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 Pacific Gardens Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident’s oxygen was set above the ordered flow rate, another resident’s oxygen was adjusted by an LVN despite policy limiting that task to an RN, and a third resident received oxygen without a physician order. Two residents had dusty oxygen concentrator filters, one resident received insulin lispro too long before breakfast, another resident’s calcium acetate was given before meals instead of with meals, and a hydralazine order lacked clear frequency. A resident’s low calcium lab result was not documented as reported to the physician, and there was no evidence of follow-up.
Controlled medication reconciliation was inadequate because the DON received discontinued controlled meds from nursing staff and stored them in a locked cabinet until destruction, but there was no separate log to track how many were received and awaiting destruction. The DON acknowledged the facility could not accurately account for all controlled substances in the cabinet, and the consultant pharmacist stated a record was needed for accountability and to prevent theft/diversion. The facility policy required regular reconciliation of current, discontinued, and unused controlled substances held for destruction.
The facility failed to ensure three residents were free from unnecessary drugs when required lab monitoring was not completed for medications affecting lab values. A resident receiving magnesium oxide had no follow-up magnesium labs, a resident on amiodarone had no TSH monitoring, and a resident on levothyroxine had no TSH monitoring documented. RN and DON interviews confirmed the missing lab follow-up, and the cited drug references stated these medications require periodic monitoring of the relevant labs.
Medication administration errors caused the facility’s medication error rate to reach 18.52%. An RN left levothyroxine with a resident instead of witnessing ingestion, an RN gave oxycodone-acetaminophen without first assessing pain, and insulin lispro/aspart was administered to three residents too far before meals. The DON and consultant pharmacist stated the medications should have been administered with direct observation, pain assessment, and meal timing consistent with the orders and insulin guidance.
An opened lorazepam oral solution was found in a medication fridge at the wrong temperature and without proper labeling, insulin pens had opened and expiration dates placed on removable caps instead of the pens, and several inhalers and an insulin MDV lacked resident identifiers. Discontinued enoxaparin and ondansetron remained in medication carts, vancomycin and LR were stored in a room at an elevated temperature, and testosterone vials were kept with OTC meds instead of with controlled substances. Staff and the DON acknowledged the labeling and storage problems during observation and interview.
Menu Not Followed During Lunch Meal Service: A dietary cook ran out of the scheduled sweet potato item during lunch and substituted mashed potatoes and pasta for the remaining meal trays. Residents on regular, CCHO, SB6, PU4, large portions, and no added salt diets were observed receiving items that did not match the menu. The DM and RD stated the meal should follow the approved menu and recipes, and records showed the facility had standardized recipes for the sweet potato dish.
Failure to Obtain Consent for Side Rail Use: A resident with severe cognitive impairment, dementia, and a history of falls was observed in bed with both side rails in the guard position. Staff could not produce a signed consent form or physician order for the side rails, and interviews confirmed the rails were being used as a restraint without documented informed consent or prior assessment.
Unassessed Expired Eye Drops Stored at Bedside: A resident had expired polyethylene glycol 400 0.25% eye drops stored on the bedside table and used them without an order or completed MSA. The resident said the drops were brought from home and had been kept at bedside since admission, and a family member applied them. Staff observed the drops at bedside, and the LVN and DON confirmed there was no order for that medication and no self-administration assessment on file.
Two residents were found to have psychotropic medication issues. One resident with Alzheimer’s disease, depression, anxiety, and dementia was prescribed quetiapine, divalproex sodium, duloxetine, and trazodone for behavioral or mood-related indications that staff and leadership said were not appropriate or not well supported, and the resident’s behavior monitoring and care plan lacked measurable goals. The same resident also had no GDR attempts for several psychotropics despite consultant pharmacist recommendations. A second resident with schizoaffective disorder and depression was receiving divalproex sodium, but behavior monitoring on the MAR used a yes/no format instead of documenting the number and type of behavior episodes, and the care plan was not individualized.
A comprehensive person-centered care plan was not developed for several residents with significant care needs. One resident had side rails in use without a care plan for getting out of bed unassisted or for the rails themselves, another had no care plan for refusing nail care despite repeated refusals and a long thumbnail, a third had no care plan for an antibiotic ordered for a peritoneal abscess, and a fourth had no care plan for a right nephrostomy tube after hospital readmission. Staff interviews and record review confirmed the missing care plans.
Failure to provide nail care during ADL assistance: A resident with a PICC line had fingernails on both hands observed to be long, jagged, and dirty with buildup under the nail beds, and the resident stated she wanted them cleaned and trimmed. A CNA and RN both confirmed the nails were long and dirty, while the DSD and DON stated nail care was part of ADLs and hand hygiene, especially for a resident with an IV/PICC line.
Failure to monitor a resident’s nutritional status and weight loss. A resident with CVA, Alzheimer’s disease, DM2, and protein-calorie malnutrition had significant weight loss while ordered health shakes and snacks were in place. Staff documented supplements as given, but interviews showed the resident often refused or only partially accepted them, and consumption was not recorded. Weekly weights were identified in the record and by the RD as needed, but they were not completed, and the resident continued to lose weight.
A resident with cerebral infarction, Alzheimer’s disease, dementia, schizophrenia, depression, and a history of falls was observed with bed rails in the guard position. Staff could not produce a consent form, physician order, or bed assessment for the rails, and the DON stated the resident should not have had the rails up without those requirements in place. Facility policy required alternatives first, then an entrapment-risk assessment and informed consent before bed rail use.
Expired latanoprost eye drops were found in a med cart and had been administered to a resident with glaucoma for over a month. The Charge Nurse confirmed the expired medication was given, the DON stated it was not potent and posed an infection control issue, and the consultant pharmacist stated the drops should be discarded 6 weeks after opening.
Improperly Prepared Minced and Moist Vegetables: Two residents on an MM5 diet were served broccoli that was not prepared in the proper minced and moist form during lunch meal service. Staff observed large pieces of broccoli on one resident’s tray, and the DM later stated another resident also received the improper vegetable form. The RD and RDC stated the cooks were using the wrong recipe and that MM5 foods should meet IDDSI size requirements of 4 mm by 15 mm.
Failure to Provide Documented Protein Preference: A resident with pneumonia, DM2, and protein calorie malnutrition did not receive the documented double-protein food preference on a lunch tray. The meal ticket showed a standing order for Entree/Protein (2X), but only one slice of ham was on the tray; a DA confirmed the mismatch, and the RD stated the resident should have received two slices of ham.
A dietary staff member prepared resident sandwiches without changing gloves after handling a cardboard box, and the RD and IP stated gloves should be changed after touching non-food items and handwashing performed before continuing food prep. In the residents' freezer, an oven thermometer was being used instead of a freezer thermometer, and unlabeled frozen food was observed stored in the freezer despite facility policy requiring food to be labeled and dated.
The facility failed to maintain infection control practices when staff provided high-contact care to a resident on EBP without the required gown and gloves. Staff also left another resident's NC and oxygen tubing on the oxygen concentrator instead of storing them in a clean bag when not in use, and observed the same resident's Foley catheter tubing touching the floor with white sediment in the tubing. Interviews and facility policies confirmed the expected PPE use and equipment handling practices were not followed.
Surveyors found that nursing staff failed to document ordered wound and skin treatments for five residents with complex medical conditions, including diabetes, COPD, venous stasis ulcers, skin tears, peri-anal rash, MASD, and fungal rash. Review of Treatment Administration Records showed multiple missing nurse initials for ordered treatments on specific shifts, despite physician orders for daily or every-shift wound care. Facility leadership, including the DON, ADON, and Administrator, stated that standard practice requires following physician orders and documenting care, and that if wound care is not documented, it is considered not done. Another LVN confirmed that documentation after providing wound care is required to ensure continuity of care and to reflect the treatments residents receive, indicating that the missing entries represented a failure to meet professional standards and facility policy for charting and documentation.
The facility did not ensure that all residents were treated equally in matters of transfer, discharge, and service provision, regardless of their payment source.
A resident did not receive restorative nursing assistant (RNA) services after being discharged from physical therapy, leading to a contracture in the right hand. The resident, with a history of hemiplegia and hemiparesis, was not transitioned to RNA services due to a lack of coordination between PT and RNA staff. The Director of Nursing acknowledged the failure to follow the process, which was crucial for maintaining the resident's activities of daily living.
The facility failed to inform and document information on how to formulate an advance directive for four residents, violating their rights. Interviews revealed that residents were not informed about advance directives, and staff acknowledged the lack of documentation. The facility's policy requires informing residents of their rights to establish an advance directive, but this was not consistently followed.
The facility failed to maintain a safe and comfortable environment for residents, as evidenced by cold room temperatures, exposed wiring, and malfunctioning equipment. Two residents experienced discomfort due to cold rooms, while another resident's room had holes with exposed insulation and wiring. Additionally, a resident faced issues with a broken bed and poor TV reception, affecting their comfort and quality of life.
A facility failed to properly store and label medications, with two inhalers lacking open and expiration dates, and two medication refrigerators operating outside the recommended temperature range. This affected medications for several residents, risking their potency and effectiveness. Observations and interviews confirmed these deficiencies, highlighting the need for adherence to storage and labeling policies.
The facility's cook staff failed to accurately measure milk and margarine for pureed rice, affecting 12 residents on a pureed diet. Cook 1 used incorrect measuring techniques, leading to potential inconsistencies in nutrient content. The RD acknowledged the importance of following recipes but had not verified staff measurements. The DON noted the absence of a policy for pureed food preparation, while Cook 2 described a different measurement approach.
The facility failed to maintain safe and sanitary food preparation and storage practices. Observations included unlabeled potatoes and thawing beef kabobs, a dietary aide not washing hands after scratching their ear, and dust on the ceiling above a fan in the food storage room. These deficiencies posed a risk of foodborne illnesses to residents.
The facility failed to maintain effective infection control, with issues such as improper storage of nebulizer mouthpieces, catheter bags on the floor, and lack of Enhanced Barrier Precautions for residents with wounds. Additionally, oxygen tubing was found on the floor, and opened medical supplies were improperly stored, posing infection risks.
The facility failed to maintain secure handrails in the hallways, increasing fall risk for residents. Observations revealed broken and loose handrails, with missing parts exposing metal brackets and screws. The Maintenance Supervisor acknowledged the risk and noted the use of the TELS System for repair notifications, but obsolete parts hindered replacements. Facility policies emphasized a safe environment, yet the handrails were not adequately maintained.
Two residents in the facility were observed without dignity bags covering their foley catheter drainage bags, leaving the urine visible and violating their right to dignity. Staff members, including CNAs and an LVN, acknowledged that this was against the facility's policy and did not provide dignity or privacy. The facility's policies emphasize the importance of maintaining resident privacy and treating them with respect and dignity.
Two residents were transferred to the hospital without receiving written information about the facility's bed hold policy, despite verbal notifications. The facility's policy required written notice, but it was not provided, leading to potential confusion and disputes over bed availability.
The facility failed to implement comprehensive care plans for several residents, leading to potential risks and unmet needs. A resident with a Foley catheter lacked a care plan, increasing infection risk. Another resident's visual needs were unmet due to missing glasses, risking injury. Two residents on anticoagulants lacked care plans for monitoring side effects, highlighting the need for individualized care plans.
A facility failed to update a resident's care plan after a stage two pressure ulcer had healed, leaving active treatment interventions in place. Staff interviews revealed that accurate care plans are crucial for guiding resident care, and the Director of Nursing acknowledged the potential for negative outcomes if care plans are not updated. The facility's policy requires regular evaluation and revision of care plans.
Two residents in the facility received incorrect oxygen flow rates, contrary to physician orders. One resident with COPD was given 2.5 LPM instead of the ordered 2 LPM, while another resident with multiple health issues had an oxygen flow rate set at 3 L/min instead of 2 L/min. Additionally, the second resident's oxygen tubing was not labeled with the date, risking infection. These actions were against the facility's policy and procedure for oxygen administration.
A resident with reduced mobility and no cognitive deficits experienced discomfort due to long, jagged toenails, as the facility failed to provide proper toenail care. Despite policies requiring routine care, staff did not adequately trim, file, or document the resident's toenail care, leading to potential risks of injury or infection.
A resident's foley catheter tubing was improperly managed, being wrapped around her prosthetic leg, posing a risk of falls or injury. Staff interviews revealed a lack of training and adherence to facility policies, highlighting a deficiency in ensuring resident safety.
The facility did not post accurate daily staffing information, omitting the total number and actual hours worked by RNs, LVNs, and CNAs. The Assistant Staff Development Coordinator admitted the posted form was incomplete, and the Administrator was unaware of CMS requirements. This deficiency prevented residents and families from accessing accurate staffing details.
A resident was administered mirtazapine for several months without documented attempts at a gradual dose reduction (GDR), despite no recorded depressive episodes. The facility's policy requires quarterly evaluations and documentation of GDR assessments, which were not followed.
A resident in an LTC facility was administered potassium chloride 20MEQ by RN 1 without following the manufacturer's instructions. The medication was given without a meal and the resident was allowed to lie down immediately after, contrary to guidelines. The resident had a history of paroxysmal atrial fibrillation and gastro-esophageal reflux disease, and was cognitively intact.
A resident in an LTC facility did not have a completed POLST on file, despite being admitted with multiple serious health conditions. The resident was cognitively intact and had expressed a DNR preference, but the lack of a POLST meant their end-of-life wishes might not be honored in an emergency. The facility's policy required timely completion of such documents, but the POLST remained incomplete for a month, which was acknowledged as unacceptable by the ADON.
An LVN at an LTC facility failed to perform necessary assessments and inaccurately documented care for a resident who was hospitalized. The LVN recorded vital signs, pain assessments, and enteral feeding interventions that were not provided while the resident was in a general acute care hospital. This resulted in an inaccurate clinical record, as confirmed by the ADON and DON, who stated the documentation was unacceptable and illegal.
A facility failed to ensure accurate documentation by an LVN, who recorded care for a resident while they were hospitalized. The resident, with multiple health conditions, was transferred to a hospital for shortness of breath, yet the LVN documented vital signs, pain assessments, and enteral feeding as if the resident were still in the facility. Interviews with the ADON and DON confirmed the documentation was inappropriate and illegal, as it falsely indicated care was provided. The LVN admitted to the mistake, acknowledging the failure to accurately document the resident's care.
The facility's kitchen was found in unsanitary conditions with debris, buildup, and dead cockroaches present. Observations revealed a golden-colored buildup behind the stove, debris on the floor in various areas, and a black substance on the pantry storage counter. The presence of dead cockroaches was also noted, indicating a failure to maintain cleanliness and pest control as per the facility's guidelines and FDA Food Code.
The facility failed to maintain an effective pest control program, evidenced by dead cockroaches in the kitchen and other areas. Staff confirmed awareness of the issue, and pest control reports indicated ongoing live cockroach activity despite treatments. The facility did not adhere to FDA Food Code requirements for pest prevention and cleanliness.
A resident developed a preventable Stage 3 pressure ulcer due to the facility's failure to implement the prescribed skin integrity care plan, including daily and weekly skin assessments. The resident, who had multiple diagnoses and moderate cognitive deficits, was admitted without pressure ulcers but later readmitted to an acute hospital with a Stage 3 ulcer. Staff interviews confirmed the care plan was not followed, and the Director of Nursing acknowledged the facility's failure to adhere to its skin integrity policy.
Oxygen, Medication Timing, and Lab Notification Deficiencies
Penalty
Summary
Resident 1 was observed in bed wearing an oxygen nasal cannula with the oxygen flow set at 2 L/min, although the facility’s order review listed oxygen at 1 L/min via nasal cannula continuously. During interview, the charge nurse confirmed the physician order was for 1 L/min and stated the oxygen rate should not have been set at 2 L/min. The DON also stated oxygen is considered a medication and that staff needed to follow physician orders, adding that it was not acceptable to give oxygen at 2 L/min when 1 L/min was ordered. Resident 55 was observed receiving oxygen through a nasal cannula connected to an oxygen concentrator set at 4 LPM, while the order review listed oxygen at 2 LPM continuous. During a concurrent observation, an LVN adjusted the flow to 2 LPM and stated only an RN is authorized to adjust oxygen flow rate, noting that he sometimes forgets this after working at the facility for many years. The DON and DSD stated that only RNs, physicians, and respiratory therapists were permitted to administer, initiate, or regulate oxygen, and the facility’s oxygen administration policy stated LVNs are not authorized to adjust oxygen flow or titrate oxygen. Resident 127 was observed with a nasal cannula connected to an oxygen concentrator set at 2.5 L/min, but the resident had no physician order for oxygen therapy. RN 2 stated the resident did not have an order for oxygen nasal cannula therapy and that oxygen is a medication requiring a physician order, and RN 3 stated administering oxygen without a physician order was outside nursing scope of practice. The DON stated oxygen is a prescribed treatment requiring a physician order and that the facility did not follow policy or standards of practice when the resident received 2.5 L/min without an order. Resident 155 and Resident 72 were both observed using oxygen concentrators with air filters covered in white dusty-looking lint. CNA 7 stated the filter was very dusty, and the DSD and IP both observed that the filters were dirty and dusty. The DSD stated dirty filters could potentially lead to more respiratory issues, and the DON stated central supply was responsible for cleaning and replacing oxygen concentrator air filters, though she was not sure why the filters had not been cleaned or replaced. The facility’s oxygen concentrator instruction guide stated the cabinet filter should be washed with each inspection and replaced if needed. Resident 167 had blood glucose checked at about 5 a.m., and insulin lispro was administered around 6 a.m. even though breakfast was not expected until about 7:20 a.m. RN 4 stated insulin lispro should be given about 30 minutes before food and acknowledged the resident could become hypoglycemic if there was a long period between insulin administration and food service. The DON stated insulin lispro should be given no more than 15 minutes before meals, and the consultant pharmacist stated it should be administered within 15 minutes before a meal or immediately after a meal. Resident 102 had calcium acetate ordered to be given with meals, but it was administered around noon before lunch and earlier in the morning before breakfast was served. RN 1 stated the medication would not be as effective if given too early before a meal and would be effective when given with meals. Resident 102 also had hydralazine ordered as "give one tablet by mouth with meals for HTN," and RN 1 stated the medication would still be administered even if the resident did not eat, based on blood pressure parameters rather than the meal. The DON stated the hydralazine order was not clear enough because the frequency should have been stated in the body of the order. Resident 150 had a calcium lab result of 7.2, which was below the reference range, but there was no progress note documenting the result and no evidence that the physician was notified. RN 1 stated that if labs were low, the supervisor should be informed, the physician should be notified, and it should be documented in the progress notes. The DON confirmed the calcium level was low and stated the expectation was for the nurse to notify the physician and for the physician to give orders as needed, but she was unable to provide documentation that the physician had been notified.
Controlled Medication Reconciliation System Was Inadequate
Penalty
Summary
The facility failed to have an adequate system for reconciling controlled drugs awaiting destruction. During an interview, the DON stated that when controlled medications were discontinued, nursing staff gave them to the DON and signed them into a controlled medication binder at the nurses’ station. The DON stated the discontinued controlled medications were then stored in a locked cabinet in her office until destroyed by the facility’s consultant pharmacist, and that both she and the pharmacist signed a printed log form at the time of destruction to account for the number destroyed. The DON stated there was no other log showing how many controlled medications were received from nursing staff, so she could not track all controlled medications received and awaiting destruction. She acknowledged it would be difficult to know if controlled medications were removed from the office cabinet and stated the facility did not have an effective system for reconciliation and destruction of controlled medications. The consultant pharmacist stated there should be a record indicating the quantity of controlled medications the DON received from nursing staff, and the facility policy required regular reconciliation of current and discontinued controlled substances, including unused controlled substances held in storage awaiting destruction.
Failure to Monitor Required Labs for Magnesium Oxide, Amiodarone, and Levothyroxine
Penalty
Summary
The facility failed to ensure that three sampled residents were free from unnecessary drugs because required laboratory monitoring was not completed for medications that affect lab values. Resident 3 had an active order for magnesium oxide 400 mg by mouth three times daily for hypomagnesemia, and the record showed a low magnesium level of 1.3 on the last documented lab result. RN 1 stated that magnesium levels should be checked after a resident is started on magnesium, but there were no orders for follow-up magnesium labs and no labs were drawn after the resident began taking the medication. The DON also stated there were no labs completed after the documented magnesium result and that the resident’s magnesium levels should have been checked since the medication was started. Resident 79 had an active order for amiodarone HCl 200 mg by mouth daily for CHF, and the DON stated the resident started amiodarone on 3/28/26. The DON stated TSH labs should have been done when the resident was started on amiodarone so the medication could be adjusted if needed. The record review and interview showed no TSH monitoring was completed for this resident after the medication was started. The professional reference cited in the report stated amiodarone can cause hypothyroidism or hyperthyroidism and that thyroid function should be monitored prior to treatment and periodically thereafter. Resident 150 had an active order for levothyroxine sodium 100 mcg by mouth daily for hypothyroidism. RN 1 stated the EHR showed no TSH labs were completed for monitoring, and the resident was on hospice. The DON stated that even though the resident was on hospice, the expectation was for TSH labs to be completed and that the therapeutic level should be monitored so the medication could be adjusted. The cited drug reference stated that adequacy of levothyroxine therapy should be assessed by periodic laboratory testing and clinical evaluation, with serum TSH monitored after dosage changes and every 6 to 12 months when stable.
Medication Error Rate Exceeded Threshold
Penalty
Summary
The facility failed to keep the medication error rate below 5 percent; surveyors calculated an error rate of 18.52 percent based on 27 opportunities for error. The report identified medication administration errors involving five residents: one resident did not receive a prescribed levothyroxine dose because the medication was left with the resident, one resident received oxycodone-acetaminophen without a pain assessment, and three residents received insulin too far in advance of meals. For the resident prescribed levothyroxine for hypothyroidism, an RN attempted to administer the medication but left it with the resident when the resident said she wanted to use the restroom. The RN stated he did not see the resident consume the medication. The DON stated nurses were expected to wait for the resident to take the medication and to ensure it was witnessed, and the consultant pharmacist stated medications should not be left with residents because staff would not have sight of what was happening with the medication. The resident’s record showed an active order for levothyroxine sodium 125 mcg daily for hypothyroidism. For the resident prescribed oxycodone-acetaminophen for moderate to severe pain, an RN administered the medication after the resident stated she was in pain, but the RN did not assess the resident’s pain level first. The RN stated he did not ask for the pain level before giving the medication. The resident’s record showed an active order for oxycodone-acetaminophen 10-325 mg every six hours as needed for pain rated 4 to 10. The DON and consultant pharmacist both stated a pain level should be obtained before administering the medication, and the facility’s pain management policy required residents to be interviewed and evaluated for pain. The report also identified insulin timing errors for three residents. One resident received 10 units of insulin lispro about 45 minutes before breakfast, and breakfast had not yet been served at the time of follow-up observation. Two other residents received insulin lispro or insulin aspart before their meals were available; one resident had not yet had her meal and another ate at noon. The DON stated insulin lispro or aspart should be given when breakfast is available and no more than 15 minutes before the meal starts, and the consultant pharmacist stated these insulins should be administered within 15 minutes before a meal or immediately after a meal. The residents’ records showed active orders for insulin lispro or insulin aspart for diabetes management.
Medication Labeling and Storage Deficiencies
Penalty
Summary
Drugs and biologicals were not consistently labeled and stored according to facility policy and manufacturer guidance. In Station 4 medication room, an opened lorazepam oral solution was observed in the medication refrigerator at 10 C, and the medication was not labeled with the date opened or discard date. The Charge Nurse stated the medication should have been labeled and that the refrigerator temperature was too high. The Director of Nursing stated that if a medication is not stored at the required temperature, it can affect potency and effectiveness. The Consultant Pharmacist stated staff should monitor refrigerator temperatures, document them, and notify the appropriate personnel when temperatures are out of range. Insulin pens for multiple residents were observed in medication carts with the date opened and expiration date labels placed on the removable caps rather than on the actual pens. Staff stated the caps could be mixed up or switched, which would leave nursing staff unable to know when the insulin was first used or which expiration date belonged to which pen. In addition, an insulin regular multi-dose vial for one resident and inhalers for four residents had no patient identifiers on the actual products. Staff stated the inhalers and vial needed resident identifiers so the medications would not be mixed up or used for the wrong resident. Discontinued medications were also left in active medication storage. Enoxaparin syringes for one resident remained in the medication cart after the order had been discontinued, and discontinued ondansetron medication cards for two residents were still present in the cart. Staff stated discontinued medications should have been removed from the cart and placed with discontinued medications so they would not be accidentally given. In Station 1 medication room, vancomycin premix and lactated Ringer's bags were observed stored in a room at 80 F, which was above the temperature stated by staff and above the manufacturer storage guidance cited in the report. Two testosterone vials for one resident were found in the top drawer of a medication cart with OTC medications rather than separated with controlled medications. Staff stated the testosterone was a controlled medication that should be locked, counted, and verified by pharmacy before use.
Menu Not Followed During Lunch Meal Service
Penalty
Summary
The facility failed to follow the lunch menu for 20 of 66 sampled residents when mashed sweet potatoes were not provided as listed on the menu during the lunch meal service. The menu for the meal listed baked honey glaze ham, baked sweet potatoes, and French style green beans for multiple diet types, including regular, puree level 4, minced and moist level 5, soft and bite level 6, easy to chew level 7, and consistent carbohydrate diets. During observation of the meal service, a large hotel pan and a half pan of mashed sweet potatoes were placed on the steam table, and the Dietary Cook portioned sweet potatoes for residents until the supply was used up. As the lunch meal service continued, the mashed sweet potatoes ran out and the Dietary Cook began using regular mashed potatoes and pasta for the last meal cart for 20 residents. Several residents whose meal tickets reflected regular, CCHO, no added salt, large portions, SB6, PU4, or small portions diets were observed receiving mashed potatoes or pasta instead of the sweet potatoes listed on the menu. One resident on a regular CCHO diet received mashed potatoes, another resident on a regular, no added salt diet received mashed potatoes, and two residents on regular, CCHO or small portions, CCHO diets received pasta. The Dietary Cook stated the mashed sweet potatoes ran out and that regular mashed potatoes and pasta were used as alternatives for the remaining trays. The Dietary Manager stated the mashed sweet potatoes ran out toward the end of lunch service and regular mashed potatoes were made as an alternative. The Registered Dietitian stated it was her expectation that dietary staff follow menus and recipes for the correct consistency, amount, and products. Facility records reviewed included recipes for sweet potatoes and a food preparation policy stating approved recipes are to be used and standardized to meet the resident census.
Failure to Obtain Consent for Side Rail Use
Penalty
Summary
Resident 12 was observed asleep in bed with the left and right side rails in the guard position and a fall mat on the right side of the bed. The resident’s record showed diagnoses including cerebral infarction, Alzheimer’s disease, dementia, schizophrenia, depression, and a history of falling. The MDS indicated a BIMS score of 3, showing severe cognitive impairment, and functional assessments showed the resident was dependent for chair/bed-to-chair transfer and had impairment on one side of the upper extremity. During interviews and record review, staff were unable to locate a signed consent form or physician order for the use of side rails. CNA 1 stated the side rails were up because the resident tried to get out of bed and had fallen in the past. LVN 1 reviewed the EMR and stated she could not find a consent form or physician order for the side rails. The ADON also stated it was important to have consent for side rails because they were a form of restraint, but was unable to provide a signed consent form. Further interviews showed staff understood side rails should have been supported by assessment, physician involvement, and consent before use. LVN 1 stated the resident should have had a consent form and physician orders for side rails, and the DON stated the resident should not have had side rails up without a consent and bed assessment. The facility policy on Bed Rails required alternatives be attempted first and informed consent be obtained from the resident or representative before installation or use, and the restraint policy required assessment and informed consent for restraint device use.
Unassessed Expired Eye Drops Stored at Bedside
Penalty
Summary
The facility failed to ensure that one sampled resident was assessed before self-administering and storing medication at bedside. Resident 61 had a bottle of polyethylene glycol 400 0.25% eye drops on the center of the bedside table, and the expiration date on the bottle was 10/2018. During observation and interview, the resident stated the eye drops were brought from home when he was admitted and had been stored on the bedside table since admission. The resident also stated his daughter applied the eye drops to his eyes every day when she visited. During observation, a CNA was seen delivering the resident’s breakfast tray and moving the eye drops from the center of the bedside table to the corner of the bedside table. During record review and interview, an LVN stated the resident did not have an order for the polyethylene glycol 400 0.25% eye drops and did not have a Medication Self-Administration Assessment Form completed. The LVN stated the resident did have a PRN order for polyethylene glycol-propylene glycol eye drops, which was a different medication, and stated the resident was at risk for unsafe medication storage and self-administration without an order and assessment. The resident’s family member stated she had visited the resident and administered the eye drops, and the CNA stated she had observed the eye drops on the bedside table since admission. The DON stated unlicensed and licensed staff were responsible for identifying medications stored and self-administered at bedside, and that residents required an order and an MSA to safely store and administer their own medications. Review of the resident’s OSR showed no order for the eye drops and no order to self-administer or store them at bedside. The facility policy stated self-administration required interdisciplinary assessment and documentation on the MSA form, and that nursing staff were responsible for removal of expired medications.
Unnecessary Psychotropic Use and Inadequate Monitoring
Penalty
Summary
The facility failed to ensure two sampled residents were free from unnecessary psychotropic medications and were appropriately monitored while receiving them. Resident 3 had diagnoses including Alzheimer’s disease, depression, anxiety, and dementia, but was prescribed quetiapine fumarate for neurocognitive disorder with behavioral disturbance, along with divalproex sodium, duloxetine, and trazodone for reported behaviors and symptoms. During the survey, the ADON, DON, MD, and consultant pharmacist all stated that neurocognitive disorder was not an appropriate indication for quetiapine or divalproex sodium and that the indication needed to be updated or changed. The record also showed Resident 3’s MDS indicated a BIMS score of 15/15 and no psychosis or behavioral symptoms were coded, while staff interviews described him as cooperative, alert, oriented, and not showing behaviors. Resident 3’s behavior monitoring was not adequately documented for quetiapine, divalproex sodium, duloxetine, and trazodone. The care plan did not contain objective goals or measurable targets for the behaviors being monitored, and staff interviews showed inconsistent understanding of how to document behavior episodes. One nurse stated she would document a total of behaviors on the MAR, while the ADON and DON stated the documentation should reflect the number of episodes for each behavior and that the existing documentation was not appropriate. The DON also stated the resident had received further training on how to appropriately monitor and document behavioral episodes for psychotropic medications. Resident 3 also did not have gradual dose reductions attempted for divalproex sodium, duloxetine, and trazodone. The consultant pharmacist recommended GDRs in multiple medication regimen reviews, including recommendations to evaluate continued need and attempt reduction of antidepressants, but the physician declined the recommendations or documented no specific resident-centered rationale. The ADON and DON acknowledged that no GDR attempt had been completed for divalproex sodium and that the resident had not been seen by the outside psychiatrist since admission. A second resident, Resident 32, who had diagnoses including schizoaffective disorder, bipolar type, depression, and a history of suicidal behavior, was also not adequately monitored while receiving divalproex sodium. The MDS showed a BIMS score of 15/15 and no behaviors, but the MAR used a yes/no format for behavior monitoring rather than documenting the number and type of behavior episodes, and the care plan was described as generic and not individualized.
Incomplete care planning for bed rails, nail care refusal, antibiotics, and nephrostomy tube
Penalty
Summary
The facility failed to ensure a comprehensive person-centered care plan was developed and implemented for four sampled residents. Resident 12 was observed in bed with side rails raised on both sides and a fall mat on the right side of the bed. The resident had diagnoses including cerebral infarction, Alzheimer’s disease, dementia, schizophrenia, depression, and a history of falling, and the MDS showed severe cognitive impairment and dependence for transfers. Staff stated the side rails were up because the resident had tried to get out of bed and had fallen in the past, but the record review and interviews showed there was no care plan for getting out of bed unassisted or for the use of side rails. The DON stated the facility was a non-restraint facility and side rails were considered a restrictive device, and that the resident should have had a care plan to monitor the device and the resident’s safety. Resident 15 was observed in bed with an oxygen nasal cannula, a skin tear on the right pinky, discoloration on the left shin, missing toes, contracted hands, and a long dark-colored right thumbnail. The resident had diagnoses including arthritis due to bacteria to the right knee, dementia, dysphagia, CHF, type 2 diabetes mellitus, acquired absence of the right great toe, and depression, and the MDS showed severe cognitive impairment and dependence for personal hygiene. The record review showed no care plan for refusal of nail care and no CNA documentation of nail care refusal in the task record. Staff stated the resident had been refusing nail care, that refusals were to be communicated to the nurse and carried over in shift report, and that a care plan should have been developed for the refusal of nail care. Resident 120 was observed lying in bed and did not answer questions during the initial tour. The resident had diagnoses including fibromyalgia, a sacral pressure ulcer, UTI, and peripheral vascular disease. Record review and staff interview showed the resident returned to the facility from the hospital with an antibiotic order for a peritoneal abscess, but there was no care plan for the antibiotic. Resident 139 was also observed lying in bed and not answering questions during the initial tour. The resident had diagnoses including hydronephrosis, obstructive and reflux uropathy, and staff stated the resident returned to the facility after a cystoscopy with nephrostomy tubes, including a right nephrostomy tube placed at the hospital. Record review and interviews showed there was no care plan for the right nephrostomy tube, and staff stated a care plan should have been in place for the tube.
Failure to Provide Nail Care During ADL Assistance
Penalty
Summary
The facility failed to provide ADL care for one resident when the fingernails on both hands were observed to be long, jagged, and dirty with brownish to blackish buildup underneath the nail beds. During a concurrent observation and interview, the resident stated she had been admitted to the facility with a PICC line in place to the right upper arm for antibiotic administration and said her nails were long, dirty, and felt like a mess. She stated she wanted her fingernails cleaned and trimmed. During the survey, a CNA observed the resident in bed and stated the resident was unable to reposition independently and needed assistance, and that nail care was provided during ADL care, on scheduled shower days twice a week, and as needed. An RN also observed the resident’s fingernails and stated they were long, uneven with sharp edges, and dirty with buildup under the nail bed. The RN stated the CNA could have provided nail care because the resident was non-diabetic, and explained that keeping nails short and clean helped prevent scratching that could lead to skin breakdown and infection. The DSD stated CNA's or nurses were expected to assist with hand hygiene during ADLs, before and after meals, including nail care, and as needed. The DON stated nail care was part of ADLs and hand hygiene, and that proper nail care and hand hygiene helped prevent transmission of infection, bacteria, and other microorganisms, especially when a resident had an IV line or PICC line. The facility policy stated nail assessments were to be conducted on admission, routine cleaning and inspection were to be provided during ADL care on an ongoing basis, and nails should be kept smooth to avoid skin injury.
Failure to Monitor Weight Loss and Nutritional Intake
Penalty
Summary
The facility failed to ensure acceptable nutritional status was maintained for one resident with a history of cerebral infarction, Alzheimer’s disease, type 2 diabetes mellitus, and protein-calorie malnutrition. The resident had documented weight loss from 155.8 lbs. on 11/19/25 to 148.8 lbs. on 12/17/25, then to 134 lbs. on 2/18/26, and 135.2 lbs. on 3/18/26. The record showed weight losses of 4.49% in one month, 13.48% in three months, and 9.14% in three months across the documented periods. The resident had physician orders for a consistent carbohydrate, no added salt diet, health shakes twice daily between meals, and snacks twice daily. The record also showed poor oral intake, including meal intake documented at 54%, then 27%, 25%, and 33% during IDT reviews, with recommendations to change to weekly weights, continue health shakes and snacks, and monitor weight closely. The resident’s EMR and staff interviews showed that health shakes and snacks were marked as given, but staff stated the check marks did not indicate consumption and that the resident often refused or only partially accepted the supplements. Weekly weights were not implemented as identified in the record and by staff interviews. The RD stated the resident’s significant weight loss should have triggered review in December and acknowledged that did not happen. The RD also stated weekly weights were changed from monthly weights as the only intervention when declining oral intake and significant weight loss were identified, but the weekly weights were not done. RNA staff stated a refusal on one weight date did not mean the resident should have been removed from weekly weights, and the DON acknowledged that weekly weights and documentation of supplement and snack consumption should have been followed to monitor weight changes and evaluate the effectiveness of nutritional interventions.
Bed Rails Used Without Required Assessment and Consent
Penalty
Summary
The facility failed to ensure Resident 12 was assessed for entrapment risk before bed rails were used, and failed to have a consent form, physician order, indication for use, and care plan in place for the side rails. During observation, Resident 12 was seen asleep in bed with the right and left side rails in the guard position and a fall mat on the floor beside the bed. The resident’s record showed diagnoses including cerebral infarction, Alzheimer’s disease, dementia, schizophrenia, depression, and a history of falling, and the MDS indicated severe cognitive impairment with a BIMS score of 3. Staff interviews confirmed the absence of required documentation for the bed rails. An LVN stated she could not find a consent or physician order for the side rails. The ADON observed the resident with the rails up and stated a consent was important because the rails were a form of restraint, but she was unable to provide one. The MNT stated he needed a physician’s order before installing bed rails and described a bed assessment process, but later stated the resident did not have a physician’s order or bed assessment for the side rails. The DON stated Resident 12 should not have had the side rails up and needed a consent and bed assessment before the rails were applied. The DON also stated the facility was a non-restraint facility and side rails were considered a restrictive device. Facility policies reviewed by surveyors stated alternatives should be attempted before bed rails, the interdisciplinary team should assess for entrapment risk, and informed consent should be obtained prior to installation or use. The restraint policy also required informed consent, a physician’s order, alternate methods used, and monitoring and observation related to restraint use.
Expired Eye Drops Administered for Glaucoma
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors when Resident 34 was administered expired latanoprost ophthalmic solution for over one month. During a concurrent observation, interview, and record review, a partially used and almost empty bottle of latanoprost with an open date and beyond-use date was found in the medication cart at nursing station 4b and was available for use for Resident 34. The Charge Nurse stated discontinued medications should be removed from the cart so they are not accidentally administered, and stated there was no other latanoprost available in the cart for the resident. Record review showed Resident 34 had an active order for latanoprost ophthalmic solution, 1 drop in both eyes at bedtime for glaucoma, and the MAR reflected the medication was administered from one date range and then again from another date range. The Charge Nurse stated expired medication had been administered to Resident 34 and that it could cause adverse reactions and would not work like it should. The resident’s admission record identified type 2 diabetes mellitus and low tension glaucoma. The DON stated latanoprost is for glaucoma, a disease that could cause blindness, and that medication given beyond the use date was not potent and was also an infection control issue. The consultant pharmacist stated nursing staff should dispose of latanoprost 6 weeks after opening, and the facility policy required expired or deteriorated medications to be removed from medication rooms and identified expiration dates during medication administration.
Improperly Prepared Minced and Moist Vegetables
Penalty
Summary
The facility failed to ensure that food was prepared and processed in a form designed to meet individual resident needs for two sampled residents on a minced and moist diet. During lunch meal service, Resident 86’s tray contained minced sweet and sour pork, rice, puree bread, and large pieces of broccoli. The resident’s lunch ticket showed a handwritten diet order of minced and moist. A Dietary staff member observed the tray and stated the broccoli needed to be soft and the size was okay, and the tray continued down the line before the Dietary Manager later removed it from the cart and began mashing the broccoli with a fork. During the same meal service, the Registered Dietitian Consultant and Dietary Manager observed that the broccoli on Resident 86’s tray was not in the proper form. The RDC stated the pieces needed to be smaller and later stated the cooks were looking at the incorrect recipe and should have prepared the food to 4 mm by 15 mm for the minced and moist diet. The Dietary Manager also stated that Resident 73, who was on a minced and moist level 5 diet, received the improper form of vegetable, broccoli, on the lunch tray prepared at the beginning of meal service. Resident 73’s face sheet documented admission with dysphagia. Resident 86’s face sheet documented admission with hemiplegia, hemiparesis following cerebral infarction, and acute respiratory failure. The RD stated it was her expectation that dietary cooks follow menus and recipes for the correct consistency and products, and that staff had received IDDSI training implemented in 1/2026. The facility’s recipe for soft mashable broccoli stated that for the IDDSI minced and moist level 5 diet, all food pieces must be less than 4 mm by 15 mm, and the dietary manual stated vegetables must be under 4 mm in size, non-stringy and non-fibrous, and cooked until soft and easily mashable.
Failure to Provide Documented Protein Preference
Penalty
Summary
The facility failed to ensure that Resident 26 received the food preference of double protein on the lunch tray served on 4/21/26. During lunch meal service, the resident’s meal ticket showed a standing order for Entree/Protein (2X), but observation of the tray found only one slice of ham. A Dietary Aide checked the tray against the meal ticket, confirmed that only one slice of ham had been provided, and asked another Dietary staff member to provide an additional slice of ham. The Registered Dietitian later reviewed the meal ticket and stated that the standing order was the resident’s food preference, not a physician’s order, and that the resident should have received two slices of ham. Resident 26’s face sheet showed diagnoses of pneumonia, type 2 diabetes mellitus, and protein calorie malnutrition. The lunch menu for the regular diet included baked honey glazed ham, baked sweet potato, and French style green beans, and the resident’s lunch meal ticket indicated two servings of protein under the standing order. The deficiency occurred when the tray did not match the documented food preference for double protein.
Improper glove use and freezer food storage practices
Penalty
Summary
Food was not stored, prepared, and served in accordance with professional standards when Dietary staff handled non-food items while making resident sandwiches. During an observation in the kitchen, a dietary staff member prepared turkey sandwiches with gloves on, opened a cardboard box containing bread, opened plastic bags of bread, and continued assembling the sandwiches on the preparation table without changing gloves after touching the cardboard box. The same gloves were used while handling the bread and continuing sandwich preparation. The Registered Dietitian stated that gloves should be changed when touching anything else or when visibly dirty, and that gloves should be changed after opening a cardboard box, with handwashing performed before continuing sandwich preparation to prevent cross-contamination. The Infection Preventionist stated dietary staff had received training on handwashing and proper glove use and that gloves should be changed after handling or touching non-food items, with handwashing performed to prevent cross-contamination and foodborne illness. Facility policy on glove use stated disposable gloves are a single-use item and should be discarded after each use, especially before handling clean food items, and should be changed before beginning a different task. Food safety concerns were also identified in the residents' freezer. The top-mounted freezer of the residents' refrigerator contained an oven thermometer instead of a freezer thermometer, and the Activity Director stated she was responsible for monitoring the temperature but was unaware the oven thermometer was being used for that purpose. The Registered Dietitian Consultant confirmed it was an oven thermometer and stated a correct thermometer would be provided, while the Registered Dietitian stated an oven thermometer was not the correct thermometer for freezer monitoring. In addition, frozen food in the residents' freezer was observed without a label, and the Activity Director stated all food items stored in the residents' refrigerator should be labeled. Facility policy required resident food to be labeled, and the freezer storage procedure required all frozen food to be labeled and dated.
Failure to Follow Infection Control Practices for EBP, Oxygen Equipment, and Foley Catheter Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program when staff did not follow Enhanced Barrier Precautions for a resident who was on EBP for surgical incisions to the left hip. During a concurrent observation and interview, two CNAs were observed dressing the resident, transferring her to a wheelchair, changing bed linens, and putting on shoes without wearing gowns and gloves. One CNA wore gloves only while removing linens, and both CNAs continued providing high-contact care without the required PPE. The resident had been admitted with subdural hemorrhage, multiple pelvic fractures, type 2 diabetes mellitus, Alzheimer's disease, and dementia, and her MDS showed a BIMS score of 3, indicating severe cognitive impairment. The facility also failed to properly manage another resident's oxygen equipment. During observation, the resident's nasal cannula and oxygen tubing were found sitting on top of the oxygen concentrator while the machine was turned on, and the resident was not wearing the cannula at that time. The resident's order indicated oxygen at 3 L/min via NC as needed, with tubing and storage bag to be changed monthly. Staff interviews and the facility's policy indicated that oxygen tubing and the cannula should be stored in a clean bag when not in use, but the tubing and cannula were observed placed on the concentrator instead. In addition, the same resident's indwelling urinary catheter tubing was observed touching the floor, with white sediment visible in the urine inside the tubing. Staff interviews stated the tubing should not touch the floor and should be kept in the dignity bag, and that sediment in the tubing should be reported to the nurse. The resident's record showed diagnoses including encephalopathy, spinal stenosis, atrial fibrillation, stiffness of the right hand, and major depressive disorder, and the MDS showed a BIMS score of 14, indicating cognitive intactness. The facility's catheter care policy required daily and as-needed catheter care to decrease the risk of infection, but the tubing was observed on the floor with sediment present.
Failure to Document and Perform Ordered Wound and Skin Treatments
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing services and documentation met professional standards of quality and the facility’s own Charting and Documentation policy for five residents. Surveyors identified multiple instances where ordered wound and skin treatments were not documented on the Treatment Administration Records (TARs), and facility leadership consistently stated that if care was not documented, it was considered not done. The Assistant Director of Nursing (ADON), Director of Nursing (DON), and Administrator all confirmed that complete and accurate documentation is required to reflect the care provided and that staff are expected to follow physician orders and document wound care after it is performed. For one resident with a history including metabolic encephalopathy, COPD, chronic venous hypertension with ulcer and inflammation of the left lower extremity, prediabetes, and dependence on a respirator and supplemental oxygen, physician orders directed daily-shift wound care to a venous stasis wound on the right lower leg and skin tears on both arms. Review of the TAR for December showed that on a specific day, there were no licensed staff initials for the ordered wound care during the day shift. The ADON stated that LVN 1 had been assigned to this resident for that shift and should have initialed the TAR to indicate the wound care was provided, but did not, and reiterated that if it was not documented, it was not done. For a second resident with diabetes mellitus type 2, cervical disc disorder with radiculopathy, and malignant neoplasm of the skin, the TAR contained an order to cleanse and dress a rash on the right hand every shift until the order was discontinued. On one night shift, there were no licensed staff initials to show that the treatment was provided. The DON stated that LVN 2 had been assigned to this resident that night and should have initialed the TAR but did not, and stated that if LVN 2 did not document the wound care, then it was not provided. For a third resident with hypertensive heart disease, dementia, diabetes mellitus type 2, malignant neoplasm of the prostate, and a cardiac pacemaker, the TAR showed an order for daily care of a skin tear with flap on the left dorsal hand, including cleansing with normal saline, applying steri-strips, and covering with a dry dressing. On a reviewed night shift, there were no licensed staff initials indicating that the ordered treatment was completed. The DON confirmed LVN 2 was assigned to this resident that night and should have initialed the TAR but did not, and again stated that lack of documentation meant the care was not provided. For a fourth resident with paraplegia, diabetes mellitus type 2, hypertensive chronic kidney disease, severe morbid obesity, and malignant neoplasm of the large intestine, the TAR contained orders to apply antifungal powder to a peri-anal rash every shift and as needed after incontinence episodes, and to cleanse and treat moisture-associated skin damage at the coccyx with a menthol and zinc oxide ointment every shift and as needed after incontinence. On the reviewed night shift, there were no licensed staff initials for these treatments. The DON stated LVN 2 was assigned to this resident that night and should have initialed the TAR to show the treatments were provided but did not, and reiterated that if LVN 2 did not document the wound care, then it was not provided. For a fifth resident with congestive heart failure, COPD, diabetes mellitus type 2, severe morbid obesity, benign neoplasm of cranial nerves, schizoaffective disorder, and dependence on a respirator and supplemental oxygen, the TAR showed an order to cleanse abdominal folds, pat dry, apply antifungal powder, and monitor and report to the MD for worsening every shift for a fungal rash over a 14-day period. On the reviewed night shift, there were no licensed staff initials indicating that this treatment was performed. The DON stated LVN 2 was assigned to this resident that night and should have initialed the TAR but did not, and again stated that if LVN 2 did not document the wound care, then it was not provided. LVN 1 and LVN 2 were not available for interview. Another LVN stated that standard practice is to follow physician wound care orders and document after providing care, and that if wound care is not documented, it is considered not provided, emphasizing that documentation is required to indicate continuity of care and to reflect the wound care residents receive. The facility’s Charting and Documentation policy defined the resident’s clinical record as an account of treatment, care, response to care, signs, symptoms, and progress of the resident’s condition, and stated that it provides a multidisciplinary record of the physical and mental status of the resident. The identified missing documentation of ordered wound and skin treatments for all five residents showed that the facility did not adhere to this policy or to the stated standard of practice that care must be documented to demonstrate it was provided.
Unequal Treatment in Transfers, Discharges, and Services Based on Payment Source
Penalty
Summary
The facility failed to treat all residents equally regarding transfer, discharge, and the provision of services, regardless of their payment source. This deficiency indicates that some residents may have experienced differences in how they were transferred, discharged, or received services based on their payment method. The report specifically notes the lack of equal treatment but does not provide further details about individual residents or specific incidents.
Failure to Provide Restorative Nursing Services Post-PT Discharge
Penalty
Summary
The facility failed to provide necessary restorative nursing assistant (RNA) services to a resident after the discontinuation of physical therapy (PT) services. The resident, who was discharged from PT on March 6, 2024, did not receive the prescribed range of motion (ROM) exercises until February 4, 2025, resulting in a lapse of nearly 11 months. This failure potentially contributed to the development of a contracture in the resident's right hand, as observed by the occupational therapist during a reevaluation. The resident, who had a history of hemiplegia and hemiparesis following a cerebral infarction, was initially receiving PT and occupational therapy (OT) services to address functional limitations and prevent further decline. Despite the PT discharge summary indicating a good prognosis with consistent staff follow-through, the transition to RNA services was not executed. The RNA program, which was supposed to maintain the resident's current level of function, was not implemented due to a lack of coordination and communication between the PT and RNA staff. Interviews with facility staff revealed that the process for transitioning residents from PT to RNA services was not followed. The RNA did not receive the necessary restorative therapy referral form from the PT, and the MDS Coordinator was not informed of the need for RNA services. The Director of Nursing acknowledged the breakdown in the process and the importance of following through with PT recommendations to maintain residents' activities of daily living (ADLs).
Failure to Inform Residents About Advance Directives
Penalty
Summary
The facility failed to inform and provide written information on how to formulate an advance directive for four residents, which is a violation of their rights. The deficiency was identified through interviews and record reviews, revealing that the facility did not document information on how to obtain an advance directive in the residents' charts. This oversight could potentially prevent the residents' wishes from being followed if they become unable to make decisions. Interviews with residents revealed that they were not informed about the option to formulate an advance directive. For instance, one resident stated that the facility did not discuss advance directives with her, and another resident mentioned that he had provided a copy of his advance directive to the facility, but it was not documented in his medical record. The facility's staff, including the Licensed Vocational Nurse and the Social Services Director, acknowledged that there was no documentation of discussions about advance directives with the residents. The facility's policy and procedure documents indicate that residents should be informed of their rights to establish an advance directive upon admission. However, interviews with staff members, including the Director of Nursing and the Assistant Director of Nursing, revealed that the facility did not consistently follow these procedures. The Social Services Director and other staff members admitted that there was no documentation to show that residents were offered assistance with formulating an advance directive, highlighting a systemic issue in the facility's handling of advance directives.
Facility Fails to Maintain Safe and Comfortable Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents, as evidenced by several deficiencies observed during a survey. Two residents, identified as Resident 34 and Resident 57, experienced discomfort due to cold room temperatures at night. Despite complaints to the staff, the room temperatures were not maintained within the recommended range of 71-81 degrees Fahrenheit. The Maintenance Supervisor admitted to checking room temperatures only during the day and not at night, which contributed to the residents' discomfort and potential health risks. Another deficiency was observed in Resident 42's room, where a large hole and a smaller hole with exposed insulation and wiring were found behind the bed. The holes posed potential environmental hazards, including the risk of electrocution. Despite the presence of these hazards, no maintenance order was placed in the TELS system to address the issue, and the holes remained partially unaddressed for some time. The Maintenance Assistant and Supervisor acknowledged the oversight and the potential risks associated with the exposed wiring and uncovered outlets. Additionally, Resident 305 experienced issues with a malfunctioning bed and poor television reception, which affected the resident's comfort and quality of life. The bed was stuck in a seated position, and the TV channels were not clear due to antenna issues. Although the Maintenance Supervisor was aware of the problems, there was a lack of timely and effective repairs, as indicated by the absence of recent maintenance requests in the TELS system. These deficiencies highlight the facility's failure to provide a homelike environment and ensure the safety and comfort of its residents.
Improper Storage and Labeling of Medications
Penalty
Summary
The facility failed to properly store and label drugs and supplies in accordance with acceptable standards of practice. Two inhalers, belonging to two residents, were not labeled with an open date or expiration date. This oversight was confirmed during observations and interviews with LVNs and the Director of Infection Prevention. The lack of labeling could lead to the administration of expired medications, which may not be effective and could potentially cause adverse reactions. The facility's policy requires medications to be labeled with open and expiration dates to ensure their potency and effectiveness. Additionally, the facility did not maintain proper temperature control in two of its medication refrigerators. Observations revealed that the temperatures in these refrigerators were outside the recommended range of 36°F to 46°F. Medications stored in these refrigerators, belonging to three residents, were at risk of losing their potency due to improper storage conditions. Interviews with the ADON and DON confirmed that the refrigerators were out of range for several hours, and the medications stored within them were discarded and replaced. The facility's policy on the storage and expiration of medications emphasizes the importance of maintaining appropriate temperature and sterility conditions. The failure to adhere to these guidelines resulted in the potential degradation of medications, which could lead to ineffective treatment and adverse reactions for the residents involved. The report highlights the need for regular inspections and compliance with storage requirements to ensure the safety and efficacy of medications administered to residents.
Inaccurate Measurement of Ingredients in Pureed Diets
Penalty
Summary
The facility's cook staff failed to accurately measure milk and margarine while preparing a pureed rice recipe for 12 residents on a pureed diet. During an observation, Cook 1 used a 1/2 cup metal measuring cup three times to measure 1.5 cups of milk, but the milk did not level to the top edge of the measuring cup each time. Additionally, Cook 1 used a round plastic measuring cup to measure margarine, which left open areas between the block of margarine and the measuring cup wall, resulting in an inaccurate measurement. Cook 1 added a total of 2 additional cups of 2% milk to achieve the targeted pudding texture for the pureed rice. Cook 1 acknowledged the importance of following the recipe to ensure the correct consistency and nutrient content. The Registered Dietician (RD) confirmed the importance of following pureed recipes to achieve the right consistency and stated that additional milk would not significantly increase protein content or harm residents. However, the RD had not verified whether staff were properly measuring ingredients. The Director of Nursing (DON) stated that the facility did not have a policy for pureed food preparation but expected cooks to follow recipes. Cook 2, who also prepared pureed rice, described a different measurement approach, using a cylinder plastic measuring cup for milk and melted margarine for easier blending. The facility's job descriptions emphasized the importance of preparing food according to standardized recipes and ensuring high-quality food provision.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to maintain safe and sanitary food preparation and storage practices, as observed during a survey. A box of potatoes was found in the kitchen without a label indicating the received date or use-by date. The Dietary Manager (DM) acknowledged that the potatoes were not dated and stated that all food should be labeled to ensure kitchen staff are aware of how long food has been on the shelf. The Registered Dietician (RD) also confirmed that unlabeled or undated foods pose a risk of serving expired or spoiled food to residents, potentially leading to foodborne illnesses. Additionally, a dietary aide was observed scratching their ear and continuing to handle clean cups without washing their hands. The DM stated that staff should wash their hands after touching their head or face to prevent cross-contamination. The RD emphasized the importance of handwashing to promote infection control and food safety practices, noting that failure to do so could result in residents acquiring foodborne illnesses. Further observations revealed that thawing frozen beef kabobs in the walk-in refrigerator were not labeled with a prepared by or use-by date. The DM admitted that the kabobs should have been labeled and dated, as this practice helps prevent the use of old food that could be contaminated. Dust was also identified on the ceiling above the fan in the food storage room, which the DM stated could affect temperature control and lead to spoiled food. The Supervisor of Maintenance acknowledged the responsibility to clean the fan and ceiling, noting that dust in the storage room could create a fire hazard and potentially contaminate food, leading to foodborne illnesses for residents.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observations and interviews. Resident 34's nebulizer mouthpiece was found on top of the machine next to a urinal, which was not stored in a bag as required to prevent cross-contamination. This oversight was acknowledged by both the Licensed Vocational Nurse and the Director of Infection Prevention, who confirmed that the improper storage posed a risk for respiratory infections. Resident 37's foley catheter bag and tubing were observed on the ground, which is against the guidelines for catheter maintenance. The Registered Nurse and the Director of Staff Development both recognized that this practice increased the risk of cross-contamination and infection. Similarly, Resident 152's urinal was found on a bedside table with food and personal items, which was not sanitary and posed a risk for infection, as noted by the Certified Nursing Assistant. The facility also failed to implement Enhanced Barrier Precautions (EBP) for residents with surgical wounds, as observed with Residents 152 and 305. Licensed nurses did not use gowns during wound care, and therapy staff did not follow EBP when assisting Resident 306 with Activities of Daily Living. Additionally, Resident 505's oxygen tubing was found on the floor, which was not stored properly, increasing the risk of contamination. The facility's storage practices were also deficient, as evidenced by an opened debridement tray found in a treatment cart and staff personal belongings stored in a utility supply room, both of which posed potential infection control issues.
Failure to Maintain Secure Handrails in Hallways
Penalty
Summary
The facility failed to ensure that corridors were equipped with firmly secured handrails on each side, which increased the risk of falls for residents using the handrails for assistance with walking. During an observation in the Station 2 Hallway, a handrail was found to be broken and loose, and another was missing a curved piece of wood, exposing the metal bracket and screws. This deficiency was confirmed during an interview with the Maintenance Supervisor, who acknowledged that broken and loose handrails posed a risk of injury to residents. The Maintenance Supervisor stated that the facility used the TELS System to notify the maintenance department of repair needs, and any staff member could access this system. Despite being notified of the broken handrails, the curved ends were obsolete and could not be replaced. The facility's policy and procedure documents emphasized the importance of maintaining a safe, clean, and comfortable environment, with regular facility rounds and oversight by the Executive Director, Director of Nursing, and Maintenance/Housekeeping Supervisor. However, the failure to maintain the handrails in good condition was a deviation from these policies.
Failure to Provide Dignity Bags for Catheter Drainage
Penalty
Summary
The facility failed to ensure dignity for two residents by not providing dignity bags for their foley catheter drainage bags, leaving the urine visible to anyone entering their rooms. For Resident 3, observations on multiple occasions revealed that the catheter bag was uncovered, and staff members, including CNAs and an LVN, acknowledged that this was against the facility's policy and did not provide dignity or privacy. The Director of Nursing confirmed that Resident 3's right to dignity was violated due to the lack of a privacy bag. Similarly, Resident 305 was observed with an uncovered catheter bag while lying in bed. The resident, who was cognitively intact, was unaware if the urinary bag was covered when outside the room. Staff members, including a CNA and an LVN, stated that a dignity cover should have been used to protect the resident's privacy and dignity. The facility's policies on resident rights and dignity emphasize the importance of maintaining resident privacy and treating them with respect and dignity.
Failure to Provide Written Bed Hold Policy During Resident Transfers
Penalty
Summary
The facility failed to provide written information regarding the bed hold policy to two residents, Resident 3 and Resident 455, during their transfers to the hospital. Resident 3 was transferred to the hospital without receiving a written notice of the facility's bed hold policy, despite verbal notifications being made to the resident's responsible party (RP). Interviews with the Licensed Vocational Nurses (LVN) and the Admissions Coordinator (AC) revealed that while verbal communication occurred, no physical documentation of the bed hold policy was provided, which is a requirement according to the facility's policy and procedure. Resident 455, who was cognitively intact, also did not receive a written bed hold policy upon transfer to the hospital. The Social Services Director (SSD) and LVN confirmed that the resident was not provided with the policy, as it was not standard practice for residents with non-Medi-Cal insurance. The facility's policy and procedure documents did not clearly mandate the provision of a physical copy of the bed hold policy upon transfer, leading to this oversight. The Director of Nursing (DON) acknowledged the importance of providing the bed hold policy to ensure residents and their representatives understand the terms and can ask questions if needed. The facility's failure to provide the necessary documentation could lead to confusion and disputes regarding bed availability and the terms of the bed hold, as the residents were not adequately informed in writing as required by the facility's own policies.
Deficiencies in Care Plan Implementation in LTC Facility
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for several residents, leading to potential risks and unmet needs. Resident 37 did not have a care plan developed for an indwelling Foley catheter, which was necessary due to a neurogenic bladder. This oversight was attributed to a breakdown in communication among staff, resulting in the absence of a care plan that could guide staff in monitoring and managing the catheter, potentially increasing the risk of infection and compromising the resident's safety. Resident 26's care plan interventions for visual needs were not implemented, resulting in the resident not wearing glasses for five days. This failure was due to staff not following the care plan, which required ensuring the resident wore glasses when up. The absence of glasses increased the risk of injury and decreased participation in activities of daily living, as the resident struggled with vision-related tasks and required assistance from staff. Residents 409 and 86 did not have care plans addressing the use of anticoagulants, which are critical for monitoring potential side effects such as bruising and bleeding. The lack of a care plan for Resident 409 meant that the resident did not receive education on anticoagulant side effects or complications, while Resident 86's care plan lacked monitoring interventions for bleeding or bruising. These deficiencies highlighted the importance of having individualized care plans to ensure appropriate monitoring and education for residents on anticoagulant therapy.
Failure to Update Care Plan for Healed Pressure Ulcer
Penalty
Summary
The facility failed to revise a comprehensive person-centered care plan for a resident, identified as Resident 120, after a stage two pressure ulcer had healed. The care plan still contained active treatment interventions for the ulcer, which had already resolved. This oversight was discovered during a review of Resident 120's records, which showed that the pressure ulcer had healed on January 15, 2025, but the care plan dated December 2, 2024, had not been updated to reflect this change. Interviews with staff, including CNAs and an LVN, revealed that care plans are essential for guiding resident care, and if they are not accurate, specific care for the resident could be missed. The Director of Nursing (DON) confirmed the importance of accurate care plans for communicating resident needs and acknowledged the potential for negative outcomes if care plans are not updated. The facility's policy and procedure on comprehensive care plans, dated December 2017, indicated that resident progress should be regularly evaluated and care plans revised as appropriate. The DON stated that the care plan for Resident 120 should have been resolved by the end of the nurse's shift on the day the wound was considered healed.
Oxygen Administration Deficiencies for Two Residents
Penalty
Summary
The facility failed to adhere to professional standards of practice for two residents, Resident 112 and Resident 306, regarding the administration of oxygen. Resident 112, who had a diagnosis of Chronic Obstructive Pulmonary Disease (COPD), emphysema, and obstructive sleep apnea, was observed receiving oxygen at a rate of 2.5 liters per minute (LPM) instead of the ordered 2 LPM. This discrepancy was noted over several days, and the registered nurse (RN) acknowledged the error, stating that the oxygen order was not followed. The Director of Nursing (DON) confirmed that the resident received more oxygen than ordered, which could be detrimental to the resident's health. Resident 306, who was admitted with multiple diagnoses including Methicillin Resistant Staphylococcus Aureus (MRSA), Parkinson's disease, and congestive heart failure, was observed with an oxygen flow rate set at 3 L/min instead of the prescribed 2 L/min. The Licensed Vocational Nurse (LVN) confirmed that the oxygen saturation was at 96% and did not require oxygen at the time, indicating that the physician's order was not followed. Additionally, Resident 306's oxygen tubing was not labeled with the date it was placed, which is a requirement to prevent infection and ensure timely changes of the equipment. The facility's policy and procedure for oxygen administration require checking the physician's order for the correct flow rate and method of administration, as well as labeling and changing the oxygen tubing regularly. The failure to follow these procedures for both residents put them at risk for potential health complications, including infection and respiratory issues. The Assistant Director of Nursing (ADON) emphasized the importance of following physician orders and maintaining proper labeling to prevent such risks.
Failure to Provide Proper Toenail Care
Penalty
Summary
The facility failed to provide appropriate toenail care for Resident 28, resulting in long, jagged, and uncomfortable toenails. Resident 28, who was admitted with a displaced intertrochanteric fracture of the right femur and required assistance with personal care due to muscle weakness and reduced mobility, reported discomfort from her toenails. Despite having no cognitive deficits, she relied on staff for toenail care, which was inadequately performed, leaving her toenails sharp and uneven. Interviews with staff, including CNAs and LVNs, revealed that routine toenail care was expected to be performed twice a week with each shower, including trimming, filing, and cleaning. However, Resident 28's toenails were observed to be long and jagged, with the right big toenail growing at an angle into the toe, causing discomfort. The staff acknowledged the risk of long, jagged toenails leading to potential injury or infection, yet the care was not documented or performed as required. The facility's policies and training materials emphasized the importance of proper toenail care to prevent infection and maintain hygiene. Despite this, the documentation on the Shower Day Inspection form indicated that Resident 28's routine toenail care was not completed. The Director of Nursing and other staff members confirmed the expectations for toenail care and the failure to meet these standards, as evidenced by the condition of Resident 28's toenails.
Improper Foley Catheter Management Poses Risk to Resident
Penalty
Summary
The facility failed to ensure a resident was free from accidents when the resident's foley catheter tubing was wrapped around her prosthetic right lower leg while she was sitting in her wheelchair. This situation posed a risk of causing a fall or injury to the resident, either by tripping her during a transfer or by the catheter being pulled from her bladder. The resident, who was cognitively intact, was unaware of the tubing being wrapped around her leg and acknowledged the potential danger it posed. Interviews with staff revealed that the catheter was identified as a trip hazard, and it was noted that the physical therapy assistant who transferred the resident was not trained on the proper placement of the catheter. The Director of Staff Development and other staff members acknowledged that the catheter should not have been wrapped around the resident's leg and that the facility's policies and procedures regarding falls management and incident management were not followed. The facility's Incident Management Policy emphasizes the need to provide a safe environment and reduce the incidence of reoccurrence, which was not adhered to in this case.
Failure to Post Accurate Staffing Information
Penalty
Summary
The facility failed to post accurate daily staffing information, specifically the total number and actual hours worked by Registered Nurses (RNs), Licensed Vocational Nurses (LVNs), and Certified Nursing Assistants (CNAs). During an observation, it was noted that the Census and Direct Care Services Hours Per Patient Day (DHPPD) form did not include these details. The Assistant Staff Development Coordinator (ASDC) admitted that the posted form did not reflect the actual hours worked and that the detailed hours were only available on a separate worksheet not accessible to residents or their families. This omission prevented residents and their families from having access to the actual direct care staff hours and the total number of staff providing care daily. In an interview, the Administrator acknowledged that the DHPPD form lacked the necessary information about RN and LVN hours and confirmed that this information should have been posted. The Administrator was unaware of the requirement by the Centers for Medicare & Medicaid Services (CMS) to post such information. The facility used a form provided by the California Department of Public Health (CDPH), but it did not meet the CMS requirements. This oversight resulted in a deficiency as it failed to provide transparency to residents and their families regarding the staffing levels and hours worked by direct care staff.
Failure to Document Gradual Dose Reduction for Antidepressant
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs. Specifically, a resident was administered mirtazapine, a medication used to treat depression, from November 2, 2024, to February 6, 2025, without any documented attempts at a gradual dose reduction (GDR). The resident, who was admitted with diagnoses of depression and anxiety, received mirtazapine daily despite having no recorded depressive episodes. The Licensed Vocational Nurse (LVN) acknowledged that the resident would have benefitted from a GDR and confirmed that no GDR attempt was documented. Interviews with the Social Services Director (SSD) and the Director of Nursing (DON) revealed that the last medication review was conducted in November 2024, but no GDR was recommended. The SSD admitted to not properly documenting the doctor's recommendation regarding a GDR, which would have explained why a GDR was not performed. The facility's policy on psychotropic medication management requires the interdisciplinary team to evaluate the necessity of such medications quarterly, including documentation of GDR assessments, which was not adhered to in this case.
Medication Administration Error for Potassium Chloride
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 556, was free from significant medication errors. The error occurred when RN 1 administered potassium chloride 20MEQ to Resident 556 without following the manufacturer's instructions. The instructions specified that the medication should be taken with a meal and that the resident should avoid lying down for at least 10 minutes after administration. However, RN 1 gave the medication at around 10:10 a.m., after the resident had breakfast at 7:30 a.m., and allowed the resident to lie back down immediately after taking the medication. Resident 556, who was cognitively intact with a BIMS score of 15, had a medical history of paroxysmal atrial fibrillation and gastro-esophageal reflux disease. The Assistant Director of Nursing confirmed that RN 1 did not adhere to the manufacturer's guidelines, which could have affected the medication's absorption and effectiveness. The facility's policy emphasized the importance of verifying medication instructions to prevent errors, but this was not followed in this instance.
Incomplete POLST for Resident in LTC Facility
Penalty
Summary
The facility failed to maintain accurate and complete medical records for a resident, specifically regarding the Physician Orders for Life-Sustaining Treatment (POLST). The POLST, which contains critical medical orders for end-of-life care, was not completed for the resident, who had been admitted to the facility from an acute care hospital with multiple diagnoses including MRSA, Parkinson's disease, schizoaffective disorder, congestive heart failure, and depression. The resident was observed to be cognitively intact with a BIMS score of 15, indicating the ability to make informed decisions about their care. During the review of the resident's records, it was found that there was no completed POLST on file, which was confirmed by the Medical Records Administrator (MRA). The MRA acknowledged the importance of the POLST in emergencies to ensure the resident's treatment preferences, such as DNR status, are honored. The Assistant Director of Nursing (ADON) also emphasized the significance of the POLST in respecting the resident's wishes for medical interventions. The facility's policy required timely completion and auditing of health records, but the POLST had remained incomplete for a month, which was deemed unacceptable by the ADON.
Inaccurate Documentation by LVN During Resident's Hospitalization
Penalty
Summary
The facility failed to provide services that meet professional standards of practice for a resident when an LVN did not perform necessary assessments and continued to document on the resident's clinical record during a period when the resident was admitted to a general acute care hospital. The LVN documented vital signs, pain assessments, feeding tube assessments, enteral feeding intake, and non-pharmacological pain interventions that were not provided from December 25 to December 30, 2021, while the resident was hospitalized. This resulted in an inaccurate clinical record that did not reflect the resident's current medical status. The resident had been admitted to the facility with multiple diagnoses, including hemiplegia, hemiparesis, type 2 diabetes mellitus, morbid obesity, dysphagia, aphasia, vascular dementia, sepsis, and chronic kidney disease. On December 25, 2021, the resident was transferred to the hospital due to shortness of breath. Despite the resident's absence from the facility, the LVN documented various medical interventions and assessments as if they had been performed, which was confirmed by the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) during interviews. The ADON and DON acknowledged that the documentation by the LVN was unacceptable and illegal, as it falsely indicated that services and treatments were provided when they were not. The LVN admitted to the mistake, stating that her electronic signature was on the Medication Administration Record (MAR) and that she was responsible for the inaccurate documentation. The facility's policy and procedure documents emphasize the importance of accurate documentation and adherence to professional standards, which were not followed in this case.
Inaccurate Documentation by LVN During Resident's Hospitalization
Penalty
Summary
The facility failed to ensure that a licensed nurse performed accurate assessments and documentation for a resident who was admitted to a general acute care hospital. The Licensed Vocational Nurse (LVN 1) documented vital signs, pain assessments, feeding tube assessments, enteral feeding intake, and non-pharmacological pain interventions for Resident 1 from December 25 to December 30, 2021, despite the resident being hospitalized during this period. This resulted in an inaccurate clinical record that did not reflect the resident's current medical status. Resident 1 had multiple diagnoses, including hemiplegia, hemiparesis, type 2 diabetes mellitus, morbid obesity, dysphagia, aphasia, vascular dementia, sepsis, and chronic kidney disease. The resident was transferred to the hospital on December 25, 2021, due to shortness of breath. Despite this, LVN 1 continued to document care and treatments as if the resident were still in the facility, including enteral feeding orders and pain management interventions. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) confirmed that LVN 1's documentation was inappropriate and illegal, as it falsely indicated that care was provided when the resident was not present in the facility. LVN 1 admitted to the mistake, acknowledging that her electronic signature was on the Medication Administration Record (MAR) and that she failed to accurately document the resident's care. The facility's policies and procedures emphasize the importance of accurate documentation and adherence to professional standards, which were not followed in this case.
Unsanitary Kitchen Conditions and Pest Presence
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, as observed during a survey. There was a golden-colored buildup and debris accumulation behind the stove, and the floor in various areas, including next to the water inlet, behind the ice machine, and between the pantry and kitchen, was littered with soiled napkins, straws, beverage cups, wrappers, and food debris. The pantry floor had a dark granular substance and a dark glob, while the floor underneath the pantry wire storage rack was scattered with debris such as utensils, jelly cups, brown paper bags, napkins, a hairnet, and saltine crackers in plastic wrap. Additionally, a one-foot length of vinyl baseboard molding was found peeled off and on the floor in the pantry, and the pantry storage counter holding five-gallon water jugs had a black substance buildup. The presence of pests was also noted, with two dead cockroaches found under the food preparation table, one beneath the three-compartment sink area, and another caught in a web near the ceiling by the dishwasher. These unsanitary conditions were confirmed by both the Dietary [NAME] and the Dietary Manager during observations and interviews. The facility's Employee Handbook and the Food and Drug Administration's Food Code emphasize the importance of maintaining clean work areas and controlling pests, which the facility failed to adhere to, potentially risking foodborne illness among residents.
Pest Control Deficiency in Facility
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of multiple dead cockroaches in critical areas such as the kitchen floor beneath the food preparation area, the three-compartment sink, and behind the hallway ice machines. These observations were made during a survey, and interviews with staff confirmed awareness of the cockroach problem. The Dietary Manager and Dietary staff validated the presence of dead cockroaches in the kitchen and pantry areas, acknowledging the importance of cleanliness, which was not maintained. The facility's pest control company had previously treated the kitchen and other areas with roach gel bait, as indicated in service tickets from August 2024. However, the problem persisted, with live cockroach activity noted in the pest control reports. The Food and Drug Administration's Food Code requires that food establishments be protected against pests by sealing openings and maintaining cleanliness, which the facility failed to uphold, leading to the deficiency.
Failure to Implement Skin Integrity Care Plan
Penalty
Summary
The facility failed to ensure that a resident, who was assessed as a moderate risk for developing pressure ulcers, did not develop such ulcers. The nursing care plan, which included daily and weekly skin assessments, was not implemented from 1/6/24 to 1/19/24. This failure resulted in the resident developing a preventable Stage 3 pressure ulcer on the sacrum area. The resident was admitted to the facility with no pressure ulcers or open skin and was later readmitted to an acute hospital with a Stage 3 pressure ulcer due to the facility's negligence in following the care plan. The clinical record review revealed that the resident had multiple diagnoses, including acute respiratory failure, generalized muscle weakness, hypertension, mild cognitive impairment, pneumonia, and morbid obesity. The resident's Minimum Data Set (MDS) assessment indicated moderate cognitive deficits. Despite the facility's policy requiring routine skin assessments and an interdisciplinary care plan to maintain skin integrity, these measures were not followed. The resident's skin was not assessed daily or weekly, leading to the late recognition of the pressure ulcer. Interviews with staff, including a CNA and RN, confirmed that the resident's skin integrity care plan was not implemented. The CNA, who was new and assigned to the resident, did not receive proper instructions or documentation regarding the resident's skin assessment. The RN and Assistant Directors of Nursing (ADONs) acknowledged the failure to conduct the required skin assessments. The Director of Nursing (DON) admitted that the facility did not follow its policy on skin integrity, contributing to the development of the Stage 3 pressure ulcer.
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 368 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
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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 | 0.2 mi | ★★★★★ | 2 | 0 |
| Orchard Post Acute | 0.7 mi | ★★★★★ | 2 | 0 |
| Twilight Haven | 0.9 mi | — | 0 | 0 |
| Stonehaven Senior Living | 0.9 mi | — | 0 | 0 |
| Sierra Vista Healthcare | 1.8 mi | ★★★★★ | 18 | 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.