Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
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 Newport Subacute Healthcare Center during CMS and state inspections, most recent first.
A resident with severe intellectual disability and a known history of pica repeatedly ingested non-food items, including plastic and glove material, despite orders for shift monitoring and a care plan for choking risk. Staff interviews showed the resident could remove mittens, reach and grab items, and likely needed 1:1 supervision, but no sitter was provided and the physician was not notified when the resident first vomited plastic. The resident had multiple hospital transfers, sepsis, ICU admission, and surgery to remove foreign material from the GI tract.
Failure to Report Injury of Unknown Source: The facility did not report an injury of unknown source for a resident who was dependent in self-care and mobility, had no capacity to make medical decisions, and was later admitted to the ICU with a subdural hematoma after transfer to an acute care hospital for elevated HR and increased work of breathing. The DON verified the event met the definition of an injury of unknown origin and should have been reported, but it was not.
Failure to Investigate Injury of Unknown Source: A resident who had no decision-making capacity and was dependent for care was sent to the hospital after respiratory decline, and the facility was later informed that the resident had been admitted to the ICU with a subdural hematoma. The DON confirmed the event met the definition of an injury of unknown source, but the facility did not investigate the incident as required by policy.
Failure to timely update and implement a fall care plan: A resident with no capacity for medical decisions had an unwitnessed fall, but the care plan was not initiated until weeks later and ordered neuro checks were not documented as completed. The resident later had another fall, and the care plan was not updated with new focus, goals, and interventions for that event.
A resident who was cognitively intact but assessed as not capable of and not wishing to self-administer medications was found with a cup of liquid cough medicine and two unlabeled red capsules on the bedside table. The resident reported that a nurse had provided the medications and left them at the bedside so the cough medicine could be taken gradually. Record review showed an order for docusate sodium but no MD order for cough medication and no order permitting self-administration. An LVN and an RN confirmed there was no documentation of coughing as a change in condition, no physician notification, no order for cough medicine, and no authorization for self-administration, verifying that cough medication had been administered and left at the bedside contrary to facility P&P and without a prescriber’s order.
A resident’s medical record contained inaccurate physician progress notes and extensive missing CNA task documentation. The physician repeatedly documented that the resident had a tracheostomy, GT, Foley catheter, oxygen via T-bar, and enhanced barrier precautions for Candida auris, despite there being no corresponding orders and no such devices or precautions observed on the resident. CNA task documentation for this resident lacked multiple entries for ADLs and clinical observations, including bathing, continence, bowel movements, bed mobility, dressing, locomotion, personal hygiene, skin observations, toileting, transfers, walking, meal intake, and nourishments, as well as required CNA initials.
The facility did not ensure complete and accurate medical records for two residents who lacked decision-making capacity. For one resident, multiple ordered medications and treatments, including laxatives, a protein supplement, famotidine, Sinemet, chlorhexidine mouthwash, ammonium lactate lotion, and G-tube site care, were not signed as administered on the MAR and TAR on numerous occasions, despite policy requiring staff to document each administration. For another resident, several health status notes and an IDT note in the progress notes remained in draft status and were never signed, leaving the documentation incomplete and open to alteration. The DON confirmed these documentation gaps during record review.
A resident with severe cognitive impairment and a tracheostomy was observed wearing bilateral hand mittens, which the facility used to prevent removal of medical devices without completing required restraint procedures. The physician’s order for the mittens lacked documentation of specific medical symptoms, frequency, duration, and monitoring, and there was no evidence of a pre-restraint assessment or attempts at less restrictive interventions. The resident’s representative was not informed of the risks and benefits or asked for consent, and no care plan addressed the mittens or restraint reduction. Required documentation specifying how, when, and by whom the mittens could be applied, as well as monitoring of circulation, mobility, and skin, was also missing, contrary to facility P&P.
A resident with a GT did not consistently receive TwoCal HN enteral feeding as ordered, and staff failed to document administration in the MAR on several occasions. Facility policy required thorough documentation of enteral feedings, but interviews with nursing staff revealed that feedings were sometimes given without proper documentation, and the DON confirmed that the MAR should not be left blank.
A resident's medical record was found to be incomplete and inaccurate when multiple prescribed medications were not documented as administered on the MAR. Despite staff and family reports that the medications were given, the responsible nurse did not sign the MAR or enter a progress note, contrary to facility policy. The DON confirmed that proper documentation was not completed.
A resident receiving IV antibiotics for a UTI was not monitored for changes in condition or adverse effects during and after treatment, and the care plan was not updated to reflect the new interventions. Nursing staff confirmed the lack of documentation and care plan updates, in violation of facility policy.
The facility did not procure food from approved or satisfactory sources and failed to store, prepare, distribute, and serve food according to professional standards.
Multiple deficiencies were identified in the infection prevention and control program, including the lack of completed infection surveillance reports, failure to implement Enhanced Barrier Precautions for residents with indwelling devices, improper use of PPE by staff, and unsanitary practices such as refilling water pitchers from bathroom sinks and leaving personal items on the floor. Staff were observed not following established infection control procedures during resident care and medication administration.
Several residents were administered psychotropic medications and had bedrails applied without proper or current informed consent, as required by law and facility policy. In some cases, consents were not renewed every six months, and in others, the consent on file did not match the device in use. Nursing staff and the DON confirmed that these consents were missing or outdated at the time of use.
A resident who developed MASD to the coccyx was not promptly reported to the physician or resident representative as required by facility policy. Nursing staff and the DON confirmed that neither the physician nor the family were notified of the change in condition, and wound care orders were entered by treatment nurses without physician involvement.
Three residents were not properly monitored for psychotropic medication use, with staff failing to document required behavioral observations, side effect monitoring, and nonpharmacological interventions. Monthly psychotherapeutic drug summaries were also not completed as required, and staff did not record the number of hours slept for a resident on trazodone. These deficiencies were confirmed by nursing staff and the DON.
Three residents experienced deficiencies in pressure ulcer prevention and care, including inaccurate documentation of skin conditions, improper LAL mattress settings not aligned with physician orders or resident weight, and failure to reposition a resident as required by the care plan. Staff interviews and observations confirmed these lapses, with nursing and CNA staff acknowledging the issues.
A resident with a history of urinary retention and UTI had an indwelling Foley catheter in place without documented assessment for its continued necessity. Medical records lacked evidence of reassessment or attempts at catheter removal, and staff interviews confirmed the absence of appropriate evaluation for ongoing catheter use.
The facility failed to document and monitor PICC line external catheter length and arm circumference measurements for two residents, as required by physician orders and facility policy. This included not establishing baseline measurements upon admission and not recording measurements with dressing changes, as confirmed by nursing staff and the DON.
Multiple residents did not receive respiratory care in accordance with physician orders and facility policy, including failures to administer oxygen as ordered, maintain and label respiratory equipment, and obtain necessary physician orders for oxygen therapy. Staff confirmed that equipment such as nasal cannulas, oxygen tubing, and suction filters were not changed, labeled, or dated as required, and documentation of care was inconsistent.
Several residents receiving dialysis did not have complete or accessible emergency dialysis kits at their bedside, with some kits missing essential items like clamp scissors. In addition, staff failed to follow physician orders for obtaining pre- and post-dialysis weights on the correct days, and inappropriately documented assessments for a central venous catheter. These actions and omissions resulted in the facility not adhering to required dialysis care protocols.
The facility did not ensure proper assessment, documentation, and care planning for the use of bed rails for four residents. In several cases, there was no evidence that less restrictive alternatives were attempted before using side rails, and required physician's orders, informed consent, and care plan interventions were missing. Staff interviews confirmed these omissions, and observations showed residents using side rails without the necessary documentation or prior evaluation.
Two residents receiving apixaban were not monitored for signs and symptoms of bleeding, as required by facility policy and FDA guidelines. Nursing staff and the DON confirmed that monitoring should have occurred and been documented, but medical records showed no evidence of such monitoring for either resident.
Two nurses made multiple medication administration errors, including incorrect preparation and dosing of potassium chloride, multivitamin with minerals, lactulose, and vitamin D for two residents. These actions resulted in a medication error rate of 12.5%, exceeding the acceptable threshold.
Surveyors found multiple failures in medication and supply management, including expired medical supplies left in a medication room, prescription topical and inhalational medications stored without proper labeling or physician orders, staff personal items and over-the-counter medications stored with facility supplies, and residents with medications at the bedside without required orders or assessments. Facility staff and administration confirmed these deficiencies.
The facility did not ensure that two outdoor garbage dumpsters were properly maintained, as both lids were left partially open due to trash bags and a bag of trash was found on the ground. The Maintenance Supervisor confirmed that the lids should remain fully closed for infection control, in accordance with facility policy and the USDA Food Code.
A resident was not provided with hospice services, nor was assistance given to transfer the resident to a facility that could arrange for hospice care.
The facility did not have a program in place to monitor antibiotic use, as required. There was no evidence of tracking or evaluating antibiotic administration among residents.
A resident who verbally consented to receive the pneumococcal vaccine did not have documented evidence of vaccine administration or refusal in the medical record. Both the IP and DON confirmed the vaccine was not given, which was not in accordance with facility policy requiring assessment, administration, and documentation of immunizations.
A resident who had the capacity to make healthcare decisions and verbally consented to receive the COVID-19 vaccine was not administered the vaccine. Facility staff failed to follow policy requiring vaccination and documentation, and interviews with the IP and DON confirmed the vaccine was not given.
The facility did not complete or document required zone entrapment assessments and measurements when installing bilateral half side rails for three residents, including one who used side rails without a physician's order or care plan intervention. Facility policy required compatibility checks and documentation, but records and staff interviews confirmed these steps were not followed.
A resident's legal representative, holding power of attorney, requested the resident's medical records, facility care policies, and staffing data. Despite valid authorization and multiple follow-up attempts, the facility did not provide the requested documents until 13 days after the initial request, exceeding the required two working day timeframe.
The facility did not consistently provide or document written information and assistance regarding advance directives for several residents, including those with cognitive impairment and those unable to make decisions, resulting in missing or incomplete records and lack of evidence that residents or their representatives were informed of their rights.
Multiple residents did not have care plans addressing their specific medical needs, such as enteral feeding, insulin administration, and the use of psychotherapeutic and anticoagulant medications. In some cases, care plan interventions, like scheduled blood pressure checks for a resident with hypotension, were not implemented as required. These deficiencies were confirmed through staff interviews, observation, and medical record review.
Two residents were not assisted with feeding in a manner that maintained their dignity, as CNAs stood rather than sat at eye level during mealtime assistance, contrary to facility policy and expectations. Both CNAs acknowledged the oversight, and facility leadership confirmed that staff are expected to sit at eye level to promote resident dignity.
A resident was not provided with the required NOMNC and SNF ABN forms upon discharge from Medicare Part A services, as both forms lacked signatures and there was no documentation that the notices were delivered. The Business Office Manager attempted phone notification, but the resident's representative did not receive the written notices or information about appeal rights. The DON acknowledged these findings.
A hole left unrepaired in a shared bathroom wall allowed flies to enter resident rooms, leading to unsanitary conditions. Residents and their representatives reported concerns about flies, especially for those unable to protect themselves while sleeping. Maintenance staff confirmed the hole was left open after plumbing repairs, contributing to the ongoing pest issue.
Two residents receiving GT feedings did not have their feeding formulas properly labeled or stored. One resident's formula bottle was left at the bedside without a label indicating the resident's name or the date and time it was opened, and another resident had an extra bottle of Jevity 1.5 Cal left unattended at the bedside. Staff confirmed these practices did not follow facility policy for safe administration and storage of enteral nutrition.
The facility did not post complete daily nurse staffing information, omitting actual hours worked by licensed and unlicensed staff, as well as actual DHPPD and CNA DHPPD. The required data was not entered for an entire month, and both the DSD and Administrator acknowledged the deficiency.
Failure to Provide Written Transfer and Bed-Hold Notices: A resident was transferred to an acute care hospital after a fall, but the record did not show that the resident or representative received the required written transfer/discharge notice or the facility’s bed-hold policy. RN and the DON-related records review confirmed there was no signature or other documentation showing the notices were provided in writing when the resident could not sign and the representative was unavailable.
A resident was placed in a right hand mitten to prevent interference with a tracheostomy without a physician's order, consent, or assessment, and without a care plan in place. Staff and family interviews confirmed that required procedures were not followed, and the facility's own policy for restraint use was not adhered to.
A resident with a tracheostomy and cognitive impairment experienced multiple episodes of self-decannulation and manipulation of respiratory equipment, such as pulling out the tracheostomy tube and chewing on oxygen tubing. Despite these repeated incidents, the facility did not develop a comprehensive care plan to address the resident's specific respiratory care needs, as confirmed by staff interviews and medical record review.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents, as observed by surveyors who noted environmental risks and insufficient staff monitoring.
A resident was provided with bilateral upper bedrails without a physician's order, informed consent, or documented assessment for safety risks. Staff confirmed the bedrails were used to prevent falls, but the medical record lacked evidence of attempted alternatives, required documentation, and a care plan addressing bedrail use. The DON and Administrator acknowledged these omissions.
A resident with severe cognitive impairment and total dependence for ADLs was transferred by a CNA without the required two-person assistance or use of a Hoyer lift, despite clear care plan instructions. The CNA attempted the transfer alone after waiting for help, resulting in an assisted fall and an abrasion to the resident's upper back. Facility staff confirmed the transfer was not performed according to the resident's documented needs.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, resulting in a deficiency related to resident safety.
A resident who alleged physical abuse by a CNA was found with a skin tear and pain, but the required change of condition assessment and consistent 72-hour shift monitoring were not completed as per facility policy. Nursing staff and the DON confirmed that the assessment should have been initiated, and documentation was missing for several shifts, resulting in a failure to provide care according to established protocols.
A resident was administered midodrine for hypotension on several occasions when their systolic blood pressure was above the physician-ordered threshold, despite facility policy and staff knowledge requiring the medication to be held in such cases. Both the LVN and DON confirmed that the medication was given and documented even when the resident's BP exceeded the specified parameters.
Three residents receiving enteral feeding did not receive proper G-tube care, as two had medication ports with visible black substances and another did not have required water flushes before and after medication administration as ordered by a physician. Staff confirmed the tubing should have been kept clean or changed, and documentation of required flushes was missing.
A resident with a history of CVA and hemiparesis was repeatedly observed with a soft mitten restraint on the right hand without an active physician's order, updated consent, or care plan. Staff confirmed that required assessments and monitoring were not conducted, and previous orders and consents for the restraint had been discontinued. The facility's policy for restraint use was not followed.
Failure to Monitor and Notify for Repeated Foreign Object Ingestion
Penalty
Summary
The facility failed to provide necessary care and services to maintain the highest practicable well-being for a resident with chromosome eight syndrome and no capacity to understand or make decisions. The resident had physician orders to monitor for episodes of ingesting non-edible items every shift and a care plan addressing the risk of choking from ingestion of non-edible objects, with interventions including mittens, frequent visual monitoring, and removal of non-edible objects from the resident’s reach. The record and staff interviews showed the resident was able to use both arms, reach and grab items, remove mittens with his mouth, and had a history of swallowing non-food items. The resident experienced multiple incidents involving foreign objects. On one occasion, dark brown drainage with a foul stool-like odor was noted from the tracheostomy and gastrostomy tube, and the resident was transferred to the hospital. Hospital records showed sepsis and a foreign body in the abdomen/pelvis, and surgery was performed to remove material described as possibly plastic resembling gloves and cloth drawstring. Later, non-edible brief-like material was found in stool and removed from the anus, and the resident was sent for a CT scan, but the medical record did not contain the CT result. The care plan was revised to address swallowing non-food items, including use of a jumpsuit to prevent access to diapers, but the record also showed the resident continued to have episodes involving non-edible material. On another occasion, the resident vomited a foreign object described as plastic in appearance, and staff observed a clear rigid plastic object and smaller plastic particles in the emesis. The resident later had dark colored emesis and was transferred to the emergency department, where he was admitted to the ICU with sepsis, acute organ dysfunction, and septic shock. Operative findings later documented removal of two nitrile gloves from the stomach. Staff interviews indicated the resident would need 1:1 supervision, yet staff stated no sitter was provided, families were not present for the full shift, and the physician was not notified when the resident first vomited plastic on 4/22/26 until after the second emesis on 4/23/26 at 0500 hours. An observation of the resident’s room also found glove boxes near the bed and items in a drawer labeled not to leave items inside.
Failure to Report Injury of Unknown Source
Penalty
Summary
The facility failed to ensure that an injury of unknown source was reported for one of nine sampled residents. The report states that the facility was informed by the acute care hospital that the resident had been admitted to the ICU related to a subdural hematoma, but this incident was not reported as an injury of unknown origin. Facility policies reviewed by surveyors required accidents, incidents, unusual occurrences, and alleged violations, including injuries of unknown source, to be investigated and reported to the administrator and to appropriate agencies within required timeframes. Resident 1's closed medical record showed the resident had no capacity to make medical decisions, was dependent in self-care and mobility, and had been discharged to the acute care hospital after an elevated heart rate and increased work of breathing while on a ventilator. The next day, the facility was notified that the resident had been admitted to the ICU related to a subdural hematoma. During interview, the DON stated the resident had a brain injury, was unable to move, and was totally dependent on staff, and verified that the incident would be considered an injury of unknown origin that needed to be reported. The Administrator and DON later acknowledged the unreported incident.
Failure to Investigate Injury of Unknown Source
Penalty
Summary
The facility failed to investigate an injury of unknown source for one of nine sampled residents after it was informed by the acute care hospital that the resident had been admitted to the ICU with a subdural hematoma. Facility policy required accidents, incidents, unusual occurrences, and alleged violations, including injuries of unknown source, to be promptly investigated and documented, with reporting completed as required by regulation. The report states that the incident was not investigated even after the facility learned of the hospital admission related to the subdural hematoma. Resident 1 had no capacity to make medical decisions, was dependent for self-care and mobility, and had been discharged to the acute care hospital after an episode of elevated heart rate and increased work of breathing while on a ventilator. The medical record showed that the facility was later informed of the resident’s ICU admission related to subdural hematoma. During interview, the DON stated the resident had a brain injury, was unable to move, and was totally dependent on staff, and verified that the event would be considered an injury of unknown source requiring investigation. The Administrator and DON were later informed of the uninvestigated incident and acknowledged the findings.
Failure to Timely Update and Implement Fall Care Plan
Penalty
Summary
The facility failed to develop and implement the care plan for a resident who had falls, including failing to timely create the care plan after an unwitnessed fall and failing to implement the neuro check intervention that was included in the care plan. The resident was admitted and later readmitted to the facility, and the H&P dated 1/15/26 stated the resident did not have the capacity to make medical decisions. After an unwitnessed fall in the room on 4/1/26, the care plan focus, goals, and interventions were not initiated until 4/28/26, and the DON verified that the care plan should have been revised right after the fall incident. The record also showed that the care plan for the 4/1/26 fall included neuro checks for 72 hours, but the medical record did not show documented evidence that the neuro checks were completed. RN staff stated the process for a fall episode would include assessment, neuro checks, physician notification, risk management, fall risk assessment, and an IDT review, and the DON later verified the neuro checks were not done. In addition, after the resident was found on the floor again on 4/24/26, the care plan was not updated with new focus, goals, and interventions for that fall, and the DON stated she could not find the care plan for that event.
Unauthorized Cough Medication and Improper Bedside Medication Storage
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services in accordance with physician orders and its own medication administration policy for one resident. During an initial tour, a resident who was cognitively intact but not approved or wishing to self-administer medications was observed in bed, not feeling well and coughing intermittently. On the bedside table, surveyors observed a medicine cup half-filled with cherry-colored liquid and another cup with two unlabeled red capsules. The resident identified the liquid as cough medicine and the capsules as stool softeners, and stated that a licensed nurse had given them that morning and left them at the bedside because the resident preferred to take the cough medicine a little at a time. Review of the resident’s medical record showed an order for docusate sodium 250 mg twice daily for bowel management, but no physician’s order for cough medication and no order authorizing self-administration of medications. A prior self-administration assessment documented that the resident did not wish to self-administer medications and was not capable of doing so. Interviews with nursing staff confirmed that the cough medication had been given and left at the bedside without a physician’s order and without authorization for self-administration. An LVN reported seeing the medications at the start of her shift and being told by the resident that the night shift nurse had given cough medicine, but there was no report, documentation of coughing as a change in condition, or physician notification in the medical record. Review of the communication log and orders by an RN likewise showed no documentation of coughing, no physician notification, and no order for cough medication or self-administration at the time the medication was administered and left at the bedside. The DON was informed of and verified these findings, confirming that the facility did not follow its Medication Administration policy requiring medications to be administered according to prescriber orders and limiting self-administration to residents assessed and approved by the physician and interdisciplinary team.
Inaccurate Physician Documentation and Missing CNA Task Entries
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and complete medical records for a resident, contrary to its policy requiring objective, complete, and accurate documentation of all services, conditions, and responses to care. The facility’s Charting and Documentation P&P states that all services provided, progress toward care plan goals, and any changes in medical, physical, functional, or psychosocial condition must be documented in the medical record to facilitate communication among the interdisciplinary team. Despite this, the resident’s medical record contained inaccurate physician progress notes and multiple missing CNA task documentation entries. Physician progress notes dated 2/24, 3/10 (late entry for 3/3), and 3/26 documented that the resident had a Shiley XLT size 7 cuffed tracheostomy with ongoing trach treatment, GT skin, an indwelling Foley catheter, diagnoses including chronic respiratory failure, perforation of the esophagus, and pyothorax without fistula, oxygen at 3 L/min via T-bar with humidifier during the daytime, and enhanced barrier precautions for a history of Candida auris. Review of the resident’s order summary did not show any orders for a tracheostomy, GT, indwelling Foley catheter, oxygen via T-bar, or enhanced barrier precautions. Observation of the resident confirmed there was no tracheostomy, GT, Foley catheter, oxygen via T-bar, or enhanced barrier precaution signage at the room. The Medical Records Director and DON both verified that these physician progress notes were inaccurate, and the Medical Records Director stated the resident never had a tracheostomy or the other documented devices. In addition, the resident’s CNA Task Documentation Survey Report showed multiple missing entries across several dates and shifts. Missing documentation included bathing self-performance, support provided, and CNA initials; bladder continence details including urinary continence, toileting used, perineal care, catheter output (if applicable), and CNA initials; and bowel movement information such as occurrence, number, size, consistency, and CNA initials. Other missing entries involved bed mobility, bowel continence, corrective lenses use, dental status (dentures), dressing, locomotion on and off unit, personal hygiene (hair, nails, oral care, shaving), rejection of care, skin observations, toilet use, transfers, walking in room and corridor, amount eaten and eating performance, and nourishments including percentage of snacks and fluids taken and CNA initials. The Medical Records Director confirmed these entries were not completed and stated CNAs should have documented this information.
Incomplete MAR/TAR Entries and Unsigned Progress Notes for Two Residents
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with its own charting and documentation policies. For one resident who lacked decision-making capacity, review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for January and February showed multiple instances where ordered medications and treatments were not signed as administered. These included laxatives (polyethylene glycol and sennosides), a protein supplement (Pro-Stat), famotidine for GERD, Sinemet for Parkinson’s disease, chlorhexidine mouthwash, ammonium lactate lotion, and G-tube site care on numerous specific dates and times. Facility policy required the individual administering medications to initial the MAR after giving each medication and before administering the next, and required that all services, medications, and treatments be documented completely and accurately in the medical record. For another resident, also documented as lacking capacity to understand and make decisions, review of the closed medical record showed that multiple progress notes over several months were left in draft status and not signed. Specifically, six health status notes and one IDT note were incomplete, as indicated by the “view draft” status in the electronic record. During interviews and concurrent record reviews, the DON confirmed the gaps and incomplete documentation in the MAR and TAR for the first resident and verified that the second resident’s progress notes were not signed and therefore incomplete, acknowledging that the medical record remained open to alteration because the notes were not finalized. These findings demonstrated that the facility did not ensure complete documentation of medications, treatments, and progress notes as required by its policies.
Failure to Assess, Document, and Obtain Consent for Use of Bilateral Hand Mittens as Restraints
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from physical restraints unless needed for medical treatment, in accordance with its own restraint policy. During an initial tour, a resident who was nonverbal and severely cognitively impaired (BIMS score of 0) was observed in bed wearing bilateral hand mittens. The resident’s history and physical documented that the resident lacked capacity to understand and make decisions. The facility’s policy defined physical restraints, listed hand mitts as a possible restraint, and required a pre-restraint assessment, identification of a specific medical symptom, attempts at less restrictive interventions, informed consent, and detailed physician orders and documentation when restraints are used. Medical record review showed a physician’s order for hand mittens to prevent the resident from pulling out medical devices, but the order did not include the required medical symptoms, frequency, duration, or monitoring parameters for the mittens. The record lacked any assessment to determine the existence of medical symptoms warranting restraint use and did not show that less restrictive measures were attempted before applying the mittens. There was no documentation that the resident’s responsible party had been informed of the potential risks and benefits of the mittens or that consent for their use had been obtained, despite the facility policy requiring such consent. Further review of the resident’s record showed no care plan addressing the use of bilateral hand mittens, including no interventions related to restraint reduction or underlying causes of the behavior. The facility also failed to document key elements required by its policy while the mittens were in use, such as the anticipated length of time the restraint would be used, who could apply it, when and how it should be applied, and monitoring of circulation, mobility, and skin. During interviews, an LVN confirmed the resident was wearing bilateral mittens due to episodes of pulling tracheostomy tubing and verified the absence of required assessments, documentation of least restrictive measures, responsible party notification, consent, and care planning. The DON and Administrator were later informed of and acknowledged these findings.
Failure to Administer and Document Enteral Feeding per Physician Orders
Penalty
Summary
The facility failed to ensure that a resident with a gastrostomy tube (GT) received enteral feeding as ordered by the physician and that the administration of the feeding was properly documented in the Medication Administration Record (MAR). Specifically, the resident had physician orders for TwoCal HN, a calorie and protein-dense nutritional supplement, to be administered at set intervals. However, review of the MAR revealed that the enteral feeding was not documented as administered on multiple occasions, and staff interviews confirmed that nurses sometimes forgot to sign the MAR after giving the feeding. In some instances, the feeding was delayed at the request of the resident's family, but documentation was still incomplete or missing. Facility policies required that all procedures related to enteral feeding, including verification of tube placement, amount and type of feeding, and resident response, be recorded in the medical record. Additionally, all services provided were to be documented to facilitate communication among the care team. Despite these policies, the MAR was left blank on several dates, and staff acknowledged that they may have forgotten to sign after administering the feeding. The Director of Nursing confirmed that the MAR should not be left blank and that refusals or delays should also be documented.
Incomplete Medication Administration Documentation in Medical Record
Penalty
Summary
The facility failed to ensure that a resident's medical record was accurate and complete, specifically regarding the documentation of medication administration. According to facility policy, the individual administering medication is required to initial the Medication Administration Record (MAR) after giving each medication and before administering the next. Additionally, all services provided, progress toward care plan goals, and any changes in the resident's condition must be documented in the medical record to facilitate communication among the interdisciplinary team. For one resident, the MAR for November showed that multiple prescribed medications, including a multivitamin-mineral supplement, lactobacillus, famotidine, and Docuprene, were not documented as administered on a specific date. Interviews with nursing staff confirmed that the MAR lacked documentation for these medications, despite reports from the resident's family and staff observations that the medications had been prepared and given. The nurse responsible did not recall missing any doses, but the MAR was not signed, and no progress note was entered to confirm administration. The Director of Nursing acknowledged that the nurse should have documented the medication administration in the MAR and entered a progress note, as required by facility policy.
Failure to Monitor and Update Care Plan for Resident on Antibiotic Therapy
Penalty
Summary
The facility failed to provide necessary treatment and services to maintain the highest practicable well-being for one of twelve sampled residents. Specifically, the facility did not monitor a resident who was receiving antibiotic treatment for a urinary tract infection (UTI) and did not update the resident's care plan to address the treatment interventions and management of the UTI. The facility's policies require that a baseline care plan be developed to meet immediate health and safety needs and that significant changes in a resident's condition prompt an interdisciplinary review and care plan revision. However, after the resident experienced a change in condition and was started on antibiotics, there was no documented evidence that the resident's condition or response to antibiotic therapy was monitored as required. Additionally, the resident's care plan was not updated to reflect the new treatment for the UTI. Interviews with nursing staff confirmed that the care plan lacked information about the UTI management and that there was no documentation of monitoring during and after the antibiotic course. The facility's own policies and CDC guidance highlight the importance of monitoring for adverse effects during antibiotic therapy, but these were not followed in this case.
Failure to Follow Food Procurement and Handling Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events are provided in the report.
Infection Control Program Deficiencies and Lapses in Precautionary Practices
Penalty
Summary
The facility failed to maintain its infection prevention and control program as required, resulting in multiple deficiencies. Infection control surveillance reports and mapping were not completed for the months of May and June 2025, as confirmed by the Infection Preventionist (IP) and Director of Nursing (DON). The absence of these reports hindered the facility's ability to identify, investigate, and track infection patterns, which are necessary for planning interventions and staff training. The IP, who had recently started in the role, acknowledged that the reports had not been updated and emphasized the importance of monthly surveillance for infection control. Several residents with indwelling medical devices or wounds were not placed on Enhanced Barrier Precautions (EBP) as ordered by their physicians. For example, residents with Quinton catheters, indwelling urinary catheters, AV fistulas, and PEG/GT tubes did not have EBP signage outside their rooms, and staff were observed providing care without donning the required gowns. Staff members reported that they relied on signage to know when to implement EBP, and the lack of signage led to missed precautions. Additionally, staff were not consistently informed about which residents required EBP, resulting in improper use of personal protective equipment (PPE) during high-contact care activities. Other infection control lapses included staff refilling residents' water pitchers from bathroom sinks, which poses a risk of cross-contamination, and leaving personal items such as water jugs on the floor. Observations also revealed that trash bins were not emptied when full, and used washable gowns were not discarded properly. During medication administration, a nurse failed to don the required gown for a resident with a GT and did not perform hand hygiene or change gloves after picking up a dropped medication cup from the floor. These actions were in direct violation of the facility's infection control policies and procedures, as well as CDC guidelines.
Failure to Obtain and Renew Informed Consent for Psychotropic Medications and Bedrails
Penalty
Summary
The facility failed to properly obtain and renew informed consent for the use of psychotropic medications and bedrails for several residents, as required by law and facility policy. For three residents receiving psychotropic medications, the facility either did not obtain the initial informed consent or failed to renew the consent every six months as mandated. Specifically, one resident did not have current consents for multiple psychotropic medications, with the last consents obtained more than six months prior. Another resident was administered antipsychotic medications without the required renewal of informed consent after six months. A third resident was given psychotropic medications without any documented informed consent in the medical record. Additionally, the facility failed to obtain the correct informed consent for the use of bedrails for another resident. The consent on file was for bilateral half side rails, while the resident was observed using bilateral quarter side rails, and there was no documentation of consent for the specific type of bedrail in use. Interviews with nursing staff and the DON confirmed these findings and acknowledged that the required consents were either missing or not current at the time the medications and bedrails were in use. The deficiencies were identified through interviews, medical record reviews, and policy and procedure reviews. The facility's own policies require that informed consent be obtained and documented for the use of psychotropic medications and physical restraints, including bedrails, and that these consents be renewed every six months. The lack of current and appropriate consents was verified by both nursing staff and the DON during the survey process.
Failure to Notify Physician and Representative of Change in Condition
Penalty
Summary
The facility failed to immediately notify a resident's physician and resident representative of a change in condition when the resident developed Moisture-Associated Skin Damage (MASD) to the coccyx. According to the facility's policy, prompt notification of the resident, physician, and representative is required for any change in the resident's medical or mental condition. Medical record review showed that the assessment documented the presence of MASD and included a plan of care and wound care orders, but did not indicate that the physician or resident representative had been notified of the change. Additionally, the assessment did not specify which physician provided the wound care order. Interviews with nursing staff and the Director of Nursing (DON) confirmed that the physician and resident representative were not informed of the resident's change in condition. Staff also reported that treatment nurses sometimes entered wound care orders themselves without physician involvement. The DON verified that the facility's expectation is for licensed nurses to notify the physician for interventions and to inform the family or responsible party, but acknowledged that this did not occur in this instance.
Failure to Monitor and Document Psychotropic Medication Use and Interventions
Penalty
Summary
The facility failed to ensure that three out of five sampled residents were free from unnecessary psychotropic medications and that appropriate monitoring and nonpharmacological interventions were implemented as required. For one resident, staff did not monitor for specific behavioral manifestations as ordered by the physician for Risperdal, nor did they monitor for orthostatic hypotension, a known side effect of antipsychotic medication. Additionally, the number of hours the resident slept was not documented in relation to trazodone administration, with staff only placing checkmarks instead of recording actual sleep duration. Another resident was prescribed multiple psychotropic and neurological medications, including Remeron, divalproex, Nuedexta, Seroquel, and buspirone HCL, for various psychiatric and behavioral symptoms. The medical record lacked evidence that nonpharmacological interventions were attempted or provided in conjunction with these medications. Furthermore, required monthly psychotherapeutic drug summary sheets had not been completed for these medications since April, and there was no documentation that side effects for Remeron, divalproex, and Nuedexta were monitored. A third resident, who was prescribed buspirone HCL and Seroquel for anxiety and schizophrenia, also did not have documentation of nonpharmacological interventions related to these medications. Monthly psychotherapeutic drug summary sheets were not completed for this resident since April. These findings were confirmed by interviews with the RN and DON, who acknowledged the lack of required monitoring, documentation, and implementation of nonpharmacological interventions as outlined in facility policy and physician orders.
Failure to Prevent and Accurately Document Pressure Ulcers and Support Surface Use
Penalty
Summary
The facility failed to provide necessary care and services to prevent the development or worsening of pressure injuries for three residents. For one resident, licensed nurses inaccurately documented the presence of pressure injuries on the buttocks when the actual condition was moisture-associated skin damage (MASD) to the coccyx. This discrepancy was confirmed through interviews and direct observation, where no pressure injury was found, and both the RN and DON acknowledged the documentation errors. Another resident was found to have a low air loss (LAL) mattress set incorrectly according to both the physician's order and the resident's weight. The mattress was set at a higher level than ordered and not in accordance with the manufacturer's guidelines for the resident's actual weight. Additionally, this resident's care plan required repositioning at least every two hours, but documentation showed that repositioning was not performed as frequently as required. Staff interviews revealed that the CNA was unable to reposition the resident due to difficulty and did not notify licensed nurses, and the DON confirmed that staff should have reported this issue. A third resident was observed lying on a LAL mattress that was set on static mode and at a weight setting inconsistent with the resident's actual weight and the physician's order. Staff interviews confirmed that the mattress should have been on alternate mode and set according to the resident's weight. The DON and RN verified that the mattress settings were not checked daily as required, and that the discrepancies undermined the intended preventative function of the support surface.
Failure to Assess Ongoing Need for Indwelling Urinary Catheter
Penalty
Summary
The facility failed to assess the appropriateness and continued use of an indwelling urinary Foley catheter for a resident who was cognitively intact and had a history of urinary retention and urinary tract infection. Medical record review showed a physician's order for the catheter but did not indicate the reason for its continued use. There was no documentation in the resident's medical record to show that the facility had assessed whether the catheter was still necessary or had attempted to remove it to determine if the resident could urinate independently. Interviews with nursing staff confirmed that the diagnosis of urinary retention alone was not an adequate indication for ongoing catheter use and that there was no evidence of reassessment or attempts at catheter removal. The resident reported not recalling how long the catheter had been in place and stated that the facility had not tried to remove it. The DON acknowledged these findings during the investigation.
Failure to Document and Monitor PICC Line Measurements
Penalty
Summary
The facility failed to provide necessary care and services related to the maintenance and monitoring of peripherally inserted central catheter (PICC) lines for two residents. For one resident, the facility did not measure the length of the PICC line on the date specified by the physician's order, nor did they establish a baseline measurement upon admission, as confirmed by both the RN and the Director of Nursing (DON). The resident was observed with a PICC line in place and an undated dressing, and the medical record lacked documentation of the required measurement. The DON acknowledged that baseline measurements are essential to ensure the catheter remains intact and has not been dislodged. For another resident, the facility did not obtain or document the PICC line external catheter length and arm circumference measurements upon admission or with subsequent dressing changes, despite the presence of physician's orders for regular dressing changes. The medical record review and interviews with nursing staff confirmed the absence of these measurements, which are necessary to monitor for complications such as infiltration or catheter dislodgement. The DON verified these findings during the investigation.
Failure to Provide Safe and Appropriate Respiratory Care Services
Penalty
Summary
The facility failed to provide necessary and appropriate respiratory care services for multiple residents, as evidenced by observations, interviews, and medical record reviews. For one resident, oxygen was not administered per the physician's order, the oxygen concentrator was not functioning properly, and the nasal cannula was neither dated nor changed weekly as required. Additionally, oxygen saturation was not consistently monitored or documented, and the oxygen concentrator was found to be incapable of delivering the ordered flow rate, necessitating replacement. Other deficiencies included failure to label and date respiratory equipment such as nasal cannulas, oxygen tubing, nebulizer bags, and prefilled humidifier bottles for several residents. In one case, a resident's Yankauer suction set-up bag was not dated or labeled, and the suction bacterial filter for another resident was not changed monthly as ordered. There were also instances where respiratory supplies were not changed according to facility policy or physician orders, and documentation of respiratory interventions was lacking in the medical records. Furthermore, one resident was administered oxygen therapy without a physician's order, and the equipment used was not labeled or dated. Staff interviews confirmed a lack of adherence to protocols regarding the changing, labeling, and dating of respiratory care equipment. The Director of Nursing and other staff acknowledged these findings during interviews, confirming that the facility's policies and physician orders were not consistently followed for respiratory care and infection control.
Failure to Provide Safe and Appropriate Dialysis Care and Emergency Preparedness
Penalty
Summary
The facility failed to provide safe and appropriate dialysis care for multiple residents requiring such services. Specifically, the facility did not ensure that physician orders for pre- and post-dialysis weights were followed for one resident, as post-dialysis weights were not obtained on the prescribed days but instead were taken on Thursdays, contrary to the order for weights to be taken on each dialysis day. This was confirmed by both the RNA and RN, who acknowledged the discrepancy between the physician's order and the actual practice. Additionally, the facility did not maintain complete and accessible dialysis emergency kits at the bedside for several residents. Observations revealed that some residents who were receiving dialysis did not have an emergency dialysis kit at their bedside, while others had kits that were incomplete, lacking essential items such as clamp scissors needed to prevent bleeding. Staff interviews confirmed the absence or incompleteness of these kits and acknowledged that the kits should be present and fully stocked for all residents undergoing dialysis. Furthermore, the facility's licensed staff inappropriately documented the presence of bruit and thrill for a resident with a central venous catheter, despite this assessment being applicable only to peripheral access sites. This was verified by both the RN and DON, who stated that such documentation was not appropriate for central catheter sites. The combination of these failures demonstrates that the facility did not adhere to its own policies and procedures regarding dialysis care and monitoring, as well as physician orders for dialysis-related assessments and emergency preparedness.
Failure to Ensure Proper Assessment and Documentation for Bed Rail Use
Penalty
Summary
The facility failed to ensure proper assessment, documentation, and care planning regarding the use of bed rails for four residents. For one resident, although informed consent from the responsible party and a physician's order for side rails as an enabler were documented on one occasion, there was no current physician's order in the medical record for the use of bilateral half side rails, nor was there a care plan intervention addressing their use. Observations confirmed that the resident's bed had the side rails elevated, and both the RN and DON verified the absence of the required order and care plan. For two other residents, the facility did not document that less restrictive alternatives were attempted prior to the use of bilateral half side rails. Both residents were observed using the side rails and reported using them to assist with turning in bed. While physician's orders for the use of side rails as enablers were present, the Bed Safety Rail assessments did not show evidence that alternatives such as roll guards, foam bumpers, or lowering the bed were tried before implementing side rails, as required by facility policy. Another resident was observed with bilateral half side rails elevated and reported using them for turning, but required staff assistance for safety. The medical record review showed no documented evidence of a physician's order or informed consent for the use of side rails, and no care plan was initiated to address their use. Staff interviews confirmed that the required steps, including attempting less restrictive alternatives, obtaining physician's orders, and informed consent, were not completed for these residents prior to the use of side rails.
Failure to Monitor Residents on Apixaban for Bleeding
Penalty
Summary
The facility failed to ensure that two residents receiving apixaban, an anticoagulant medication, were properly monitored for signs and symptoms of bleeding as required by both FDA guidelines and the facility’s own policies and procedures. For one resident, who had a history of stroke and had been on blood thinners since 2016, there was no documented evidence in the medical record that monitoring for bleeding was performed. Interviews with nursing staff confirmed that such monitoring should occur, and the DON acknowledged the lack of documentation and monitoring for this resident. For the second resident, who was prescribed apixaban for atrial fibrillation, the medical record also lacked documentation of monitoring for bleeding. Additionally, the resident’s care plan did not address the use of apixaban, despite the resident being cognitively intact and aware of their medication regimen. Nursing staff and the DON confirmed that monitoring for bleeding should have been performed and documented every shift, but this was not done. Both residents were observed and interviewed, and both were aware of their anticoagulant therapy. However, the facility did not follow its own protocol, which requires staff to monitor for complications such as excessive bruising, hematuria, hemoptysis, or other evidence of bleeding, and to notify the physician if such symptoms occur. The lack of monitoring and documentation was verified by staff and acknowledged by facility leadership during interviews.
Medication Administration Errors Result in Elevated Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed rate of 12.5%. During medication administration observations, two licensed nurses were found to have made multiple errors. One nurse did not follow the physician's order for administering potassium chloride to a resident with a gastrostomy tube, crushing the tablet and dissolving it in only 10 ml of water instead of the prescribed 60 ml. The same nurse also failed to fully administer a crushed multivitamin with minerals, leaving an excessive amount of residue in the medication cup after administration. Another nurse administered only half the prescribed dose of lactulose to a resident, giving 10 gm instead of the ordered 20 gm. Additionally, this nurse administered a higher dose of vitamin D than prescribed, giving 1000 IU instead of 400 IU. These errors were confirmed through observation, interviews, and medical record reviews, and were not in accordance with the facility's policy and procedure for medication administration.
Medication Storage, Labeling, and Disposal Deficiencies
Penalty
Summary
The facility failed to ensure proper storage, labeling, and disposal of medications and medical supplies as required by policy and professional standards. Expired medical supplies, including BD Precision Glide needles and Luer Lok Red Caps, were found in Medication Room A and were verified by nursing staff as expired and not discarded. In Medication Cart A, prescription topical medications such as Venelex and Derma Syn/Ag were found opened and unlabeled, and there was no physician's order for their presence. Additionally, a staff member's personal over-the-counter medication was stored with facility wound supplies in the same cart. Further deficiencies were observed in Medication Cart B, where opened and unlabeled ampules of prescription inhalational medications (Combivent and Proventil) were found removed from their original packaging without proper dating, contrary to manufacturer instructions. In Medication Cart C, opened insulin vials and pens for specific residents were not labeled with the date opened. The Director of Nursing (DON) confirmed these findings. In Dialysis Cart A, a staff member's personal purse was stored among dialysis supplies, which was acknowledged by both the dialysis technician and the dialysis RN supervisor as a violation of infection control measures due to the risk of cross-contamination. The facility also failed to follow its policy regarding bedside medication storage. One resident was found with a tube of Venelex wound dressing ointment and a bottle of Sea-Clens wound cleanser at the bedside without a physician's order or documentation of authorization for bedside storage, and the resident was unaware of the medications' presence. Another resident was found with a bottle of Forze VF Gold multivitamin supplement at the bedside, despite lacking the capacity to make decisions and without a physician's order or assessment for self-administration. These findings were verified by facility staff and administration.
Improper Storage and Disposal of Garbage in Dumpsters
Penalty
Summary
The facility failed to ensure proper storage and disposal of garbage in two outdoor dumpsters. During an observation with the Maintenance Supervisor, both dumpster lids were found partially propped open by trash bags, preventing them from fully closing, and a bag of trash was observed on the ground nearby. The Maintenance Supervisor confirmed that the lids should be completely closed at all times for infection control. Review of the facility's policy and the USDA Food Code indicated that garbage must be stored in tightly closed, leak-proof containers and that the trash area must be kept clean and vermin-proof, with daily inspections to ensure lids are closed and no debris is present.
Failure to Arrange Hospice Services
Penalty
Summary
The facility failed to arrange for the provision of hospice services for a resident or assist the resident in transferring to a facility that would provide such services. This deficiency indicates that the necessary steps were not taken to ensure the resident received appropriate hospice care or was transferred to a setting where hospice services could be arranged.
Failure to Monitor Antibiotic Use
Penalty
Summary
The facility failed to implement a program that monitors antibiotic use. There is no evidence provided in the report that the facility had a system in place to track, review, or evaluate the use of antibiotics among residents. This lack of monitoring could result in inappropriate or unnecessary antibiotic administration, but the report only states the absence of a monitoring program and does not provide further details about specific residents or incidents.
Failure to Administer and Document Pneumococcal Vaccine
Penalty
Summary
The facility failed to administer the pneumococcal vaccine to one of five sampled residents reviewed for immunizations. According to the facility's policy and procedure, all residents are to be assessed for eligibility and offered the pneumococcal vaccine series within thirty days of admission, unless medically contraindicated, previously vaccinated, or refused by the resident. Medical record review for the resident in question showed that the resident was approached and verbally consented to receive the influenza, pneumococcal, and COVID-19 vaccines. However, there was no documented evidence in the medical record that the pneumococcal vaccine was administered or refused. During interviews and concurrent medical record review, both the Infection Preventionist (IP) and Director of Nursing (DON) confirmed that the pneumococcal vaccine had not been given to the resident. The facility's policy also requires documentation of vaccine administration or refusal, as well as education provided to the resident or their representative. The absence of documentation and lack of vaccine administration constituted a failure to follow established procedures for immunization.
Failure to Administer COVID-19 Vaccine After Resident Consent
Penalty
Summary
Facility staff failed to administer the COVID-19 vaccine to one of five sampled residents, despite the resident having the capacity to make healthcare decisions and providing verbal consent for the vaccine. Medical record review showed that the resident was approached by staff and consented to receive the influenza, pneumococcal, and COVID-19 vaccines. There was no documented evidence that the resident refused the COVID-19 vaccine. Further review and interviews with the Infection Preventionist (IP) and Director of Nursing (DON) confirmed that the COVID-19 vaccine was not given to the resident. The facility's policy required offering and documenting COVID-19 vaccination for all residents unless medically contraindicated or refused, but this process was not followed for the resident in question.
Failure to Complete and Document Bed Rail Entrapment Assessments
Penalty
Summary
The facility failed to complete and document zone entrapment assessments and measurements upon installation of bed rails for three residents who were using bilateral half side rails. For two residents, the required entrapment assessments were not completed or recorded at the time of bed rail installation, as evidenced by the absence of documentation in the facility's Bed Safety Checklist for the relevant months. Observations confirmed that these residents were using the side rails, and interviews with staff indicated that the maintenance department was responsible for installation and assessment, but the necessary documentation was missing. One resident was found to be using bilateral half side rails without a physician's order or a care plan intervention for their use. The maintenance supervisor confirmed that without a physician's order, the entrapment assessment process was not initiated, and no measurements were taken. This was further verified by the absence of documentation in the facility's records and acknowledged by the DON. The facility's policy required that bed frames, mattresses, and bed rails be checked for compatibility and that any gaps in the bed system be within safety dimensions established by the FDA. The policy also mandated routine inspections and proper installation according to manufacturer instructions. However, the lack of completed assessments and documentation for the residents using side rails demonstrated noncompliance with these requirements.
Failure to Timely Provide Resident Records and Facility Documents
Penalty
Summary
The facility failed to provide a copy of a resident's medical record and related facility documents to the resident's legal representative within the required two working days after receiving a valid request. The legal representative, acting through a law firm, submitted a written and signed authorization for the release of the resident's medical records, billing records, photographs, charts, admission agreements, utilization review committee records, x-rays, facility resident care policies, and posted nurse staffing data for the previous eighteen months. Despite multiple follow-up attempts by the legal assistant via phone and email, the facility did not provide the requested records until 13 days after the initial request was received. The resident in question had moderately impaired cognitive function and had a designated representative with power of attorney for health care. The Director of Medical Records confirmed receipt of the request and verified the authorization but acknowledged that the records were not provided within the regulatory timeframe. The facility also failed to provide the daily posting of the staffing record and resident care policies as requested. The DON was informed of these findings and acknowledged the delay.
Failure to Provide and Document Advance Directive Information
Penalty
Summary
The facility failed to provide written information and assistance regarding the formulation of advance directives to several residents, as required by its own policies and federal regulations. Specifically, five out of sixteen sampled residents did not receive the necessary written information or documentation about their rights to formulate an advance directive. For two residents, there was no evidence that written information or assistance was provided, and for two others, there was no documentation that the information was offered or discussed. In one case, the facility did not provide written information to a resident's representative when the resident lacked capacity. Medical record reviews revealed that documentation was missing or incomplete for these residents. For example, some residents' records did not include the Advance Directive Acknowledgment form, and progress notes failed to show that the formulation of an advance directive was offered or discussed. In cases where residents were unable to make decisions, there was no evidence that their legal representatives were provided with the required information. Interviews with the MDS Coordinator and DON confirmed these documentation gaps and acknowledged that the process for following up on advance directives was inconsistent, especially after staff changes. The affected residents included individuals with varying cognitive abilities, including those with moderate cognitive impairment, those who were cognitively intact, and those who lacked capacity due to medical conditions such as anoxic brain injury or persistent vegetative state. Despite these differences, the facility did not consistently provide or document the provision of written information about advance directives, as required by policy and regulation.
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans that addressed the specific needs and medical interventions for multiple residents. For several residents, including those with complex medication regimens and specialized treatments, the care plans did not include problems or interventions related to their current physician orders. For example, one resident receiving enteral feeding via a gastrostomy tube did not have a care plan addressing this intervention, despite direct observation of the feeding setup and a physician's order for the feeding formula and rate. Another resident prescribed NPH insulin for Type 2 Diabetes Mellitus did not have a care plan problem or interventions related to insulin administration, as confirmed by both the RN and DON during record review. Additionally, the facility did not develop care plans for residents prescribed multiple psychotherapeutic and anticoagulant medications. One resident was receiving Remeron, Nuedexta, and divalproex sodium for various psychiatric and mood disorders, but the care plan did not address the use of these medications. Another resident was prescribed olanzapine, sertraline, trazodone, and apixaban, yet there was no documented care plan for these medications. Similarly, a resident with a history of stroke and on apixaban for anticoagulation did not have a care plan addressing the use of this medication, as verified by staff interviews and medical record review. The facility also failed to implement care plan interventions as written. In the case of a resident with hypotension, the care plan included an intervention to check blood pressure every 12 hours. However, the blood pressure summary showed that readings were not consistently documented at the required frequency. Staff interviews confirmed that the care plan interventions were not fully implemented, and the DON acknowledged these findings. These deficiencies were identified through observation, interviews, and review of medical records and facility policies.
Failure to Maintain Resident Dignity During Mealtime Assistance
Penalty
Summary
The facility failed to promote dignity and respect for two residents during mealtime assistance. In the first instance, a resident with blindness in one eye and limited mobility required partial assistance with eating. During observation, a CNA was seen standing next to the resident's bedside while assisting with feeding, rather than sitting at eye level as required by facility policy. The CNA acknowledged that she should have been seated to better observe and interact with the resident during feeding. In the second instance, another resident on a controlled carbohydrate, pureed diet with aspiration precautions required one-to-one feeding. A CNA was observed standing while feeding the resident, despite a chair being available. The CNA confirmed he should have been seated at eye level. Facility leadership, including the DSD and DON, stated that staff were expected to sit at eye level when assisting residents with feeding to maintain dignity, but the DSD had not provided in-service training on dignity or respect since starting at the facility.
Failure to Provide Required Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to provide the required written Notice of Medicare Non-coverage (NOMNC) and the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) to a resident who was being discharged from Medicare Part A services and remaining in the facility under private pay insurance. Medical record review showed that the NOMNC form was undated and lacked the signature of the resident or their representative. Similarly, the SNF ABN form was not signed by the resident or representative, and there was no documentation that copies of these notices were provided to them at the time of the Medicare Part A discharge. Interviews with the Business Office Manager revealed that attempts were made to notify the resident's responsible party by phone, but there was no evidence that the required forms were mailed or otherwise delivered for review and signature. The resident's representative confirmed not receiving the written notices and did not recall being informed about appeal rights or the appeal process. The Director of Nursing acknowledged these findings during the survey.
Failure to Maintain Sanitary and Homelike Environment Due to Unrepaired Wall Damage
Penalty
Summary
The facility failed to maintain a clean, sanitary, and homelike environment for several residents, as evidenced by the presence of a hole in the wall underneath the bathroom sink shared between two rooms. This hole, located adjacent to plumbing pipes, was left open after maintenance staff accessed the plumbing to fix a clogged toilet. The Maintenance Supervisor confirmed that the hole remained open and acknowledged that flies could enter the facility through this and other gaps, such as opened windows and sliding doors. Multiple residents, including those with and without decision-making capacity, were observed in the affected rooms. Resident representatives and residents expressed concerns about flies entering the rooms, particularly for residents who sleep with their mouths open, increasing the risk of flies entering their mouths. The issue was reported to maintenance staff, who attributed the fly problem to openings in the facility, including the unrepaired hole in the bathroom wall.
Failure to Ensure Proper Labeling and Storage of GT Feeding Formula
Penalty
Summary
The facility failed to provide appropriate care and services related to gastrostomy tube (GT) feeding for two residents. For one resident, the GT feeding formula (Glucerna 1.5) was observed stored at the bedside with 800 ml remaining in the bottle, and the bottle was not labeled with the resident's name or the date and time it was opened. Medical record review confirmed that the resident was receiving bolus GT feedings as ordered, and staff interviews verified that the formula bottle should have been properly labeled. Additionally, it was confirmed that the correct packaging (can or Tetra Pak) should be used to ensure accurate administration, but this was not followed. For another resident, a bottle of Jevity 1.5 Cal was observed left unattended at the bedside while the resident was receiving tube feeding. The physician's order specified the administration of Jevity 1.5 Cal at a set rate via enteral feeding pump. Staff interviews confirmed that an extra bottle of tube feeding formula should not be left at the bedside to prevent contamination, but this protocol was not followed. Both incidents were acknowledged by facility leadership during interviews.
Incomplete Posting of Actual Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the daily posted nurse staffing information included the total number and actual hours worked by both licensed and unlicensed nursing staff directly responsible for resident care. Additionally, the posted information did not include the actual Direct Care Services Hours Per Patient Day (DHPPD) and Certified Nursing Assistant (CNA) DHPPD, as required. Review of the facility's Census and Direct Care Service Hours Per Patient Day (DHPPD) forms for the month of July 2025 revealed that while scheduled hours and scheduled DHPPD were documented, the actual total direct care service hours, actual total CNA direct care service hours, actual DHPPD, and actual CNA DHPPD were missing for the entire month. During interviews, the Director of Staff Development (DSD) confirmed that there was no automated system to populate the actual hours on the required form, and that she was responsible for manually entering this information at the end of each day. The DSD acknowledged that she did not have the opportunity to enter the actual staffing data for July 2025. The Administrator was also informed of these findings and acknowledged the deficiency. No information about specific residents or their conditions was provided in the report.
Failure to Provide Written Transfer and Bed-Hold Notices
Penalty
Summary
The facility failed to notify Resident 37 and/or the resident’s representative in writing of the transfer and the reasons for the transfer when the resident was sent to an acute care hospital for evaluation related to a fall. The facility’s policy stated that transfer/discharge notices are to be provided to the resident and resident representative as soon as practicable before transfer, and the medical record showed a physician’s order to transfer the resident and a progress note documenting the resident was sent to the hospital. A transfer/discharge notice dated 8/8/25 identified the hospital as the transfer location and stated the reason was that the resident’s welfare required transfer because needs could not be met in the facility, but the record did not show that the resident or representative received the written notice when the transfer occurred. Resident 37’s medical record also did not show written notification of the facility’s bed hold policy at the time of transfer. The facility’s bed hold policy stated residents and representatives are to receive written information about bed-hold policies at least twice, including at the time of transfer or within 24 hours for an emergency transfer, and that multiple attempts to notify the representative should be documented if timely contact cannot be made. The Bed Hold Informed Consent indicated the resident was transferred to the hospital and the representative was notified, but it did not contain a signature from the resident or representative, and the record did not show that the policy was provided in writing. Interviews confirmed the missing documentation. RN 1 verified the resident was transferred and stated she could not find documentation that the transfer/discharge notice or bed hold policy was provided in writing when the resident could not sign and the representative was unavailable. The Director of Medical Records also verified there was no signature from the resident or representative and stated she could not find documentation that either document was provided in writing; she further stated the facility did not mail or email the notices when the resident was unable to sign and the representative was not available. The resident later stated he did not receive the transfer/discharge notification or bed hold policy in writing and did not remember receiving any paper at the time of transfer.
Failure to Follow Restraint Protocols for Resident Using Hand Mitten
Penalty
Summary
The facility failed to ensure that a resident was free from physical restraints by applying a right hand mitten without following required procedures. The resident, who lacked capacity to make decisions, was observed with a mitten on her right hand and bilateral bedrails in place. Staff interviews confirmed that the mitten was used to prevent the resident from pulling at her tracheostomy. However, a review of the medical record revealed there was no physician's order, no documented consent from the resident's representative, and no completed assessment prior to the application of the mitten. Additionally, there was no evidence that less restrictive interventions were attempted before using the restraint. Further review showed that the facility did not initiate a care plan addressing the use of the right hand mitten for the resident. The facility's policy requires a pre-restraining assessment, physician order, consent, and care planning for any restraint use, none of which were completed in this case. Interviews with staff and the resident's family member confirmed that consent was not obtained and the family was not informed prior to the application of the mitten. The Administrator and DON acknowledged these findings during the survey.
Failure to Develop Individualized Respiratory Care Plan
Penalty
Summary
The facility failed to develop a comprehensive and individualized care plan to address a resident's specific respiratory care needs. Despite multiple documented incidents in the medical record, including the resident pulling out their tracheostomy tube, placing the nasal cannula in their mouth, biting the cannula, and chewing on oxygen tubing, there was no evidence that these behaviors were incorporated into the resident's care plan. The facility's policy requires that care plans include measurable objectives and timetables to address identified problems and risk factors, but this was not followed for the resident in question. Medical records and interviews confirmed that the resident had a tracheostomy, used supplemental oxygen, and lacked capacity to make decisions. Several health status notes detailed repeated episodes of self-decannulation and manipulation of respiratory equipment, which were observed by staff and reported by a family member. Both the RN and DON verified that the care plan did not address these behaviors, and the DON acknowledged that a care plan should have been developed to ensure appropriate care for the resident.
Failure to Maintain Safe Environment and Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Obtain Assessment, Consent, and Physician Order Prior to Bedrail Use
Penalty
Summary
The facility failed to follow its own policy and regulatory requirements regarding the use of bed rails for a resident. Specifically, the facility did not ensure that a physician's order, informed consent, or a comprehensive assessment was obtained prior to the application of bilateral upper bedrails. The resident was observed with the bedrails elevated, and staff confirmed that the bedrails were being used to prevent falls. However, a review of the resident's medical record showed no documentation of an assessment for safety risks, no evidence that alternatives to bedrails were attempted, and no record of informed consent being obtained from the resident's representative, despite the resident lacking capacity to make decisions. Additionally, the facility did not initiate a care plan to address the use of bedrails for this resident. The facility's policy requires that alternatives be attempted, risks and benefits reviewed, and informed consent obtained before bedrails are used, but these steps were not documented or completed. The DON and Administrator acknowledged that the required documentation and processes were not present in the resident's record.
Failure to Provide Required Two-Person Assistance During Resident Transfer
Penalty
Summary
A deficiency occurred when facility staff failed to provide the required two-person assistance during a transfer for a resident with severely impaired cognition and total dependence on staff for activities of daily living (ADLs). The resident's medical record and MDS assessment indicated a need for two or more staff members and the use of a Hoyer lift for all transfers. Despite this, a CNA attempted to transfer the resident alone from a shower bed to the resident's bed after waiting approximately 30 minutes for assistance, resulting in an assisted fall and an abrasion to the resident's left upper back. The CNA acknowledged awareness of the resident's transfer requirements but proceeded without the necessary help. Interviews with facility staff, including the DSD and DON, confirmed that the CNA did not wait for the second staff member or the Hoyer lift as required by the resident's care plan. The DSD observed the CNA with the resident and instructed another staff member to bring the Hoyer lift, but the transfer was attempted before assistance arrived. The DON verified that the resident sustained a fall during the transfer and that the CNA should have waited for the required assistance.
Failure to Maintain Safe Environment and Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Initiate Change of Condition Assessment and Monitoring After Abuse Allegation
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, resident preferences, and goals for one of three sampled residents. A resident made an allegation of physical abuse by a CNA, which was reported to the charge nurse. Upon assessment, the resident was found to have a skin tear on the left forearm and reported pain. The incident was reported to the RN Supervisor, who notified the DON, Administrator, and police, and wound care was provided. Despite the facility's policy and procedure requiring a change of condition assessment and monitoring every shift for 72 hours following such incidents, the medical record review revealed that this assessment was not initiated for the resident after the allegation of abuse. Progress notes documented some monitoring, but there were missing entries for specific shifts, and no formal change of condition assessment was completed. Interviews with nursing staff and the DON confirmed that the assessment should have been completed and that the incident constituted a change in condition per facility protocol. The failure to initiate the required change of condition assessment and consistent monitoring as outlined in the facility's policy had the potential to result in the resident not receiving appropriate care and monitoring to prevent complications or delayed medical treatment related to the abuse allegation. The DON and staff acknowledged these findings during interviews and record reviews.
Failure to Hold Blood Pressure Medication per Physician Order
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary medications by not following a physician’s order regarding the administration of midodrine, a blood pressure support medication. The physician’s order specified that midodrine 10 mg should be administered every 12 hours for hypotension, but the medication was to be held if the resident’s systolic blood pressure (SBP) was greater than 120 mmHg. Despite this, medical record review showed that the resident received midodrine on multiple occasions when their SBP exceeded the specified threshold, with documented SBP readings ranging from 121 to 132 mmHg at the time of administration. Interviews with both an LVN and the DON confirmed that the facility’s policy required licensed nurses to check for any BP parameters in the physician’s order and to hold the medication if the resident’s BP was outside those parameters. Both staff members acknowledged that the medication was administered and documented in the MAR even when the SBP was above the ordered limit. The DON verified the findings during a review of the resident’s medical record and MAR, confirming that the medication should have been held on the identified dates and times.
Failure to Maintain G-Tube Cleanliness and Follow Flushing Orders
Penalty
Summary
The facility failed to provide necessary care and services related to G-tube management for three residents receiving enteral feeding. For two residents, observations revealed that the medication ports on their G-tube tubing contained a black substance, indicating that the ports were not kept clean or patent as required. Staff interviews confirmed that the tubing should have been changed or cleaned, and the presence of the black substance was verified by both CNAs and LVNs during the observations. Medical record reviews supported that these residents had orders related to G-tube care, but the observed conditions did not meet those standards. For another resident, the facility did not follow physician orders to flush the enteral feeding tube with 30 ml of water before and after medication administration. Medical record reviews showed a lack of documentation that the required flushes were performed over a specified period, despite clear physician orders. The DON acknowledged that the licensed nurse should have documented the flushes and followed the physician's orders. These failures were identified through observation, interview, and review of medical records and facility policies.
Failure to Ensure Proper Authorization and Monitoring of Physical Restraint
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints, as required by policy and regulation. A resident with a history of CVA and left-sided hemiparesis was observed multiple times with a soft mitten restraint on the right hand. There was no active physician's order, updated informed consent, or current care plan authorizing the use of the restraint. The resident's medical record indicated that previous orders and consents for the mitten restraint had been discontinued years prior, and the care plan addressing the restraint had been resolved. Additionally, the resident's medication administration record did not show any current monitoring for the use of the restraint. Staff interviews confirmed that the soft mitten was being used without the necessary documentation, assessment, or monitoring. Both LVN and RN staff acknowledged that the facility's policy required a physician's order, family consent, care plan, and regular monitoring for restraints, none of which were in place for this resident. The administrator also acknowledged these findings. The lack of appropriate assessment, documentation, and monitoring for the use of the restraint constituted a failure to provide an environment free from unnecessary physical restraints.
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 2,775 citations issued within 25 miles in the last 12 months — including the 6 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Costa Mesa
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Victoria Healthcare And Rehabilitation Center | 0.8 mi | ★★★★★ | 1 | 0 |
| Mesa Verde Post Acute Care Center | 2.2 mi | ★★★★★ | 25 | 0 |
| Newport Nursing And Rehabilitation Center | 2.7 mi | ★★★★★ | 11 | 0 |
| Pelican Ridge Post Acute | 2.8 mi | ★★★★★ | 62 | 0 |
| Crystal Cove Care Center | 2.9 mi | ★★★★★ | 6 | 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.