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 July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Park Vista At Morningside during CMS and state inspections, most recent first.
Infection Control Practices Not Maintained: The facility had inaccurate infection surveillance data that did not match QAPI reports, and staff failed to follow infection control practices in multiple areas. In the laundry room, clean linen touched clothing and the floor, a beverage was present, and a gown was not worn. For a resident on EBP for a Stage 3 pressure injury, an RNA did not wear a gown during care and clean gloves were placed on the resident’s bed during wound care. Additional failures included a CNA feeding a resident with knees on the bed, a NP not following C. diff precautions when disinfecting equipment and using hand hygiene, and no EBP signage or cart for a resident with a PICC line.
A resident with a reopened Stage 3 sacrococcyx pressure injury did not have Weekly Pressure Injury Evaluations completed after the last documented assessment, and the DON could not identify when the wound healed and reopened. During wound care, the DSD/IP cleansed the wound with Skintegrity wound cleanser labeled for another resident instead of the ordered normal saline. The DON verified the missing weekly wound monitoring and the failure to follow the physician’s wound care order.
A resident with an indwelling urinary catheter had no documented I&O monitoring as ordered, and the record did not show ordered bladder training was actually provided. The TAR had check marks for some shifts, but the DSD/IP verified output monitoring was missing and the catheter was not documented as being clamped for 2 hours and unclamped for 15 minutes as ordered; the resident also reported staff sometimes forgot to unclamp the catheter.
A resident with a GT and aphasia was receiving enteral feeding while the head of bed was elevated less than 90 degrees, despite a physician order to keep the head of bed at 90 degrees during feeding and after feeding stopped. An LVN confirmed the positioning was below the ordered level, and the DON stated the expectation was to elevate the head of bed at 90 degrees during and after feeding to prevent aspiration.
A resident with a midline catheter had no active physician orders for site monitoring, arm and catheter measurements, or dressing changes. The chart showed only orders for the catheter itself and NS flushes, while prior IV MAR orders for monitoring and measurements had been discontinued. An RN confirmed the missing orders during record review.
Failure to provide ordered respiratory care affected two residents. One resident with acute respiratory failure and hypoxia had a physician order for continuous O2 via nasal cannula, but the cannula was not dated and the resident was later observed without O2 while the SpO2 was 88%. Another resident with a CPAP order had equipment observed stored improperly, and staff acknowledged the CPAP machine and mask were not cleaned as ordered despite MAR documentation indicating the task was completed.
Improper Medication Storage and Labeling: A resident had a container of CBD Pain Relief Ointment at the bedside without a physician order, and staff were unaware it was there. In addition, a medication cart contained opened single-use wound care items, and a medication room stored external-use items together with oral medications. The DON acknowledged that internal and external medications should not be stored together.
Improper Hot Beverage Temperature Checks by Dietary Aide: A Dietary Aide was observed checking hot beverage temperatures during tray line with the thermometer touching the bottom of the cup, resulting in an inaccurate reading. Facility policy required hot beverages to be served between 140 and 155 degrees Fahrenheit, and interviews confirmed the thermometer should be placed in the center of the liquid without touching the sides or bottom of the cup. The aide acknowledged the error despite prior in-services on temperature checking and logging.
Kitchen food safety and sanitation failures were observed when a Dietary Aide used a thermometer to check a resident’s hot beverage, set it on an uncovered clipboard where it contacted the tie, and then reused it without sanitizing it. Ice Machine 1, which supplied resident ice and iced beverages, was also observed with brown residue inside and was acknowledged by management to be unclean and not maintained.
Failure to Maintain a Full-Time Dedicated IP: The facility did not have a full-time, dedicated IP responsible for the infection prevention and control program. Time records showed the DSD/IP split duties between DSD, treatment nurse, and IP roles, while an RN Supervisor served as a back-up IP on weekends. The DON verified that the DSD/IP did not work full time as the IP and confirmed the recorded IP hours for both staff members.
A resident with an indwelling urinary catheter was observed in bed with the urine collection bag hanging on the side of the bed and not placed inside the privacy bag. An LVN confirmed the bag should have been inside the privacy bag for privacy, and the DON stated the expectation for all residents with indwelling catheters was to keep collection bags inside the privacy bag to provide dignity.
A facility failed to keep resident records private when its public survey binder contained four confidential resident rosters with resident names and identifiers. The binder was observed in a wall pocket near the Social Services office and available for public viewing, and the DON confirmed the rosters should not have been included.
A resident’s comprehensive MDS was not coded to show hospice services even though the physician’s orders included hospice and the order triggered the assessment. During record review, the MDS Coordinator stated the MDS should have reflected hospice services but did not.
The facility failed to include individualized care plan problems for two residents’ ordered treatments. One resident had an order for midodrine via GT for hypotension, but the care plan did not address the medication. Another resident had a midline catheter to the right upper arm, but the care plan did not address catheter use, monitoring, or maintenance; an RN confirmed the omission during record review.
A resident with significant physical and cognitive impairments was not evaluated for hot beverage safety, resulting in a hot tea spill that caused burns. Staff failed to promptly notify licensed nursing personnel or provide immediate and appropriate interventions, leading to delayed assessment, documentation, and treatment of the burn injury. Two other residents were also not assessed for hot beverage safety as required by facility policy.
A resident with a full thickness skin tear did not receive wound care as ordered by the physician, with staff applying foam dressings instead of Steri-Strips and not consistently assessing the wound. Documentation and monitoring were incomplete, and the wound later developed cellulitis, indicating a failure to follow prescribed wound care protocols.
A resident with respiratory failure and dependence on supplemental oxygen was not consistently provided with continuous oxygen therapy as ordered by the physician. Oxygen saturation levels were not maintained above the prescribed threshold, and the resident experienced a significant drop in oxygen saturation, resulting in transfer to an acute care facility. Nursing staff confirmed the resident should have been on continuous oxygen, in accordance with facility policy and physician orders.
Staff failed to follow infection control protocols, including hand hygiene and proper use of gloves, during wound care and while delivering meals to residents in contact isolation. A nurse used expired hand sanitizer and reused supplies that should have been discarded, while a CNA did not wear gloves or perform hand hygiene after contact with contaminated items, then provided care and delivered meals to other residents. These actions were not in accordance with facility policies and were acknowledged by staff and the DON.
Surveyors found that two residents' medical records were incomplete and inaccurate, with missing or incorrect documentation of intake, output, and eating percentages for one resident, and a lack of documentation regarding a hot tea spill incident for another. Facility staff confirmed missed charting and failure to initiate required change of condition documentation, contrary to facility policy.
The facility failed to meet sanitary requirements in the kitchen, with issues such as improper labeling and dating of food items, expired items, and inadequate cleanliness of equipment. Food brought in by visitors was also not properly labeled or dated. Additionally, food storage practices were not followed, with items stored on the floor and cross-contamination risks present.
A resident experienced significant weight loss over seven weeks, with inadequate nutritional intake and insufficient follow-up on RD recommendations. Despite the facility's P&P for weight management, timely interventions were not implemented, and there was no documented communication with the physician regarding the exhausted nutritional interventions. Interviews with staff confirmed the lack of follow-up and communication, contributing to the deficiency.
The facility failed to provide proper respiratory care for four residents, with issues including incorrect oxygen administration, improper storage, and outdated equipment. A resident received oxygen at a higher rate than ordered, and nasal cannulas were not stored or changed as required. An LPN confirmed these findings, and the DON and Administrator were informed.
The facility failed to provide adequate pharmaceutical services, resulting in medication discrepancies and unavailability of necessary medications for residents. Medications were left at a resident's bedside, and another resident's routine medications were unavailable, potentially leading to poor health outcomes. Discrepancies in the Omnicell system and a breakdown in communication with the pharmacy contributed to these deficiencies.
A resident did not receive a scheduled dose of the antibiotic piperacillin sodium tazobactam as ordered by the physician. The medication was to be administered every six hours for a UTI, but the 0600 hours dose was missed. This was confirmed by the resident and verified by RN 2 during a medical record review.
The facility failed to properly store and label medications in a medication room and two medication carts. An opened tuberculin vial lacked an open date, expired food thickener packets were found, and a bag of home medications was unlabeled. Temperature logs were incomplete. Expired Non-Adhesive Pads were in one cart, and two residents' topical medications lacked open dates.
The facility failed to follow the planned menu for three residents, as they did not receive the garlic breadstick included in their meal tickets. This oversight was due to a kitchen staff error, which was not caught by the checking process involving a third server and nursing staff. The issue was confirmed by the CDM and Chef de Cuisine.
The facility failed to maintain accurate medical records for a resident, with missing documentation for behavior monitoring related to psychotropic medications. This included medications for poor meal intake, anxiety, and hyperventilation. The MDS Coordinator confirmed the nursing staff's responsibility to complete this documentation.
The facility failed to ensure proper infection control practices, as LVNs did not don appropriate PPE when administering medications to residents on enhanced barrier precautions. Additionally, improper storage of incontinence briefs and isolation carts touching trash bins were observed, posing a risk of infection spread.
The facility failed to educate and offer influenza and pneumococcal vaccinations to five residents, as required by its policies. Educational materials detailing the risks and benefits were not provided, nor was the type of pneumococcal vaccine specified. This was confirmed by the IP during a review.
The facility failed to maintain two ice machines in safe operating condition by not following the manufacturer's cleaning and sanitizing guidelines. The Maintenance Director admitted that the machines were not cleaned as required, and an orange residue was observed on one machine's spout, indicating improper cleaning.
The facility failed to conduct complete entrapment risk assessments for residents using bed side rails, assessing only some of the necessary zones. This oversight involved three residents, including one who used side rails for repositioning and another who lacked decision-making capacity. The Maintenance Director confirmed the incomplete assessments, which could lead to potential entrapment risks.
A facility failed to assess a resident for the safety of self-administering eye drops and did not obtain a physician's order or develop a care plan for this practice. The resident was observed with the medication on their bedside table and stated they used it as needed, but there was no documentation supporting this self-administration in their medical record.
A facility failed to ensure a call light was within reach for a resident, posing a risk of delayed care. The resident, who required assistance due to immobility and cognitive impairment, was observed in a wheelchair with the call light on the floor. The MDS Coordinator confirmed the call light was out of reach, although the resident could press it when accessible.
A facility failed to provide and document information on formulating an advance directive for a resident, as required by policy. The resident, who did not have an advance directive, had a legally recognized decision-maker. However, the medical record lacked documentation showing that the resident or their responsible party was informed of their rights. The SSD confirmed this oversight during an interview.
A facility failed to provide the SNF ABN Form CMS-10055 to a resident's responsible party when the resident's Medicare Part A skilled services benefits were exhausted. The facility's guidelines require this notice to be given when a resident no longer needs daily skilled services but remains in the facility. The Social Services Director confirmed the oversight during an interview.
The facility failed to complete and transmit the MDS for discharge for two residents, as required by the CMS RAI Manual. The MDS Coordinator confirmed that the assessments for these residents, who were discharged, were not completed and transmitted within the specified timeframe.
The facility failed to properly store garbage in three of five dumpsters, which were overfilled and unable to close completely. This was observed during an inspection with the Maintenance Director. The FDA Food Code requires that outdoor refuse receptacles be covered with tight-fitting lids. The facility's policy also mandates covered trash bins for infection control. The EVS Director and other staff acknowledged the issue.
Infection Control Practices Not Maintained
Penalty
Summary
The facility failed to maintain an accurate infection control surveillance log that matched the data reported in the QAPI infection control reports for June, July, September, and October 2025. During interview and document review, the DSD/IP stated she completed the Infection Control Surveillance Log and reported the findings monthly and quarterly, but the reviewed records did not align. For June 2025, the QAPI report showed 26 new infections with 14 HAIs and 12 CAIs, while the surveillance log showed 15 HAIs and 11 CAIs. For July 2025, the QAPI report showed 38 new infections with 23 HAIs and 15 CAIs, while the log showed 24 HAIs and 11 CAIs. For September 2025, the QAPI report showed 32 new infections with 17 HAIs, while the log showed 15 HAIs. For October 2025, the QAPI report showed 32 new infections with 21 HAIs, while the log showed 22 HAIs. The DSD/IP verified these discrepancies, and the DON was informed and acknowledged the findings. The facility also failed to maintain infection control practices in the laundry room. The facility policy stated clean linen should not touch the floor, food and drinks were not allowed in the laundry room, and a clean gown was to be worn when handling clean linen. During observation, a drinking water bottle was seen on the clean side of the laundry room. Laundry personnel was observed folding clean linen toward her body so that the linen touched her clothing and the floor at the same time multiple times, and she was not wearing a clean gown. The laundry personnel acknowledged the observations, and the Housekeeping Supervisor stated beverages were not allowed in the laundry room, clean linen should not touch the floor, and a gown was expected when folding clean linen. Resident-specific infection control failures were also observed. Resident 55 had enhanced barrier precautions ordered due to a reopened Stage 3 sacrococcyx pressure injury and had a wound treatment order in place; the resident also had orders for daily range of motion exercises. During observation, RNA 1 provided mobility exercises without wearing a protective gown, and later acknowledged the omission. During wound care for the same resident, the DSD/IP placed a clean box of gloves on the resident’s bed, and exposed gloves touched the incontinent pads on the bed. The DSD/IP stated the gloves should not have been placed on the bed and were contaminated. Resident 52 was observed being fed by CNA 1, who sat with her knees on the resident’s bed while feeding the resident; CNA 1 acknowledged this and stated she should not have had her knees on the bed. Resident 41 had C. difficile and Burkholderia in sputum and was ordered on transmission-based precautions, but a NP used alcohol-based wipes to disinfect a stethoscope used for the resident and then placed the stethoscope in the isolation cart; the NP stated alcohol wipes were not effective against C. difficile and that hand hygiene should have been done with soap and water. Family members were observed leaving the room after removing PPE and using ABHR. Resident 69 had a double lumen PICC line in the right upper arm, but no EBP signage or isolation cart was observed inside or outside the room, and RN 1 verified the findings.
Failure to Monitor Pressure Injury and Follow Wound Care Order
Penalty
Summary
Resident 55 had a reopened sacrococcyx Stage 3 pressure injury and was identified in the facility record as having no capacity to understand and make decisions. The facility’s Pressure Injury Evaluation documentation showed the wound was acquired on 4/21/25 and measured 1 cm by 0.8 cm with no depth on 10/27/25. After that date, the medical record did not show that the Weekly Pressure Injury Evaluation was completed again, even though the wound remained an active pressure injury. The facility’s DSD/IP and DON both acknowledged during interview that the pressure injury had reopened, but neither could identify when it had healed and reopened. The DON verified that the record failed to show Weekly Pressure Injury Evaluations after 10/27/25 and stated she expected weekly evaluations for all residents with pressure injuries. The DON also stated she would complete a Weekly Pressure Injury Evaluation for Resident 55. During wound care observation, the DSD/IP was observed cleansing Resident 55’s sacrococcyx pressure injury with Skintegrity wound cleanser instead of the physician-ordered normal saline. The bottle used was labeled with another resident’s name and had been opened on 10/13/25. The DSD/IP stated the cleanser belonged to another resident receiving hospice services and that she did not want to waste the supply. The DON verified the 11/29/25 wound treatment order required cleansing the wound with normal saline and stated licensed nurses were expected to follow physician orders when providing wound care.
Failure to Monitor Foley Output and Provide Ordered Bladder Training
Penalty
Summary
The facility failed to provide appropriate care and services for Resident 65 related to an indwelling urinary catheter. The resident was admitted with capacity to understand and make decisions. Physician orders dated 11/27/25 directed staff to place an indwelling urinary catheter and to monitor intake and output every shift for 30 days. A later order dated 12/1/25 directed bladder training by clamping the catheter for two hours and unclamping for fifteen minutes every shift until 12/3/25. Review of the resident’s MAR and Task-Output monitoring record showed no documentation that fluid output was monitored as ordered, and the medical record did not show output monitoring beginning on 11/27/25. The record also did not show that the ordered bladder training was provided as directed. Although the TAR contained check marks for some shifts, the medical record did not show the catheter was actually clamped for two hours and unclamped for fifteen minutes as ordered. During an observation and interview, Resident 65 stated the nursing staff had removed the catheter drainage bag, was not sure whether intake and output were being monitored, and reported that staff would clamp the catheter but sometimes forgot to unclamp it, causing pressure on the bladder. The DSD/IP verified that the output monitoring was not documented and that the TAR did not show the catheter was clamped every two hours and unclamped after fifteen minutes. The DON was informed and acknowledged the findings.
Improper Head-of-Bed Positioning During Enteral Feeding
Penalty
Summary
Resident 42 had a gastrostomy tube and a diagnosis of aphasia. The resident’s physician orders included elevating the head of bed to 90 degrees during feeding and after feeding stopped, and administering Isosource 1.5 via pump at 65 ml per hour for 18 hours per day starting at 0500 hours until the required dose was completed. The facility’s policy stated that nursing staff must review and implement physician orders. During observation on 12/3/25, Resident 42 was seen lying in bed receiving enteral feeding with the head of bed elevated less than 90 degrees. On 12/4/25, LVN 2 observed the resident receiving enteral tube feeding with the head of bed elevated less than 90 degrees and confirmed that it should have been elevated as ordered to prevent aspiration. The DON later stated that when a resident was receiving enteral feeding, the expectation was to elevate the head of bed at 90 degrees during and after feeding to prevent aspiration pneumonia. The DON, AIT, and Executive Director were informed of and acknowledged the findings.
Missing Physician Orders for Midline Catheter Care
Penalty
Summary
The facility failed to ensure current physician orders were obtained for the monitoring and dressing changes of one resident’s midline catheter. The resident had a midline catheter in the right upper arm, and the medical record showed active orders for the catheter itself and for flushing it with 10 mL of normal saline every 12 hours for maintenance. However, the record did not contain active physician orders for midline site monitoring, arm circumference measurements, catheter length measurements, or dressing changes. Review of the resident’s IV MAR showed prior orders for measuring arm circumference three inches above the insertion site weekly and as needed with dressing changes, measuring catheter length with each dressing change, and monitoring the IV site every shift for redness, tenderness, edema, and leaking. Those orders were last documented on 11/23/25 or 11/29/25 and were discontinued. During interview and concurrent record review, RN 1 stated there should have been physician orders for midline catheter maintenance, measuring, monitoring, and dressing changes for residents with midline catheters, and verified that no such orders were present for the resident.
Failure to Provide Ordered Respiratory Care
Penalty
Summary
The facility failed to provide respiratory care for two residents who had physician-ordered respiratory treatments. One resident was admitted and readmitted with acute respiratory failure with hypoxia and had no capacity to understand and make decisions. A physician order dated 12/1/25 directed continuous oxygen via nasal cannula at 2 to 5 liters per minute for shortness of breath or when oxygen saturation was less than 92%. During observation on 12/3/25, the resident’s nasal cannula was in place but was not dated, and RN 1 confirmed the missing date. During a later observation on 12/4/25, the resident was not receiving oxygen therapy, and the oxygen saturation level was measured at 88% while the physician order remained for continuous oxygen when saturation was less than 92%. The facility also failed to clean another resident’s CPAP equipment as ordered. That resident had a focus problem for altered respiratory status or difficulty breathing, and the care plan included cleaning the CPAP machine and mask per manufacturer’s instructions every Sunday on the 7-3 shift. The physician’s order in the record also directed weekly cleaning of the CPAP machine and mask. During the initial tour, the CPAP mask and strap were observed hanging on the head of the bed and placed on the mattress rather than stored in a bag, and the resident stated the CPAP machine had not been cleaned since admission. RN 1 verified the CPAP equipment should be placed in a bag for infection prevention. On follow-up interview, LVN 1 stated the facility did not have the manufacturer’s manual to refer to when cleaning the CPAP machine and acknowledged initialing the MAR for the weekly cleaning as completed even though the machine was not cleaned or checked with the resident. The DON and Executive Director were informed and acknowledged the findings.
Improper Medication Storage and Labeling
Penalty
Summary
The facility failed to provide necessary pharmacy services to ensure proper medication storage. During observation of Resident 42, who had been admitted and readmitted to the facility and whose H&P dated 9/15/25 showed capacity to understand and make decisions, a container of CBD Pain Relief Ointment was found on top of the bedside cabinet. LVN 1 verified the medication was at the bedside and stated she did not know the resident had it there. LVN 1 also stated there was no physician's order for the CBD Pain Relief Ointment. The facility's policy stated bedside medications were not to be provided without a physician/prescriber order and approval, and that bedside medications were to be stored in a locked compartment within the resident's room. Inspection of Medication Cart A found one open and cut individual pack of Cutimed Sorbion Sachet S and one open and cut individual pack of Skin Closure Strips Reinforced Wound Closure, both identified as single-use items. The DSD/IP stated the individual pack supplies were single use and needed to be discarded after use. Inspection of Medication Room A found five bottles of Fleet Enema Saline Laxative stored with three bottles of Chest Congestion Relief oral solution and a box of Lidocaine relief patches. The DON stated external and internal medications needed to be separated and not stored in the same cabinet.
Improper Hot Beverage Temperature Checks by Dietary Aide
Penalty
Summary
The facility failed to ensure kitchen staff had the appropriate skill sets to safely perform the daily operation of the Food and Nutrition Services Department. During tray line, a Dietary Aide was observed checking the temperature of hot beverages, but the end of the thermometer was touching the base of the cup while the reading showed 158 degrees Fahrenheit. The facility’s policy for safe holding and serving temperatures for hot beverages stated hot beverages should be served between 140 and 155 degrees Fahrenheit, and that the Dietary staff should record hot beverage temperatures for every meal and allow hot liquids to cool before serving. Facility interviews confirmed the Dietary Aide had attended multiple in-services on temperature checking and logging of hot beverages, including training in September, October, and again on 12/4/25. The Dietary Aide acknowledged the thermometer should not touch the sides or bottom of the cup and stated that doing so would make the reading inaccurate and could potentially cause a burn to residents. The Food and Beverage Manager, Executive Chef, and Dietary Manager each stated the thermometer should be placed in the center of the liquid without touching the sides or bottom of the cup, and that the purpose of checking hot beverage temperatures was to prevent residents from being burned.
Kitchen Food Safety and Ice Machine Sanitation Failures
Penalty
Summary
The facility failed to ensure food safety and sanitary requirements were met in the kitchen. During tray line on 12/4/25, a Dietary Aide was observed checking the temperature of a hot water beverage with a thermometer, then placing the thermometer on an uncovered clipboard where it touched the tie attached to the clipboard, and continuing to use the thermometer to check a resident’s hot water temperature without sanitizing it. The Dietary Aide later acknowledged the thermometer had not been sanitized before reuse and stated sanitizing before and after use was important to avoid contamination. The facility also failed to keep Ice Machine 1 sanitary and free from buildup. On 12/4/25, the inside of Ice Machine 1, which was used for residents’ ice supply and iced beverages, was observed to have a brown residue. The Maintenance Supervisor acknowledged the residue and stated the machine was sanitized twice a year, cleaned every three months and as needed, and inspected monthly. The Plant Operations Director was later informed and acknowledged that Ice Machine 1 was not clean and not maintained.
Failure to Maintain a Full-Time Dedicated IP
Penalty
Summary
The facility failed to designate a qualified infection preventionist responsible for the infection prevention and control program because it did not have a full-time, dedicated IP. Review of the All Facilities Letter summary dated 12/13/21 showed that SNFs are required to employ a full-time, dedicated IP, which may be filled by one full-time IP or by two staff members sharing the IP responsibilities as long as the total time equals at least a full-time staff member. The same guidance also stated that IP hours cannot be counted toward the 3.5 direct care hours per patient day provided to residents. Facility time records showed the DSD/IP worked with infection prevention for 20 hours per week during October and November 2025, while RN 2 worked with infection prevention for 18.74 hours in October 2025 and 8 hours in November 2025. During an interview, the DSD/IP stated she was working as DSD, treatment nurse, and IP, and that she spent four hours a day as the IP; she also stated RN 2 oversaw infection prevention on weekends. The DON stated the DSD/IP did not work full time as the IP and that RN 2 served as a back-up IP. The DON verified the recorded infection prevention hours for both staff members and later acknowledged the findings.
Urinary Catheter Bag Left Visible
Penalty
Summary
The facility failed to ensure dignity and respect for a resident with an indwelling urinary catheter when the catheter collection bag was not placed inside the privacy bag. During an initial tour, the resident was observed lying in bed with an indwelling urinary catheter draining yellow urine into the collection bag, which was hanging on the right side of the bed and visible rather than being covered by the privacy bag. An LVN later verified the observation and stated the urine collection bag should be inside the privacy bag for the resident's privacy. Resident 65 had been admitted to the facility and had an H&P dated 11/26/25 showing the resident had the capacity to understand and make decisions. The medical record also showed a physician's order dated 11/27/25 for a closed-system indwelling urinary catheter, size 16 Fr/10 ml, for mechanical dysfunction or blockage of the urinary catheter system. The DON stated that for all residents in the facility with an indwelling urinary catheter, the expectation was for the collection bags to be inside the privacy bag to provide dignity.
Confidential resident rosters left in public survey binder
Penalty
Summary
The facility failed to protect residents' identifiable information by leaving confidential resident rosters in the Survey Inspection Results binder that was posted for public viewing. During observation, the binder was seen in a wall pocket next to the Social Services office and available for public access. Review of the binder showed four Confidential Resident Rosters from prior surveys, each listing resident identifiers and names, including a concurrent relicensing and recertification survey roster with five residents, an abbreviated survey roster with six residents, another abbreviated survey roster with two residents, and a recertification survey roster with 22 residents. The rosters were marked confidential and had "Confidential" printed diagonally across the pages. The DON reviewed the binder and verified that the four confidential resident rosters should not have been included in the survey binder for public view.
MDS Not Coded for Hospice Services
Penalty
Summary
The facility failed to ensure Resident 6’s MDS assessment was coded accurately to reflect that the resident received hospice services. Review of the facility’s MDS guidelines showed that MDS data is used to guide care planning, monitor resident outcomes, and support quality improvement initiatives, with accuracy and interdisciplinary collaboration identified as essential. In the closed medical record for Resident 6, the physician’s orders included an order for hospice services, and the resident’s comprehensive MDS was triggered by that order, but the MDS did not indicate that hospice services were received. During an interview and concurrent record review, the MDS Coordinator stated that the assessment should have been coded to show hospice services but was not.
Care Plans Did Not Address Midodrine Use or Midline Catheter Care
Penalty
Summary
The facility failed to develop comprehensive care plans that reflected the individual care needs of two sampled residents. For Resident 41, the medical record showed an order to administer midodrine HCl 2.5 mg via GT twice daily for hypotension and to hold the medication if the SBP was greater than 140 mmHg. The H&P documented hypotension, but the resident’s plan of care did not include a care plan problem addressing the use of midodrine. During an interview and concurrent record review, RN 2 verified the resident’s midodrine use and confirmed that no care plan had been developed for it. For Resident 35, the medical record showed a physician’s order for a midline catheter to the right upper arm. The resident was observed sitting up in bed with a dressing to the right upper extremity covered with elastic netting. The resident’s plan of care did not include a care plan problem addressing the midline catheter. During an interview and concurrent record review, RN 1 verified the resident had a midline catheter and stated that midline catheters should be flushed for maintenance and that the site should be checked weekly during dressing changes and measurements; RN 1 also verified the care plan did not address the resident’s midline catheter use, monitoring, or maintenance.
Failure to Assess Hot Beverage Safety and Provide Timely Burn Care
Penalty
Summary
The facility failed to ensure that residents were evaluated for their ability to safely handle and consume hot beverages, as required by its own policies and procedures. Specifically, three residents were not assessed for hot liquid safety, including a resident with significant physical and cognitive impairments such as hemiplegia, hemiparesis, aphasia, and lack of capacity to make medical decisions. Despite the facility's policy mandating hot liquid safety evaluations upon admission, readmission, and change of condition, no such assessments were documented for these residents. An incident occurred in which the resident spilled hot tea onto her lap during lunch. Staff present at the time, including two restorative nursing assistants, did not immediately notify a licensed nurse or supervisor as required by facility policy. Instead, they patted the resident dry and allowed her to finish her dessert before informing a CNA, who later reported the incident to licensed nursing staff. The delay in notification resulted in a lack of prompt assessment and intervention for the burn injury. Following the incident, the resident developed blisters on her left upper thigh, which were not discovered until the following day during routine care. Documentation of the injury, physician notification, and appropriate treatment were not initiated until approximately 30 hours after the incident. The initial intervention included the application of ice to the burn, which is not recommended and can be harmful. There was no evidence that the resident's condition was promptly assessed, that a physician's order for burn treatment was obtained, or that the resident was properly monitored in the immediate aftermath of the incident.
Failure to Provide Wound Care as Ordered and Inadequate Monitoring
Penalty
Summary
The facility failed to provide necessary wound care services to a resident with a full thickness skin tear on the right lower leg. The physician's order specified the application of Steri-Strips every shift for 21 days, monitoring for infection or drainage, and specific actions if drainage or infection was noted. Medical record review showed that the treatment administration record was marked as completed, but interviews with nursing staff revealed inconsistencies in the actual care provided. Staff reported using a foam dressing instead of Steri-Strips and did not consistently open the dressing to assess the wound, relying instead on monitoring for pain and discharge around the dressing. The treatment nurse admitted to cleansing the wound without a physician's order and acknowledged that the wound care orders were incomplete and should have been clarified. Documentation in the resident's progress notes indicated the presence of a full thickness skin tear with visible adipose tissue and serosanguinous drainage, and later development of cellulitis requiring antibiotic therapy. The care plan included providing treatment as ordered, but staff interviews and record reviews indicated that the wound was not always treated according to the physician's instructions, and wound monitoring and documentation were not accurately performed. These actions and inactions led to a failure in providing the necessary wound care services as ordered.
Failure to Provide Continuous Oxygen Therapy as Ordered
Penalty
Summary
The facility failed to provide necessary respiratory care services for one resident who had diagnoses including lung cancer, acute and chronic respiratory failure with hypoxia, and dependence on supplemental oxygen. The physician's order required continuous oxygen administration via nasal cannula, with oxygen saturation to be maintained above 92%. Medical record review showed that the resident's oxygen saturation was recorded at 92% on room air and with nasal cannula on multiple occasions, and at 93% on room air. Despite the order for continuous oxygen, the resident was not consistently maintained on supplemental oxygen as prescribed. On one occasion, the resident's oxygen saturation dropped significantly from 93% to 51% within less than an hour, leading to the resident being transferred to an acute care facility. Interviews with nursing staff confirmed that the resident should have been on continuous oxygen and that the oxygen should have been titrated to maintain the ordered saturation level. The facility's policy required that all physician orders be specific and complete, and that treatments be administered as ordered, but these requirements were not met in this case.
Infection Control Lapses in Wound Care and Contact Isolation
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices for three of nine sampled residents, resulting in multiple breaches of protocol. During wound care for one resident, a treatment nurse did not perform hand hygiene or change gloves after removing a soiled dressing, and used the same gloves to handle clean supplies and enter the restroom. The nurse also used an expired alcohol-based hand sanitizer and returned unused gauze, which had been brought into the resident's room, back to the treatment cart for use with other residents. The nurse acknowledged that hand hygiene should have been performed and that unused, potentially contaminated supplies should have been discarded. A certified nursing assistant (CNA) was observed delivering meal trays and providing care in contact isolation rooms without wearing gloves or performing hand hygiene after touching contaminated items. The CNA handled residents' bedside tables, adjusted bedding, and fed a resident without gloves or hand hygiene, and then proceeded to deliver another meal tray to a different resident without sanitizing hands. The CNA admitted to not following proper personal protective equipment (PPE) and hand hygiene protocols when entering contact isolation rooms. Facility policy reviews confirmed that staff are required to perform hand hygiene after removing soiled dressings, dispose of unused disposable supplies brought into resident rooms, and wear gloves and gowns when entering contact isolation rooms. Staff interviews, including with the Director of Nursing (DON), confirmed awareness of these policies and acknowledged the observed failures to adhere to them.
Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to ensure complete and accurate documentation of medical information for two of nine sampled residents. For one resident, there were multiple instances where intake, output, and eating percentage documentation were either missing or incorrectly recorded. Physician orders required monitoring and documenting intake and output every shift, but several entries were left blank or marked as 'not applicable' without justification. Similarly, eating percentages were either not documented or recorded inaccurately. The Director of Nursing confirmed that these omissions and incorrect entries were due to missed charting and acknowledged that the documentation was not accurate. For another resident, the facility did not document an incident in which the resident spilled hot tea on her left thigh. Although the event was verbally reported to nursing staff and the resident was evaluated and treated for redness and later blisters, there was no corresponding documentation in the medical record regarding the incident on the day it occurred. Staff interviews confirmed that the incident was not documented, and the required change of condition process was not initiated at the time of the event. Facility policies required that all services, changes in condition, and incidents be documented objectively, completely, and accurately in the medical record to facilitate communication among the interdisciplinary team. The lack of documentation for both the intake/output monitoring and the incident involving the hot tea spill resulted in incomplete clinical records for the affected residents.
Sanitary Violations in Kitchen and Improper Food Labeling
Penalty
Summary
The facility failed to adhere to sanitary requirements in the kitchen, as evidenced by improper labeling and dating of food items. During an inspection, it was observed that several food items in Refrigerator 1, such as tilapia filets, cleaned chicken, mushrooms, egg salad, chopped onions, and tomato wedges, were not labeled according to the facility's policy. Additionally, expired items like pork chops, mushrooms, marinated vegetables, chopped tomatoes, and Tuscan Caesar dressing were found. Similar issues were noted in Freezer 1, the pantry area, Refrigerator 2, and Freezer 2, where various food items were not labeled as required. The facility also failed to ensure that food brought in by visitors for residents was properly labeled and dated. In Refrigerator 3, several items, including whipped cream cheese spread, veggie spread, ranch dressing, a croissant sandwich, and a bagel with spread, were found unlabeled and undated. Some items were labeled with the resident's name but lacked a date, and expired items like a Silk soy milk carton were also present. The facility's policy required these items to be dated and discarded after three days, but this was not consistently followed. Furthermore, the facility did not maintain cleanliness and proper storage practices in the kitchen. Food items were stored on the floor in Freezer 1, contrary to USDA Food Code requirements. Equipment such as the can opener, blender, microwave, oven, and plate lowerator were found with residues and substances indicating inadequate cleaning. Additionally, there was a failure to prevent cross-contamination, as egg salad was stored on a shelf designated for raw meats, posing a risk of foodborne illnesses to residents.
Failure to Address Resident's Significant Weight Loss
Penalty
Summary
The facility failed to ensure timely Registered Dietitian (RD) evaluations and interventions for a resident experiencing significant weight loss. The facility's policy and procedure (P&P) for weight management required identification and intervention for significant weight variance, but these were not implemented in a timely manner for the resident. The resident experienced a weight loss of 23.4 lbs over seven weeks, with multiple instances of significant weekly and monthly weight loss percentages. Despite the resident's oral intake being consistently below the assessed needs, there was no documented evidence of timely RD or physician intervention to address the ongoing weight loss. The resident's medical records indicated a pattern of inadequate nutritional intake, with a high percentage of meals consumed at 50% or less. The RD made several recommendations, including dietary changes and the use of nutritional supplements, but these were not effectively communicated or followed up with the physician. The RD's recommendations on 7/25/24 to notify the physician about the exhausted nutritional interventions were not documented as communicated, and there was no evidence of further evaluation or recommendations from the physician or RD from 7/25/24 to 8/15/24. Interviews with facility staff, including the RN, DON, and RD, confirmed the lack of documented follow-up on the RD's recommendations and the failure to notify the physician. The RD acknowledged the absence of follow-up documentation regarding the resident's weight loss during the critical period. The DON confirmed that the nursing staff should have carried out the RD's recommendations promptly, ideally the next day, but this did not occur, contributing to the deficiency in addressing the resident's nutritional needs.
Inadequate Respiratory Care and Equipment Management
Penalty
Summary
The facility failed to provide appropriate respiratory care for four residents, as evidenced by several deficiencies in the administration and management of oxygen therapy. Resident 36 was observed receiving oxygen at four liters per minute, contrary to the physician's order of two to three liters per minute. Additionally, the humidifier was empty, and the oxygen nasal cannula and storage bag were not changed timely, being dated 11/20/24. LVN 1 confirmed these observations and was unaware of the correct physician's order. The MDS Coordinator also verified the discrepancy in the oxygen administration. For Resident 32, the nasal cannula was improperly stored on top of the oxygen concentrator instead of inside the storage bag when not in use, and both the nasal cannula and storage bag were undated or outdated. Similar issues were observed with Resident 31, whose nasal cannula was not stored properly and was undated, with the storage bag dated 11/20/24. Resident 18's nasal cannula was found on the floor, unlabeled, and not stored in a sanitary manner. LVN 1 confirmed these findings and acknowledged the improper storage and labeling of the equipment. The DON and Administrator were made aware of these deficiencies.
Medication Management Deficiencies in LTC Facility
Penalty
Summary
The facility failed to provide adequate pharmaceutical services, resulting in medication discrepancies and unavailability of necessary medications for residents. One resident had medications left at their bedside, and another resident did not have their routine medication available, which could potentially lead to poor health outcomes. The facility's failure to ensure accurate reconciliation and disposal of medications was evident in the discrepancies found in the Omnicell automatic drug delivery system. The facility's policies and procedures for the Automated Drug Delivery System (ADDS) were not followed, leading to several discrepancies in medication counts. For instance, there were unexplained changes in the bin quantities of medications such as zolpidem, hydralazine, tramadol, and levofloxacin. The Director of Nursing (DON) and pharmacy staff were unable to provide explanations for these discrepancies, indicating a lack of proper oversight and accountability in medication management. Additionally, a resident's routine medications, Eliquis and zinc sulfate, were not available due to a failure in the reordering process. Despite multiple attempts by a Licensed Vocational Nurse (LVN) to contact the pharmacy, the medications were not delivered in a timely manner. This highlights a breakdown in communication and coordination between the facility and the pharmacy, further contributing to the deficiency in pharmaceutical services.
Failure to Administer Prescribed Antibiotic
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors. Specifically, Resident 25 was not administered the piperacillin sodium tazobactam antibiotic as ordered by the physician. The physician's order, dated 11/29/24, required the medication to be administered intravenously every six hours for seven days to treat a urinary tract infection. On 12/2/24, Resident 25 reported not receiving the 0600 hours dose during the previous night shift. A review of the resident's Infusion Medication Administration Record confirmed the omission of the dose. RN 2 acknowledged and verified these findings during an interview and concurrent medical record review.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications in one of its medication storage rooms and two medication carts. In the medication room, an opened tuberculin vial was found in the refrigerator without an open date, and an opened box of instant food thickener contained multiple expired packets. Additionally, a bag of home medications without a resident's name was stored on the counter. The temperature log for the medication room had multiple missing entries, which were verified by the Director of Nursing (DON). In Medication Cart A, three packets of Non-Adhesive Pad were found to be expired. In Medication Cart C, topical medications for two residents were not labeled with an open date, as per the facility's policy. The medical records for these residents showed physician orders for the use of diclofenac sodium topical gel for pain management, but the medications were not properly labeled with open dates, which was confirmed by the staff.
Menu Adherence Failure for Three Residents
Penalty
Summary
The facility failed to adhere to the planned menu for three residents, resulting in a deficiency related to nutritional needs. On the specified date, three residents did not receive the garlic breadstick as indicated on their meal tickets. Resident 43, who was supposed to receive a pureed garlic breadstick and butter, did not have it on her meal tray. Similarly, Resident 40's meal tray was missing the soft and buttered garlic breadstick, and Resident 22 also did not receive the pureed garlic breadstick and butter as per his meal ticket. These discrepancies were verified by the Certified Dietary Manager (CDM) and other staff members. The issue arose due to an oversight by the kitchen staff responsible for serving the pureed bread, who missed including the garlic breadstick on the first few trays. Despite having a third server on the line to check the trays and nursing staff performing a final check before meals were served, the error was not caught in time. The CDM and Chef de Cuisine acknowledged the mistake during an interview, indicating that the process for checking meal trays was not effectively implemented in this instance.
Incomplete Medical Records and Behavior Monitoring Deficiency
Penalty
Summary
The facility failed to maintain accurate and complete medical records for one of the sampled residents, identified as Resident 30. The medical record review revealed multiple instances of missing documentation related to behavior monitoring for various psychotropic medications prescribed to Resident 30. These medications included Remeron for poor meal intake, buspirone for verbalization of feeling anxious, Ativan for anxiety manifested by biting nails and scratching, and lorazepam for hyperventilation. The missing documentation spanned several dates and shifts, indicating a pattern of incomplete record-keeping. Additionally, the facility did not ensure the monitoring of behavior for psychotropic medication on another resident's Medication Administration Record (MAR), identified as Resident 2. This oversight had the potential to impact the resident's care needs due to the incomplete and inaccurate medical record. During an interview and concurrent medical record review, the MDS Coordinator confirmed that the nursing staff should have completed the documentation for Resident 30's behavior monitoring and noted that any inability to do so should have been documented in the progress notes.
Infection Control Lapses in PPE Usage and Storage Practices
Penalty
Summary
The facility failed to implement a safe and sanitary environment to prevent the transmission of infections for three residents. Specifically, the facility did not ensure that Licensed Vocational Nurses (LVNs) donned appropriate personal protective equipment (PPE) when administering medications to residents on enhanced barrier precautions (EBP). For Resident 26, who was on EBP due to a gastrostomy tube, LVN 3 was observed multiple times administering medications and performing medical procedures without wearing an isolation gown. Additionally, the isolation cart for Resident 26 was improperly placed, touching the trash bin inside the room. Similarly, LVN 2 did not wear an isolation gown while administering medication to a nonsampled resident, Resident 2, who required EBP due to a wound. The isolation cart for Resident 2 was also inside the room, indicating a lack of adherence to infection control protocols. Both LVNs were unaware of the residents' EBP status, which contributed to the oversight in PPE usage. Further observations revealed improper storage of incontinence briefs and isolation carts touching trash bins in residents' rooms. In Room A, a stack of incontinence briefs was stored on top of the isolation cart, and in Room B, Resident 31's incontinence briefs were stored on the floor. These practices posed a risk of spreading infection, as acknowledged by LVN 1 during interviews. The facility's failure to maintain proper infection control measures for these residents highlights significant lapses in adherence to established protocols.
Failure to Educate and Offer Vaccinations
Penalty
Summary
The facility failed to ensure that five residents, including four from the final sample and one non-sampled, were educated and offered influenza and pneumococcal vaccinations. Specifically, the facility did not provide educational materials detailing the risks and benefits of these vaccines to Residents 12, 21, 24, 25, and 507. Additionally, the facility did not specify which type of pneumococcal vaccine was offered to these residents, as required by the facility's policies and procedures. The medical records for each of these residents lacked documentation showing that the educational materials were provided or that the type of pneumococcal vaccine was specified. This oversight was confirmed during an interview and concurrent medical record review with the Infection Preventionist (IP), who acknowledged the findings. These failures put the residents at risk for infection and transmission of pneumococcal and influenza infections.
Improper Maintenance of Ice Machines
Penalty
Summary
The facility failed to maintain essential kitchen equipment, specifically two of the three ice machines, in safe operating condition. The ice machines were not cleaned and sanitized according to the manufacturer's guidelines, as required by the facility's policy and procedure. The policy stated that internal components of the ice machines must be cleaned and sanitized at least twice a year per manufacturer guidelines. However, the Maintenance Director confirmed that the ice machines were not cleaned per these guidelines. Instead, the facility cleaned the filters weekly and the inside every three months, without using any chemicals, which deviated from the manufacturer's instructions. During an observation, an orange residue was noted on the spout of Ice Machine 2, indicating a lack of proper cleaning. The Maintenance Director acknowledged this finding and admitted that the icemaker and ice storage bin had not been cleaned as required. The failure to follow the manufacturer's cleaning and sanitizing instructions had the potential to affect the health status of the residents, as the equipment might not function as intended.
Incomplete Entrapment Risk Assessments for Bed Rails
Penalty
Summary
The facility failed to ensure accurate and complete entrapment assessments for residents using bed side rails, which could lead to potential entrapment, serious injury, or death. The report highlights that the facility did not assess all necessary zones for entrapment risk as per the Hospital Bed System Dimensional and Assessment Guidance. Specifically, the Maintenance Director only assessed Zones 2, 3, and 4, neglecting Zones 1, 5, 6, and 7, which are critical areas where entrapment could occur. Resident 507, who had the capacity to understand and make decisions, used the side rails to reposition herself in bed. Her entrapment risk evaluation indicated the use of side rails as an enabler for independence and safety, but the assessment did not cover all potential entrapment zones. Similarly, Resident 30, who lacked the capacity to understand and make decisions, also had side rails as enablers, but the assessment was incomplete, missing several zones. The Maintenance Director confirmed the oversight during an interview. Resident 38, who could understand and make decisions, used the side rails for support while turning in bed. Her entrapment risk evaluation also failed to assess all necessary zones, with only Zones 2 and 3 being checked. The Maintenance Director acknowledged the incomplete assessments during a review of the documentation. Interviews with staff, including a CNA and the DON, confirmed the findings, indicating a systemic issue with the facility's assessment process for bed safety.
Failure to Assess and Document Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a resident was assessed for the safety and clinical appropriateness of self-administering medications. Specifically, Resident 507 was observed to have a bottle of carboxymethylcellulose sodium ophthalmic solution 0.5% eye drops on their bedside table and stated that they self-administered the drops when experiencing dry eyes. However, there was no documentation in the resident's medical record indicating that a physician's order was obtained or that a care plan was developed to address the self-administration of this medication. The facility's policy on self-administration of medications requires an assessment by the interdisciplinary team (IDT) to determine if self-administration is safe and appropriate for each resident. Additionally, the policy mandates that specific medications for self-administration be listed in the physician's orders and documented in the resident's care plan. In this case, the facility did not comply with its policy, as there was no evidence of an assessment, physician's order, or care plan for Resident 507's self-administration of eye drops. This oversight had the potential to lead to unsafe medication administration and negatively impact the resident's physiological well-being.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a call light was within reach for a nonsampled resident, identified as Resident 307. During an observation on November 18, 2024, at 0900 hours, Resident 307 was seen awake and sitting in a wheelchair with the call light on the floor, out of reach. A review of the facility's policy and procedure from October 2010 indicated that call lights should be within easy reach when a resident is in bed or confined to a chair. Resident 307's medical records showed a care plan addressing risks related to bowel incontinence and deficits in daily living self-care performance, requiring staff assistance for toileting and repositioning. At 1005 hours, the MDS Coordinator confirmed the call light was out of reach and verified that Resident 307 could press the call light when it was accessible.
Failure to Inform Resident of Advance Directive Rights
Penalty
Summary
The facility failed to provide and document information on how to formulate an advance directive for Resident 508, as required by their policy. The policy, revised on 6/24/15, mandates that written information regarding the rights to formulate an advance directive be provided to residents and their responsible parties. Resident 508, who was admitted to the facility on an unspecified date, did not have an advance directive according to the Social Services Evaluation dated 11/21/24. The POLST dated 11/19/24 indicated that the resident had a legally recognized decision-maker. However, the medical record lacked documentation showing that Resident 508 or their responsible party was informed of their rights to formulate an advance directive. During an interview on 12/3/24, the SSD confirmed that neither Resident 508 nor the responsible party had been informed of these rights.
Failure to Provide SNF ABN Form CMS-10055
Penalty
Summary
The facility failed to provide the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) Form CMS-10055 to a resident's responsible party, which is required when a resident no longer requires daily skilled services but remains in the facility. This deficiency was identified during a review of the facility's Beneficiary Notice Guidelines, which indicated that the SNF ABN should be provided regardless of payer type. The medical record review for the resident, who was admitted and readmitted to the facility, showed that their Medicare Part A skilled services benefits were exhausted on May 17, 2024. An interview with the Social Services Director (SSD) confirmed that the responsible party was not given the SNF ABN Form CMS-10055, despite the exhaustion of benefits, which should have been done to allow informed decision-making regarding Medicare services.
Failure to Complete and Transmit Discharge MDS Assessments
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) for discharge was completed and transmitted to the Centers for Medicare & Medicaid Services (CMS) for two nonsampled residents, identified as Residents 42 and 46, who were reviewed for resident assessments. According to the facility's guidelines, as outlined in the CMS RAI Manual Version 3.0 Chapter 2, Discharge Assessments for Return Not Anticipated must be completed within 14 days after the discharge date and submitted within 14 days after the MDS completion date. However, a closed medical record review initiated on December 5, 2024, revealed that Resident 42, who was discharged on July 3, 2024, and Resident 46, who was discharged on July 5, 2024, did not have their discharge MDS assessments completed and transmitted. During an interview and concurrent medical record review, the MDS Coordinator confirmed these findings, acknowledging the failure to complete and transmit the required assessments.
Improper Garbage Storage in Facility Dumpsters
Penalty
Summary
The facility failed to ensure proper storage of garbage in three out of five dumpsters, which were observed to be overfilled, preventing the lids from closing completely. This observation was made during an inspection conducted with the Maintenance Director. The FDA Food Code 2022 requires that receptacles for refuse be kept covered with tight-fitting lids if stored outside. The facility's policy, dated January 2015, also mandates that trash be moved in covered bins for infection control purposes. The Environmental Services (EVS) Director acknowledged that the dumpster lids should always be covered. The findings were also acknowledged by the CDM, Food and Nutrition Manager, and Chef de Cuisine.
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What surveyors actually found near you
We read the 5,552 citations issued within 25 miles in the last 12 months — including the 12 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Nursing homes near Fullerton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Pavilion At Sunny Hills | 1.1 mi | ★★★★★ | 9 | 0 |
| Greenfield Care Center Of Fullerton, Llc | 1.1 mi | ★★★★★ | 15 | 0 |
| Terrace View Care Center | 1.2 mi | ★★★★★ | 28 | 0 |
| St Elizabeth Healthcare Center | 1.2 mi | ★★★★★ | 25 | 0 |
| Gordon Lane Care Center | 1.7 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.