplinary team did not notify her. The RD also stated the nutritional assessment related to the significant change of condition was not done, even though the resident had significant weight loss and continued meal refusals. Record review showed Resident 9 had a Nutrition Risk Assessment dated 6/5/25, a nurse's note dated 6/26/25 indicating hospice admission, a weight summary showing 90 lbs. on 8/10/25 compared with 123 lbs. on 4/3/25, and an MDS with a significant change of condition assessment ARD of 7/8/25. The MDS coordinator stated the last Nutrition Risk Assessment was done on 6/5/25 and no Nutrition Risk Assessment was completed for the significant change of condition assessment. The DON stated it was her expectation for the RD to complete a nutritional assessment related to the resident's significant change of condition and significant weight loss. The facility also failed to follow medication administration standards for Resident 23. During the morning medication pass, LVN 1 administered PRN acetaminophen for pain without assessing the resident's pain first. LVN 1 later stated she did not assess the pain prior to giving the medication and completed the pain assessment after administration, documenting a pain score of 3 out of 10 to the hip. The resident had stated she needed pain medication, and the DON stated it was her expectation that licensed nurses assess pain before giving pain medication and that orders should include the pain parameter and location of pain. LVN 1 also administered metoprolol without checking the resident's blood pressure and heart rate beforehand. LVN 1 stated she used vital signs taken earlier in the day and later stated she should check blood pressure and heart rate before administering metoprolol to determine whether the medication needed to be held. The DON stated it was her expectation that licensed nurses check necessary vital signs before medication administration, and that blood pressure medication can lower blood pressure and heart rate. Resident 23 was cognitively intact with a BIMS score of 15 and had diagnoses including chronic atrial fibrillation, cardiac arrhythmia, and essential hypertension.
Medication Labeling and Storage Deficiencies
Penalty
Summary
Drugs and biologicals used in the facility were not stored and labeled in accordance with accepted professional standards for five residents. In the medication cart, multiple resident-specific over-the-counter medications and supplements were labeled only with room numbers rather than patient identifiers. During observation, an LVN identified a joint health supplement marked with 106B as Resident 20’s medication, artificial tears marked with 112A as Resident 21’s medication, cetirizine hydrochloride marked with 117B as Resident 8’s medication, glucosamine chondroitin marked with 120B as Resident 28’s medication, two bottles of an eye vitamin and mineral supplement marked with 114A and 120B as Resident 1’s and Resident 28’s medications, and vitamin D3 capsules marked with 120B as Resident 28’s medication. The LVN stated the facility’s process was to place the resident’s room number on patient-specific medications if they were not facility stock, and to change the room number if the resident moved rooms. Interviews with staff confirmed that patient labels were not being used for resident-specific over-the-counter medications. An LVN stated the practice was to write the room number on resident-brought over-the-counter medications and acknowledged that patient labels would be more secure than room numbers because residents sometimes moved rooms. The DON stated the facility had been putting room numbers on resident-specific over-the-counter medications and stated that medications ordered by the physician and patient specific should have patient identifiers, including name and date of birth. The DON also stated that if medications did not have a patient label, they could be given to another patient and a medication error could happen. The medication room was also observed open and unattended. During observation, the medication room across from the nursing station was widely open while the RNS was at the nursing station working on the computer. When interviewed, the RNS stated she did not notice the medication room was open and said it should be locked at all times. An LVN stated the medication room should be kept locked to prevent residents, families, and visitors from accessing medications, and the DON stated the medication room should be closed and locked at all times because anyone could access medications and medical supplies if it was left open. Facility policies stated medications and biologicals must be stored in locked compartments and that the medication room must remain locked at all times when not in use.
Improper Thawing and Unsanitary Dishwasher Surface
Penalty
Summary
Food was not stored and prepared in accordance with professional standards for food services safety when a portion of chicken meat was observed thawing under running water without being fully submerged. During the observation, the meat was not completely under the water or in the path of the running water, and the dietary staff member present stated it should have been fully submerged. The Dietary Services Supervisor and Registered Dietitian later stated that meat thawed under running water should be fully submerged, with a larger container used if needed, so it thaws at a safe temperature and does not become exposed to contaminants. The facility policy on thawing meats and the USFDA Food Code both required food thawed under running water to be completely submerged. Food service sanitation was also not maintained when the dishwasher was observed with a buildup of white residue on the surface and black and brown dirt and debris on the top surface. A dietary aide stated the dishwasher should have been cleaned and that debris on the machine could fall onto clean dishes and contaminate food. The Dietary Services Supervisor and Registered Dietitian stated the dishwasher should be kept clean and maintained because debris on the equipment could cross contaminate clean dishes. The facility sanitation policy required equipment to be kept clean and maintained in good repair, and the USFDA Food Code stated that dirt or food debris on nonfood-contact surfaces may provide a suitable environment for microorganisms that employees may transfer to food.
QAPI recommendations for RD participation in IDT meetings were not followed
Penalty
Summary
The facility failed to implement its QAPI process for 29 of 29 sampled residents when the Registered Dietitian’s QAPI recommendation to participate in Interdisciplinary Team (IDT) meetings was not followed. The RD stated that she had emailed her QAPI report and recommendations to the facility and had recommended being involved in IDT meetings, but no action had been taken. She stated she wanted to be invited to the meetings so she could be better informed about resident weight loss and any new conditions residents may have. During interview and record review, the Administrator and DON acknowledged that the RD’s reports repeatedly stated that IDT monthly weight meetings were not happening, that the RD was not included in IDT weight meetings, and that skin reports were not provided to the RD unless she requested them. The RD’s reports dated 1/16/25, 1/23/25, 4/1/25, 5/23/25, and 6/20/25 all reflected that monthly IDT weight meetings were not occurring and that the RD was not included. The ADM stated the RD sent her report and recommendations by email for the QAPI committee because she could not attend physically, and it was the responsibility of the DON and ADM to present the report and follow the recommendations during QAPI. The DON stated they did not document any attempt to get the RD involved in IDT meetings, and the ADM stated they did not follow the RD’s recommendation to involve her in IDT meetings.
Infection Control Lapses in Medication Room and Oxygen Storage
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program in the medication room when an LVN stored personal belongings on the medication counter. During observation, an open bag, two drink containers, and a wallet were sitting on the counter, and the LVN stated the items were hers and that she normally kept her drinks in the medication room because it was the only space available. The RNS also identified the bag and water container as belonging to a nurse. The DON stated staff personal belongings were not allowed on the medication room counter because it was an infection control issue and could contaminate medication. The facility policy stated the medication room was to be maintained as a secure, clean, restricted-access area for medications and approved medical supplies, and that staff charge nurses may place personal belongings under the sink. The facility also failed to maintain infection control for Resident 15’s oxygen nasal cannula. During observation, Resident 15 had an oxygen NC stored in an open package sitting on top of the oxygen concentrator. Staff interviews indicated that oxygen tubing should be dated when opened, kept sealed, and stored in a sealed bag because it could become contaminated. The DON stated that once the original package was opened, it should be placed in another sealable bag, dated, and initialed, and that NC tubing should be stored enclosed and protected so it does not get contaminated. Resident 15’s record showed diagnoses including hypertensive heart disease with heart failure, chronic kidney disease, and interstitial pulmonary disease, and an order for oxygen via NC or face mask at 2 L/min as needed for dyspnea. The facility further failed to protect Resident 3’s oxygen nasal cannula from contamination. During observation, Resident 3’s NC was found in the top drawer of the nightstand, out of the sterile package and touching the inside of the drawer. Staff stated that once opened, the NC should be dated and stored in a resealable plastic bag to keep it clean, and that if it was out of its package it was contaminated. The DON stated that once a nasal cannula is out of its original package it should be stored enclosed and protected in another bag, and that a cannula in a drawer without a package is contaminated and should be thrown out. Resident 3’s record showed diagnoses including cerebral infarction, hypertensive chronic kidney disease, and acute respiratory failure with hypoxia, with an order for oxygen via NC at 2 L/min as needed.
Failure to Use Communication Supports and Provide Dignified Meal Assistance
Penalty
Summary
The facility failed to promote residents’ rights and treat residents with respect and dignity for two sampled residents. For a resident who primarily spoke Russian and had diagnoses including vascular dementia and hypertensive heart and chronic kidney disease without heart failure, staff did not consistently use the communication supports identified in the care plan. During observations and interviews, staff stated they usually communicated with the resident using a translation app on a phone, and a communication card was not found in the resident’s room. The care plan identified the resident’s preferred language as Russian and directed staff to use a communication card so she could point to what she needed, but staff and management stated the card was not being used. The DON stated the facility had no translator service, no staff who spoke Russian, and that it was possible for the resident not to get her needs met when a translator was not used. For another resident with dementia, aphasia, osteoarthritis, major depressive disorder, anxiety disorder, and muscle weakness, the resident was observed in the dining room waiting to be fed while another resident at the same table was eating. The resident was sitting in a wheelchair with a lunch tray in front of her, was unable to verbally respond during conversation, and was observed touching food with her fingers and becoming restless while waiting. CNA 1 stated the resident required one-on-one assistance with meals and should not have been waiting while another resident was eating. CNA 1 also stated residents needing meal assistance should be fed at the same time by different CNAs, and that the resident should not be watching another resident eat. The DON and other staff acknowledged that residents requiring one-on-one meal assistance should be helped at the same time and that the resident should not have been waiting and watching others eat. The facility’s resident rights policy stated employees shall treat all residents with kindness, respect, and dignity. The dining observation showed the resident remained waiting for assistance while another resident at the table was being fed, and staff later began feeding her after a delay.
Failure to Use Language Assistance and Implement Fall Mats
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident who primarily spoke Russian. The resident’s care plan identified an interpretation need, stated that the resident spoke Russian and understood simple English, and included interventions to use a communication card so the resident could point to what she needed. During observations and interviews, staff reported that they usually communicated with the resident using a translation app on a phone, and one CNA was unable to find a communication card in the resident’s room. The LVN/MDSC stated the facility had a communication card but staff did not use it, and the DON stated the facility had no translator service and no staff who spoke Russian. The DON also stated the communication card should have been implemented so staff could better understand the resident. The resident’s admission record listed diagnoses including vascular dementia and hypertensive heart and chronic kidney disease without heart failure. The facility’s Language Barrier Policy and Procedure stated that communication with residents who have a language barrier must include identifying communication needs, providing access to qualified interpreters, and documenting communication preferences and efforts to provide language assistance in the medical record. The policy also referenced interpreter options and communication boards. Despite this, staff described relying on the translation app and not using the communication card that was included in the resident’s care plan. The facility also failed to implement a fall-related intervention for another resident. That resident’s care plan identified moderate fall risk related to confusion, deconditioning, gait and balance problems, and included an intervention for floor mats to be placed on the floor on both sides of the bed. Multiple observations showed the resident in bed with the two floor mats placed against the wall by the room door rather than on the floor beside the bed. An LVN later removed the mats from the wall and placed them on both sides of the bed, stating they should be in place on the floor. The resident’s order summary also directed that floor mats be placed on the floor on the sides of the bed every shift, and staff interviews confirmed the resident had a history of multiple falls with minor injuries and unpredictable attempts to get out of bed.
Missing nurse signatures on controlled drug receipt records
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured appropriate receipt, reconciliation, and identification of controlled drugs for two sampled residents when licensed nurses did not verify and complete the controlled drug record upon receipt from the pharmacy. The Director of Nursing stated that when controlled drugs were delivered, the licensed nurse was expected to check the manifest against the medication and sign the controlled drug record if everything was correct. The consultant pharmacist also stated that the nurse was supposed to sign the controlled drug record when controlled drugs were received, and that this was important to prevent drug diversion. For one resident with diagnoses including a right fibula fracture, diabetes mellitus due to an underlying condition with diabetic neuropathy, and dorsopathy, the controlled drug record for hydrocodone-acetaminophen 5 mg/325 mg tablets showed a quantity of 30 received on 8/16/25, but the nurse signature line was blank. For another resident with diagnoses including atherosclerotic heart disease, unspecified dementia, and encounter for palliative care, the controlled drug record for lorazepam 0.5 mg tablets also had no nurse signature, no date, and no number of doses received. The facility policy stated that controlled substances are counted upon delivery, the receiving nurse and delivery person must count them together, and both individuals must sign the designated controlled substance record.
Failure to Provide Written Transfer Notification
Penalty
Summary
The facility failed to notify the resident's representative in writing of a transfer to the General Acute Care Hospital for one of three sampled residents. Resident 33 was transferred to the hospital on 7/4/2025 after a sudden change in baseline, including not properly holding food in his mouth, appearing pale, and weak. The progress notes state the physician was notified by phone and ordered the resident sent to the emergency room by ambulance for further evaluation, and the resident's RP was spoken to and agreed to the transfer. During interviews, the LVN/DSD stated the RP was given verbal notice of the transfer but was not provided written notice, and stated she was not aware written notice was required whenever a resident is transferred to GACH. The DON stated the facility practice was for the nurse to call the family and explain the reason for transfer, and that the practice did not include notifying the resident or representative in writing. The resident's record showed diagnoses of heart failure, atrial flutter, and cardiomegaly, and the facility policy stated that emergent transfers to an acute care setting require resident/representative notification and orientation, with notice given as soon as practicable but before the transfer.
Failure to Update Care Plans After Significant Change of Condition
Penalty
Summary
The facility failed to revise Resident 9’s comprehensive person-centered care plan after a significant change of condition assessment was completed. Resident 9’s nutritional care plan was not updated to reflect the resident’s significant change of condition assessment, and the activities care plan was also not revised to reflect that assessment. The report states that these failures occurred after the resident had been admitted to hospice and after the significant change of condition assessment was completed. Resident 9’s record showed diagnoses including dementia, type 2 diabetes mellitus, hypertension, anemia, wedge compression fracture, TIA, metabolic encephalopathy, hypertensive heart disease, and chronic kidney disease. Observations on multiple occasions showed the resident in bed, asleep or weak, with limited interaction. During one observation, CNA 2 fed the resident at bedside, and the resident accepted liquids but refused the main meal, turned her head away, and kept her mouth closed when offered food. CNA 2 stated the resident had been refusing meals, liked liquids, was always thirsty, was getting weak, and was no longer able to get up in her wheelchair. CNA 2 also stated the resident had a decline in condition. The RD stated she was not aware the resident had a significant change in condition and had been admitted to hospice, and said the IDT did not notify her. The RD stated the resident’s nutritional assessment related to the significant change of condition was not done, despite the resident’s significant weight loss, poor oral intake, and meal refusals. The MDSC stated the nutritional care plan was not reviewed and updated when the resident was admitted to hospice and when the significant change assessment was completed. The AD stated the activities care plan was not revised and updated to reflect the resident’s current assessment, noting that the resident had been staying in bed and no longer wandering, while activity staff were providing one-on-one room visits and hand massages. The DON stated it was her expectation that the IDT review and revise care plans when residents had a significant change of condition assessment.
Failure to Provide Nail Care
Penalty
Summary
The facility failed to ensure nail care was provided for one of three sampled residents, Resident 9, whose fingernails were observed to be long and dirty with brownish dirt built up underneath the nails. During a concurrent observation and interview on 9/2/25, Resident 9 was awake, alert, and oriented to her name only, and her left hand fingernails were noted to be long and dirty, with brownish dirt built up underneath the nails, mostly on the left thumb. Her right hand was tucked underneath the blanket, and she declined to be interviewed. During a later observation on 9/4/25, CNA 2 checked Resident 9's fingernails on both hands and stated they were long and dirty with brownish dirt built up underneath the nails. CNA 3 attempted to remove the dirt from the thumb nail using a handmade cone-shaped paper without resistance from Resident 9. CNA 2 stated CNAs and activity staff were responsible for weekly nail care and that Resident 9 was dependent on staff for ADLs. LVN 1 stated activity staff and CNAs were responsible for weekly nail care and that licensed nurses also checked residents' nails to ensure they were trimmed and cleaned. The DON stated Resident 9's fingernails should be trimmed and cleaned, that activity staff and CNAs were assigned to provide nail care to all residents, and that long, dirty fingernails can harbor microorganisms and cause infection, while long fingernails can cause self-inflicting skin scratches. Resident 9's record showed diagnoses including dementia, type 2 DM, HTN, anemia, wedge compression fracture, TIA, hypertensive heart disease, and CKD. The facility policy stated nail care includes daily cleaning and regular trimming to clean the nail bed, keep nails trimmed, and prevent infections.
Failure to Maintain Hearing Device Use
Penalty
Summary
The facility failed to ensure a hearing device was in place to maintain a resident’s hearing abilities for one of three sampled residents. The resident had a left ear implant hearing device, but staff did not have the device identified in the care plan and were not aware of the implant. During observation, the resident had difficulty hearing during conversation with staff and other residents, and staff had to speak close to the resident’s ear to communicate. The resident stated both ears were impaired, that the right ear was weaker than the left, and that he needed a battery for the implant to hear adequately and clearly. Record review showed nurses’ notes documented a left ear implant, but the care plan report did not include it until it was revised later. The DON stated the left ear implant should have been identified on admission and addressed by the IDT, and that licensed nurses were responsible for initiating, reviewing, and communicating the care plan to CNAs. The SSD/MR was not aware of the resident’s hearing difficulty or the presence of the left ear implant. The facility policy stated staff will assist hearing-impaired residents to maintain effective communication and assist with care and maintenance of hearing devices.
Failure to Honor Food Preferences and Fortified Diet Orders
Penalty
Summary
The facility failed to ensure that residents received food that accommodated their preferences and, for one resident on a fortified diet, failed to provide a fortified substitute meal of similar nutritive value when the resident refused the meal served. During lunch service, one resident on a fortified mechanical soft diet was served a regular chicken noodle soup after refusing the original tray and requesting bread or a grilled cheese sandwich. Staff stated the soup was not fortified, and the Dietary Services Supervisor and Registered Dietitian both stated that fortified diets include extra calories and that substitutes for residents on fortified diets should also be fortified. The resident’s record identified him as at risk for weight loss, malnutrition, and dehydration, and his care plan directed staff to honor food preferences within the diet order and provide the ordered fortified diet. A second resident was served lunch that included gravy even though the resident’s cardex listed gravy as a dislike for breakfast, lunch, and dinner. The resident stated he did not like gravy, ate only a small amount of the meal, and later told staff he did not like the food. A CNA acknowledged that the resident ate about 10 percent of the meal and did not offer a substitute meal that day, despite stating that substitutes were sometimes offered when the resident did not eat much. The Dietary Services Supervisor confirmed the resident should not have received gravy because it was a stated preference and said an alternative meal should have been offered. The records reviewed showed both residents had diet orders and documented food preferences. One resident had a fortified mechanical soft diet order, and the facility’s fortified diet policy and in-service stated that fortified diets are intended to increase calorie density and that alternatives for residents on fortified diets must be fortified. The other resident had a mechanical soft, no-added-salt diet with documented dislikes for gravy, and the facility’s food preferences policy stated that substitutes for disliked foods would be given from the appropriate food group. Interviews with dietary and nursing staff showed that the meal served to each resident did not match the documented diet or preference information.
POLST Not Signed by Current Responsible Party
Penalty
Summary
The facility failed to ensure that medical records were complete and accurately documented for one of three sampled residents when the resident’s POLST form was not signed by the current responsible party. Social Services Director/Medical Records stated the facility’s process was to review and update the POLST annually and as needed, and stated the resident’s spouse had previously been the responsible party before 5/2025. The SSD/MR stated the spouse’s health status changed and he was no longer able to make healthcare decisions, and that the resident’s son was now the responsible party. The SSD/MR stated the POLST needed to be updated with the son’s signature as the responsible party. Licensed Vocational Nurse 2 stated the licensed nurse was responsible for ensuring a POLST form was complete and that a POLST was not valid if it was not signed by the responsible party. The Director of Nursing stated the POLST needed to be completed entirely and signed by the responsible party, and that if the form was not filled out completely it was not valid. Review of the resident’s record showed diagnoses of Type 2 DM with ketoacidosis without coma, Huntington’s disease, and COPD. The POLST in the record indicated DNR, selective treatment, transfer to hospital only if comfort needs could not be met in the current location, and no artificial means of nutrition, but the signature section identified the resident’s spouse as the legally recognized decision maker and was signed by the spouse rather than the current responsible party, the son.
Unmonitored Portable Heater in IP Office
Penalty
Summary
The facility failed to identify and monitor safety and accident hazards when a personal portable electric heater was being used in the Infection Preventionist's room. During a concurrent observation and interview on 9/5/25 at 8:40 a.m., a personal portable heater was found on the floor behind the Infection Preventionist's chair in the Social Services Director/Infection Preventionist's room, and the Infection Preventionist was not present. The Social Services Director stated the heater belonged to the Infection Preventionist and that it was hot in the room, and that the Infection Preventionist had been using the heater because she was always cold. During later observation and interviews, the heater was seen turned on and producing heat, including at 9:17 a.m. when the Maintenance Supervisor stated he was not aware of the heater in the room, there was no temperature monitoring of it, and it should not be allowed in the room except for an emergency. At 10:00 a.m., the heater was observed running and unattended. The Interim Administrator stated he had no knowledge of the heater's use in the room and later stated the facility had no policy about the use of personal portable electric heaters. The Infection Preventionist stated she needed the heater because she was always cold and said the Maintenance Supervisor was aware of it and had instructed her to use it.
Lack of Full-Time Oversight in Food and Nutrition Services
Penalty
Summary
The facility failed to ensure there was a full-time qualified person responsible for food and nutrition services (FNS), as both the Registered Dietitian (RD) and Dietary Services Supervisor (DSS) were employed part-time. This lack of full-time oversight had the potential to compromise the dietary and nutritional needs of the residents. Observations and interviews revealed that the DSS was only present at the facility during limited hours, often in the early mornings or late evenings, and was not able to provide adequate supervision of the FNS staff. During observations, it was noted that several staff members, including dietary aides and cooks, were not adhering to proper food safety protocols, such as wearing hair restraints correctly. Personal items were also found in the kitchen, which could lead to cross-contamination. Interviews with staff, including the Assistant and the Infection Preventionist, highlighted the need for a full-time supervisor to ensure proper oversight and adherence to food safety standards. The RD, who worked as a consultant for six hours weekly, was unaware that the DSS was not full-time and emphasized the importance of having a full-time DSS for proper management of FNS. The DSS herself acknowledged the need for full-time presence to fulfill her duties effectively, which included scheduling, inventory management, and staff training. The facility's job descriptions and state regulations require a full-time dietetic services supervisor if the RD is not employed full-time, which was not being met in this case.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by several observations and interviews. Expired food products were found in the spice storage area, including a bottle of vanilla extract and chili powder that had been opened since 2022. The Assistant Cook acknowledged that these items should have been discarded according to facility policies, as expired food could lead to contamination and illness. The Licensed Vocational Nurse, who serves as the Infection Preventionist, admitted to not noticing these expired items during her weekly audits, highlighting a lapse in monitoring and oversight. Additionally, personal belongings and used items were found on a cart in the kitchen area, posing a risk of cross-contamination. The cart contained various personal items such as empty egg cartons, food in plastic bags, personal bags, and unmarked jars. Both the Assistant Cook and Dietary Aide recognized that these items should not have been in the kitchen, as they could potentially contaminate food. The Dietary Services Supervisor (DSS) confirmed that the presence of personal items in the kitchen had been an ongoing issue, and staff were expected to keep their belongings in the breakroom. Furthermore, four staff members were observed not wearing their hair restraints properly, with hair exposed around their ears, temples, and forehead. This improper use of hair restraints was acknowledged by the staff, including the Cook, who admitted that exposed hair could shed and contaminate food. The Registered Dietitian and DSS both emphasized the importance of proper hair coverage to prevent physical contamination. The report also noted that the DSS worked part-time, which was deemed insufficient for proper oversight of the Food and Nutrition Services, as it limited the ability to ensure staff competencies, retraining, and inventory management.
Failure to Provide Written Bed-hold Notice at Time of Transfer
Penalty
Summary
The facility failed to provide a written Bed-hold notice to a resident's responsible party at the time of transfer to an acute care hospital, as required by federal regulations. The resident, who was transferred to the hospital for diabetic ketoacidosis, was not given a written notice specifying the duration of the Bed-hold policy. This oversight was identified during interviews and record reviews, where it was revealed that the responsible party had signed the Bed-hold policy upon admission but did not receive a written notice at the time of transfer. The facility's process involved providing a written Bed-hold policy during admission only, and subsequent notifications were made by phone. The Business Office Manager stated that it was the family's responsibility to contact the facility for a Bed-hold when a resident was transferred. However, there was no documentation of a written notice being provided at the time of transfer, and the facility's policy and procedure did not align with federal regulations requiring written notice upon transfer. Interviews with facility staff, including the Administrator and Director of Nursing, confirmed that the responsible party was not provided a written Bed-hold notice when the resident was transferred to the hospital. The facility's policy and procedure documents were reviewed, and it was acknowledged that the policy was not followed, as the written notice was not provided as required by federal regulations.
Facility Fails to Allow Resident Return Post-Hospitalization
Penalty
Summary
The facility failed to permit a resident to return after hospitalization, violating the bed-hold policy. Resident 1, who was medically cleared to return from an acute care hospital, was not allowed back into the skilled nursing facility. This decision was made despite the resident's proximity to the facility and the hardship it caused for the resident's spouse, who had to reduce visit frequency due to the resident being transferred to a facility in another city. The facility's administration cited unpaid bills and expired bed-hold as reasons for not allowing the resident's return. The Administrator and Director of Nursing mentioned that Resident 1 was private pay and had not settled the bill, and the seven-day bed-hold had expired. Additionally, they expressed concerns about the resident's behaviors, which they considered dangerous, although the Licensed Vocational Nurse noted that the behaviors were mostly yelling and did not endanger other residents. The Social Services and Business Office Manager provided conflicting information regarding the bed-hold policy and the resident's discharge. The Social Services staff mentioned that the resident's spouse did not agree to pay for a bed-hold, and the Business Office Manager stated that the family was responsible for contacting the facility for a bed-hold. Despite the facility's policy requiring them to take residents back after hospitalization, the resident was discharged due to the bed-hold not being paid and the facility's assessment that the resident required a higher level of care.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to ensure that two residents were treated with dignity and respect. Resident 19, who was nonverbal and had severe cognitive impairment, was assisted with lunch by a CNA who did not engage in conversation with her or inform her when providing food or beverages. The CNA also wiped Resident 19's face without warning, while engaging in conversation with others in the dining room. This lack of communication and focus on the resident resulted in a dining experience that did not respect Resident 19's dignity. Additionally, Resident 128's urinary catheter bag was left uncovered while attached to her wheelchair. During an observation, it was noted that the bag contained urine and was not placed in a dignity bag as required by the facility's policy. Resident 128 was unaware that the bag should be covered to maintain her dignity. The facility's policy clearly states that urinary catheter bags should be covered to ensure privacy and dignity for the residents. Both incidents highlight a failure to adhere to the facility's policy on maintaining resident dignity. The CNA and LVN involved acknowledged that the actions did not meet the facility's expectations for respectful and dignified care. The Director of Nursing confirmed that the facility's policy was not followed in both cases, emphasizing the importance of treating all residents with respect and dignity at all times.
Failure in Medication Explanation and Meal Verification
Penalty
Summary
The facility failed to meet professional standards of practice in two key areas, affecting 17 out of 25 sampled residents. Firstly, during medication administration, an LVN did not explain the medication names and their indications to several residents, including those with conditions such as hypertension, anemia, major depressive disorder, and neuropathy. This oversight was observed during medication pass observations, where medications like Gabapentin and Ferrous Sulfate were administered without explanation. The LVN acknowledged the failure to inform residents about their medications, which is a violation of the facility's policy and procedure guidelines that emphasize the importance of explaining procedures to residents. Secondly, the facility did not ensure that a licensed nurse confirmed that lunch meal trays matched the residents' dietary orders. Observations in the dining room revealed that CNAs distributed meal trays without verification from licensed staff, which is contrary to the facility's policy requiring licensed nurses to check meal trays for accuracy. This lapse was confirmed by interviews with CNAs and the DON, who stated that licensed staff are responsible for verifying meal orders before distribution. The failure to verify meal trays could potentially lead to residents receiving incorrect meals, posing risks such as choking, allergic reactions, and weight loss. The report highlights specific instances where the facility's practices did not align with established policies and procedures, particularly in medication administration and meal distribution. The deficiencies were identified through direct observations and interviews with staff, including the LVN and DON, who acknowledged the lapses in following the facility's expectations. The report underscores the importance of adhering to professional standards to ensure resident safety and well-being.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by several deficiencies observed during the survey. Resident 177, who was on contact precautions due to shingles, did not have isolation gowns stocked outside their room for staff use. This was confirmed by multiple staff members, including the Laundry Staff, CNA 2, the Infection Preventionist, and the Director of Nursing, all of whom acknowledged the importance of having gowns available to prevent the spread of infections. The facility's policy and procedure on using gowns clearly indicated the necessity of wearing protective equipment when treating residents on contact isolation. Additionally, CNA 1 did not use an alcohol-based hand rub (ABHR) when distributing breakfast trays to several residents, including Residents 128, 8, 1, 9, and 177. Despite entering the rooms, CNA 1 believed that ABHR was only necessary when physically touching residents. This practice was contrary to the facility's hand hygiene policy, which required the use of ABHR before and after entering a resident's room, handling food, and providing care. Interviews with CNA 3, the Infection Preventionist, and the Director of Nursing confirmed that the expected protocol was not followed, highlighting a lapse in infection control practices. Furthermore, CNA 1 also failed to use ABHR before and after feeding two residents, Residents 16 and 19. This oversight was noted during observations and confirmed by the Infection Preventionist and the Director of Nursing, who reiterated the importance of hand hygiene in preventing the transmission of pathogens. The facility's hand hygiene policy emphasized the need for ABHR use before and after direct contact with residents and when handling food, underscoring the significance of these practices in maintaining infection control standards.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 68 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Los Banos
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Los Banos Post Acute | 2 mi | ★★★★★ | 33 | 0 |
| San Luis Care Center | 21.7 mi | ★★★★★ | 22 | 0 |
| Grace Home Inc. | 23.3 mi | ★★★★★ | 0 | 0 |
| Anberry Post Acute | 23.5 mi | ★★★★★ | 0 | 0 |
| Anberry Nursing And Rehabilitation Center | 24.3 mi | ★★★★★ | 13 | 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 June 2026) and official state health department websites.