Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Oakpark Healthcare Center during CMS and state inspections, most recent first.
A resident with Parkinsonism and psychotic disorder was prescribed Nuplazid for Parkinson's induced psychosis and later quetiapine for psychosis with delusions and visual hallucinations. The MAR included shift-based monitoring for both medications, but the quetiapine order did not identify specific target behaviors, and the DON stated it duplicated Nuplazid's indication for visual hallucinations. Facility policy required clinically indicated psychotropics, adequate efficacy monitoring, and documentation of specific target behaviors.
Incomplete and Non-Individualized Care Plans: The DON and record review showed that a resident with anxiety had a care plan that did not describe how the anxiety manifested, a resident receiving Lovenox had MAR documentation that did not show actual injection site rotation despite a care plan intervention to rotate sites, and a resident with a new seizure disorder had a care plan that lacked resident-specific seizure interventions such as padded side rails and ongoing seizure/medication monitoring.
Controlled substances were not reconciled in an Ativan eKIT and three other CS eKITs, and a medication cart count did not match the actual contents for a resident’s modafinil and lacosamide. An LPN stated doses were documented before administration, and the DON confirmed the documentation error. The facility also omitted an ordered enoxaparin injection for a resident with dysphagia, DM2, HTN, and cognitive impairment when the nurse did not check the eKIT or obtain a STAT pharmacy delivery.
Medication labeling and storage errors were found involving an open Rocklatan bottle, two latanoprost eye drop bottles, four albuterol inhalation solutions, and expired guaifenesin with dextromethorphan oral liquid cups. An LPN and the DON stated the eye drops were multi-dose medications that needed first-use dates, one unopened latanoprost bottle should have been refrigerated, the albuterol needed to stay in the foil pouch until use, and the expired stock should have been removed from use.
A facility failed to maintain sanitary kitchen conditions and follow food handling rules. A refrigerator in the dry storage room had rust and amber discoloration on the shelves, and the DSM stated the shelves could not be effectively cleaned because of the rust. In addition, a cook was observed wearing a bracelet while serving food from the stove to resident trays, with no gloves on, despite the facility policy and FDA Food Code limiting jewelry during food preparation.
A resident with DM, dysphagia, and cognitive impairment had inaccurate MAR documentation for subcutaneous meds. The MAR repeatedly listed “40” or “40 mg” in the injection site field for enoxaparin instead of an anatomical site, and the MAR for insulin glargine included an invalid blood sugar entry of “10” and an improper injection site entry of “10.” The DON acknowledged the entries were incorrect and not acceptable documentation.
Improper labeling and storage of multi-dose eye drop medications were found for three residents. An open latanoprost bottle and an open Rocklatan bottle were stored at room temperature without a date showing when use began, and another latanoprost bottle was kept at room temperature despite a pharmacy label directing refrigeration. The DON and nurses stated the bottles were multi-dose medications with six-week limits after opening and that the missing dates and improper storage made the expiration status unknown.
A resident with dysphagia, DM2, HTN, and cognitive impairment missed an ordered daily enoxaparin injection for DVT prophylaxis. The MAR and nursing note showed the dose was not given, the LPN did not check the EKit, and the LPN waited for pharmacy delivery instead of notifying the physician. The DON stated the medication was available in the EKit and that the physician should have been informed when the dose was not administered.
Ripped Side Rail Padding: A resident with moderate cognitive impairment and Parkinsonism had padded side rails ordered for bed mobility, but the foam padding on the lower portion of one side rail was ripped, leaving part of the rail exposed. An HKP said the damaged padding could not be cleaned, and the DON stated it looked bad and could allow the resident to bump against the rail and hurt herself.
A resident with Parkinsonism, psychotic disorder, depression, anxiety, and insomnia had an MDS that did not reflect documented hallucinations or delusions. The MAR showed repeated episodes of psychosis tied to Nuplazid and quetiapine use, but the MDS recorded no hallucinations or delusions; the DON acknowledged the discrepancy and that the MDS had not been accurately marked and transmitted.
A resident with epilepsy, cognitive impairment, and an order for Levetiracetam had a documented seizure event and hospital transfer, but the DON and an LVN could not provide records showing licensed nurses documented the presence or absence of seizure activity or monitored for adverse effects of anti-seizure medication as required by facility policy.
A resident with epilepsy, cognitive impairment, and significant assistance needs had a seizure while in bed and was transferred to the hospital via 911. During observation, the DON noted the resident’s metal side rail had no padding, even though the resident had a seizure disorder and was receiving levetiracetam for seizure control. The facility policy addressed bed safety and reducing environmental hazards.
Bent Window Screen Left Gaps in Shared Room: A shared resident room had an open window with a bent screen that left gaps at the bottom and side. The MS confirmed the openings could allow insects and dust into the room, and the DON stated the screen should be flush with no gaps. The room was occupied by one resident with Parkinsonism, acute respiratory failure, and dementia who needed substantial ADL assistance, and another resident with metabolic encephalopathy and COPD who needed moderate ADL assistance.
Three residents at risk for pressure ulcers had their low air loss mattresses (LALMs) set incorrectly, with settings not matching their actual weights as required by physician orders, facility policy, and manufacturer guidelines. Nursing staff and the DON confirmed the improper settings, which were identified through observation and record review.
Several residents at high risk for falls did not receive physician-ordered safety interventions, including floor mats, bed alarms, and personal alarms, as observed and confirmed by staff. Additionally, an LPN left medications unattended and out of eyesight at a bedside, contrary to facility policy. The DON acknowledged these lapses and their potential impact on resident safety.
The facility did not ensure that a resident received oxygen therapy according to physician orders, with one resident receiving a higher flow rate than prescribed. Additionally, three residents' oxygen tubing and humidifiers were not labeled with the date of last change as required by facility policy, and staff could not confirm when the equipment was last changed. These deficiencies were identified through observation, record review, and staff interviews.
Two residents experienced medication errors when one did not receive prescribed medications within the required time frame and another received eight crushed medications mixed together via g-tube, contrary to facility policy. These actions resulted in a medication error rate of 24.39%, significantly above the acceptable threshold.
Three residents experienced significant medication errors: one did not have insulin injection sites rotated as required, another did not receive carvedilol and pancrelipase at the prescribed times with meals, and a third received eight crushed medications mixed together via g-tube instead of each being administered separately with water flushes. These actions were contrary to physician orders and facility policy, as confirmed by staff and the DON.
Surveyors found that several opened food items, including ice cream, sweet relish, creamy Italian dressing, whole egg mayonnaise, and unsalted margarine, were not labeled with use by or expiration dates as required by facility policy. Both the Dietary Supervisor and DON confirmed that proper labeling was not followed, potentially affecting nearly all residents.
A CNA and an LVN failed to wear isolation gowns while providing high-contact care to two residents on enhanced barrier precautions for MDRO colonization and indwelling device use. Both staff members provided care—dressing and gastrostomy tube medication administration—without the required PPE, despite facility policy and signage indicating the need for gown and glove use during such activities.
A nurse entered a resident's room multiple times without knocking while administering medication, despite facility policy requiring staff to knock and request permission before entry. The resident had severe cognitive impairment and required significant assistance with daily activities. This action was confirmed by the nurse and acknowledged by the DON as a violation of the resident's right to dignity and privacy.
A resident with a history of COPD, UTI, and atrial fibrillation, who required substantial assistance and had moderately impaired cognition, tested positive for ESBL-producing E. coli. Despite lab confirmation and initiation of antibiotics and contact precautions, staff did not develop a comprehensive, person-centered care plan to address the resident's change in condition, as required by facility policy.
A resident with multiple diagnoses, including Parkinsonism and dementia, experienced an unanticipated change of condition involving right shoulder pain. Although a stat X-ray was ordered, the resident's pain care plan was not reviewed or revised by the interdisciplinary team as required by facility policy. The DON confirmed the care plan was not updated following the change of condition.
Two residents did not receive care in accordance with professional standards: one received repeated insulin injections in the same abdominal site despite a care plan and policy requiring site rotation, and another was given amiodarone despite blood pressure readings below the physician-ordered hold parameters. Facility staff and documentation confirmed these failures to follow established protocols.
A resident with cognitive and mobility impairments was found in bed without access to a call light, which was on the floor, preventing the resident from signaling for assistance. The DON confirmed this was against facility policy, which requires call lights to be within reach to ensure timely response to resident needs.
The facility failed to maintain the dignity of three residents by not knocking before entering their rooms. CNAs entered the rooms of residents with various medical conditions without knocking, despite acknowledging the importance of this action. The DON confirmed that knocking is required to respect residents' dignity, as per the facility's policy.
The facility failed to provide a private space for resident council meetings, as required by its policy. Meetings were held in the activity room with other residents and staff present, which compromised privacy. The Activity Director confirmed the lack of a designated private area, acknowledging the need for such a space to uphold residents' rights.
A facility failed to document non-pharmacological interventions before administering opioid pain medication to a resident with prostate cancer and impaired cognition. Despite a physician's order for as-needed medication, the facility did not record any attempts to use alternative pain management methods, as required by their policy. This oversight occurred over several days, potentially increasing the risk of adverse side effects.
The facility failed to administer blood pressure medications within prescribed parameters for a resident with multiple cardiovascular conditions, leading to potential adverse effects. Additionally, there was a discrepancy between the Medication Count Sheet and the Medication Administration Record for another resident receiving pain medication, highlighting documentation issues. These deficiencies were contrary to the facility's medication administration policy.
A resident with breast and bone cancer, requiring moderate assistance, was found without access to her call light, which was on the floor. The facility's policy requires call lights to be within reach to ensure timely assistance, but this was not adhered to, as confirmed by a CNA and the DON.
A resident with Parkinsonism and neurocognitive disorder experienced a fall, but the LTC facility failed to notify the resident's responsible party and physician as required by policy. The MDS Nurse confirmed the lack of documentation for these notifications, despite the care plan's directive to inform both parties. This oversight could have affected treatment decisions.
A facility failed to ensure a window screen was properly affixed in a resident room, creating a half-inch gap. This was observed during a facility tour and confirmed by the ADON, who noted the potential hazard of insect entry. The room was occupied by three residents, and the facility's maintenance policy requires safe and operable conditions.
A facility failed to develop a person-centered care plan for a resident's antibiotic use, despite the resident having a physician's order for fosfomycin to treat a urinary tract infection. The resident, who required supervision and partial assistance for ADLs, had no care plan addressing the antibiotic therapy, which was confirmed by the Infection Preventionist Nurse. This was contrary to the facility's policy requiring comprehensive care plans for each resident.
Two residents in the facility were found with long, untrimmed fingernails, indicating a failure to provide necessary assistance with personal hygiene. One resident, with conditions such as dementia, had dirty nails with black substances, while another resident, with heart failure and mobility issues, reported not being offered nail trimming services. The DON and a CNA acknowledged the oversight, emphasizing the importance of maintaining nail hygiene to prevent infection.
The facility failed to conduct post-fall evaluations for two residents identified as high risk for falls, following incidents where they experienced falls. Despite the facility's policy requiring such evaluations, there was no documented evidence of rehabilitation assessments being conducted. The Rehabilitation Director was unaware of the facility's fall policies, leading to non-compliance with the required procedures.
A facility failed to document a post-dialysis assessment for a resident with end-stage renal disease, as required by their care plan. The resident's Dialysis Communication Record lacked documentation for cognitive status, vital signs, and access site assessment post-dialysis. The DON confirmed the absence of documentation and highlighted the importance of these assessments for resident safety. This oversight represents a failure to follow the facility's policy for caring for residents with end-stage renal disease.
The facility failed to adhere to infection control protocols in two cases: a CNA did not wear PPE when entering a droplet isolation room, and a resident's nasal cannula tubing was found touching the floor. These actions were against the facility's policies and posed a risk of infection spread.
Duplicate Antipsychotic Use Without Specific Target Behavior Monitoring
Penalty
Summary
The facility failed to ensure that Resident 24 was free from unnecessary psychotropic medication use by not documenting specific target behaviors for quetiapine and by allowing duplicate antipsychotic treatment with quetiapine and Nuplazid. Resident 24 was admitted and re-admitted with diagnoses including Parkinsonism, psychotic disorder, depression, anxiety, and insomnia. The MDS dated 1/2/2026 showed a BIMS score of 12, indicating moderately impaired cognition for daily decision making, and the resident was noted to have no symptoms of feeling down, depressed or hopeless, no trouble falling asleep, no hallucinations or delusions, and routine antipsychotic use. The order summary dated 4/7/2026 showed Nuplazid 34 mg daily for Parkinson's induced psychosis manifested by verbalizing auditory and visual hallucinations that people are after her, and quetiapine 25 mg in the afternoon for psychosis manifested by delusions and visual hallucinations. The MAR for April 2026 included monitoring instructions for both medications, with hashmark documentation of episodes of psychosis. The record showed 10 episodes documented for Nuplazid use and 17 episodes documented for quetiapine use across multiple shifts in early April 2026. During the concurrent record review and interview on 4/7/2026, the DON stated psychotropic and antipsychotic medications should have specific indications and behaviors to ensure accurate behavior monitoring, assessment of medication effectiveness, and to prevent adverse consequences from unnecessary medications. The DON stated the quetiapine order did not identify a specific behavior manifestation for monitoring and duplicated Nuplazid's indication for psychosis manifested by visual hallucinations. Facility policy required residents to receive only clinically indicated medications, adequate monitoring for efficacy, and documentation of specific target behaviors when medications are prescribed for behavioral symptoms.
Incomplete and Non-Individualized Care Plans
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident 3, whose diagnoses included encephalopathy and anxiety disorder. The resident’s MDS indicated the resident was able to express ideas and wants and understand others, and required substantial or moderate assistance with most ADLs. During record review with the DON, the care plan titled "Anxiety" did not identify how the resident’s anxiety manifested. The DON stated the care plan should be accurate and individualized and should include the specific manifestations of anxiety because staff were monitoring the resident’s anxiety and assessing the effectiveness of the resident’s anxiety medication. The facility also failed to fully implement Resident 15’s care plan related to enoxaparin sodium injections. Resident 15 had diagnoses including dysphagia, type 2 diabetes mellitus, and hypertension, and the H&P indicated the resident did not have capacity to understand and make decisions. The care plan for skin discoloration in the abdomen related to insulin and Lovenox injections included an intervention to rotate injection sites regularly. However, review of the MAR from 3/01/2026 to 4/08/2026 showed the injection site field for enoxaparin sodium 40 mg/0.4 mL was documented as "40" on multiple dates. The DON stated this was not an anatomical site and that the resident’s care plan intervention to rotate injection sites was not followed. The DON also stated she could not provide documentation showing that the Lovenox injection sites were rotated. The facility further failed to develop an individualized care plan for Resident 40 after a new seizure diagnosis. Resident 40 was admitted and later readmitted with diagnoses including epilepsy, type 2 diabetes mellitus, and hypertension, and the H&P indicated a seizure diagnosis. The resident’s MDS showed moderate to severe cognitive impairment and significant assistance needs with transfers and mobility. The care plan titled "At Risk for injuries related to seizure disorder" included general interventions such as administering medication as ordered, assessing for auras, recording seizure characteristics, notifying the physician if seizures occurred, and giving levetiracetam 250 mg twice daily. During observation, the DON noted the resident’s metal side rails had no padding and stated the side rails must be padded to prevent potential injury during seizure. The DON and MDS nurse stated the care plan was not resident specific and was missing interventions such as padded side rails, monitoring and documenting seizures, and monitoring medication side effects.
Controlled Substance Reconciliation and Medication Omission
Penalty
Summary
The facility failed to reconcile controlled substances in medication emergency kits and in a medication cart, and it also failed to account for two doses of controlled substances for one resident. In Medication Room 1, an eKIT labeled Ativan eKIT and stored in the refrigerator contained controlled substances, but there was no accountability log documenting reconciliation of the inventory count at each shift change for April 2026. In Medication Cart South, three medication eKITs labeled NM726, NARC1 118, and NARC2 185 contained controlled substances, but there was no accountability log for shift-by-shift reconciliation for April 2026. In Medication Cart South, the count for one resident’s controlled substances did not match the medication count sheet. One dose of modafinil 100 mg was present in the bubble pack even though the count sheet indicated zero tablets should have remained after the last documented administration. One dose of lacosamide 50 mg was also present in the bubble pack even though the count sheet indicated 18 tablets should have remained after the last documented administration. LVN 4 stated that the doses had been overlooked and that the medications were documented on the count sheet before they were administered. The DON stated that the nurse failed to follow facility policy requiring documentation after preparation and administration. The facility also failed to administer enoxaparin sodium solution as ordered for a resident with dysphagia, type 2 diabetes mellitus, hypertension, moderate cognitive impairment, and no capacity to understand and make decisions. The resident’s physician ordered enoxaparin 40 mg/0.4 ml subcutaneously once daily for DVT prophylaxis. The MAR showed the dose was charted with code 9, and an administration note stated the medication was not given and needed to be reordered. The DON stated the resident did not receive the injection as ordered, and the nurse stated she did not check the eKIT or request a STAT pharmacy delivery when the medication was not available on the unit.
Medication Labeling and Storage Errors
Penalty
Summary
The facility failed to label and store several medications in accordance with manufacturer instructions and facility policy. In Medication Cart East, an open and used Rocklatan eye drop bottle for Resident 9 was found at room temperature without a date showing when it was first opened or used. The LVN stated the bottle was a multi-dose medication and needed a first-use date to determine when it expired, and the DON later stated the bottle was considered expired because it was not labeled with the date it began use. In Medication Cart South, an open latanoprost eye drop bottle for Resident 30 was found at room temperature without a date showing when room-temperature storage began. An unopened latanoprost eye drop bottle for Resident 45 was also found at room temperature without a date showing when room-temperature storage began, and it had a blue pharmacy label indicating refrigeration. The same cart contained an open foil pouch with four albuterol inhalation solutions for Resident 41 stored outside the pouch and without a date indicating when the inhalation solutions were removed from the foil pouch. The LVN stated the latanoprost bottles were multi-dose medications that required a first-use date, that unopened latanoprost should be refrigerated, and that the albuterol inhalation solutions needed to remain in the foil pouch until time of use. In the medication room, four unopened boxes containing 40 guaifenesin with dextromethorphan oral liquid cups for facility stock were found stored with other stock medications even though the manufacturer date showed they expired in February 2026. The DON acknowledged the cups were expired and stated expired medications should be removed from use and placed in the expired medication bin. Facility policy required multi-dose containers to be dated when opened, refrigerated medications to be stored in the refrigerator, and outdated non-controlled drugs to be stored in a secured area designated for disposal. Manufacturer information for latanoprost, Rocklatan, and albuterol also specified refrigeration or protection from light and storage in the pouch until use, and stated contaminated or improperly stored products may lose potency.
Rusty refrigerator shelves and improper jewelry use during food service
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen. During observation and interview in the dry storage room, the shelves in a refrigerator had rust with amber discoloration. The Dietary Service Manager stated the shelves should not be that way and that, because of the rust, they could not effectively clean the shelves. The facility policy titled Sanitation, last reviewed on 10/29/2025, stated the food service area would be maintained in a clean and sanitary manner and that shelves and equipment would be kept clean, maintained in good repair, and free from breaks, corrosion, cracks, and chipped areas that may affect their use or proper cleaning. The facility also failed to follow food handling requirements when a cook was observed wearing a bracelet while serving food from the stove to resident trays and had no gloves on. The Dietary Service Manager observed and validated that the cook was wearing a bracelet and stated she was unsure of the facility's policy on wearing bracelets in the kitchen. Review of the FDA Food Code, dated 2022, and the facility's Food Preparation and Service policy, last reviewed on 10/29/2025, showed that jewelry is not to be worn while preparing food except for a plain ring such as a wedding band, and that hand jewelry is to be covered with gloves.
Inaccurate MAR Documentation for Subcutaneous Medications
Penalty
Summary
The facility failed to maintain accurate clinical records for Resident 15, who had diagnoses including dysphagia, type 2 DM, and HTN, and was documented as lacking capacity to understand and make decisions with moderate cognitive impairment. During record review, the MAR for enoxaparin sodium 40 mg/0.4 mL showed repeated documentation of “40” or “40 mg” in the injection site field on multiple administration dates rather than an anatomical site, despite the order requiring subcutaneous administration and rotation of sites. The DON stated that licensed nurses are required to document the correct injection site for all subcutaneous medications and acknowledged that the entries of “40” were not anatomical sites and were incorrect. The MAR for Insulin Glargine Solution Pen 100 units/mL also contained inaccurate documentation. The order directed 10 units subcutaneously in the morning for DM, with instructions to hold if blood sugar was less than 100 mg/dL. The MAR showed that on one date the injection site field was documented as “NA” and the blood sugar was documented as “10,” and on another date the injection site field was documented as “10.” During interview and record review, the DON stated that the blood sugar entry of 10 was inaccurate because it was outside the expected physiological range, and that the injection site entry of 10 was not an acceptable or appropriate site entry. The facility policy required documentation to be objective, complete, and accurate, including the injection site when applicable.
Improper labeling and storage of multi-dose eye drop medications
Penalty
Summary
The facility failed to label and store multi-dose eye drop medications in accordance with manufacturer requirements and facility policy for three residents. In Medication Cart South, an open latanoprost bottle for one resident was found stored at room temperature without a date showing when room-temperature storage began. An unopened latanoprost bottle for another resident was also found at room temperature without a date indicating when that storage began, and it had an additional pharmacy label directing refrigeration. The nurse who was interviewed stated the bottles were not stored properly and that the open bottle’s expiration date could not be determined because the date of first use was unknown. In Medication Cart East, an open and used Rocklatan bottle for a third resident was found stored at room temperature without a date indicating when it was first opened or first used. The nurse who observed the bottle stated it was a multi-dose medication and should have had a date of first use to determine when it expired. The nurse also stated the bottle was considered expired because the first-use date was unknown. The DON confirmed that the latanoprost bottle for one resident and the Rocklatan bottle for another resident were not labeled with the date when first used, and that the latanoprost bottle for the third resident was not stored in the refrigerator. The DON stated the eye drop bottles were multi-dose medications with a six-week expiration after opening and that the bottles were considered expired, potentially lost efficacy, and no longer sterile. Facility policy required the date opened to be recorded on multi-dose containers and medications requiring refrigeration to be stored in the refrigerator. Manufacturer information stated unopened latanoprost should be refrigerated and opened latanoprost and Rocklatan could be stored at room temperature for up to six weeks after opening.
Failure to Notify Physician After Missed Anticoagulant Dose
Penalty
Summary
The facility failed to notify the physician when a resident did not receive enoxaparin sodium injection as ordered. Resident 15 was admitted with diagnoses including dysphagia, type 2 diabetes mellitus, and hypertension, and the H&P stated the resident did not have capacity to understand and make decisions. The MDS indicated moderate cognitive impairment, dependence for showering, substantial/maximal assistance with toileting hygiene, and partial/moderate assistance with eating and dressing. The physician order report showed an order for enoxaparin sodium 40 mg/0.4 ml subcutaneously once daily for DVT, with site rotation. The MAR for the month showed the medication entry coded as 9, indicating other/see progress notes. An administration note documented that the resident did not receive the medication and that it needed to be reordered. During interview, the DON stated the resident did not receive the Lovenox injection as ordered and that the medication was available in the EKit on the date of the missed dose, so it should have been obtained from there or requested STAT from the pharmacy. LVN 2 stated she was assigned to the resident during the shift when the dose was due, did not administer the medication because it was not available at the time, did not check the EKit, and waited for the pharmacy to deliver it. LVN 2 also stated she did not inform the physician and should have done so to determine whether new orders were needed. Facility policies cited in the report addressed anticoagulation therapy, medication administration, adverse consequences and medication errors, and prompt notification of the attending physician and resident representative when a resident’s condition or treatment changes.
Ripped Side Rail Padding
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for one resident when the padding covering the resident’s side rail was ripped. Resident 24 was admitted to the facility on 9/12/2022 and was most recently readmitted on 7/15/2024 with diagnoses including aftercare following joint replacement surgery and Parkinsonism. The resident’s MDS dated 1/2/2026 indicated moderate cognitive impairment and that the resident required moderate assistance for most ADLs. An order dated 4/22/2025 directed padded side rails while in bed to assist with bed mobility. During observation on 4/6/2026, the resident was in bed with black foam padding covering the side rails, and the padding on the lower portion of the left side rail was ripped, leaving part of the bed rail exposed. During a later observation and interview, the HKP stated the padding was ripped and could not be cleaned, and she would report it for replacement. The DON stated the ripped padding looked bad and that the missing portion could allow the resident to bump against the side rail and hurt herself. The facility policy titled Homelike Environment stated residents are to be provided with a safe, clean, comfortable, and homelike environment.
MDS Did Not Match Documented Psychosis Behaviors
Penalty
Summary
The facility failed to ensure one sampled resident’s MDS accurately reflected behavior indicators for psychosis. The resident had diagnoses including Parkinsonism, psychotic disorder, depression, anxiety, and insomnia. The MDS dated 1/2/2026 indicated a BIMS score of 12, no symptoms of feeling down, depressed, or hopeless, and no hallucinations or delusions, while also showing routine antipsychotic use. A review of the resident’s December 2025 MAR showed orders for Nuplazid 34 mg daily for Parkinson’s induced psychosis manifested by verbalizing auditory and visual hallucinations that people are after her, and quetiapine 25 mg in the afternoon for psychosis manifested by delusions and visual hallucinations. The MAR contained 54 documented episodes of psychosis for Nuplazid use and 77 documented episodes of delusions and visual hallucinations for quetiapine use. During interview, the DON acknowledged the discrepancy between the MAR and the MDS, stated the facility failed to accurately mark and transmit the MDS, and said the MDS needed correction.
Failure to Document Seizure Activity and Monitor Anti-Seizure Medication Effects
Penalty
Summary
The facility failed to document the presence or absence of seizure activity and failed to monitor for complications associated with anti-seizure medications for one sampled resident. Resident 40 was admitted with diagnoses that included epilepsy, type 2 diabetes mellitus, and hypertension, and the H&P also identified a seizure diagnosis. The MDS showed moderate to severe cognitive impairment and significant assistance needs with transfers and bed mobility. The physician ordered Levetiracetam 250 mg by mouth twice daily for seizure disorder, and the MAR showed the medication was administered from 4/3/2026 through 4/8/2026. Resident 40 had a documented seizure on 3/28/2026 at 7:25 P.M. and was transferred to the hospital via 911. During interview and record review, the DON stated she could not provide documentation showing licensed nurses were monitoring and documenting the presence and absence of seizure activity in accordance with facility policy. LVN 1 also stated that licensed nurses are required to monitor and document seizure activity each shift, including side or adverse effects of anti-seizure medications, but could not provide documentation showing this was done. The facility’s Seizures and Epilepsy - Clinical Protocol required staff and the physician to monitor the progress of individuals with a new seizure or seizure disorder, document periodically and objectively the presence or absence of seizure activity, and monitor for complications related to antiepileptic medications.
Unpadded Bed Side Rail for Resident With Seizure Disorder
Penalty
Summary
The facility failed to provide an environment free from accident hazards for one sampled resident with epilepsy. Resident 40 was admitted to the facility with diagnoses that included epilepsy, type 2 diabetes mellitus, and hypertension, and the H&P also documented a seizure disorder. The MDS showed moderate to severe cognitive impairment and indicated the resident required partial to moderate assistance with bed mobility and substantial to maximal assistance with transfers. The resident’s physician ordered levetiracetam twice daily for seizure disorder, and a licensed progress note documented that the resident had a seizure in bed and was transferred to the hospital via 911. During a concurrent observation and interview, the DON observed that the resident’s metal side rail had no padding and stated that the resident had recently had a seizure and been sent to the hospital, and that the side rails must be padded to prevent potential injury during seizures. The facility policy on Safety and Supervision of Residents stated that the environment should be as free from accident hazards as possible and that care team interventions should address individual risks related to environmental hazards, including bed safety.
Bent Window Screen Left Gaps in Shared Resident Room
Penalty
Summary
A window screen in the shared room of two residents was bent, leaving a gap between the screen and the window. During observation, the window facing outside was open and the screen was visibly bent, creating openings at the bottom and side of the screen. The Maintenance Supervisor confirmed the screen was bent and identified an approximate inch-wide gap at the bottom and a half-inch gap at the side, stating that insects and dust could come into the room through the openings. The facility's policy stated that windows are to be screened at all times and that residents are to be provided with a safe, clean, comfortable, and homelike environment. The room was occupied by one resident with Parkinsonism, acute respiratory failure, and dementia who was rarely or never able to express ideas or wants, rarely or never understood others, and required substantial assistance with all ADLs. The second resident had metabolic encephalopathy and COPD, had intact cognition, and required moderate assistance for most ADLs. The DON stated the screen should be flush with the window with no gaps so no insects can come into the room.
Incorrect LALM Settings for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to ensure that low air loss mattresses (LALMs) were set correctly according to residents' weights for three residents who were at risk for or had a history of pressure ulcers. For one resident with dementia, muscle wasting, and moderate cognitive impairment, the LALM was set at 350 lbs, while the resident's actual weight was 119 lbs. The physician's order required the LALM to be checked for proper placement and function every shift, but this was not done, as confirmed by the nurse and the Director of Nursing (DON). Another resident with severe cognitive impairment and muscle wasting had an LALM set at 50 lbs, despite a sticker on the device indicating it should be set between 100-150 lbs for the resident's actual weight of 128 lbs. The nurse confirmed the setting was incorrect and that the LALM was being used for pressure ulcer prevention. The DON acknowledged that the LALM should be set according to the resident's weight and that failure to do so could negatively affect the resident's skin. A third resident with dementia, difficulty walking, and epilepsy had an LALM set at 320, while the resident's weight was 108 lbs and a sticker on the device indicated the correct setting should be 100. Both the registered nurse and the treatment nurse confirmed the setting was incorrect and explained that improper settings could cause discomfort and increase the risk of pressure injury. Facility policy and the manufacturer's guide both required LALMs to be set according to the resident's weight, and staff interviews confirmed that this was not consistently done.
Failure to Implement Fall Prevention Interventions and Safe Medication Practices
Penalty
Summary
The facility failed to implement physician-ordered fall prevention interventions and safe medication administration practices for several residents at high risk for accidents. One resident with chronic obstructive pulmonary disease, dementia, and left-sided weakness was identified as high risk for falls and had a physician's order and care plan for a floor mat to be placed on the right side of the bed. However, during observation, no floor mat was present, and the assigned CNA confirmed never seeing one at the bedside. The DON acknowledged that the absence of the floor mat increased the resident's risk for complications from falls. Another resident with Parkinsonism, ataxic gait, and severe cognitive impairment had a physician's order for a personal alarm to be applied while in bed and in a wheelchair, with monitoring every shift. Despite documentation indicating staff monitored the alarm, observation revealed the resident in a wheelchair without any alarm device attached. The activity assistant confirmed the absence of the alarm, and the DON stated that staff did not follow the physician's order, which could result in recurrent falls and injuries. A third resident with encephalopathy, muscle wasting, and dementia, also at high risk for falls, had a physician's order and care plan for a bed alarm following an unwitnessed fall. Observation found the resident asleep in bed without a bed alarm, and the CNA confirmed its absence. The DON stated the importance of the bed alarm for alerting staff to unassisted transfers. Additionally, a nurse was observed leaving medications unattended and out of eyesight at a resident's bedside while retrieving equipment, which the nurse later verified. The DON stated that medications should not be left unattended to prevent unauthorized access and accidental ingestion. Facility policies reviewed supported the need for these interventions and safe practices.
Failure to Follow Physician Orders and Label Oxygen Equipment
Penalty
Summary
The facility failed to ensure that a resident received oxygen therapy as ordered by the physician. One resident was observed receiving oxygen at a rate greater than 5 liters per minute via nasal cannula, despite the physician's order specifying administration at 2 liters per minute as needed, with titration up to 5 liters per minute to maintain oxygen saturation at or above 92%. The registered nurse present was unsure of the correct oxygen flow rate and confirmed that the resident was receiving more than the ordered amount. The Director of Nursing also confirmed that staff are required to follow physician orders for oxygen administration. Additionally, the facility did not ensure that oxygen tubing and humidifiers for three residents were labeled with the date and time of the last change, as required by both physician orders and facility policy. Observations and interviews revealed that the oxygen tubing and humidifiers in use for these residents lacked proper labeling, and staff were unable to confirm when the equipment was last changed. The facility's policy and care plans for these residents specified that oxygen tubing should be changed weekly and labeled accordingly. The residents involved had significant medical histories, including dementia, chronic obstructive pulmonary disease (COPD), congestive heart failure, and other chronic conditions requiring continuous or as-needed oxygen therapy. The lack of adherence to physician orders and facility protocols regarding oxygen administration and equipment maintenance was confirmed through staff interviews, record reviews, and direct observation.
Medication Error Rate Exceeds Acceptable Threshold Due to Improper Administration
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as evidenced by 10 medication errors out of 41 observed opportunities, resulting in an error rate of 24.39%. Two residents were directly affected by these errors. For one resident with a history of malignant neoplasm of the pancreas, hypertensive heart disease with heart failure, and difficulty walking, the facility did not administer carvedilol and pancrelipase within the prescribed time frame. The physician's orders specified that carvedilol should be given with breakfast and dinner, and pancrelipase with meals, both within a one-hour window of the scheduled time. However, the medications were not administered as ordered, and the resident reported not receiving them with breakfast as required. The nurse involved acknowledged the delay and confirmed it was outside the facility's policy for timely medication administration. Another resident, who had severe cognitive impairment, Parkinsonism, gastrostomy status, and a history of urinary tract infections, received eight crushed medications mixed together and administered at once via a gastrostomy tube. Facility policy required that each medication be crushed and administered separately, with a water flush between each to prevent drug interactions and tube clogging. The nurse administering the medications confirmed that she did not follow this protocol and instead gave all medications together in one dose. The DON also confirmed that this was not in accordance with facility policy and that medications should be given separately through the g-tube. Both incidents were confirmed through observation, interviews with staff, and review of medical records and facility policies. The facility's own policies defined these actions as medication errors, as they were not in accordance with physician orders, manufacturer specifications, or accepted professional standards. The errors were acknowledged by the staff involved and the DON, and the facility's documentation supported that the medications were not administered as required.
Failure to Prevent Significant Medication Errors
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors in three distinct instances. For one resident with type two diabetes mellitus and severe cognitive impairment, staff did not rotate insulin injection sites as required. Documentation showed repeated administration of insulin in the same area of the abdomen over multiple days, despite care plan interventions and facility policy mandating site rotation. Both the LVN and DON confirmed that injection sites were not rotated, which was acknowledged as a medication administration error according to facility policy. Another resident with a history of pancreatic cancer and hypertensive heart disease did not receive prescribed medications, carvedilol and pancrelipase, at the times ordered by the physician. The resident reported not receiving these medications with breakfast as required, and the MAR confirmed administration times did not align with physician orders. The LVN and DON both stated that administering medications outside the prescribed timeframe is considered a medication error, and facility policy requires medications to be given within one hour of the scheduled time unless otherwise specified. In a third instance, an LVN was observed mixing eight crushed medications together and administering them all at once via a gastrostomy tube to a resident with parkinsonism and severe cognitive impairment. Facility policy and the LVN's own statements indicated that each medication should be administered separately with a water flush between each to prevent drug interactions and tube clogging. The DON confirmed that the medications were not administered correctly, as per facility policy, which defines such actions as a medication error.
Failure to Label and Date Opened Food Items in Storage
Penalty
Summary
Surveyors observed that the facility failed to store food items in accordance with professional standards for food service safety. Specifically, two open boxes of ice cream in the freezer, as well as one gallon each of sweet relish, creamy Italian dressing, whole egg mayonnaise, and one pound of unsalted margarine in the walk-in refrigerator, were not labeled with use by or expiration dates. The Dietary Supervisor confirmed during interviews that these items should have been labeled and acknowledged that the absence of proper labeling could affect residents' safety. The Director of Nursing also stated in an interview that food items should be labeled with use by and expiration dates to prevent spoilage. A review of the facility's policies confirmed that all frozen and opened food items are required to be labeled and dated according to storage guidelines. These deficiencies had the potential to affect 45 out of 46 residents in the facility.
Failure to Use Required PPE During High-Contact Care for Residents on Enhanced Barrier Precautions
Penalty
Summary
Certified Nursing Assistant (CNA) 3 failed to wear an isolation gown while dressing a resident who was on enhanced barrier precautions (EBP) due to colonization with ESBL-producing E. coli. The resident had a history of chronic obstructive pulmonary disease, urinary tract infection, and atrial fibrillation, and required substantial assistance with activities of daily living. Despite signage indicating EBP and facility policy requiring gown and glove use for high-contact care activities such as dressing, CNA 3 was observed providing care without the required personal protective equipment. CNA 3 stated she was unaware of the resident's EBP status and the need to wear an isolation gown during care. A Licensed Vocational Nurse (LVN) also failed to don a gown while administering medications via a gastrostomy tube to another resident on EBP for a history of multidrug-resistant organism (MDRO) colonization and indwelling device use. The resident had severe cognitive impairment and required maximal assistance for most activities of daily living. The LVN confirmed not wearing a gown during the medication administration, despite a physician's order and facility policy specifying the need for gown and glove use during high-contact care activities, including device care for residents on EBP. Interviews with the Infection Preventionist and Director of Nursing confirmed that both staff members should have worn isolation gowns during these high-contact care activities, as required by facility policy and the residents' precaution status. The facility's policy, last reviewed in October 2024, clearly outlined the use of enhanced barrier precautions, including gown and glove use for residents with MDROs or indwelling devices during high-contact care activities such as dressing and device care.
Failure to Knock Before Entering Resident Room Violates Dignity Policy
Penalty
Summary
Licensed Vocational Nurse 1 (LVN 1) failed to knock on a resident's door before entering the room on multiple occasions while administering medication. This was directly observed during a medication pass, and LVN 1 confirmed in an interview that she did not knock prior to entering the resident's room. The Director of Nursing (DON) stated that staff are expected to knock before entering residents' rooms to respect their privacy and dignity, as the facility is considered the residents' home. The resident involved had been admitted and readmitted to the facility with diagnoses including Parkinsonism and was assessed as having severely impaired cognitive skills, requiring maximal assistance with most activities of daily living. The facility's policy on dignity, last reviewed in October 2024, requires staff to knock and request permission before entering residents' rooms to promote residents' sense of well-being and respect their private space. The failure to follow this policy resulted in a violation of the resident's right to dignity and respect.
Failure to Develop Care Plan for Resident with ESBL-Positive UTI
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan for a resident who tested positive for extended spectrum beta-lactamase (ESBL) producing Escherichia coli (E. coli). The resident, who had a history of chronic obstructive pulmonary disease, urinary tract infection, and atrial fibrillation, was readmitted to the facility and required substantial assistance with activities of daily living due to moderately impaired cognition. Despite laboratory results confirming a urinary tract infection with ESBL-producing E. coli and the initiation of antibiotic therapy and contact precautions, there was no evidence that an interdisciplinary team (IDT) care plan meeting was conducted to address this change in condition. Interviews with facility staff, including the Infection Preventionist and the Director of Nursing, confirmed that the facility's policy required the development of a care plan in response to such changes in a resident's condition. Review of the resident's records and care plans from the relevant period showed that this requirement was not met, resulting in a failure to document and implement a care plan tailored to the resident's new diagnosis and needs.
Failure to Update Care Plan After Change of Condition
Penalty
Summary
The facility failed to update and revise a resident's care plan following a change of condition for one of three sampled residents reviewed under the Accidents care area. The resident, who had diagnoses including Parkinsonism, ataxic gait, and unspecified dementia, experienced right shoulder pain that was not anticipated. The resident's Minimum Data Set indicated severely impaired cognitive skills and required varying levels of staff assistance for daily activities. On the date of the change of condition, a stat X-ray was ordered for the resident's right shoulder. Despite the change of condition and the new physician order, the resident's care plan for pain, which had been initiated earlier, was not reviewed or revised to reflect the new development. The Director of Nursing confirmed that the care plan was not updated after the change of condition, even though facility policy requires care plans to be reviewed and updated after significant changes in a resident's condition. The failure to update the care plan was identified during a review of records and interviews with facility staff.
Failure to Follow Professional Standards in Medication Administration
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality in two separate instances involving medication administration. In the first instance, a resident with type 2 diabetes, unspecified dementia, and dependence on renal dialysis received repeated insulin injections in the same area of the abdomen, specifically the left lower quadrant, over multiple days. The resident's care plan specifically required rotation of insulin injection sites to prevent skin discoloration and tissue damage, and the facility's policy also mandated site rotation. Despite these directives, the Medication Administration Record (MAR) showed that staff administered insulin in the same location repeatedly, and both the LVN and DON confirmed that site rotation did not occur as required. In the second instance, another resident with a history of compression fracture, paroxysmal atrial fibrillation, and chronic obstructive pulmonary disease was prescribed amiodarone with specific hold parameters: the medication was to be withheld if the resident's systolic blood pressure (SBP) was less than 100 mm Hg or if the pulse was less than 60. The MAR indicated that the resident received amiodarone on two occasions when the SBP was below the prescribed threshold. The DON confirmed that the medication should not have been administered under these circumstances and that the medication should have been held and documented as such according to facility policy. Both deficiencies were confirmed through interviews and record reviews with facility staff, including the DON and LVN. The facility's own policies and procedures, as well as the residents' care plans and physician orders, were not followed in these cases, resulting in medication administration practices that did not meet professional standards of quality.
Call Light Not Accessible to Resident with Mobility and Cognitive Impairments
Penalty
Summary
A deficiency was identified when a resident with a history of encephalopathy, cerebrovascular disease, hemiplegia, and hemiparesis affecting the left dominant side was observed lying in bed without access to their call light, which was found on the floor. The resident was cognitively impaired and required moderate assistance from staff for transfers, toileting, dressing, and bathing, as documented in their Minimum Data Set. During an observation with the DON, it was confirmed that the call light was not within the resident's reach, contrary to facility policy, which requires that call lights be accessible to residents when in bed. The DON acknowledged that the lack of access to the call light could result in delayed care. The facility's policy also emphasizes the importance of ensuring timely responses to residents' needs by keeping call lights accessible.
Failure to Knock Before Entering Residents' Rooms
Penalty
Summary
The facility failed to maintain the dignity and respect of three residents by not knocking before entering their rooms. This deficiency was observed during a survey where Certified Nursing Assistants (CNAs) entered the rooms of three residents without knocking. Resident 29, who was admitted with heart failure, atrial fibrillation, and dementia, required moderate assistance with daily activities. Resident 30, with Parkinsonism and neurocognitive disorder, had intact cognitive skills and required supervision or assistance with daily activities. Resident 33, with heart failure and a history of falls, required substantial assistance with personal hygiene. The CNAs acknowledged their failure to knock and recognized the importance of doing so to show respect. The Director of Nursing confirmed that staff are expected to knock and introduce themselves before entering a resident's room to uphold the residents' dignity. The facility's policy on dignity, revised in February 2022, mandates that each resident should be cared for in a manner that promotes their well-being and self-esteem, which includes knocking and requesting permission before entering a resident's room. The failure to adhere to this policy was identified as a deficiency that could potentially affect the residents' self-esteem and self-worth.
Lack of Private Space for Resident Council Meetings
Penalty
Summary
The facility failed to implement its policy and procedure for the resident council by not providing a private space for meetings. This deficiency was identified during an interview with the Activity Director (AD), who stated that resident council meetings are held monthly in the activity room. However, the AD acknowledged that the meetings are not private, as other residents and staff who are not part of the council are present in the room, engaging in activities such as coloring or drawing. The AD admitted that the facility lacks a designated private area for these meetings, which is necessary for maintaining residents' privacy and rights. The facility's policy, titled 'Resident Council,' indicates that the care center should support the formation of a resident council and provide a private space for meetings. The policy also assigns responsibility to a staff member, often the Activities Director or social service designee, to organize, facilitate, and record the minutes of the meetings. Despite this policy, the facility did not ensure a private meeting space, potentially violating the residents' rights to hold private council meetings.
Failure to Document Non-Pharmacological Interventions Before Administering Opioids
Penalty
Summary
The facility failed to ensure that licensed nurses attempted non-pharmacological interventions before administering as-needed opioid pain medication to a resident. This deficiency was identified for one of the 14 sampled residents, who had been diagnosed with malignant neoplasm of the prostate and had moderately impaired cognition, requiring maximum assistance for most activities of daily living. The resident had a physician's order for oxycodone with acetaminophen to be administered every six hours as needed for severe pain. However, the facility did not document any non-pharmacological interventions prior to administering the medication on multiple occasions. The Director of Nursing confirmed that from early June to mid-June, the resident received the prescribed pain medication without any documented attempts of non-pharmacological interventions. The facility's policy on pain assessment and management, revised in March 2020, emphasized the importance of identifying pain and developing interventions consistent with the resident's needs, which could include non-pharmacological methods. The lack of documentation and adherence to this policy led to the deficiency, potentially increasing the resident's risk of adverse side effects from the medication.
Medication Administration and Documentation Deficiencies
Penalty
Summary
The facility failed to ensure that licensed nurses administered blood pressure medications within the prescribed parameters for one of the residents. Resident 16, who was admitted with diagnoses including atrial fibrillation, cardiomegaly, hypertension, and hypotension, had specific physician's orders for medications such as Amiodarone, Metoprolol, and Midodrine, with instructions to hold the medications if certain blood pressure or heart rate thresholds were not met. However, the review of the Medication Administration Record (MAR) revealed that these medications were administered even when the resident's blood pressure was below the specified parameters, contrary to the physician's orders. Additionally, the facility did not ensure that the Medication Count Sheet (MCS) coincided with the MAR for another resident. Resident 5, who had severely impaired cognition and required maximum assistance, had an order for hydrocodone-acetaminophen for severe pain. The MCS indicated that the medication was administered on two occasions, but these administrations were not documented in the MAR. This discrepancy was acknowledged by the Registered Nurse and the Director of Nursing, who emphasized the importance of documenting administered controlled substances in both records to prevent medication errors and ensure accurate pain management. The facility's policy on administering medications, which requires medications to be administered as prescribed and documented appropriately, was not followed in these instances. The Director of Nursing confirmed that medications should be held or administered according to the physician's order and that proper documentation is crucial to avoid potential medication errors and ensure continuity of care.
Resident's Call Light Not Within Reach
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, which is a device used by residents to signal their need for assistance from staff. This deficiency was identified for one of the sampled residents, who was admitted with diagnoses including breast cancer and bone cancer. The resident had intact cognition and required moderate assistance for some activities of daily living. The resident's care plan included interventions to place belongings within reach and to remind the resident to use the call light for help. During an observation, the resident was found awake in bed and stated she did not know where her call light was. The call light was observed on the floor, and a Certified Nursing Assistant confirmed it should have been within reach. The Director of Nursing emphasized the importance of having call lights accessible to residents to ensure timely responses to their needs. The facility's policy on answering call lights also indicated that call lights should be accessible to residents when in bed, from the toilet, shower, or floor.
Failure to Notify Responsible Party and Physician After Resident Fall
Penalty
Summary
The facility failed to adhere to its policy on notifying a resident's responsible party and physician following a change in condition, specifically after a fall incident involving a resident. The resident, who was admitted with diagnoses including Parkinsonism, neurocognitive disorder with Lewy bodies, and emphysema, experienced a fall. Despite the facility's policy requiring notification of the resident's physician and responsible party in such events, there was no documented evidence that these notifications were made. This oversight was identified during a review of the resident's progress notes, which lacked any indication that the responsible party and physician were informed of the fall. The resident's care plan explicitly stated the need to notify the physician and family member in the event of a fall. However, the MDS Nurse confirmed that the required notifications were not documented, highlighting a lapse in following the facility's procedures. The facility's policy, revised in 2017, mandates prompt notification of changes in a resident's condition to the attending physician and responsible party. The failure to notify could have impacted the resident's treatment decisions, as the physician might have needed to order additional interventions following the fall.
Window Screen Deficiency in Resident Room
Penalty
Summary
The facility failed to ensure that the window screen in one of the resident rooms was properly affixed to the frame, resulting in a gap or opening from top to bottom measuring half an inch. This deficiency was identified during an initial facility tour and room observation, where it was noted that the room was occupied by three residents. The Assistant Director of Nursing (ADON) confirmed the observation during a subsequent interview and acknowledged that the gap could pose a potential hazard by allowing insects to enter the room. The facility's policy on maintenance service, which was last reviewed in October 2023, indicates that the maintenance department is responsible for maintaining the building in a safe and operable manner at all times.
Failure to Develop Care Plan for Antibiotic Use
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for a resident's antibiotic use, which was identified as a deficiency. The resident, who was initially admitted in September 2022 and readmitted in September 2023, had diagnoses including muscle weakness, urinary tract infection, and gastro-esophageal reflux disease. The resident's Minimum Data Set (MDS) indicated they had the capacity to make themselves understood and required supervision and partial assistance for activities of daily living. A physician's order dated March 2024 prescribed fosfomycin for urinary tract infection prophylaxis, with a dosage change in June 2024. However, there was no care plan developed to address the antibiotic therapy. During an interview and record review with the Infection Preventionist Nurse (IPN), it was confirmed that there was no care plan for the resident's antibiotic use, despite the facility's policy requiring a comprehensive, person-centered care plan for each resident. The IPN acknowledged that a care plan should have been developed to state the goal of treatment and the interventions to achieve those goals, and it should be periodically evaluated. The absence of a care plan for the antibiotic therapy was identified as a failure to deliver necessary care and services, as per the facility's policy.
Failure to Provide Nail Care for Residents
Penalty
Summary
The facility failed to provide necessary assistance with nail trimming for two residents, leading to a deficiency in maintaining personal hygiene. Resident 23, who was admitted with conditions including hypertension, chronic obstructive pulmonary disease, and dementia, required moderate assistance with personal hygiene. Observations revealed that Resident 23 had long, dirty fingernails with black substances underneath, indicating a lack of grooming services. The Director of Nursing (DON) acknowledged the issue, stating that the nursing staff is responsible for ensuring residents are clean and well-groomed, including nail care. Similarly, Resident 33, who was admitted with heart failure, atrial fibrillation, and mobility issues, also had long, untrimmed fingernails. Despite requiring assistance with personal hygiene, Resident 33 reported that no one had offered to trim his nails. A Certified Nursing Assistant (CNA) confirmed the oversight, attributing it to the resident's recent readmission. The DON reiterated that both licensed nurses and CNAs are responsible for maintaining residents' nail hygiene to prevent infection and ensure cleanliness.
Failure to Conduct Post-Fall Evaluations
Penalty
Summary
The facility failed to implement its fall policy by not conducting post-fall evaluations for two residents, placing them at risk of not receiving appropriate care after fall incidents. Resident 29, admitted with conditions including heart failure, atrial fibrillation, and dementia, was identified as high risk for falls. Despite a fall occurring on 3/12/2024, there was no documented evidence of a rehabilitation evaluation being conducted post-fall, as confirmed by both the Director of Nursing and the Physical Therapy Assistant during interviews and record reviews. Similarly, Resident 30, with diagnoses including Parkinsonism, neurocognitive disorder with Lewy bodies, and emphysema, was also identified as high risk for falls. After a fall on 3/21/2024, where the resident was found slid down on a mat next to the bed, there was no documented rehabilitation assessment conducted. The Rehabilitation Director admitted to not being aware of the facility's fall policies and instead followed the company's protocols. The facility's policy, which requires a post-fall evaluation by a nurse or physical therapist, was not adhered to in these cases.
Failure to Document Post-Dialysis Assessment
Penalty
Summary
The facility failed to complete a post-dialysis assessment for a resident, identified as Resident 5, who required dialysis services. Resident 5 was admitted to the facility with diagnoses including end-stage renal disease, dependence on renal dialysis, and diabetes mellitus. The resident's care plan, initiated upon readmission, specified that vital signs should be taken pre- and post-dialysis. However, a review of the Dialysis Communication Record revealed that the post-dialysis assessment was not documented, leaving sections for cognitive status, vital signs, and access site assessment blank. During an interview and record review, the Director of Nursing confirmed the absence of documented evidence for the post-dialysis assessment. The DON emphasized the importance of these assessments to ensure resident safety and monitor any deviations from baseline conditions. The facility's policy on the care of residents with end-stage renal disease mandates care according to recognized standards, which includes thorough post-dialysis assessments. The lack of documentation for Resident 5's post-dialysis assessment represents a failure to adhere to these standards, potentially placing the resident at risk for complications.
Infection Control Lapses in PPE Use and Equipment Handling
Penalty
Summary
The facility failed to maintain proper infection control practices in two instances. In the first instance, a Certified Nursing Assistant (CNA 4) did not don the required personal protective equipment (PPE) before entering a droplet isolation room for a resident diagnosed with parainfluenza virus. Despite signage indicating droplet precautions, CNA 4 entered the room without gloves, gown, and goggles, stating that he was only in the room for a short period. This action was contrary to the facility's policy, which mandates wearing a mask, gown, and gloves for droplet precautions to prevent the spread of infection. In the second instance, a resident's nasal cannula tubing was observed touching the floor, which poses a risk of contamination. The resident, who required oxygen therapy due to congestive heart failure and atrial fibrillation, had severely impaired cognition and needed moderate assistance with daily activities. The CNA present acknowledged the tubing was on the floor and indicated she would replace it. The facility's policy and CDC guidelines emphasize keeping medical equipment off the floor to prevent bacterial contamination. Both deficiencies highlight lapses in adhering to established infection control protocols, which are critical in preventing cross-contamination and ensuring resident safety. The Director of Nursing confirmed the importance of following PPE protocols and keeping medical equipment off the floor to minimize infection risks.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 5,434 citations issued within 25 miles in the last 12 months — including the 28 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Tujunga
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| La Crescenta Healthcare Center | 1.6 mi | ★★★★★ | 15 | 0 |
| North Valley Nursing Center | 2.3 mi | ★★★★★ | 13 | 0 |
| Montrose Springs Skilled Nursing & Wellness Center | 2.5 mi | ★★★★★ | 7 | 0 |
| High Valley Lodge | 3.2 mi | ★★★★★ | 5 | 0 |
| Sunland Post Acute | 3.4 mi | ★★★★★ | 35 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.