Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Park Regency Care Center during CMS and state inspections, most recent first.
Bed rail use lacked required assessment, alternatives, and installation documentation. Four sampled residents had elevated side rails observed in bed, but the facility did not document manufacturer specifications for installation and maintenance for three residents, and one resident had no bed rail assessment despite a physician order for bilateral 1/4 side rails. For another resident, the record showed the rails were not indicated, and for a resident with no capacity to make decisions, the record did not show least restrictive alternatives were tried before the rails were used.
Kitchen and Dining Area Sanitary Deficiencies: Surveyors observed boxed food stored too close to the ceiling in the walk-in refrigerator and freezer, blocking fire sprinkler spray, along with a missing piece of floor tile near the ice machine and a ceiling tile with a hole in the dining room. Surveyors also found Station A’s freezer missing a thermometer and ice buildup on a container of ice cream, and the Dietary Supervisor was observed with artificial fingernails extending about one-half inch beyond her fingertips during trayline prep.
The facility failed to fully carry out its infection prevention and control program by not tracking residents who had signs and symptoms of infection but were not on antibiotics. A CNA was observed providing direct care with artificial nails extending beyond her fingertips, despite the facility policy prohibiting them. In addition, a resident’s room drape had a black substance along the bottom, and staff were unaware of the soiled curtain.
Failure to Obtain Informed Consent for Side Rails and Bed Placement: The facility did not document informed consent before using bilateral 1/4 side rails for one resident who lacked decision-making capacity, and it also did not obtain informed consent before placing another resident's bed against the wall. RN and DON review confirmed the missing consent documentation, while staff could not explain why the bed was positioned that way.
Failure to assess self-administration of bedside medication: A resident had Systane eyedrops at the bedside and stated she used them herself twice daily, but the record lacked a physician order for the eyedrops, an order for self-administration, a care plan problem, and an IDT assessment of whether she was safe to self-administer. An LVN, RN, and the DON verified the findings.
The facility failed to provide advance directive information to one resident who had capacity and no advance directive on file, and failed to obtain a copy of another resident’s advance directive after the resident said one existed. Review of the medical record and interviews with the SSD and DON confirmed there was no documentation showing the residents or responsible parties were given the required information or that follow-up was completed to secure the document.
A resident with dementia, psychosis, anxiety, and a hx of falls was found with the bed positioned against the wall, which the facility’s P&P identified as a physical restraint when it prevents voluntary bed exit. Staff interviewed about the setup did not know why the bed was placed that way; one CNA said the resident could get out independently, an LVN thought it was the resident’s preference, and an RN said she had just noticed it and did not know how it occurred.
Psychotropic medication monitoring and documentation were incomplete for three residents. One resident’s orthostatic BP checks ordered with Zyprexa and other psychotropics were documented with identical readings in all positions, while two residents receiving mirtazapine for poor PO intake lacked required monthly behavior summaries. For one resident, the mirtazapine dose was increased without documented MD assessment or rationale, and RN verification confirmed the missing documentation.
A facility failed to develop comprehensive, individualized care plans for three residents. One resident with a fluid restriction had no care plan problem for that order, one resident’s post-fall plan included only two interventions, and another resident with dementia, psychosis, anxiety, and a history of falls had no care plan problem for a bed placed against the wall.
Failure to Follow Ordered Fluid Restriction: A resident with a physician-ordered 1500 ml/day fluid restriction had a posted restriction sign, but staff were unaware of the order and multiple fluid containers were observed at the bedside. Record review showed inaccurate fluid documentation, including nursing intake that exceeded the ordered allotment and meal fluids that did not match the dietary order.
Two residents had respiratory care issues involving oxygen and nebulizer equipment. One resident was observed on oxygen with unlabeled, undated tubing touching the floor and an uncovered nebulizer mask and tubing on a bedside drawer, despite facility policy requiring verified orders and proper weekly changes and storage. Another resident was receiving oxygen, but the chart lacked a physician order for oxygen use, and staff confirmed the missing order.
Medication administration errors exceeded the allowed rate, with surveyors finding a 7.69% error rate. An LPN crushed Macrobid for a resident and gave it without food despite the label and order indicating it should be taken with food, and another LPN gave ursodiol to a second resident without food even though the label and order required it with meals. The DON acknowledged that nurses should know which meds can be crushed and which must be given with food.
Improper Administration of Macrobid: An LVN crushed a Macrobid capsule and gave it to a resident without food, despite the label stating to take it with food. The resident had an order to crush all crushable meds, but the pharmacy consultant stated Macrobid should not be crushed and should be administered with food.
Medication Storage and Security Failures: Staff failed to properly store, label, and dispose of medications in multiple medication areas. An opened acetylcysteine vial lacked an open date, an opened tuberculin PPD vial was past its discard timeframe, an open medication incinerator bin contained whole oral meds, and a bottle of nystatin powder was kept beyond its labeled opening period. In addition, an LPN left a medication cart unlocked and unattended while entering a resident's room, and the DON acknowledged the findings.
A resident’s personal ice chest was found soiled inside the room with bananas and melted ice packs, and staff confirmed they were responsible for cleaning it. The resident and RP gave conflicting accounts of how long it had been there, and the item was not listed on the resident’s inventory. RN stated the family brought the ice chest in and had been educated to check with nursing staff before bringing food items and to use the facility refrigerator for perishable foods.
Missing Entrapment Assessment Before Side Rail Use: A resident with impaired bed mobility and no capacity to understand or make decisions had bilateral 1/4 side rails in use for bed mobility and enabler use, but the record lacked documentation of an entrapment assessment before the rails were used. The RN stated he was not familiar with zones of entrapment, and the Maintenance Director confirmed he was responsible for monthly bed inspections and side rail installation but verified there was no documentation of the required assessment.
A resident’s admission MDS contained inaccurate height and weight information. The medical record and dietary documentation showed the resident was 73 inches tall and weighed 169 lbs, but the MDS listed 61 inches and 86 lbs. The MDS Nurse and RN confirmed the entries were incorrect, and the DON was informed of the findings.
Care Plan Not Updated for Temazepam Order Change. A resident’s care plan still reflected temazepam as PRN for insomnia even after the physician changed the order to routine bedtime administration. Review of the MAR/order summary and care plan, along with an interview with the DON, confirmed the care plan was not revised to match the current order.
A resident’s medical record contained inaccurate weight documentation, with large unexplained fluctuations recorded in the chart, including a major loss and gain within short timeframes. RNA staff could not recall weighing the resident on the dates in question, and an LVN and RN both acknowledged the weights were mistakenly documented, possibly in kg instead of lbs.; the DON was informed of the findings.
Two residents with cognitive impairment were not provided with timely, individualized care plans after assessments identified wandering and elopement risks. In both cases, care plans addressing these risks were not initiated until days after the behaviors or risks were documented, as confirmed by RN and DON review.
A resident with severe cognitive impairment and a history of wandering was able to elope from the facility after staff failed to complete an elopement risk assessment and did not respond promptly to a door alarm. Staff interviews confirmed lapses in supervision and failure to follow protocols, resulting in the resident being found outside the facility by police.
A resident with a Stage 3 pressure injury did not receive a low air loss (LAL) mattress as required by the facility's care plan and protocol. Staff confirmed the absence of a LAL mattress and lack of a physician's order for one, despite the care plan specifying this intervention for wound management. This deficiency was identified through observation, staff interviews, and medical record review.
The facility failed to provide necessary care for three residents, with care plans not addressing floor mat use and incomplete post-fall neurological assessments. Floor mats were observed but not documented in care plans, and neurological flowsheets lacked required assessments, as confirmed by the DON.
The facility failed to assess and supervise two residents' ability to handle hot liquids, leading to an incident where a resident spilled hot chocolate on herself, causing injury. Despite the facility's policy requiring such assessments, they were not conducted, and the resident was left unsupervised while consuming the hot beverage. This posed a risk of injury to residents consuming hot liquids.
The facility failed to maintain sanitary conditions in the kitchen, with observations of chipped and discolored utensils, unclean equipment with food residue, and improper drying of blenders. The kitchen hood also had dirt residue, posing contamination and fire risks. The DSS confirmed these issues, acknowledging the potential hazards.
The facility failed to conduct complete entrapment assessments for residents using side rails, impacting 15 residents. Observations and interviews revealed that the Bed System Measurement Device Test Results Worksheets lacked documentation for critical zones, posing potential risks. Despite physician orders for side rails, the facility's maintenance staff did not assess all necessary zones, which was confirmed by the Maintenance Director and acknowledged by the administration.
The facility failed to ensure call lights and bed controls were accessible for several residents, including one with a non-functional call light. Observations revealed call lights on the floor or out of reach, and a bed control on the floor. These residents had cognitive impairments or required substantial assistance, highlighting the importance of accessibility.
The facility failed to maintain a clean and homelike environment for several residents. A resident was observed entering a shower room with a soiled towel and unpackaged adult briefs, raising infection control concerns. Another resident's room had scratches, unpainted areas, and stained curtains, leading to dissatisfaction. Additional residents' rooms had similar maintenance issues, indicating a risk for unsanitary conditions and potential impact on residents' quality of life.
The facility failed to ensure accurate Level 1 PASRR screenings for two residents, leading to potential inappropriate placements without necessary evaluations. One resident, diagnosed with psychosis and major depressive disorder, was inaccurately screened as having no mental illness, despite being prescribed Seroquel. Another resident with a depressive disorder was also incorrectly screened, missing a potential Level II evaluation. The MDS Coordinator and DON acknowledged these discrepancies.
A resident with severe cognitive impairment and high fall risk was found without the required floor mattresses on both sides of their bed, as ordered by the physician and outlined in the care plan. This deficiency was observed during a facility tour and confirmed by both an LVN and the DON, highlighting a failure to follow the facility's Fall Prevention Program policy.
The facility failed to maintain proper care and documentation for PICC lines for two residents. Upon admission, required measurements and documentation were not completed, and care plans did not address the PICC lines. Dressings were not changed weekly as per policy, and there was no physician's order for one resident's PICC line care. These failures were confirmed by staff interviews and medical record reviews.
A resident with a history of central cord syndrome and other conditions was not administered the correct dosage of oxycodone for severe pain levels, as per physician's orders. Despite the facility's policy to manage pain according to comprehensive assessments, the resident received a lower dosage than prescribed for pain levels recorded as 8. Interviews with staff confirmed the oversight, highlighting a potential for ineffective pain management.
A facility failed to monitor and document the fluid intake and output for a resident with end-stage renal disease requiring dialysis. Despite a physician's order for a strict fluid restriction, the facility did not record the resident's fluid intake, as confirmed by staff interviews and medical record reviews. This oversight risked the resident's health due to their impaired kidney function.
The facility failed to ensure proper documentation and informed consent for bed rail use, affecting multiple residents. Observations and interviews revealed incomplete consent forms, missing physician orders, and absent care plans, posing potential risks to resident safety.
The facility failed to ensure informed consent and proper monitoring for residents prescribed psychotropic medications. Several residents were given antipsychotic drugs without signed consent forms, and there was inadequate monitoring for side effects and behavior manifestations. The facility's administration acknowledged these deficiencies.
The facility failed to ensure proper storage, labeling, and disposal of medications. Expired medications were found in Medication Room A and Treatment Cart A, while improper storage practices were observed in Medication Carts A and C. Medications were not stored separately according to their routes of administration, and some lacked proper labeling with open dates. These deficiencies were verified by LVNs and acknowledged by the DON.
The facility failed to ensure safe storage and handling of food brought by family or visitors, as it lacked a designated refrigerator for residents. The policy required food to be consumed within two hours, but did not address storage for later consumption, leading to potential food safety risks.
The facility failed to maintain complete and accurate medical records for several residents, leading to discrepancies in advance directives, treatment documentation, and informed consents. A resident's POLST was incomplete, while two others had conflicting advance directive information. Another resident's TAR lacked documentation of wound care treatments. Additionally, informed consents for side rails and medications were incomplete or missing physician signatures.
The facility failed to provide information on formulating advance directives and maintain documentation for three residents. One resident was not informed about advance directives despite having the cognitive ability to understand, while another's POLST was incomplete, and a third's advance directive was not documented. The DON and SSD confirmed these deficiencies.
The facility failed to ensure accurate documentation and reconciliation of controlled medications for several residents, leading to discrepancies in the Medication Administration Record (MAR) and Controlled Drug Record. Staff interviews confirmed the lapses, and the Director of Nursing acknowledged the issues.
A resident did not receive a dose of either Keppra or metformin due to a leaking medication cup during administration via enteral tube. The LVN could not identify which medication was not given, and the DON confirmed the error but was unable to determine which medication was missed. The resident, who cannot make medical decisions, was prescribed these medications for seizures and diabetes management.
The facility failed to assess and offer the COVID-19 vaccine to two residents as per its policy. One resident's medical record lacked documentation of vaccination status or an offer of the vaccine. Another resident, who was on antibiotics, had consented to vaccination but was not re-offered the vaccine after completing treatment. These deficiencies were confirmed during a review with the IP.
The facility failed to ensure glucometer quality control tests were accurately documented, with discrepancies found between recorded and observed results for two medication carts. LVNs confirmed that night shift nurses were responsible for these tests, and the DON acknowledged the expectation for nightly completion. This failure had the potential to result in inaccurate glucose readings for residents.
A resident's privacy was compromised during ADL care when a CNA left the door open, exposing the resident to passersby. Additionally, an LVN left a computer monitor displaying the resident's medical information unattended at the nurses' station, violating confidentiality policies.
The facility failed to maintain a pest-free environment as cockroaches were observed in the conference room, posing a potential infection risk. The facility's Pest Control Program requires effective eradication of pests, but observations on multiple occasions confirmed the presence of cockroaches. The QA RN, Social Services Director, and Maintenance Director all acknowledged the infestation and its associated risks.
Bed rail use lacked required assessment, alternatives, and installation documentation
Penalty
Summary
The facility failed to provide the necessary care and services related to bed rail use for four of five sampled residents reviewed. The report states the facility did not obtain the physician's order, did not provide the least restrictive alternatives, and did not conduct a bed rail assessment for Resident 12's use of side rails. The facility also failed to provide documented evidence that the manufacturers' recommendations and specifications for installing and maintaining bed rails were followed for Residents 8, 38, and 55, and it did not conduct a bed rail assessment for Resident 38. Resident 8 was observed awake in bed with the upper one-half bed rails elevated and a low air loss mattress in place. Review of the medical record showed the resident had no capacity to understand and make decisions. During interview and record review, the Maintenance Director stated he would provide the bed manuals, but the information provided did not show documented evidence of the manufacturer's recommendations and specifications for installing and maintaining the bed rails for this resident's bed. Resident 38 was observed awake in a bariatric bed with bilateral upper one-half bed rails elevated. The medical record showed the resident had the capacity to understand and make decisions, and the bed rail assessment dated in the record showed the bed rails were not indicated. The DON verified that an assessment for the bed rails was not completed. Resident 55 was observed awake in a low air loss mattress bed with bilateral mid one-half bed rails elevated, and the medical record showed the resident had the capacity to understand and make decisions. For both Residents 38 and 55, the Maintenance Director provided bed manuals that did not show documented evidence of the manufacturer's recommendations and specifications for installing and maintaining the bed rails. Resident 12 was observed lying in bed with bilateral 1/4 side rails elevated and holding the right rail while being changed by CNA 1. The resident had no capacity to understand and make decisions, required assistance with bed mobility, and had a physician's order for bilateral 1/4 side rails for bed mobility and enabler use, but the record did not show that least restrictive alternatives were attempted or that a bed rail assessment was completed before use.
Kitchen and Dining Area Sanitary Deficiencies
Penalty
Summary
The facility failed to ensure sanitary requirements were met in the kitchen and dining areas during surveyor observations and document review. The Diet Type Report dated 12/10/25 showed 91 residents received meals prepared in the kitchen. During an initial kitchen tour with the Dietary Supervisor on 12/9/25 at 0745 hours, boxed food items in the walk-in refrigerator and walk-in freezer were observed placed about two to three inches from the ceiling and blocking the spray of the fire sprinklers. The Dietary Supervisor verified the finding. During the same tour, a floor tile next to the facility’s ice machine was observed missing a piece, and the Dietary Supervisor verified that finding as well. Additional observations identified sanitation and equipment concerns in the resident dining and refrigerator areas. On 12/9/25 at 1218 hours, a ceiling tile in the dining room above the area where meal trays were uncovered and checked was observed with a hole in it, and the Dietary Supervisor verified the observation. On 12/9/25 at 0815 hours, the freezer compartment of Station A residents’ refrigerator was observed missing a thermometer, and a half-gallon container of ice cream had ice buildup around the top outer edges of the lid; the Dietary Supervisor verified both findings. On 12/10/25 at 1135 hours, during trayline preparation, the Dietary Supervisor was observed with artificial fingernails extending about one-half inch beyond her fingertips, and this was later verified.
Infection Control Lapses With Surveillance, Artificial Nails, and Soiled Drape
Penalty
Summary
The facility failed to implement its infection prevention and control program by not maintaining infection surveillance for residents who had signs and symptoms of infection but were not prescribed antibiotics. The facility’s Infection Surveillance policy stated that infection surveillance was an ongoing system used to identify infections and monitor adherence to infection prevention practices, and that notification triggers included a resident developing signs and symptoms of infection or being started on an antibiotic. During review with the IP, the tracking surveillance showed residents with signs and symptoms of infection and those prescribed antibiotics, but the IP could not provide evidence of tracking for residents with signs and symptoms who were not prescribed antibiotics. The IP stated there was documentation in the change-of-condition notes but no tracking was being done. The facility also failed to follow its employee handbook regarding artificial fingernails. The handbook prohibited artificial fingernails for employees with direct patient contact and allowed only nails of reasonable length. CNA 7 was observed providing a bed bath to a resident with leukemia who was receiving Imbruvica for treatment, and CNA 7 had artificial nails extending about 1/2 inch beyond her fingertips. When asked, CNA 7 acknowledged she was not supposed to have artificial fingernails per facility policy. The IP later confirmed the finding and stated staff doing direct care were required to keep nails trimmed and short. In addition, Resident 76’s room contained a drape with a black substance along the bottom. During observation, the resident stated she did not want to be in her room because she did not like staring at the dirty drape on her window, and said she had complained to staff about it. CNA 7 was present and verified the finding but was not aware of the dirty drape. The Maintenance Supervisor stated staff were to notify the janitor for curtain changes if soiled, otherwise curtains were changed monthly during deep cleaning, and said she was not aware of the condition of Resident 76’s drape.
Failure to Obtain Informed Consent for Side Rails and Bed Placement
Penalty
Summary
The facility failed to ensure informed consent was obtained before using bilateral 1/4 side rails for one resident. The resident had been admitted to the facility and had an H&P noting no capacity to understand and make decisions. A physician's order dated 10/28/25 authorized the bilateral 1/4 side rails for bed mobility and enable use, but the medical record did not show informed consent from the resident's responsible party. During interview and record review, RN 2 stated licensed nurses were expected to verify informed consent had been obtained before side rails were used, and the DON confirmed the record did not show that the required informed consent process had been completed before the side rails were initiated. The facility also failed to obtain informed consent before placing another resident's bed against the wall. That resident was observed in bed with the bed positioned against the wall, and the medical record did not show informed consent for that arrangement. The resident's H&P listed dementia, psychosis, anxiety, and a history of falls. Staff interviewed about the bed placement did not know why it was against the wall, and one nurse stated she thought the resident preferred it that way. RN 1 later verified there was no informed consent for having the bed against the wall.
Failure to Assess Self-Administration of Bedside Medication
Penalty
Summary
The facility failed to determine whether it was safe for Resident 54 to self-administer medications that were left at the bedside. During observation, a bottle of Systane artificial tears eyedrops and an orange bottle containing two nebules of Systane eyedrops were seen on the resident’s overbed table, and the resident stated she administered the eyedrops to herself twice a day. The resident’s medical record did not show a physician’s order for the eyedrops to be self-administered, and there was no care plan problem addressing self-administration of the medication. Review of the record also did not show that the interdisciplinary team completed an assessment to determine whether Resident 54 was safe to self-administer medications. During interviews, an LVN verified the eyedrops were at the bedside and confirmed there was no physician’s order to administer or self-administer the medication and no care plan addressing self-administration. An RN and the DON also verified these findings, and the DON stated that if a resident requested to self-administer medications, the IDT would need to assess the resident, obtain physician’s orders, initiate a care plan, and document self-administration in the MAR.
Advance Directive Information and Documentation Not Completed
Penalty
Summary
The facility failed to offer information on how to formulate an advance directive for a resident who had capacity to understand and make medical decisions and did not have an advance directive on file. The resident’s POLST showed no advance directive, and the medical record review and interview with the SSD confirmed there was no documentation that the resident or responsible party had been provided information on how to formulate one. The SSD stated she would speak with the resident’s responsible party about the formulation of an advance directive. The facility also failed to obtain a copy of another resident’s advance directive. During the social services assessment, the resident stated she had an advance directive and said she would ask her daughter to look for it, but the record did not show any follow-up documentation by social services to obtain a copy. The resident’s POLST indicated capacity, but did not show whether an advance directive existed, and the SSD confirmed there was no documentation showing follow-up with the resident’s responsible party to obtain the document.
Bed Positioned Against Wall as a Physical Restraint
Penalty
Summary
The facility failed to ensure one sampled resident remained free from the use of a physical restraint when the resident’s bed was placed against the wall. The facility’s policy titled "Restraint Free Environment," revised 12/19/22, stated that physical restraints included placing a bed close enough to a wall that the resident was prevented from rising out of a chair or voluntarily getting out of bed. On 12/9/25, the resident was observed in bed with the bed against the wall, and the same condition was again observed on 12/12/25. Resident 76 was admitted to the facility and had diagnoses that included dementia, psychosis, anxiety, and a history of falls. During interviews, CNA 7 stated she did not know why the bed was against the wall and said the resident could get out of bed independently. LVN 8 stated she thought the resident preferred the bed against the wall. RN 1 stated this was the first time she noticed the bed against the wall and did not know how it got that way.
Unnecessary Psychotropic Medication Monitoring and Documentation Failures
Penalty
Summary
The facility failed to ensure that one resident’s orthostatic blood pressure was monitored as ordered related to psychotropic medication use. Resident 2 had physician orders for Zoloft, Zyprexa in the morning and at bedtime, and clonazepam for depression, psychosis, and anxiety. The record also included an order to check orthostatic hypotension once a day every Monday by measuring blood pressure in sitting, standing, and lying positions. Review of the monitoring record for October through December 2025 showed the blood pressure readings were documented as the same in all three positions on each monitored date, and RN 1 verified the findings during interview and record review. The facility also failed to ensure appropriate documentation and monitoring related to mirtazapine for Resident 5. Resident 5 had a diagnosis of depression and was receiving mirtazapine for depression manifested by poor oral intake of less than 50% of meals. The dose was increased from 15 mg to 30 mg, but the medical record did not show documented evidence of the physician’s evaluation and assessment before the increase, and the reason for the increased dose was not documented. The record also did not contain a monthly behavior summary for the monitoring of poor oral intake associated with the medication. RN 1 verified that the dose had been increased and that no monthly behavior summary was present. The facility further failed to complete the monthly behavior summary for Resident 54’s mirtazapine use. Resident 54 had an order for mirtazapine for depression manifested by poor oral intake and an order to monitor intake less than 50% with meals. The monitoring record showed several meals with intake below 50%, but the medical record did not contain a monthly behavior summary for November 2025 related to the medication. During interview, RN 1 verified that the monthly behavior summary had not been completed and stated that meal intake was documented in both task documentation and the monitor record, with the DON later acknowledging the findings.
Incomplete Care Plans for Fluid Restriction, Falls, and Bed Placement
Penalty
Summary
The facility failed to develop comprehensive care plans that reflected the individual care needs of three residents. For one resident with a physician order for 1,500 ml/day fluid restriction, the comprehensive care plan did not include an individualized care plan problem to address the restriction. RN 1 verified there was no care problem for the fluid restriction and stated there should be care plan problems specific to it; the DON also verified the finding. For another resident, a care plan problem was initiated after the resident lost balance and fell in the activity room, but the plan included only two interventions: reminding the resident to use the call light for assistance whenever possible and to ask for assistance when needed outside the room. RN 1 verified those were the only interventions and stated the care plan should be comprehensive and individualized. For a third resident with diagnoses including dementia, psychosis, anxiety, and a history of falls, the resident’s bed was observed against the wall on two occasions, but the medical record did not show a care plan problem addressing the bed placement. CNA 7 and RN 1 both stated they did not know why the bed was against the wall, and RN 1 verified the plan of care did not include a problem for it.
Failure to Follow Ordered Fluid Restriction
Penalty
Summary
The facility failed to ensure the nutritional interventions were followed for Resident 81, who had a physician’s order dated 11/26/25 for a 1500 ml per day fluid restriction. The order specified that nursing was to provide 660 ml total per day across the three shifts and dietary was to provide 840 ml total per day at meals. During the initial tour, Resident 81 was observed in bed with a posted fluid restriction sign at the head of the bed, along with a water pitcher and a half-full bottle of colored drink on the over-bed table. Record review showed inaccurate documentation of fluids provided to Resident 81. For example, on 11/27/25 the monitor record documented 1,170 ml of fluids provided by nursing for the three shifts, which exceeded the 660 ml nursing allotment in the physician’s order. The nutrition record for that same day showed 260 ml of fluids provided at meals, while the dietary order was for 840 ml per day. CNA 4 stated she was not aware the resident was on fluid restriction and acknowledged there were many fluid containers on the resident’s table. LVN 8 also stated she was not aware of the resident’s fluid restrictions and verified there were many fluids and a water pitcher on the table. Resident 81 stated she was told she could not have a water pitcher on her table and said she was not aware of how much fluid she could drink.
Respiratory Care and Oxygen Orders Not Properly Managed
Penalty
Summary
The facility failed to ensure safe and appropriate respiratory care for two sampled residents. Resident 78 was observed receiving oxygen at 2 liters per minute via nasal cannula, but the nasal cannula tubing was unlabeled, undated, and touching the floor. The resident’s nebulizer mask and tubing were also observed uncovered on top of the bedside drawer. The facility’s policy stated that oxygen administration requires verification of a physician’s order and that oxygen tubing and mask/cannula are to be changed weekly and as needed if soiled or contaminated. During the observation and concurrent review, LVN 7 confirmed the tubing should have been dated, labeled with the resident’s name, changed routinely every Saturday, and not touching the floor, and that the nebulizer mask and tubing should have been placed inside a clear plastic bag when not in use. Resident 38 was observed receiving oxygen via nasal cannula with the concentrator set at 3 liters per minute, but the medical record did not contain a physician’s order for oxygen use. The resident stated he used oxygen long-term to help him breathe and reported a diagnosis of COPD. LVN 8 later verified that Resident 38 did not have a physician’s order for oxygen use. The report also noted that Resident 38’s H&P stated he had the capacity to understand and make decisions.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to keep the medication error rate below 5 percent; surveyors calculated a medication error rate of 7.69%. During medication administration observations, two of three licensed nurses were found to have errors. One nurse prepared Macrobid 100 mg for Resident 77 by opening the capsule, crushing it, and mixing it with applesauce, then administered it without food even though the medication label stated to take it with food and the physician’s order directed all crushable medications to be crushed. Resident 77 was observed in bed with no meal tray or food at bedside, and the nurse acknowledged giving the medication without food. A second nurse administered ursodiol 300 mg to Resident 47 without food. The medication label stated to take the medication with food, and the physician’s order directed the medication to be given with meals. Resident 47 was observed sitting in bed with no meal tray or food at bedside when the medication was given. The nurse verified that the ursodiol was administered without food and acknowledged that the label and order indicated it should be taken with food. The DON was informed of the findings and acknowledged that nurses should be aware of crushable and non-crushable medications and medications to be given with food.
Improper Administration of Macrobid
Penalty
Summary
Resident 77 was ordered Macrobid 100 mg by mouth twice daily, and the facility also had an order to crush all crushable medications. During a medication administration observation, an LVN prepared the Macrobid capsule by opening it, placing the contents in a clear pouch, crushing the medication, and mixing it with applesauce. The medication label on the bubble pack stated to take the medication with food, but when the LVN administered the crushed Macrobid to Resident 77, the resident was sitting in bed with no meal tray or food items at bedside, and the LVN did not ask whether the resident had eaten. The medical record showed Macrobid had been administered on prior shifts, and the LVN later confirmed she had crushed and given the medication without food because the resident could not take whole pills. The pharmacy consultant stated Macrobid should not be crushed and should be given with food, and that nurses should know which medications are crushable and notify the physician and pharmacy if a resident cannot swallow a medication that cannot be crushed.
Medication Storage and Security Failures
Penalty
Summary
The facility failed to ensure proper storage, labeling, and disposal of medications in Medication Room A, Treatment Cart A, and Medication Cart B. Review of the facility policy titled Medication Storage showed that medications and biologicals are to be stored safely and securely, with access limited to licensed nurses, pharmacy personnel, and other authorized persons, and that medication rooms, carts, and supplies are to be locked or attended by authorized staff. During an inspection of Medication Room A, an opened vial of acetylcysteine inhalation solution was found with no open date and a label directing disposal 96 hours after opening, an opened vial of tuberculin PPD had an open date of 11/8/25 with a label to discard after 30 days, and the medication incinerator bin was open with multiple whole oral medications that had not dissolved. LVN 4 verified these findings. During inspection of Treatment Cart A, one bottle of nystatin powder was found with an open date of 11/2/25 and a label directing disposal after 14 days of opening, and LVN 6 verified the finding. In a separate observation, LVN 11 was seen preparing a glucometer and then entering a resident's room while Medication Cart B was left unlocked and unattended in the hallway, with staff passing by. LVN 11 verified that the cart had been left unlocked and unattended, and the DON was informed and acknowledged the findings.
Soiled Personal Ice Chest With Food Items Not Properly Managed
Penalty
Summary
The facility failed to follow its personal food policy for Resident 76 by not ensuring the resident’s personal ice chest was properly handled and stored. During an observation and interview on 12/09/2025, a purple ice chest was seen inside the resident’s room with brownish and yellowish stains scattered inside it and containing two bananas and two melted ice packs. CNA 7 confirmed the findings and stated staff were responsible for cleaning the ice chest, while also saying it had only been in the room one day; however, Resident 76 stated it had been there for a while. A telephone interview with the resident’s responsible party on 12/11/2025 stated the ice chest had been brought to the room about one month earlier. Review of the resident’s H&P dated 9/28/25 showed the resident had the capacity to understand. Review of the Personal Inventory Update and Resident Clothing and Possessions inventory dated 9/25 and 10/3/25 did not show the ice chest was included in the inventory lists. On 12/12/25, RN 1 stated the family brought in the ice chest and was aware the facility had a refrigerator for storing perishable foods for three days or until expiration date, and that the family member had been educated to check with nursing staff before bringing food items for the resident.
Missing Entrapment Assessment Before Side Rail Use
Penalty
Summary
The facility failed to conduct a regular bed inspection as part of its maintenance program to identify possible entrapment areas for one resident who had bilateral 1/4 side rails in use. The resident was observed lying in bed with the bilateral 1/4 side rails elevated and was holding the right 1/4 side rail while being changed by CNA 1. The resident’s MDS showed partial/moderate to substantial/maximal assistance was needed for bed mobility, and the H&P stated the resident had no capacity to understand and make decisions. The resident had a physician’s order for bilateral 1/4 side rails for bed mobility and enabler use, but the medical record did not contain documented evidence that an entrapment assessment was completed before the side rails were used. During interview, RN 2 stated he was not familiar with the zones of entrapment and said maintenance measured and checked the beds. The Maintenance Director stated he was responsible for monthly bed inspections and installation of side rails, and he verified there was no documentation that the entrapment assessment was conducted prior to the resident’s use of the bilateral 1/4 side rails.
Inaccurate Height and Weight Documented on MDS Assessment
Penalty
Summary
The facility failed to ensure an accurate MDS assessment for one resident, identified in the report as Resident 59. Medical record review showed the resident’s Mini Nutritional Assessment and a dietary progress note documented the resident’s height as 73 inches and weight as 169 lbs. However, the admission MDS assessment documented the resident’s height as 61 inches and weight as 86 lbs, which did not match the medical record information. During interview and concurrent record review, the MDS Nurse verified that the admission MDS section K contained inaccurate height and weight information and stated the correct measurements should have been documented. RN 1 also reviewed the record and confirmed the documented height and weight were inaccurate and did not match the resident’s medical record. The DON was informed of the findings and acknowledged them.
Care Plan Not Revised for Change in Temazepam Administration
Penalty
Summary
The facility failed to revise the comprehensive care plan for one of 19 sampled residents, Resident 11, to reflect a change in the administration of temazepam from PRN use to routine bedtime administration. The facility’s policy stated that comprehensive person-centered care plans are to be developed and implemented for each resident and reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. Resident 11 was admitted to the facility and had a care plan problem dated 7/31/25 addressing temazepam use every 24 hours as needed for insomnia for 14 days. Review of the Order Summary Report showed a physician’s order dated 10/14/25 for temazepam 15 mg, one capsule by mouth at bedtime for insomnia. Review of the care plan showed it was not revised to reflect the medication change from PRN to routine administration. During an interview and concurrent record review on 12/10/25, the DON stated the care plan still reflected PRN use even though the current physician’s order was for routine administration, and verified the care plan was not revised.
Inaccurate Resident Weight Documentation
Penalty
Summary
The facility failed to ensure the medical record for one sampled resident was accurate by documenting inconsistent weights in the resident’s chart. Resident 9’s recorded weights showed a 132-lb. loss from 240 lbs. on 10/28/25 to 108 lbs. on 10/31/25 at 1233 hours, then a return to 240 lbs. later that same day at 2231 hours. The record also showed a 78-lb. gain from 230 lbs. on 12/5/25 to 308 lbs. on 12/7/25, followed by a weight of 229 lbs. on 12/8/25. During interviews and concurrent record review, RNA 1 stated RNAs were responsible for obtaining resident weights and reporting a 3-lb. gain or loss to charge nurses or supervisors, but could not remember weighing Resident 9 on 10/31 or 12/7. LVN 9 stated residents were weighed by RNAs and verified the weight discrepancies, stating the 10/31 and 12/7 weights were probably documented in kilograms instead of pounds. RN 1 reviewed the discrepancies and stated the weights recorded for 10/31 and 12/7 were mistakenly documented. The DON was informed and acknowledged the findings.
Failure to Timely Develop Care Plans for Wandering and Elopement Risks
Penalty
Summary
The facility failed to develop and implement timely, individualized care plans for two residents with identified behavioral and safety risks. For one resident with severe cognitive impairment, documentation showed the resident exhibited wandering behavior by attempting to enter other female rooms, as noted on an assessment dated 8/13/25. Despite this, there was no evidence that a care plan addressing this behavior was developed prior to the resident's elopement on 8/17/25. Both the RN and DON confirmed that the care plan should have been initiated as soon as the wandering behavior was observed, but it was not started until after the elopement occurred. For a second resident with moderate cognitive impairment, an assessment identified the resident as being at risk for elopement. However, the medical record did not show that a care plan addressing this risk was developed until several days after the risk was identified. The RN and DON both acknowledged that the care plan should have been created immediately upon identification of the elopement risk. These failures were confirmed through interviews and medical record reviews, and were acknowledged by facility leadership.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Assessment
Penalty
Summary
The facility failed to provide necessary care and services to prevent accident hazards for a resident with severe cognitive impairment, resulting in an elopement incident. The resident, who had a documented history of wandering and attempting to enter other residents' rooms, was not assessed for elopement risk following a change in condition. Despite facility policy requiring elopement risk assessments and timely staff response to alarms, there was no documented evidence that the required assessment was completed after the resident exhibited wandering behavior. On the day of the incident, the resident was able to leave the facility in a wheelchair without staff noticing, and the door alarm was not responded to promptly by staff members present. Interviews with staff revealed that the CNA did not hear the door alarm due to being busy, and another staff member, who heard the alarm during a lunch break, did not investigate, assuming someone else would respond. The lapse in supervision and failure to follow established protocols allowed the resident to exit the facility unsupervised. The resident was later found by police outside the facility. Facility leadership acknowledged that the elopement risk assessment should have been completed and that staff should have responded immediately to the door alarm.
Failure to Provide LAL Mattress for Resident with Stage 3 Pressure Injury
Penalty
Summary
The facility failed to provide necessary care and services to promote the healing of a pressure injury for one resident with a Stage 3 pressure injury. Despite the facility's policy and care plan indicating that a low air loss (LAL) mattress should be used for wound management in such cases, the resident was observed using a regular mattress. Multiple staff interviews confirmed that the resident did not have a LAL mattress upon admission and that there was no physician's order for one, even though it was facility protocol for residents with Stage 3 pressure injuries to have this intervention. Medical record review showed the resident was admitted with a Stage 3 pressure injury measuring 3 cm by 2 cm, and the care plan included an intervention for a LAL mattress. However, this intervention was not implemented, as verified by staff and direct observation. The failure to provide the LAL mattress as required by both the care plan and facility policy constituted a deficiency in the provision of necessary care and services for the resident's pressure injury.
Deficiencies in Fall Prevention and Post-Fall Assessments
Penalty
Summary
The facility failed to ensure the necessary care and services were provided for three residents, leading to deficiencies in fall prevention and post-fall assessments. For two residents, the care plans did not properly address the use of floor mats, which were observed by their beds but not documented in their care plans. Interviews with the LVN and DON revealed that the floor mats were intended as a nursing intervention for fall risk residents, but the care plans were not updated to reflect this intervention. This oversight occurred despite the residents having experienced unwitnessed falls that required hospital evaluation. Additionally, the facility did not complete post-fall neurological assessments for two residents who had unwitnessed falls. The neurological flowsheets for these residents were missing several assessment items, which were supposed to be documented according to the facility's policy. The DON confirmed that the neurological assessments were incomplete, indicating a failure to adhere to the facility's fall prevention program and documentation requirements.
Failure to Assess and Supervise Residents Handling Hot Liquids
Penalty
Summary
The facility failed to ensure that two residents, identified as Residents 1 and 3, were free from accident hazards related to the consumption of hot liquids. The facility's policy required an assessment of residents' ability to handle containers and consume hot liquids, but this was not completed for either resident. Resident 1 experienced an incident where she spilled hot chocolate on herself, resulting in redness and blisters on her left shoulder and upper back. The incident occurred while Resident 1 was lying in bed, not in an upright position, and without adequate supervision. Resident 1 had a history of cognitive loss, forgetfulness, and required partial to moderate assistance with eating due to impairments in both upper extremities. Despite these needs, there was no documented assessment of her ability to handle hot liquids. On the day of the incident, Resident 1 was given hot chocolate by a CNA, who then left to attend to another resident. Resident 1 attempted to drink the hot chocolate but spilled it on herself, causing injury. Interviews with staff confirmed that Resident 1 needed cuing and supervision during meals, and no specific assessment for handling hot liquids was conducted. Similarly, Resident 3's medical records showed no evidence of an assessment for handling hot liquids, as required by the facility's policy. Interviews with the RN confirmed the lack of such assessments for both residents. The facility's failure to conduct these assessments and provide adequate supervision posed a risk of injury to residents consuming hot liquids, as evidenced by the incident involving Resident 1.
Sanitary Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, as evidenced by several observations during a survey. Kitchen utensils were found to be in poor condition, with chipped, discolored, and partially melted surfaces, which did not comply with the USDA Food Code 2022 requirements for utensils to have a smooth, cleanable surface. The Dietary Services Supervisor (DSS) confirmed these findings, acknowledging that such utensils should not be used as they pose a hazard and could contaminate food. Additionally, the facility did not ensure that kitchen utensils were clean and free of food particles or residue. Several stainless steel utensils, including tongs, measuring cups, and serving spoons, were observed with dry and crusted residue. The DSS confirmed that these items should not be used and should be properly cleaned and sanitized to prevent cross-contamination. The facility also failed to adhere to proper drying procedures for kitchen equipment. Heavy-duty blenders used for puree preparation were found to be wet and not air-dried before storage, contrary to the facility's policy and USDA Food Code requirements. Furthermore, the kitchen hood was observed with black dirt residue, indicating inadequate cleaning, which the DSS acknowledged. This lack of maintenance could lead to contamination of food with pathogenic organisms and poses a fire hazard.
Incomplete Entrapment Assessments for Side Rail Use
Penalty
Summary
The facility failed to ensure accurate and complete entrapment assessments for residents using side rails, impacting 15 residents. The assessments did not include measurements for Zones 1, 6, and 7, which are critical areas for potential entrapment. This oversight was confirmed through observations, interviews, and document reviews, revealing that the Bed System Measurement Device Test Results Worksheets consistently lacked documentation for these zones. Several residents, including those with cognitive impairments and mobility issues, were observed using side rails for assistance with bed mobility and transfers. Despite physician orders and documented needs for side rails, the facility's maintenance staff did not complete comprehensive entrapment assessments. Interviews with staff, including the Maintenance Director, confirmed that only Zones 2, 3, and 4 were assessed, leaving potential risks unaddressed. The deficiency was acknowledged by the facility's administration, including the Director of Nursing and the Administrator. The lack of complete assessments posed a risk of entrapment, which could lead to serious injury or death. The facility's policy required regular inspections and assessments, but these were not fully implemented, as evidenced by the missing documentation for critical zones.
Failure to Ensure Accessibility of Call Lights and Bed Controls
Penalty
Summary
The facility failed to provide reasonable accommodations for the needs of several residents, as observed during a survey. Specifically, the call lights for three residents were not within reach, with one resident's call light found on the floor, another on a floor mat, and a third clipped to the wall above the bed. Additionally, a resident's bed control was found on the floor, out of reach. These residents were noted to have no capacity to make medical decisions or had moderate cognitive impairment, which further emphasizes the importance of having these devices accessible. Another resident's call light button was found to be non-functional, as it was not plugged in correctly. This resident, who required substantial assistance for bed mobility and transfers, reported that the call light had not been working the previous night. The facility's policy requires that call lights be accessible to residents, but this was not adhered to, leading to potential delays in care and impacting the residents' well-being.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment for several residents, as observed during a survey. Resident 86 was seen entering a shower room that had a soiled towel on the floor and unpackaged clean adult briefs on the floor and shower chair, which was confirmed by RN 2 as an infection control concern. Resident 49's room was found with scratches, unpainted areas on the walls and bathroom door frame, and stained curtains. Resident 49 expressed dissatisfaction with the room's condition, stating he spent most of his time in bed and expected a clean and well-maintained environment. Additionally, Resident 27's room had scratches and unpainted areas on the walls, and she mentioned that painting the walls would make her room more livable. Resident 33's room was observed with scratches and chipped paint on the walls, and although she felt comfortable, she believed her room needed maintenance. These observations indicate a failure to provide a safe, clean, and homelike environment, posing a risk for unsanitary conditions and potentially impacting the residents' quality of life.
Inaccurate PASRR Screenings for Two Residents
Penalty
Summary
The facility failed to ensure accurate Level 1 PASRR screenings for two residents, leading to potential inappropriate placements without necessary evaluations. Resident 77, diagnosed with unspecified psychosis and major depressive disorder, was prescribed Seroquel, an antipsychotic medication. However, the Level 1 PASRR screening inaccurately indicated no diagnosis of serious mental illness and no psychotropic medication prescriptions, resulting in a negative screening and no Level II evaluation. The MDS Coordinator confirmed the inaccuracies and acknowledged that a Level II evaluation might have been required. Similarly, Resident 53, diagnosed with depressive disorder, had a Level 1 PASRR screening that incorrectly showed no diagnosis of serious mental illness. This screening was completed at an acute care hospital before the resident's readmission to the facility. The MDS Coordinator verified the discrepancy between the PASRR screening and the resident's medical records, which documented the depressive disorder diagnosis. The MDS Coordinator stated that the resident required a PASRR resident review submission to inform the Department of Health Care Services about the diagnosis, potentially necessitating a Level II mental health evaluation. The facility's policy and procedure for coordinating assessments with the PASRR program were reviewed, indicating that all applicants should be screened for serious mental disorders or intellectual disabilities. A negative Level 1 screen permits admission without further PASRR process unless a serious mental disorder arises later, while a positive screen requires a Level II evaluation. The MDS Coordinator and DON acknowledged the findings, highlighting the failure to ensure accurate PASRR screenings and the potential need for Level II evaluations for the residents involved.
Failure to Implement Fall Risk Precautions
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 62, was free from accident hazards as per the physician's orders and the resident's care plan. The deficiency was observed during an initial tour and subsequent observation, where Resident 62 was found lying in a low bed without the required floor mattresses on both sides. This was contrary to the physician's order dated February 3, 2023, and the care plan interventions, which specified the use of floor mattresses as a precautionary measure due to the resident's high fall risk. Resident 62 had a history of severe cognitive impairment, lower extremity impairment, and was at risk for falls due to confusion, psychoactive drug use, psychosis, and dementia with behavioral disturbances. The facility's Fall Prevention Program policy required that residents be assessed for fall risk and receive appropriate interventions. However, the lack of floor mattresses, as confirmed by both an LVN and the DON during interviews, indicated a failure to adhere to the prescribed fall risk precautions, potentially exposing the resident to serious injury.
Deficiency in PICC Line Care and Documentation
Penalty
Summary
The facility failed to provide necessary care and services for the maintenance of PICC lines for two residents, Resident 63 and Resident 77. Upon admission, the facility did not complete or document the required measurements of the PICC line's external catheter length and arm circumference for both residents. Additionally, there was no physician's order obtained for the care and maintenance of Resident 77's PICC line, and the facility did not develop a care plan for the use of the PICC line for either resident. These omissions were contrary to the facility's policy and procedures, which require such measurements and documentation to be completed upon admission and weekly thereafter. For Resident 63, the medical record review showed that the PICC line dressing was not changed upon admission as per the physician's order, and the required measurements were not documented until several days later. The resident was receiving IV medications for sepsis and fungal prophylaxis, yet the care plan did not address the PICC line. An interview with RN 1 confirmed that the dressing change and measurements were not completed as required, and the nurse admitted to signing off on tasks that were not performed. Similarly, for Resident 77, the facility failed to document the necessary measurements and did not change the PICC line dressing weekly as required. The resident was receiving IV antibiotics for pneumonia, but the care plan did not include the PICC line. RN 1 confirmed that there was no order for the PICC line dressing change since admission, and the dressing had not been changed weekly. The Director of Nursing verified these findings, acknowledging the lack of documentation and care planning for the PICC lines.
Failure to Administer Correct Pain Medication Dosage
Penalty
Summary
The facility failed to administer pain medication according to the physician's order for a resident, identified as Resident 87, who was reviewed for pain management. The facility's policy and procedure for pain management, revised on 12/19/22, emphasized managing or preventing pain consistent with the comprehensive assessment and plan of care. However, the medical record review revealed that Resident 87, who had a history of central cord syndrome, wedge compression fracture, multiple rib fractures, and malignant neoplasm of the prostate, was not administered the correct dosage of oxycodone as per the physician's orders. Specifically, on multiple occasions, Resident 87 was given a lower dosage of oxycodone for severe pain levels, which were recorded as 8 on the pain scale, instead of the prescribed higher dosage for such pain levels. Interviews conducted with LVN 7 and the DON confirmed the findings. LVN 7 acknowledged that Resident 87 should have received two tablets of oxycodone 5 mg for the reported pain level of 8, as per the physician's order. The DON stated that licensed nurses were expected to assess the resident's pain and administer medication according to the physician's orders. The failure to administer the correct dosage had the potential for ineffective pain management for Resident 87. The facility's administration, including the Administrator, DON, and Medical Records Assistant, were informed and acknowledged the findings.
Failure to Monitor and Document Fluid Intake for Dialysis Resident
Penalty
Summary
The facility failed to provide necessary care and services for a resident with end-stage renal disease who required dialysis. The resident, who was admitted with a diagnosis necessitating dialysis three times a week, had a physician's order for a strict fluid restriction of 1000 ml per 24 hours. This order specified the distribution of fluid intake across meals and nursing shifts. However, the facility did not monitor or document the resident's fluid intake and output as ordered, which is crucial for managing the resident's condition. Interviews and medical record reviews revealed that the facility staff, including RN 1 and the DON, acknowledged the lack of documentation regarding the resident's fluid intake. The Monitor Record for the resident showed that from late September to early October, there was no recorded evidence of the resident's fluid intake, with only 'X' marks noted in the documentation areas. This oversight had the potential to result in an excess of fluids, posing a risk to the resident's health due to their impaired kidney function.
Deficiencies in Bed Rail Use and Documentation
Penalty
Summary
The facility failed to ensure the safety of residents through proper documentation and informed consent regarding the use of bed rails. For Resident 83, the Physician's Documentation of Informed Consent was incomplete, lacking a physician's signature and date, despite the resident's diagnosis of Alzheimer's disease and inability to make decisions. Observations confirmed the use of bilateral half side rails without proper consent, and staff interviews acknowledged the oversight. Residents 77 and 80 were also affected by the facility's failure to obtain physician's orders and initiate care plans for the use of side rails. Both residents were observed using the rails for mobility and repositioning, yet their medical records did not reflect the necessary documentation or care plan problems addressing the use of these devices. Interviews with staff confirmed the absence of required orders and care plans, highlighting a systemic issue in the facility's management of side rail use. Additionally, Resident 24's records showed a physician's order for side rail use, but the informed consent documentation was incomplete, missing the physician's signature. Resident 53's case further illustrated the facility's deficiencies, as there was no documentation of informed consent for side rail use upon re-admission. These failures collectively posed a risk of injury to the residents, as acknowledged by the facility's administration and nursing staff.
Deficiencies in Psychotropic Medication Management
Penalty
Summary
The facility failed to ensure that five residents were free from unnecessary psychotropic medications, as evidenced by the lack of signed and dated informed consent forms by physicians for the administration of these medications. Residents 13, 23, 77, 83, and 541 were all prescribed antipsychotic medications such as Seroquel and Risperdal without the necessary documentation of informed consent. This oversight was confirmed through interviews with licensed vocational nurses (LVNs) and the Director of Nursing (DON), who acknowledged the absence of physician signatures and dates on the consent forms. In addition to the lack of informed consent, the facility did not adequately monitor residents for adverse side effects associated with the use of psychotropic medications. For instance, Resident 541 was not monitored for orthostatic hypotension or the number of behavioral episodes, and there was no evidence of non-pharmacological interventions being implemented. Similarly, Resident 77's medical records did not show monitoring for orthostatic hypotension or adverse effects related to Seroquel use, despite the care plan indicating such monitoring should occur. Furthermore, the facility's documentation was inconsistent and incomplete regarding the behavior manifestations that warranted the use of psychotropic medications. For example, Resident 541's orders for Seroquel did not match the behavior monitoring orders, leading to discrepancies in the documented reasons for medication use. Additionally, Resident 23's records lacked documentation of behavioral monitoring and non-pharmacological interventions, which were supposed to be part of the care plan. These deficiencies were acknowledged by the facility's administration and nursing staff during interviews.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage, labeling, and disposal of medications, as observed during a survey. In Medication Room A, expired medications for a nonsampled resident were found in the refrigerator, with expiration dates that had already passed. Additionally, in Treatment Cart A, expired medications such as Bacitracin Zinc ointment, hydrocortisone cream, and triple antibiotic ointment were not removed from the current treatment supply. These expired medications were verified by the respective LVNs, who acknowledged that expired medications should not be administered due to potential adverse effects. Further inspection of Medication Cart A revealed improper storage practices, where orally administered medications were not stored separately from externally used medications and supplies. Items such as nitroglycerin tablets were stored with artificial tears, and stool softeners were stored with topical creams. Additionally, medication bottles and trays were found with sticky residues, and some opened medications lacked proper labeling with open dates. These findings were confirmed by the LVN present during the inspection. In Medication Cart C, similar issues were observed, including the improper storage of medications with different routes of administration. A bottle of shell calcium tablets was stored with suppositories and topical creams, and medications for two residents were found without open dates. The DON was informed of these findings and acknowledged the issues. These deficiencies in medication management had the potential to negatively impact residents' well-being and the effectiveness of the medications.
Deficiency in Safe Storage of Food Brought by Visitors
Penalty
Summary
The facility failed to ensure the safe use and storage of food brought in by family members or visitors, which could potentially lead to foodborne illnesses among the medically vulnerable resident population. The facility's policy and procedure (P&P) stated that residents have the right to receive food from outside sources, but it must be handled safely. The P&P required that all food items brought in must be approved by nursing staff to ensure they align with the resident's diet order, consumed within two hours, and any leftovers discarded. However, the facility did not have a designated refrigerator for residents, which was acknowledged by the Director of Social Services (DSS), Registered Dietitian (RD), and Director of Nursing (DON) during interviews. The DSS, RD, and DON confirmed that the facility lacked a refrigerator for residents and that food brought from outside was intended for immediate consumption within two hours. The DON further stated that they discouraged families from bringing perishable food due to concerns about mold and insects. The facility's P&P did not address the storage of food if a resident or their responsible party preferred to eat it later or beyond the two-hour window. This oversight in the facility's policy and lack of proper storage facilities contributed to the deficiency identified by the surveyors.
Incomplete and Inaccurate Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for several residents, leading to discrepancies and omissions in critical documentation. For Resident 541, the Physician Orders for Life-Sustaining Treatment (POLST) was incomplete, lacking advance directive information. Similarly, Residents 291 and 49 had conflicting information regarding their advance directives, with discrepancies between their POLST forms and Advance Directive Acknowledgment forms. These inconsistencies were verified by the Social Services Director (SSD) during interviews and record reviews. Resident 87's Treatment Administration Record (TAR) for October 2024 was found to be inaccurate. Although physician orders were in place for wound care treatments on the resident's heels, there was no documentation of these treatments being administered from October 3 to October 7, 2024. Licensed Vocational Nurse (LVN) 4 confirmed that the treatments were given but not signed off in the TAR, and there was no documentation in the progress notes to explain the omission. Additional deficiencies were noted in the informed consent documentation for Residents 12, 13, and 62. Resident 12's consent for side rail use was incomplete, lacking confirmation from the resident or responsible party. Resident 13's consent for bilateral half side rails was missing the physician's signature and date. For Resident 62, informed consents for multiple medications were not signed by the physician, despite verification that consent was obtained from the responsible party. These findings were acknowledged by the Director of Nursing (DON) and other staff members during interviews.
Failure to Document and Maintain Advance Directives
Penalty
Summary
The facility failed to ensure that information on how to formulate an advance directive was provided to Resident 33, who had the cognitive capacity to understand and make decisions. Despite having an Advance Directive Acknowledgment form indicating that Resident 33 had executed an advance directive, the resident stated she did not have one and was not provided with information on how to formulate it. The facility's records showed conflicting information between the POLST and the Advance Directive Acknowledgment form, and the Director of Nursing (DON) confirmed that there was no advance directive in the medical record. For Resident 87, the facility did not maintain a copy of the advance directive in the medical record, despite the resident having executed one. The POLST form was incomplete, lacking information and signatures in Section D. The Social Services Department (SSD) acknowledged that there was no documentation showing follow-up to obtain a copy of the advance directive from the resident's representative, who had promised to fax it to the facility. Resident 23's medical record also lacked a copy of the advance directive, and the POLST form did not document whether the resident had an advance directive. The SSD confirmed that there was no follow-up to verify the presence of an advance directive, and RN 1 verified that the advance health care directive was not maintained in the medical record. These deficiencies indicate a failure to uphold residents' rights to have their treatment preferences documented and respected.
Controlled Medication Documentation Deficiencies
Penalty
Summary
The facility failed to provide adequate pharmaceutical services by not ensuring accurate reconciliation and documentation of controlled medications for several residents. Specifically, the administration of hydrocodone/apap for Residents 54, 741, and 742 was not accurately documented in the Medication Administration Record (MAR), despite being signed out in the Controlled Drug Record. Additionally, Resident 48's hydrocodone/apap administration was not documented in the Controlled Drug Record, leading to discrepancies in the medication count. The facility's policies and procedures for medication administration and controlled substance accountability were not followed. The Controlled Substance Shift Count Log for Medication Cart C was also incomplete, with missing signatures from licensed nurses for specific shifts. These lapses in documentation and accountability posed a risk for medication diversion. Interviews with staff, including LVN 7, LVN 5, and RN 3, confirmed the discrepancies and acknowledged the failure to document medication administration as required. The Director of Nursing (DON) was informed of these findings and acknowledged the issues identified during the survey.
Medication Administration Error Due to Leaking Medication Cup
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 76, was free from significant medication errors. During a medication administration observation, it was noted that a liquid medication intended for Resident 76 leaked from the medication cup into the medication tray, resulting in the medication not being administered. The Licensed Vocational Nurse (LVN) involved was unable to identify which medication had leaked, as both Keppra, an anticonvulsant, and metformin, an antidiabetic medication, were prepared in unlabeled cups. This incident occurred despite the facility's policy and procedure for medication administration via enteral tube, which requires each medication to be administered separately and not combined. Resident 76, who lacks the capacity to make medical decisions, was prescribed Keppra to manage seizures and metformin for diabetes mellitus. The Director of Nursing (DON) confirmed the medication cup leakage and acknowledged that one of the medications was not administered, although it was unclear which one. The DON communicated with the physician's assistant (PA) on call, who ordered an additional dose of Keppra and instructed monitoring of the resident's blood glucose levels. However, the DON did not initially seek laboratory tests to assess the resident's condition following the medication error.
Failure to Assess and Offer COVID-19 Vaccination
Penalty
Summary
The facility failed to ensure that two residents, identified as Residents 23 and 80, were assessed for their COVID-19 vaccination status or offered the COVID-19 vaccine, as per the facility's policy. The policy, revised on June 9, 2023, mandates that residents and staff be educated and offered the COVID-19 vaccine to minimize the risk of acquiring, transmitting, or experiencing complications from COVID-19. However, a review of Resident 23's medical record showed no documentation of the resident's COVID-19 vaccination status or any offer of the vaccine. For Resident 80, the medical record indicated that informed consent for the COVID-19 vaccination was obtained on July 1, 2024, but the resident was on antibiotics and chose to wait until the treatment was completed. The facility's records did not show any evidence that Resident 80 was re-offered or received the COVID-19 vaccine after completing the antibiotic treatment. These findings were verified during an interview and medical record review with the Infection Preventionist (IP) on October 9, 2024.
Failure to Maintain Accurate Glucometer Quality Control
Penalty
Summary
The facility failed to maintain essential equipment, specifically glucometers, in safe operating condition. During a review of the Assure Platinum Glucose Monitoring System's Quality Control Records for two medication carts, it was found that the quality control test results documented in the logs did not match the results observed on the glucometer devices. For Medication Cart A, discrepancies were noted on 10/8/24 and 10/9/24, where the normal and high control results were recorded as 88 mg/dL and 230 mg/dL, and 87 mg/dL and 226 mg/dL, respectively, but these results were not observed on the device. Similarly, for Medication Cart C, discrepancies were found for multiple dates, including 10/2/24 through 10/9/24, with recorded results not matching those on the glucometer. Licensed Vocational Nurses (LVNs) 7 and 5 verified these findings, acknowledging that the 11-7 shift licensed nurses were responsible for performing and documenting the glucometer quality control tests every night shift. The Director of Nursing (DON) confirmed that the facility's expectation was for these tests to be completed every night shift. However, the failure to ensure accurate documentation and observation of glucometer quality control results had the potential to lead to inaccurate glucose readings for residents requiring glucose checks.
Privacy and Confidentiality Breach
Penalty
Summary
The facility failed to ensure the privacy of a resident during activities of daily living (ADL) care. During an observation, it was noted that a certified nursing assistant (CNA) was providing ADL care to a resident in Room A with the door wide open. The resident was seated on a shower chair and covered with a blanket from the neck to the waist, leaving the legs and buttocks exposed to anyone passing by in the hallway. Interviews with the quality assurance registered nurse (QA RN), the CNA, and the director of nursing (DON) confirmed that the privacy curtain and door should have been closed to protect the resident's privacy. Additionally, the facility failed to maintain the confidentiality of the resident's medical information. An observation at the nurses' station revealed that a licensed vocational nurse (LVN) left a computer monitor on, displaying the resident's personal medical information. The LVN walked away from the station twice, leaving the information exposed. Upon returning, the LVN acknowledged the oversight. These actions were in direct violation of the facility's policies and procedures regarding patient privacy and confidentiality.
Cockroach Infestation in Conference Room
Penalty
Summary
The facility failed to ensure the environment was free of pests, specifically cockroaches, which were observed in the conference room. The facility's Pest Control Program, revised on 12/19/22, mandates maintaining an effective pest control program to eradicate and contain common household pests and rodents. On 9/13/24, during an observation and interview with the QA RN, a cockroach was seen crawling towards a trash bin in the conference room, and the QA RN confirmed the potential risk of infection spread due to the presence of cockroaches. Later the same day, another cockroach was observed in the conference room during an interview with the Social Services Director, who acknowledged its presence. The Maintenance Director also confirmed the presence of cockroaches in the conference room and recognized the risk of spreading infection.
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 5,970 citations issued within 25 miles in the last 12 months — including the 28 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near La Habra
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bonita Hills Post Acute | 0 mi | ★★★★★ | 44 | 0 |
| Whittier Hills Health Care Ctr | 1.3 mi | ★★★★★ | 35 | 0 |
| St Elizabeth Healthcare Center | 2.7 mi | ★★★★★ | 25 | 0 |
| Imperial Healthcare Center | 2.9 mi | ★★★★★ | 1 | 0 |
| The Pavilion At Sunny Hills | 3 mi | ★★★★★ | 7 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Park Regency Care Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release June 2026) and official state health department websites.