Average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Orchard Post Acute during CMS and state inspections, most recent first.
A resident with Alzheimer’s disease, severe cognitive impairment, and total dependence for bed mobility was documented in the EMR and MDS as requiring two-person assistance for rolling and repositioning. A CNA raised the bed, removed side-support pillows, and attempted to turn the resident alone, despite facility expectations and policies that totally dependent residents receive two-staff assistance for such care. During this one-person transfer, the resident began moving extremities and rolled off the raised bed onto the floor, sustaining an eyebrow injury and requiring transfer to an acute care hospital for evaluation.
Ice Machine Exterior Not Kept Sanitary: The facility failed to maintain an ice machine in sanitary condition when white, black, and green substances were observed on the exterior. The CDM, MTD, ADM, and DON confirmed the buildup, and staff gave conflicting accounts about whether dietary or maintenance was responsible for cleaning it. The CDM stated dietary staff only wiped the front panel, while the MTD said he cleaned the inside but not the outside. Facility documents and the FDA Food Code required equipment and nonfood-contact surfaces to be kept clean.
A resident with type 2 diabetes experienced hypoglycemia, but the LTC facility failed to document a change of condition assessment as required by policy. Despite the resident's low blood sugar and symptoms, the necessary documentation was not completed, potentially delaying care. Interviews with staff confirmed the expectation for such assessments, highlighting a lapse in following professional standards.
A resident with Type 2 Diabetes Mellitus received insulin in a manner inconsistent with physician orders at an LTC facility. The resident had separate orders for Humalog insulin: a scheduled dose after meals and a sliding scale dose before meals. However, LVNs combined the doses and administered them after meals, contrary to the orders. This practice was confirmed through interviews and MAR reviews, with both LVNs acknowledging the deviation. The facility's policy emphasized adherence to physician orders, and the improper administration had the potential to affect the resident's health.
A resident's personal belongings were not inventoried upon admission and readmission, leading to the temporary loss of items like a wallet and checkbook. The facility's process required a CNA to list belongings and an LVN to enter them into the EMR, but this was not done. The items were later found in the dining room, highlighting a failure to follow the facility's policy on personal property.
The facility failed to administer oxygen according to physician orders for multiple residents, with discrepancies in the prescribed and actual oxygen flow rates. Additionally, an antibiotic was started for a resident without obtaining a necessary wound culture, contrary to standard practice. The facility also did not manage responsible party designations correctly for residents with cognitive impairments, leading to potential issues in informed consent.
The facility failed to properly store and label medications, with an unlocked medication cart, an emergency kit missing a zip tie, and hearing aid batteries stored with medications. Unlabeled medications and an insulin pen without a resident's name were found, posing risks of administration errors. A treatment cart was left unattended with keys in the lock, risking unauthorized access.
The facility failed to adhere to professional standards for food safety, affecting 91 residents. Observations included uncovered food in storage, lack of an air gap in the kitchen sink, uncalibrated and unsanitized thermometers, improper glove use, and incorrect portion control. A dietary aide was also seen without a hair net, risking contamination. These actions placed residents at risk for foodborne illness.
The facility failed to follow its policy for garbage disposal, as one trash bin was left uncovered with debris scattered around it. Interviews with the CDM, RD, and ED confirmed that trash bins should be closed and free of surrounding litter to prevent pest infestations. The facility's policy requires food waste to be stored in a manner inaccessible to pests.
Two residents experienced a lack of dignity in their care. A resident was addressed by an LVN using terms like 'mama' and 'honey' instead of her name, despite her preference. Another resident's foley catheter bag was left uncovered, compromising his privacy and dignity. Both incidents were contrary to the facility's policies on resident dignity and rights.
A resident with hereditary and idiopathic neuropathy was inaccurately assessed in their MDS, showing no impairment despite being dependent on staff for daily activities due to upper extremity limitations. The MDS Nurse did not perform a bedside assessment and relied on other staff inputs, leading to the error. Both the DON and MDS Nurse were new to their roles, contributing to the oversight.
The facility failed to implement baseline care plans for five residents on Aspirin, lacking monitoring for bleeding or bruising. This deficiency involved residents with various medical conditions, including venous insufficiency, joint replacement surgery, and cerebral infarction. Interviews confirmed that care plans should have been individualized to include anticoagulation monitoring.
The facility failed to create comprehensive care plans for three residents, leading to potential risks and unmet needs. A resident with psychosis lacked a care plan for their condition, another resident with hearing impairment did not have a care plan for hearing aid use, and a resident who spoke a foreign language had no communication plan. Staff interviews confirmed the absence of these care plans, which were necessary to address the residents' specific needs.
The facility failed to maintain an effective infection prevention and control program, with unsanitary conditions in the medication room, improper cleaning of pill crushers, and lapses in hand hygiene practices. Observations included dust, hair, and cockroaches in the medication room, pill crushers coated with debris, and staff not performing hand hygiene after handling bodily fluids or administering medication. These actions were contrary to facility policies and CDC guidelines.
A resident was prescribed Citalopram and Quetiapine without signing the informed consent form, despite being cognitively intact. The facility's policies on informed consent and medication use were not followed, as the consent form was not properly signed and dated by the resident and physician.
A resident was not treated with dignity during a meal when a CNA stood over her while spoon-feeding her breakfast in bed. The resident, dependent on staff for daily living activities, was not provided a respectful dining experience. Facility policy requires staff to sit at eye level with residents during meals to ensure dignity.
The facility failed to provide a homelike dining environment for three residents by serving meals on plastic trays without removing the items, contrary to the facility's policy. Staff interviews confirmed that the standard practice was to place items directly in front of residents to promote a homelike atmosphere, which was not followed in this instance.
A facility failed to complete and transmit MDS assessments for a resident who was discharged and readmitted, as required by guidelines. The MDSN did not follow the RAI guidelines, leading to potential unmet needs. The DON was not trained on MDS, and the ADM expected complete and accurate assessments.
A resident with severe cognitive impairment and multiple medical conditions experienced a decrease in meal intake, yet the LTC facility failed to update the care plan to address this change. Despite staff observations and reports of the resident's refusal to eat, the care plan had not been revised, potentially leaving the resident's nutritional needs unmet.
A resident was served a sandwich on white bread instead of their preferred wheat bread, leading to refusal to eat. The facility's staff, including the Dietary Manager and CNAs, failed to communicate and adhere to the resident's meal preferences, as indicated on the meal ticket. This oversight was acknowledged by the staff, highlighting a breakdown in procedure adherence.
A resident's hearing aids were not documented on her inventory sheet, leading to her not wearing them and staff being unaware of their location. The resident, with moderate cognitive impairment, was observed without her hearing aids, and staff had to raise their voices to communicate. The facility's policies required documentation of personal belongings, but the hearing aids were not included, resulting in a lack of awareness among staff.
Failure to Provide Required Two-Person Assistance During Bed Mobility Resulting in Fall
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and assistance to prevent an accident for a resident who was totally dependent on staff for bed mobility and activities of daily living. The resident was admitted with Alzheimer’s disease and adult failure to thrive, and an MDS dated 3/2/26 documented a BIMS score of 1/15, indicating severe cognitive impairment. Facility documentation, including Section GG-Functional Abilities-Mobility and a bed mobility record dated 4/1/26–4/17/26, showed the resident was dependent for rolling left and right and for sit-to-lying, requiring the assistance of two or more helpers for safe completion of these activities. During an interview, CNA 1 reported entering the resident’s room to provide care, raising the bed, and removing the pillows that had been supporting the resident on both sides. CNA 1 noted the resident was lying close to the left edge of the bed and proceeded to turn the resident to the left side to provide care while performing the task alone, despite knowing the resident was dependent on staff for all care, including toileting, turning, and repositioning. While CNA 1 was attempting to calm the resident, who began moving her arms and legs, the resident rolled off the raised bed onto the floor. As a result of this fall, the resident sustained an injury to the right eyebrow and was transferred to an acute care hospital for further evaluation. Interviews with CNA 2, the MDS nurse, LVN 2, the DON, and the administrator confirmed that the facility’s process and expectation were that residents who were totally dependent on care, including this resident, required two-person assistance for turning and repositioning to ensure safety and comfort. The facility’s policies on Activities of Daily Living and Safety and Supervision of Residents stated that residents unable to carry out ADLs independently must receive necessary services and that the facility strives to make the environment as free from accident hazards as possible through adequate supervision and communication of specific interventions. Despite these documented requirements and expectations, CNA 1 performed the turning and repositioning task alone, which led to the resident’s fall and injury.
Ice Machine Exterior Not Kept Sanitary
Penalty
Summary
The facility failed to follow professional standards of practice for food service safety and sanitary conditions related to one ice machine. During a concurrent observation and interview with the CDM, the ice machine was noted to have white, black, and green substance on the exterior side. The CDM confirmed the presence of the white and green substance and identified the white substance as calcium buildup, while stating she could not confirm what the green substance was. The MTD later confirmed the substances were present, and when the surveyor wiped the green substance with a clean white paper towel, a brownish green substance was seen on the towel. During the same observation, the MTD ran his finger along the side of the ice machine where the black substance was present and had a small quantity of the substance on his finger. The MTD stated it was almost time for his monthly cleaning and explained that his main objective was to clean the inside of the machine. He stated he cleaned the inside of the ice machine but did not clean the outside. The CDM stated dietary staff only wiped down the front panel and dispensing area, while the MTD stated maintenance was responsible for the monthly cleaning. Staff interviews showed conflicting understanding of who was responsible for cleaning the ice machine, with some stating dietary staff cleaned it daily, others stating maintenance was responsible, and others being unsure. The CDM later stated cleaning the ice machine was a daily responsibility assigned to the aides and acknowledged she did not realize the dietary staff needed to clean the sides and underneath areas more thoroughly. She also stated she did not notice the rust and water buildup on the ice machine and that both dietary staff and maintenance should work together to ensure there was no buildup. The ADM and DON reviewed the photographs and confirmed the substances were present. Facility documents stated the Dietary Supervisor was to maintain equipment in sanitary condition, the ice machine user manual required the machine and ice storage bin to be kept in a sanitary condition, and the user manual noted exterior panels would require cleaning. The FDA Food Code section reviewed stated nonfood-contact surfaces of equipment shall be kept free of accumulation of dust, dirt, food residue, and other debris.
Failure to Document Change of Condition for Hypoglycemic Episode
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality for a resident who experienced an episode of hypoglycemia. The resident, who was admitted with a diagnosis of type 2 diabetes mellitus, had a documented fasting blood sugar level of 51, indicating hypoglycemia. Despite this significant change in condition, the licensed nurses did not complete a change of condition assessment as required by the facility's policy and procedure. The resident's medical records showed that staff reported the resident was sweating and had to change clothes twice within a short period. When a nurse entered the room, the resident was awake but not verbally responsive. However, there was no documentation of a change of condition assessment in the electronic medical record, which was confirmed during an interview with a registered nurse. The facility's policy mandates that such assessments be completed to communicate changes in a resident's health status effectively. Interviews with the director of nursing and a licensed vocational nurse confirmed that the facility's expectation was to complete a change of condition assessment when there was a change in a resident's health status. The failure to document and assess the resident's change in condition resulted in incomplete documentation and had the potential to delay care. The facility's policies on change in condition and charting and documentation emphasize the importance of accurate and complete documentation to ensure appropriate communication and response to changes in a resident's condition.
Improper Insulin Administration
Penalty
Summary
The facility failed to ensure that insulin administration for a resident with Type 2 Diabetes Mellitus was conducted according to the physician's orders. The resident had two separate orders for Humalog insulin: a scheduled dose of 10 units to be administered subcutaneously after meals and a sliding scale dose to be administered before meals based on blood sugar levels. However, Licensed Vocational Nurses (LVNs) 1 and 2 combined the sliding scale insulin with the scheduled dose and administered the total amount after meals, contrary to the physician's instructions. The resident, who was cognitively intact, reported receiving more than 10 units of insulin after meals, which was confirmed by the Medication Administration Records (MAR) and interviews with the LVNs. LVN 1 admitted to administering the combined insulin doses after meals on multiple occasions, while LVN 2 also confirmed doing the same on different dates. Both LVNs acknowledged that they did not follow the physician's orders, which required the sliding scale insulin to be administered before meals. The Assistant Director of Nursing (ADON) and the Director of Nursing (DON) were aware of the separate insulin orders but were not informed that the LVNs were administering the insulin in a manner inconsistent with the physician's orders. The facility's policy and procedure for insulin administration emphasized the importance of following physician orders and administering medications safely and timely. The deviation from the prescribed insulin administration protocol had the potential to cause unstable blood sugar levels in the resident, affecting their health and wellness.
Failure to Inventory Resident's Belongings
Penalty
Summary
The facility failed to adhere to professional standards of quality by not completing an inventory of personal belongings for a resident upon admission and readmission. The resident, who was cognitively intact with a BIMS score of 15, was admitted with personal items including a wallet, checkbook, and bank card. However, no inventory list was completed during the initial admission or subsequent readmissions, as confirmed by the medical records and interviews with staff. The process at the facility required a Certified Nursing Assistant (CNA) to take inventory of a resident's belongings and hand it over to a Licensed Vocational Nurse (LVN) for entry into the Electronic Medical Record (EMR). However, this process was not followed for the resident in question. Interviews with the CNA, LVN, and Director of Nursing (DON) revealed that the inventory list was not completed, and the facility's policy and procedure for personal property were not adhered to. The failure to inventory the resident's belongings led to the temporary loss of the resident's wallet, checkbook, and bank card, which were later found in the dining room. The Social Services Director confirmed that a grievance had been filed regarding the missing items, and the facility's policy required an inventory to be completed upon admission to prevent such occurrences. The lack of documentation and adherence to policy posed a risk to the resident's personal belongings.
Oxygen Administration and Antibiotic Protocol Failures
Penalty
Summary
The facility failed to ensure that oxygen was administered according to physician orders for several residents. Resident 40 was supposed to receive 3L/min of oxygen via nasal cannula but was only receiving 2.5L/min, as confirmed by both the resident and the Licensed Vocational Nurse (LVN) 8. This discrepancy was observed over multiple days, and the Director of Nursing (DON) confirmed that the expectation was for licensed nurses to check and ensure the correct oxygen settings. Similarly, Resident 337 was receiving 5L/min of oxygen instead of the ordered 2L/min, which was verified by LVN 1. The DON emphasized the importance of following physician orders to prevent potential harm. The facility also failed to follow professional standards regarding antibiotic administration. Resident 38 was started on an antibiotic without obtaining a wound culture, which is not standard practice. The Infection Preventionist (IP) and the DON both acknowledged that a wound culture should have been done before starting the antibiotic. The facility's policy on antibiotic stewardship was not followed, as it requires cultures to be obtained before initiating antimicrobial therapy to ensure appropriate use and prevent resistance. Additionally, the facility did not properly manage the responsible party (RP) designations for residents with cognitive impairments. Resident 24's RP was not informed about changes to the resident's low air loss mattress, despite the resident having a moderate cognitive impairment. Similarly, Resident 19, who also had moderate cognitive impairment, was incorrectly listed as her own RP. The facility's policy requires residents with a BIMS score under 13 to have an RP, but this was not adhered to, leading to potential issues in informed consent and decision-making for these residents.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to adhere to proper medication storage and labeling protocols, resulting in several deficiencies. One medication cart was left unlocked and unattended by an LVN, allowing potential unauthorized access to medications. Additionally, an emergency kit in the medication storage room was found with a missing zip tie, which could lead to unauthorized access and tampering. Hearing aid batteries were improperly stored with medications in a medication cart, increasing the risk of confusion and potential administration errors. Further observations revealed that medications were stored in unlabeled containers, including a multivitamin pill in a cup and sodium pills in a clear plastic bag, which were not properly discarded. An insulin pen was also found without a resident's name or open date, posing a risk of administration to the wrong resident. These lapses in labeling and storage practices could lead to medication errors and compromised resident safety. Additionally, a treatment wound cart was left unattended with keys in the lock, creating a risk for residents to access treatment supplies unsupervised. Interviews with staff, including LVNs and the DON, confirmed that these practices were against the facility's policies, which require medications and treatment supplies to be securely stored and attended by authorized personnel.
Food Safety Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure food was stored and prepared in accordance with professional standards for food service safety, affecting 91 of 96 residents. Observations revealed several deficiencies, including an uncovered plastic container of dry bran cereal and an uncovered Styrofoam cup with brown liquid left on top of an ice chest in the dry food storage area. These actions were contrary to the facility's policy and procedure, which mandates that all foods be covered to prevent contamination. Further deficiencies were noted in the kitchen, where the food preparation sink lacked an air gap, a critical component to prevent backflow and contamination. The cook did not calibrate the food thermometer before use, nor was it sanitized before being placed in freshly cooked broccoli. Additionally, the temperature of the soup was not measured before serving, and the cook failed to change gloves after touching multiple surfaces, leading to potential cross-contamination. The cook also did not adhere to portion control guidelines, using the same scoop size for small, regular, and large portions, which could affect residents' nutrition. A dietary aide was observed walking through the kitchen without a hair net, risking contamination of the food. These failures collectively placed residents at risk for foodborne illness, as the facility did not adhere to its own policies and professional standards for food safety.
Improper Garbage Disposal Practices
Penalty
Summary
The facility failed to adhere to its policy and procedure for Food-Related Garbage and Refuse Disposal, as observed during a survey. One of the three outside trash bins was found uncovered, with a significant amount of plastic and debris scattered on the ground behind it. This observation was made in the trash bin storage area behind the facility. Interviews with the Certified Dietary Manager (CDM), Registered Dietitian (RD), and Environmental Director (ED) confirmed that the trash bins should remain closed at all times, and there should be no trash on the ground to prevent attracting pests. The facility's policy, dated October 2017, clearly states that all food waste should be stored in containers that are inaccessible to pests, and outside dumpsters should be kept closed and free of surrounding litter. The Administrator also acknowledged that the trash bins should always be covered to discourage insects and animals from accessing the trash, which could lead to the spread of infection. The failure to comply with these procedures had the potential to attract animals, insects, and pests, leading to infestations and unsanitary conditions.
Failure to Uphold Resident Dignity
Penalty
Summary
The facility failed to ensure residents were treated with respect and dignity, as evidenced by two specific incidents involving Resident 14 and Resident 67. In the first incident, a Licensed Vocational Nurse (LVN) addressed Resident 14 by calling her 'mama' and 'honey' instead of using her name, despite Resident 14 expressing a preference to be addressed by her name. Resident 14, who was moderately impaired with a Brief Interview for Mental Status (BIMS) score of 8 out of 15, stated that being called 'mama' or 'honey' did not sound right to her. The facility's policy on dignity, which was reviewed with the Director of Nursing (DON), indicated that residents should be addressed by their name unless specified otherwise in their care plan. In the second incident, Resident 67's foley catheter drainage bag was observed uncovered, violating his right to dignity and privacy. Resident 67 expressed discomfort with the visibility of his urine, especially when it was red with blood, during a hospital transfer. A Certified Nursing Assistant (CNA) and an LVN both acknowledged that the catheter bag should have been covered to preserve Resident 67's dignity. The facility's policy on resident rights emphasized treating all residents with kindness, respect, and dignity, which includes maintaining their privacy. The DON confirmed that the expectation was for all staff to ensure catheter bags are covered to uphold residents' dignity.
Inaccurate MDS Assessment for Resident with Neuropathy
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the health and functional status of a resident, specifically regarding the resident's functional limitation in the range of motion. The deficiency was identified for a resident who was observed to be dependent on staff for all activities of daily living due to upper extremity impairments. Despite these observations, the resident's quarterly MDS assessments inaccurately indicated no impairment of the upper extremities. The MDS Nurse admitted to not performing a bedside assessment and relied on information from CNA charting, therapy, and the Director of Nursing (DON), leading to the inaccurate coding. The resident in question was admitted with diagnoses including hereditary and idiopathic neuropathy, which contributed to the functional limitations observed. The MDS Nurse acknowledged the inaccuracy in the assessments and expressed the need to review the Resident Assessment Instrument (RAI) manual to prevent future errors. The DON, who was new to the position, was not oriented on MDS processes, and the Administrator noted that the MDS Nurse was also new to her role. The facility's policy emphasized the importance of accurate assessments, but the lack of proper assessment and communication led to the deficiency.
Failure to Implement Baseline Care Plans for Anticoagulation Monitoring
Penalty
Summary
The facility failed to develop and implement baseline care plans for five residents who were on anti-platelet medication, specifically Aspirin, to monitor for signs and symptoms of bleeding or bruising. This deficiency was identified for Residents 25, 31, 58, 67, and 74, who did not have individualized care plans addressing the need for anticoagulation monitoring. The absence of these care plans placed the residents at risk for complications related to bleeding, as their care needs were not adequately planned or monitored by licensed nurses. Resident 25, who had been in the facility for four months, was on Aspirin for prophylaxis but did not have a care plan for monitoring bleeding or bruising. Similarly, Resident 31, admitted with a history of joint replacement surgery and other conditions, was also on Aspirin without a care plan for monitoring bleeding. Resident 58, with a non-healing abdominal wound, was taking Aspirin but lacked a care plan for anticoagulation monitoring, despite having orders to observe for bleeding every shift. Resident 67, who had recently returned from the hospital due to bleeding after a urinary catheter change, was on Aspirin for stroke prophylaxis but did not have a care plan for monitoring bleeding. Lastly, Resident 74, with a history of cerebral infarction and Alzheimer's disease, was on Aspirin without a care plan for monitoring side effects. Interviews with the LVN and the DON confirmed that care plans should have been individualized and included monitoring for bleeding and bruising for residents on anti-platelet medications.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for three residents, leading to potential risks and unmet needs. Resident 55, who was admitted with a diagnosis of psychosis, did not have a care plan addressing this condition. Despite being cognitively intact, Resident 55 exhibited behaviors such as yelling and non-compliance with activities of daily living. Interviews with staff, including CNAs and LVNs, revealed that there was no care plan in place for psychosis, which was acknowledged as necessary by the Director of Nursing. Resident 47, who had moderate cognitive impairment and was hard of hearing, did not have a care plan for the use of hearing aids. Observations showed that Resident 47 was not wearing hearing aids, and staff had to raise their voices to communicate. Interviews with CNAs and LVNs confirmed that the use of hearing aids should have been included in the care plan upon admission to ensure staff awareness and proper communication of care needs. Resident 387, who spoke a foreign language, lacked a care plan for communication. The absence of a communication plan meant that staff were unaware of the resident's language needs, and family members had to assist with translation. The Director of Nursing and other staff acknowledged the importance of a communication care plan, which was not developed upon admission, leaving the resident's communication needs unmet.
Infection Control Deficiencies in Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during the survey. In the medication room, unsanitary conditions were noted, including the presence of dust, hair, and cockroaches on the floor, as well as the absence of a trash bin for proper disposal of waste. This was confirmed by a Licensed Vocational Nurse (LVN) and the Director of Nursing (DON), who acknowledged that the medication room should be kept clean according to facility policy and CDC guidelines. Additionally, the facility did not adhere to proper cleaning protocols for pill crushers. Observations revealed that pill crushers on multiple medication carts were coated with powder-like debris, and LVNs were using bleach disinfectant wipes contrary to the manufacturer's instructions, which specified cleaning with soap and water. The DON confirmed that bleach should not be used and that the pill crushers should be kept clean to prevent medication mixture. Furthermore, there were lapses in hand hygiene practices among staff. A Certified Nursing Assistant (CNA) failed to perform hand hygiene after handling a bag with feces, and an LVN did not remove gloves or perform hand hygiene after administering insulin to a resident. These actions were contrary to the facility's hand hygiene policy, which emphasizes the importance of hand hygiene to prevent cross-contamination and the spread of infections. The DON and Infection Preventionist reiterated the necessity of adhering to hand hygiene protocols to maintain a safe environment for residents.
Failure to Obtain Informed Consent for Psychotropic and Antipsychotic Medications
Penalty
Summary
The facility failed to ensure that informed consent was obtained for the use of psychotropic and antipsychotic medications for one resident. The resident, who was cognitively intact with a BIMS score of 14, was prescribed Citalopram and Quetiapine without signing the informed consent form. The resident was admitted with diagnoses of major depressive disorder and bipolar disorder, and began taking these medications shortly after admission. However, the informed consent form was not signed by the resident, and the physician's signature was undated, rendering the consent invalid. Interviews and record reviews revealed that the Licensed Vocational Nurse and the Pharmacy Consultant were aware of the missing signatures and had recommended obtaining them. Despite these recommendations, the consent form remained unsigned by the resident. The Director of Nursing acknowledged that the informed consent was not valid without the proper signatures and dates, and that medications should not have been administered without a valid consent. The facility's policies on informed consent and medication use were not followed, leading to the deficiency.
Resident Dignity Compromised During Meal Assistance
Penalty
Summary
The facility failed to ensure that a resident was treated with dignity and respect during a meal. Specifically, a Certified Nursing Assistant (CNA) was observed standing over a resident while spoon-feeding her breakfast in bed. The resident, who was dependent on staff for all activities of daily living due to conditions such as intervertebral disc degeneration and muscle weakness, was lying in bed with the head elevated and the bed in the highest position. The CNA acknowledged that standing over the resident while feeding her was inappropriate and recognized it as a dignity issue. Interviews with another CNA and the Director of Nursing (DON) confirmed that the proper practice when assisting residents with meals in bed is to lower the bed, elevate the head of the bed, and sit next to the resident at eye level. The facility's policy and procedure on dignity and resident rights emphasize the importance of treating residents with respect, kindness, and dignity, which was not adhered to in this instance.
Failure to Provide Homelike Dining Environment
Penalty
Summary
The facility failed to provide a homelike dining environment for three residents when meals were served on plastic trays without removing the food plates, beverage glasses, utensils, and napkins. This practice was observed during a dining session, where staff placed the entire tray in front of each resident, contrary to the facility's policy and procedure for creating a homelike environment. The residents involved in this observation included individuals with significant medical conditions such as hemiplegia, hemiparesis, and a displaced fracture of the femur. Interviews with various staff members, including a Center Scheduler, Rehabilitative Nursing Assistant, Certified Dietary Manager, Licensed Vocational Nurse, and the Director of Nursing, confirmed that the standard practice was to remove items from the plastic trays and place them directly in front of residents to promote a homelike atmosphere. The staff acknowledged that leaving items on the trays did not align with the facility's policy and the residents' rights to a comfortable and homelike environment. The facility's policy emphasized person-centered care and minimizing institutional characteristics, which was not adhered to in this instance.
Failure to Complete and Transmit MDS Assessments
Penalty
Summary
The facility failed to meet the required timelines for encoding, completion, and transmission of Minimum Data Set (MDS) assessments for a resident, identified as Resident 55. The MDS Nurse (MDSN) did not complete or transmit the necessary discharge and readmit MDS tracking assessments for this resident. Resident 55 was sent to an acute hospital and readmitted to the facility, but the MDSN did not find completed and transmitted MDS assessments for these events. The MDSN acknowledged the oversight, stating it was a mistake and that she did not follow the Resident Assessment Instrument (RAI) guidelines, which recommend opening assessments for discharges and readmissions. The Director of Nursing (DON) was unaware of the MDS process and had not been trained on it, while the Administrator expected MDS assessments to be complete and accurate, noting that the MDSN was new and could have asked questions if unsure. The facility's policy requires individuals completing MDS assessments to certify their accuracy, and the professional guidelines specify that discharge assessments are necessary when a resident is admitted to a hospital or other care setting. This deficiency resulted in the potential harm of residents' needs upon discharge going unmet.
Failure to Update Care Plan for Decreased Meal Intake
Penalty
Summary
The facility failed to revise and implement a person-centered comprehensive care plan for a resident, identified as Resident 34, who experienced a decrease in meal intake. Despite being admitted with multiple medical conditions including cerebrovascular disease, type two diabetes mellitus, hypertension, heart failure, and gastroesophageal reflux disease, the resident's care plan was not updated to address the significant change in their nutritional intake. Observations and interviews revealed that Resident 34 had severe cognitive impairment and was refusing meals, consuming less than 25% of his lunch on one occasion. Certified Nursing Assistants (CNAs) and a Licensed Vocational Nurse (LVN) noted the resident's decreased appetite and meal intake over a two-week period, yet the care plan had not been revised since the previous month. Interviews with facility staff, including CNAs and the Director of Nursing (DON), confirmed that the resident's decreased food intake was recognized but not documented in the care plan. The facility's policy and procedure for comprehensive person-centered care plans require updates when there is a significant change in a resident's condition, which was not adhered to in this case. The failure to update the care plan had the potential to leave Resident 34's nutritional needs unmet, as the care plan lacked interventions to address the decrease in meal intake.
Failure to Accommodate Resident Meal Preference
Penalty
Summary
The facility failed to accommodate a resident's meal preference by serving a sandwich on white bread instead of the requested wheat bread. This incident was observed during a meal service, where the resident expressed dissatisfaction and refused to eat the lunch provided. The resident's meal ticket clearly indicated a preference for wheat bread, which was not honored due to the kitchen running out of wheat bread the previous night. The Dietary Manager acknowledged the oversight and confirmed that the resident's preferences should have been followed. Interviews with various staff members, including the Dietary Manager, Dietary Aid, CNA, LVN, and the Director of Nursing, revealed a breakdown in communication and procedure adherence. Staff members were aware of the importance of following meal preferences to ensure residents eat their meals. However, the failure to notify the Dietary Manager about the shortage of wheat bread and to discuss alternatives with the resident led to the deficiency. The facility's policy and procedure documents also emphasized the importance of accommodating individual food preferences, which were not adhered to in this case.
Failure to Document Resident's Hearing Aids
Penalty
Summary
The facility failed to maintain complete and accurately documented records for a resident, identified as Resident 47, when her hearing aids were not documented on her inventory sheet. This oversight resulted in the resident not wearing her hearing aids, leading to her belief that they were missing. The resident, who had moderate cognitive impairment and was hard of hearing, was observed without her hearing aids, and staff were unaware of their location. During interviews and observations, it was revealed that Certified Nursing Assistants (CNAs) were responsible for documenting residents' belongings upon admission, including high-value items like hearing aids. However, Resident 47's hearing aids were not inventoried, and staff had to raise their voices to communicate with her. The hearing aids were eventually found in a drawer next to her bed, but they had not been documented in her records, including the Minimum Data Set (MDS), which should have reflected the care provided. The facility's policies and procedures required staff to inventory and document residents' personal belongings upon admission and update them as necessary. Despite these guidelines, the hearing aids were not included in the inventory sheet, leading to a lack of awareness among staff about the resident's belongings. Interviews with various staff members, including the Director of Nursing and the Social Services Director, confirmed the importance of documenting such items to prevent them from going missing.
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 396 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Fresno
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Evergreen Care Center | 0.6 mi | ★★★★★ | 2 | 0 |
| Pacific Gardens Nursing And Rehabilitation Center | 0.7 mi | ★★★★★ | 30 | 0 |
| Twilight Haven | 1.1 mi | — | 0 | 0 |
| Stonehaven Senior Living | 1.1 mi | — | 0 | 0 |
| Sierra Vista Healthcare | 1.6 mi | ★★★★★ | 18 | 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.