Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Palms Care Center during CMS and state inspections, most recent first.
A resident admitted for rehab with CHF, Afib, DM, weakness, dysphagia, and BPH had a sudden decline with lethargy, refusal of meals, inability to ambulate, and hyperglycemia. Nursing notified the MD only of the high BS and did not report the full change in condition, while therapy documented worsening function and alertness. The next morning the resident was found unresponsive with shallow breathing and low VS; an LPN did not assess after repeated requests from a CNA, and another LPN ultimately assessed the resident and arranged transfer to the hospital, where the resident was admitted to the ICU, intubated, and diagnosed with sepsis, AKI, encephalopathy, and other acute conditions.
The facility did not post daily nurse staffing information with the required breakdown of RN, LVN/LPN, and CNA hours, instead combining all hours into a single figure. The staffing information was also posted in a staff-only area, making it inaccessible to residents and visitors without assistance. Facility leadership confirmed the lack of separated data and accessible posting, and there was no policy in place to ensure compliance.
Three residents did not receive individualized, person-centered care plans to address their specific needs, including one resident's preference for ileostomy care, another's ongoing medication refusal, and a third's self-harm behaviors and fall risk. Staff were aware of these issues but did not create or implement appropriate care plans, resulting in unmet needs and increased risks.
Staff failed to follow infection prevention protocols, including not performing hand hygiene between residents during medication administration and after room entry and exit, and improper storage of oxygen tubing. These actions were observed among multiple staff and residents, with staff acknowledging the importance of hand hygiene and facility policies requiring it.
Two residents did not receive care according to professional standards: one developed open, unhealing wounds from persistent skin picking without physician notification or proper documentation by LVNs and CNAs, and another received oxygen therapy at a higher rate than ordered, with staff unable to explain the deviation or duration. Facility policies and job descriptions required adherence to physician orders and reporting of changes, but these were not followed.
A resident with no cognitive impairment and a stated preference for drawing, coloring, and writing was not provided with activities matching these interests. The care plan did not reflect the resident's preferences, and staff interviews confirmed that activity documentation and scheduling did not address the resident's requests, despite repeated mentions in resident council meetings and facility policies requiring individualized activity planning.
A facility failed to ensure that a qualified RD provided consistent consultation and oversight for food and nutrition services, resulting in a resident with complex medical needs and severe cognitive impairment not receiving timely follow-up or individualized care planning for significant weight changes. The RD worked irregular hours, did not attend IDT meetings, and did not consistently document or update care plans, leading to gaps in nutritional recommendations and monitoring.
A resident's POLST form was found to be incomplete, lacking both the date prepared and the required signature of the resident or their legally recognized decisionmaker. The form was scanned into the medical record without these critical elements, despite the responsibilities outlined for the Medical Records Clerk and Social Services Director. The resident had multiple medical conditions and moderate cognitive impairment at the time of the deficiency.
Two residents were found without accessible call lights, with one resident's call light on the floor and another's out of reach, leading to one resident hitting the wall to get staff attention. Staff and the DON confirmed that call lights are required to be within reach, and facility policy supports this expectation.
A resident with a history of aggression was left unsupervised in the dining room, leading to an altercation where the resident struck another resident, causing a skin tear and bleeding. Despite a care plan requiring one-on-one supervision, staff failed to assign a CNA during the incident, resulting in a lack of monitoring. The facility's policy to prevent abuse and ensure safety was not followed, as confirmed by the DON.
The facility failed to hire a qualified Dietary Manager (DM) to oversee food and nutrition services for 56 of 61 residents. The DM was still in school and not yet certified, which was confirmed by the Registered Dietitian (RD). The job description and FDA Food Code require certification, which the DM did not have, potentially affecting residents' nutrition and health.
The facility failed to maintain kitchen sanitation standards, affecting 56 of 61 residents. Issues included a dirty dishwasher, cracked and peeling pans, a large icicle in the walk-in freezer, and torn oven mitts, all of which posed risks of contamination and injury.
The facility failed to meet professional standards when an LPN did not follow proper inhalation technique for two residents' inhalers, and LNs signed off on a resident's splint/orthotic device without ensuring it was applied. The DON confirmed these practices were against protocol.
The facility failed to obtain informed consent for the administration of psychotropic medications to a resident with dementia. The resident was given quetiapine fumarate and risperidone without being fully informed of the risks and benefits, as confirmed by interviews with the LVN, MDSC, and DON. Facility policies require informed consent for such medications, but this was not obtained prior to administration.
A resident was placed on a low air loss mattress without being informed or allowed to decline the plan of care. The resident's request for fitted sheets was ignored, leading to feelings of frustration and physical discomfort. Staff admitted that the resident was not educated about the mattress and its contraindications, and the resident was not involved in the decision-making process.
The facility failed to provide a clean and homelike environment for a resident with malnutrition and anxiety disorder. The resident's bathroom had chipped and peeling paint, and sand in the toilet bowl, leading her to use her briefs instead. Staff confirmed the poor condition of the bathroom, acknowledging it did not meet the standard for a homelike environment.
The facility failed to ensure the MDS assessment accurately reflected a resident's health and functional status. A resident with right-sided weakness due to a cerebral infarction was inaccurately coded in the MDS assessment, which was confirmed by both an LVN and the MDSC. The DON acknowledged the responsibility for ensuring accurate MDS assessments.
A facility failed to develop and implement a comprehensive care plan for a resident on apixaban for atrial fibrillation. Despite the medication being prescribed, no care plan was initiated to monitor its side effects. This oversight was confirmed by the LVN, MDSC, and DON, who acknowledged the necessity of such a care plan. The resident, admitted with multiple diagnoses, expressed a need for assistance due to limited mobility.
An LVN left a medication cart unlocked and unattended while administering medication to a resident with asthma, quadriplegia, and heart failure. This was against the facility's policy, which requires medication carts to be locked when not under direct observation.
A facility failed to maintain an infection control program when an LVN did not sanitize a blood pressure cuff and stethoscope after use and did not wash her hands before preparing medications for a resident with hypertensive heart disease and atherosclerotic heart disease. The DON confirmed these actions violated infection control protocols.
Failure to respond to resident’s acute decline and notify physician of full change in condition
Penalty
Summary
The facility failed to accurately and appropriately respond to a significant change in condition for a resident admitted for short-term rehabilitation with diagnoses including heart failure, atrial fibrillation, diabetes mellitus, muscle weakness, dysphagia, and benign prostatic hyperplasia with urinary symptoms. The resident had been progressing with therapy and was able to ambulate 25 feet, but on the morning of 7/7/26 staff observed a sudden decline: the resident was difficult to arouse, refused to get up, was not able to ambulate, refused meals, and had an elevated blood sugar of 337. Nursing documented altered mental status and hyperglycemia, but the physician was only notified of the elevated blood sugar and was not informed of the full extent of the resident’s decline in alertness, mobility, cooperation, and meal refusal. The physician ordered insulin, blood sugar rechecks, and monitoring, but the record and interviews showed the resident continued to decline through the day. Therapy documented that the resident had more difficulty following commands, required maximal assistance with transfers, and the decline was communicated to nursing and the DON. Nursing notes later stated the resident did not eat dinner and was asleep most of the shift, and the blood sugar decreased after insulin was given. The physician later stated he was not made aware that the resident was not eating, hard to awaken, or had a decline in mobility and alertness, and said the orders would have been different if he had known the full situation. On the morning of 7/8/26, the resident was found unresponsive with shallow breathing, low blood pressure, and a low pulse. CNA 1 twice asked LVN 4 to assess the resident, but LVN 4 did not respond or complete an assessment. CNA 1 then called LVN 2, who assessed the resident and initiated transfer to the hospital. The resident was sent to the ED in critical condition and admitted to the ICU, where he was intubated for respiratory failure and diagnosed with urosepsis, acute kidney injury, encephalopathy, pleural effusion, tachycardia, hypertension, atrial fibrillation, poorly controlled diabetes, shingles, urinary obstruction, sepsis, altered mental status, and UTI. The report also states the resident remained in the acute care hospital for 28 days at the time of the survey review.
Failure to Post Complete and Accessible Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that daily nurse staffing information was posted with all required details and in a location that was readily accessible to residents and visitors. Specifically, the posted staffing documents did not separate or specify the total number and actual hours worked by Registered Nurses (RNs), Licensed Vocational/Practical Nurses (LVNs/LPNs), and Certified Nursing Assistants (CNAs). Instead, the information was combined into a single 'Total Hands on PPD' figure, omitting the breakdown required by regulations. Interviews with the Director of Staff Development (DSD), Director of Nursing (DON), and Administrator confirmed that they could not locate or provide the separated staffing data on the posted documents for multiple reviewed dates. Additionally, the daily nurse staffing information was posted behind the nursing station, an area marked as restricted to staff only, making it inaccessible to residents and visitors without staff assistance. The DSD, DON, and Administrator all acknowledged that the information was not easily accessible and that there was no facility policy or procedure in place for posting daily nurse staffing information as required. This failure affected all 60 residents in the facility, as neither they nor their visitors could independently view the required nurse staffing information.
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for three residents, resulting in unmet needs and increased risks. For one resident with an ileostomy, the care plan did not address her preference to maintain the stoma uncovered and self-manage care using personal washcloths, despite her cognitive intactness and repeated communication of her preferences to staff. Observations and interviews confirmed that staff were aware of her choices and the challenges with the ileostomy bag, but no individualized care plan was created to guide staff in honoring her preferences or managing associated risks. Another resident, who was cognitively intact and had a history of epilepsy, atrial fibrillation, and hypertension, repeatedly refused critical medications for seizure control and blood pressure management. The care plan did not address this ongoing medication refusal, and there was no documentation of person-centered interventions, education provided, or consistent notification of the responsible party and physician as required by facility policy. Staff interviews confirmed the absence of a care plan for medication refusal, and the responsible party reported not being informed of changes in the resident's condition. A third resident, with moderate cognitive impairment and a history of diabetes, depression, and gait abnormalities, exhibited self-harm behaviors by picking at wounds, leading to unhealed and bleeding injuries. No individualized care plan was developed to address this behavior or provide interventions for wound care. Additionally, the resident, identified as high risk for falls, did not receive consistent implementation of a toileting schedule or adequate supervision, resulting in an unwitnessed fall. Staff interviews and record reviews confirmed the lack of care planning and monitoring for both self-harm and fall prevention, despite documented high fall risk and previous incidents.
Failure to Maintain Infection Prevention and Control Program
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for several residents, as evidenced by multiple staff not adhering to hand hygiene protocols and improper handling of medical equipment. During medication administration, two LVNs were observed not performing hand hygiene between residents, despite facility policy and their own acknowledgment of its importance. This occurred with multiple residents, some of whom had varying levels of cognitive impairment, and was confirmed through both observation and staff interviews. The facility's policies required hand hygiene before administering medication and between resident care, but these were not followed. Additionally, a resident's oxygen nasal cannula tubing was found resting on top of the oxygen concentrator and in direct contact with the wall, rather than being stored in a protective bag as required by facility policy. Staff interviews confirmed that this was not in accordance with procedures and could lead to cross contamination. The resident in question had a history of chronic obstructive pulmonary disease and acute respiratory failure, and was actively receiving oxygen therapy per physician orders. Further, a CNA was observed failing to perform hand hygiene after leaving one resident's room and before entering and exiting another resident's room, even after providing assistance. Both the CNA and other staff acknowledged the importance of hand hygiene to prevent cross contamination, and the facility's policy required hand hygiene upon entering and exiting resident rooms. These lapses were confirmed through direct observation, staff interviews, and review of facility policies.
Failure to Follow Professional Standards in Wound Care and Oxygen Administration
Penalty
Summary
The facility failed to meet professional standards of practice for two residents. In the first case, a resident with a history of diabetes, depression, muscle weakness, and abnormal gait was observed to have open, bleeding, and unhealing wounds on her arms and shoulder due to persistent itching and picking at her skin. Licensed Vocational Nurses (LVNs) did not notify the physician about the resident's continued skin picking and resulting wounds, despite documentation in progress notes and observations by staff. Certified Nursing Assistants (CNAs) also failed to report the resident's behavior and skin condition to the charge nurse, and there was no documentation of skin checks during bathing or showering. The facility's policies and job descriptions required staff to report and document such changes, but these procedures were not followed. In the second case, another resident with chronic respiratory failure, hypoxia, heart failure, and pneumonia was not administered oxygen therapy according to the physician's order. The resident was ordered to receive oxygen at 2 liters per minute (LPM) via nasal cannula, but was observed receiving 5 LPM. The LVN and Respiratory Therapist (RT) could not determine how long the resident had been receiving the incorrect dosage or who had made the adjustment. Both staff members acknowledged that oxygen is considered a medication and must be administered as prescribed. The facility's policies, as well as job descriptions for LVNs and RTs, required adherence to physician orders for medication administration, including oxygen therapy. Interviews with facility staff, including the Director of Nursing (DON), confirmed that the observed practices did not align with professional standards or facility policies. The DON stated that all physician orders and medications must be administered as prescribed, and only authorized personnel should adjust oxygen concentrators. The failures in both cases were corroborated by record reviews, staff interviews, and direct observations, demonstrating a lack of compliance with established protocols for wound care and medication administration.
Failure to Provide Resident-Preferred Activities
Penalty
Summary
The facility failed to provide activities that met the preferences and interests of one resident, who expressed a desire to participate in drawing, coloring, and writing activities. Despite documentation in the resident's initial activity review indicating a preference for writing, and multiple verbal requests for more drawing, coloring, and writing opportunities, these interests were not reflected in the resident's care plan. The care plan only noted that the resident enjoyed watching television independently, omitting any mention of his stated interests in creative activities. Interviews with facility staff, including an LVN and the Activities Director, confirmed that the resident's care plan was not updated to reflect his preferences, and there were no progress notes documenting participation in or refusal of independent activities such as drawing or coloring. The Activities Director acknowledged responsibility for ensuring that activities matched resident interests and for updating care plans and activity notes accordingly. Additionally, the Activities Director did not add painting or coloring activities to the activity calendar in response to resident council requests, instead opting for a general "Residents Choice" day, which required residents to specifically request materials for their preferred activities. Facility documentation, including resident council minutes and activity calendars, showed repeated requests for more painting and coloring activities, but these were not consistently incorporated into the monthly activity schedules. Facility policies and job descriptions emphasized the importance of providing resident-specific activities based on comprehensive assessments and care plans, as well as supporting resident self-determination and participation. However, these policies were not followed in the case of this resident, resulting in a lack of meaningful activity options aligned with his interests.
Failure to Provide Adequate Dietitian Oversight and Nutritional Care
Penalty
Summary
The facility failed to ensure that the Registered Dietitian (RD) provided adequate consultation and support for food and nutrition services, specifically in the assessment and development of individualized care plans for a resident who experienced significant weight changes. The RD was not consistently present at the facility, working irregular hours and often after completing work at another job. The RD did not participate in staff training, interdisciplinary team (IDT) meetings, or regular follow-up on residents' nutritional needs, including those triggered for weight changes. The Certified Dietary Manager (CDM) and Director of Nursing (DON) both indicated that the RD's involvement was limited, and the RD did not create or update care plans for residents, nor did he provide timely recommendations for residents with ongoing weight fluctuations. A review of records showed that the RD had only written one note in the affected resident's chart since January, despite the resident being flagged for significant weight changes in both February and March. The DON was unsure if the RD was aware of the resident's weight loss and confirmed that the RD was not involved in weekly IDT meetings where such issues were discussed. The RD's job description required him to assess and monitor residents' nutritional status, provide recommendations, develop and update care plans, and participate in audits and staff guidance, but these duties were not consistently fulfilled due to the RD's limited and inconsistent presence at the facility. The resident involved had a complex medical history, including hemiplegia, gastrostomy, and a history of stroke, and was assessed as having severe cognitive impairment. Despite being at high risk for nutritional issues, the resident did not receive adequate follow-up or individualized care planning from the RD. The facility's documentation and interviews confirmed gaps in the RD's recommendations and lack of ongoing monitoring, which was inconsistent with both facility policy and regulatory requirements for dietetic services.
Incomplete POLST Form in Resident Medical Record
Penalty
Summary
The facility failed to maintain accurate and complete medical records for one resident when the Physician Orders for Life-Sustaining Treatment (POLST) form was found to be incomplete. During interviews and record reviews, it was observed that the POLST for the resident was missing critical information, including the date the form was prepared and the signature of the resident or their legally recognized decisionmaker. Both the LVN and the Director of Nursing confirmed that the POLST was not properly completed, as the required signatures and dates were absent. The resident had a documented history of type 2 diabetes mellitus, depression, muscle weakness, and gait abnormalities, and was assessed as moderately cognitively impaired. The facility's own job descriptions indicated that the Medical Records Clerk was responsible for ensuring records were complete before filing, and the Social Services Director was responsible for overseeing advance care planning and ensuring staff were aware of residents' end-of-life wishes. Despite these responsibilities, the incomplete POLST was scanned into the resident's chart without the necessary signatures. The facility's policy and procedure for medical records accuracy was requested but not provided during the survey.
Call Lights Not Accessible to Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for two residents, resulting in the call lights being found on the floor and tucked in bedside drawers, out of the residents' reach. One resident, who had no cognitive impairment and diagnoses including congestive heart failure, diabetes mellitus, and adult failure to thrive, was observed lying in bed without access to a call light, which was on the floor. The resident stated he could not get a hold of staff when the call light was not accessible. Another resident, with severe cognitive impairment, dementia, bipolar disorder, and muscle weakness, was observed hitting the wall to get staff attention because her call light was out of reach. She stated it was difficult to get staff's attention without the call light. Staff interviews confirmed that call lights are expected to be within residents' reach and that failure to do so could prevent residents from calling for help. The Director of Nursing also stated that staff are expected to ensure call lights are accessible and acknowledged the risk to residents if they are unable to reach their call lights. Review of facility policy confirmed the requirement for staff to keep call lights within reach of residents while in bed.
Failure to Supervise Aggressive Resident Leads to Injury
Penalty
Summary
The facility failed to ensure adequate supervision and monitoring for a resident with a history of aggressive behavior, resulting in an incident where the resident struck another resident. The aggressive resident, who had a care plan intervention for one-on-one supervision due to his aggressive tendencies, was left unattended in the dining room. This lapse in supervision led to the resident hitting another resident on the left hand, causing a skin tear and bleeding that required treatment. The aggressive resident was admitted with diagnoses including dementia and type 2 diabetes mellitus, and had a Brief Interview for Mental Status (BIMS) score indicating severe cognitive impairment. Despite the care plan specifying constant one-on-one supervision, there was a documented failure to assign a Certified Nurse Assistant (CNA) to supervise the resident during the time of the incident. Interviews with staff, including CNAs and Licensed Vocational Nurses (LVNs), confirmed that the resident was not being monitored as required, which placed other residents at risk. The Director of Nursing (DON) acknowledged that the facility's policy and procedure for preventing abuse and ensuring resident safety were not followed. The facility's policy emphasized the importance of protecting residents from physical harm and abuse, yet the lack of supervision allowed the aggressive resident to harm another resident. The incident was witnessed by another resident, but no staff member was present to intervene or witness the altercation, highlighting the failure in implementing the required supervision for the aggressive resident.
Unqualified Dietary Manager Hired
Penalty
Summary
The facility failed to hire a qualified Dietary Manager (DM) to oversee the food and nutrition services for 56 of 61 residents. During an interview, the DM admitted that she was still in school to become a certified dietary manager and had not yet completed her training or obtained certification. The Registered Dietitian (RD) confirmed that the DM was not certified and emphasized the importance of having a certified dietary manager to comply with state regulations and ensure proper food safety and nutrition standards in the kitchen. A review of the Dietary Manager job description indicated that the minimum requirements for the role included certification as a dietary manager, certification as a food service manager, or similar national certification for food service management and safety. Additionally, the Food Code from the U.S. Food and Drug Administration requires the person in charge to demonstrate knowledge of foodborne disease prevention and food safety by being a certified food protection manager. The facility's failure to meet these requirements had the potential to affect the nutrition status and health of the residents receiving food from the kitchen.
Facility Fails to Maintain Kitchen Sanitation Standards
Penalty
Summary
The facility failed to ensure safe preparation, distribution, and storage practices in the kitchen, affecting 56 of 61 residents. Observations revealed that the top of the dishwasher was covered with dirt, crumbs, and white residue, which could have contaminated the dishes. Both the Dietary Supervisor and Cook acknowledged that the dishwasher should have been cleaned daily, and the Registered Dietitian confirmed that the residue could lead to improper cleaning of the dishes. The facility's policy and procedure on sanitation, as well as the US Food Code, were not followed in this instance. Additionally, three of seven pans in the kitchen had cracked and peeling cooking surfaces. The Registered Dietitian and Dietary Supervisor both stated that the pans should have been replaced to prevent the coating from contaminating the food. The facility's policy on sanitation and the US Food Code require that equipment and utensils be clean and intact to prevent cross-contamination. The walk-in freezer had a large icicle hanging inside, which was acknowledged by the Cook, Registered Dietitian, and Dietary Supervisor as a potential hazard and an indication of a malfunctioning freezer. Torn oven mitts with exposed interior fabric were also observed, posing a risk of burns and contamination. The facility's policy on sanitation and the US Food Code emphasize the importance of maintaining equipment in good condition to ensure food safety.
Failure to Follow Proper Inhaler Technique and Treatment Orders
Penalty
Summary
The facility failed to meet professional standards of practice for three residents. Licensed Vocational Nurse (LVN) 2 did not follow the facility's procedure for proper inhalation technique for metered dose inhalers (MDI) when administering medication to two residents. Specifically, LVN 2 did not wash or wipe the mouthpiece of the inhalers before and after use, which is against the facility's infection control protocol. This was confirmed through observations and interviews with LVN 2 and the Director of Nursing (DON), who acknowledged the importance of cleaning the inhalers to prevent bacterial growth and potential respiratory infections. Additionally, the facility failed to properly follow treatment orders for a resident requiring a splint/orthotic device. Licensed Nurses (LNs) were signing the Electronic Treatment Administration Record (eTAR) without ensuring that the splint/orthotic device was applied as ordered. LVN 2 admitted to signing the eTAR without verifying the application of the device, and another LVN also confirmed this practice. The DON stated that this was not acceptable and that nurses should verify the application before signing the eTAR. The residents involved had significant medical histories, including COPD, asthma, heart failure, hypertension, and muscle weakness. One resident was cognitively intact, while another was severely impaired in decision-making. The failure to follow proper procedures for inhaler use and the application of the splint/orthotic device could have serious implications for their health and well-being.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure a physician Informed Consent was obtained for the use of psychotropic medication for one of six sampled residents (Resident 26). Resident 26 was administered quetiapine fumarate and risperidone from 3/26/24 to 4/8/24 without being fully informed of the risks and benefits, and without having the knowledge to make an informed decision. This failure was observed during an interview and record review with Licensed Vocational Nurse (LVN) 3, who confirmed that the medications were administered without a signed informed consent. The Minimum Data Set Coordinator (MDSC) and the Director of Nursing (DON) also confirmed that informed consent should have been obtained prior to the administration of psychotropic medications. Resident 26 was admitted with a diagnosis of dementia with unspecified severity and psychotic disturbance. The resident's Medication Administration Record (MAR) indicated that quetiapine fumarate and risperidone were administered daily during the specified period. The facility's policy and procedure documents, dated 7/2022 and 2/2022, respectively, state that residents and/or their representatives should be informed of the risks, benefits, and potential adverse consequences of antipsychotic and psychotropic medications, and that informed consent should be obtained. Despite these policies, the facility did not obtain the necessary informed consent before administering the medications to Resident 26.
Failure to Honor Resident's Rights in Care Plan Participation
Penalty
Summary
The facility failed to honor a resident's rights by not informing or allowing the resident to decline a plan of care. Resident 12, who was cognitively intact with a BIMS score of 15, was placed on a low air loss (LAL) mattress without being educated on its function or the reason for its use. The resident's request for fitted sheets, which were contraindicated for the LAL mattress, was ignored, leading to feelings of frustration, being ignored, and physical discomfort. During observations and interviews, it was noted that Resident 12 repeatedly requested fitted sheets for her mattress, which were not provided. The resident expressed feeling unsanitary and disrespected due to lying on a bare mattress. Licensed Vocational Nurse (LVN) 1 admitted that the resident was not educated about the LAL mattress and its contraindications for fitted sheets. The Director of Nursing (DON) confirmed that the resident should have been informed about the mattress and given the option to decline its use. Further interviews revealed that the resident was placed on the LAL mattress as a preventative measure for a red area on her buttock. However, the resident was not involved in the decision-making process and was not informed of alternative options for wound prevention. The facility's policy on resident rights emphasized the importance of involving residents in their care plans, which was not adhered to in this case.
Failure to Provide a Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a clean and homelike environment for Resident 45, who was admitted with diagnoses of malnutrition and anxiety disorder. During an interview, Resident 45 reported that the bathroom in her room was dirty, with chipped and peeling paint around the sink and sand in the bottom of the toilet bowl. She expressed that the bathroom took a long time to be cleaned, leading her to use her briefs instead of the bathroom. Observations by staff, including an LVN, the Director of Nursing, and the Director of Maintenance, confirmed the poor condition of the bathroom, acknowledging that it did not provide a homelike environment. The facility's policy and procedure on Resident Rights, dated October 2022, states that residents have the right to a safe, clean, comfortable, and homelike environment. However, the observations and interviews indicated that the facility did not meet this standard for Resident 45. The chipped and missing paint, along with the unclean bathroom, were validated by multiple staff members, including the LVN, DON, and DM, who all agreed that the condition of the bathroom was not acceptable for a homelike environment.
Inaccurate MDS Assessment for Resident with Right-Sided Weakness
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected a resident's health and functional status. Specifically, for one resident with right-sided weakness due to a cerebral infarction, the MDS assessment inaccurately coded the resident's functional limitation in range of motion. This discrepancy was identified during an observation and interview where the resident was unable to move his right arm and leg without assistance, which was confirmed by both the Licensed Vocational Nurse (LVN) and the Minimum Data Set Coordinator (MDSC). The MDSC admitted to coding the section incorrectly and acknowledged the responsibility for ensuring the accuracy of the MDS assessment. The Director of Nursing (DON) also confirmed that it was the responsibility of the staff completing the MDS assessments to ensure their accuracy. The facility's policy and procedure on conducting accurate resident assessments emphasized that qualified staff knowledgeable about the resident should conduct accurate assessments addressing each resident's status, needs, strengths, and areas of decline. Despite this policy, the MDS assessment for the resident in question was not completed accurately, potentially leading to unmet care needs for the resident.
Failure to Develop Comprehensive Care Plan for Anticoagulant Use
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident (Resident 57) who was administered apixaban, an anticoagulant medication, for atrial fibrillation. Despite the medication being prescribed on 1/30/24, no care plan was initiated to monitor the side effects of the anticoagulant. This oversight was confirmed during interviews and record reviews with the Licensed Vocational Nurse (LVN), the Minimum Data Set Coordinator (MDSC), and the Director of Nursing (DON). Each acknowledged that a care plan should have been developed to address the resident's anticoagulant use and its potential side effects, such as bleeding. Resident 57, who was admitted to the facility on 1/30/24, had multiple diagnoses including cerebral infarction, atrial fibrillation, and hypertension. During an observation and interview, Resident 57 expressed his need for assistance with care due to his inability to move the right side of his body. The facility's policy required a baseline care plan within 24 hours of admission and a comprehensive care plan within seven days, but this was not followed. The failure to create a care plan for the anticoagulant medication placed Resident 57 at potential risk for unmet anticoagulant needs.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
The facility failed to ensure drugs and biologicals were labeled and stored in accordance with currently accepted professional principles. During a medication pass observation, an LVN was seen preparing medications for a resident and then leaving the medication cart unlocked and unattended while administering the medication inside the resident's room. This action was against the facility's policy, which mandates that medication carts must be locked when not under direct observation. The incident involved a resident with multiple diagnoses, including asthma, quadriplegia, and heart failure. The Director of Nursing confirmed that the facility's practice requires medication carts to be locked when unattended to prevent unauthorized access. The facility's policy and procedure on medication storage also stipulate that all drugs and biologicals must be stored in locked compartments and only accessible to authorized personnel.
Infection Control Deficiency Due to Improper Equipment Sanitization and Hand Hygiene
Penalty
Summary
The facility failed to establish and maintain an infection control program, resulting in a deficiency when a Licensed Vocational Nurse (LVN) did not sanitize the blood pressure cuff and stethoscope after using them on a resident. The LVN also did not wash her hands before preparing medications for the same resident. This incident was observed in the east wing hallway by the resident's room, where the LVN was passing medications. The LVN admitted to not sanitizing the equipment and not washing her hands, acknowledging that these actions were against infection control protocols and could lead to cross-contamination and the spread of infection among residents. The resident involved had been admitted to the facility with diagnoses including hypertensive heart disease with heart failure and atherosclerotic heart disease. The Director of Nursing (DON) confirmed that the LVN should have followed proper infection control procedures, including sanitizing equipment and washing hands before medication preparation. The facility's policies and procedures also mandated these actions to prevent contamination and infection. The failure to adhere to these protocols was identified as an infection control issue by the DON.
What surveyors are citing around you — mapped
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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 70 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Chowchilla
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Chowchilla Memorial Healthcare District | 0 mi | ★★★★★ | 7 | 0 |
| Madera Care Center | 15.7 mi | ★★★★★ | 2 | 0 |
| Merced Behavioral Center | 16.1 mi | ★★★★★ | 0 | 0 |
| Madera Rehabilitation & Nursing Center | 16.5 mi | ★★★★★ | 3 | 0 |
| Anberry Post Acute | 16.9 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 October 2026) and official state health department websites.