Above average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Parkview Healthcare Center during CMS and state inspections, most recent first.
Menu preferences were not honored for two residents who preferred Hispanic foods. Staff and the RD stated the facility did not have a separate Hispanic menu, and the dietary supervisor confirmed the alternate menu was not posted. One resident said he preferred regular food but kept receiving Hispanic meals he did not like, while another resident was observed asking for tortillas to go with beans that had been served. The posted lunch menu did not match the meal actually served.
The facility failed to honor food preferences for a resident who requested regular menu items instead of only Hispanic food and for several other residents who preferred Mexican food. One resident with decision-making capacity was served Hispanic alternatives despite stating he wanted a variety of foods, and during observation he received a meal different from the posted menu until the DSS intervened. Other residents reported they were still served foods they disliked, including beef, pork, lasagna, and milk, even though their diet cards and interviews documented specific preferences and intolerances.
Kitchen sanitation and food storage deficiencies were identified for residents receiving meals prepared in the kitchen. Staff observed a wet stainless-steel tray stacked for storage, an open bottle of teriyaki sauce kept in dry storage despite refrigeration instructions, expired and unlabeled resident food in a refrigerator, and worn or dirty food-contact items including marred cutting boards, a cracked blender, and a scoop with residue. An outside vendor technician with a beard was also observed in the kitchen without a beard restraint.
The facility failed to coordinate hospice services for two residents. For one resident, hospice RN visits did not follow the scheduled calendar, hospice RN progress notes were missing, the hospice POC was not incorporated into the facility care plan, and the hospice med list lacked dosages; the facility also discontinued morphine and oxygen without documented notification to Hospice A. For another resident, hospice services had been discontinued, yet a hospice CHHA visit still occurred after discharge.
Infection control practices were not maintained in several areas. Laundry processing was observed with a nonfunctional temperature gauge, unclear disinfection practices, and products that were not verified as disinfectants other than bleach. A decorative fountain was treated with chlorine tablets, but the log did not document water testing and the wrong test strips were used. Infection surveillance for a resident treated with gentamicin and Levaquin was recorded incorrectly, and CNAs did not offer hand hygiene to residents before meal trays were served.
A resident room had three ceiling vents with black substances around the surfaces, a lifted restroom floor tile, and two clothing cabinets with missing knobs. The Maintenance Supervisor verified the findings and stated there was no log documenting when the vents were last cleaned.
A facility failed to monitor two residents appropriately for psychotropic medication use. One resident’s orthostatic BP checks were charted with identical lying and sitting readings, but staff said the resident refused the checks and the refusal was not documented or reported to the MD. For another resident, the behavior monitoring tied to sertraline and divalproex did not match the manifestations documented in the chart, and staff described different behaviors than those listed in the record.
A resident with no capacity to make decisions was sent to the acute care hospital for GT replacement, but the facility did not document that the resident or representative received the written transfer/discharge notice, the reason for transfer, or the bed-hold policy. The transfer notice was unsigned, and both the IP/DSD and Social Services/Activity Director verified they could not locate evidence that the required notices were mailed or otherwise provided.
A resident with basal cell carcinoma on the nose was observed with a dark red wound and long, pointy fingernails, while staff reported she frequently picked at the lesion and it tended to bleed. Her care plan addressed the picking behavior and education, but it did not include regular fingernail trimming as an intervention, despite staff confirming that this should have been included.
The facility failed to provide treatment and care according to orders and care plans for two residents. One resident with basal cell carcinoma of the nose was observed with a bleeding wound on the bridge of the nose and long, pointy fingernails while staff reported she picked at the wound. Another resident was observed using bilateral heel protectors and bilateral hand rolls, but the chart had no MD orders or care plan addressing either device, and an RN confirmed the devices were being used without documented authorization.
Appropriate care and services were not provided for a resident with a GT. An LVN was observed administering meds via the GT when the tubing fell to the floor, then picked it up and placed it back on the GT pole. Afterward, the syringe used for GT meds was placed into a plastic bag without being cleaned. The LVN later verified the findings.
A facility failed to properly dispose of unknown pills, secure the narcotic destruction cabinet, monitor storage conditions for enteral feedings, and hold a stool softener when a resident had loose stools. An IP kept the cabinet key in a personal purse, the Administrator also had access to the cabinet containing controlled substances, and a resident with no decision-making capacity continued receiving docusate despite repeated loose BMs documented by CNA staff.
A resident’s record was inaccurate because the POLST listed a family member as the HC agent even though the filed DPOA was for financial matters only and did not name a HC agent. The record also showed hospice had been discontinued, but the facility did not complete a required comprehensive MDS after hospice ended, and a later MDS still incorrectly coded hospice services as active.
A resident received gentamicin drops and Levaquin for a right ear infection, but the infection surveillance form showed the symptoms met only 3 of 4 required criteria and did not meet infection criteria. The record did not show additional symptoms to support a true infection, and the IP/DSD later verified the physician was not notified to reassess the need for continued antibiotic therapy.
Improper Maintenance and Cleaning of Wrist BP Machine: An LVN was observed using a Velcro wrist BP machine on multiple residents during med pass. The device manual was not kept in the med cart, the cuff was cleaned with Clorox wipes instead of the manufacturer’s directions, and the RN stated the machine was not routinely serviced and staff training documentation for its use, cleaning, and maintenance was not available.
A resident's medical record was found to be incomplete, with sections of the Elopement Evaluation left blank and missing documentation of monitoring during a shift following a change in condition involving agitation and attempts to leave. The DON and administrator confirmed the omissions during record review.
A resident with lower extremity contractures did not receive consistent application of physician-ordered bilateral AFOs, and staff failed to document the times of application and removal or perform and record required skin assessments. The care plan and facility policy did not address skin assessment during AFO use, and multiple staff confirmed the lack of documentation and protocol.
A resident with severe cognitive impairment and high fall risk did not have a floor mat placed on the left side of the bed as ordered by the physician and outlined in the care plan. Staff confirmed the absence of the mat despite being aware of the order and facility policy, resulting in a deficiency in accident prevention.
Three residents receiving oxygen therapy did not receive care in accordance with physician orders, and their nasal cannula oxygen tubing was observed touching the floor. For two residents, the oxygen flow rate did not match the physician's order, and for all three, the tubing was not maintained in a sanitary manner, as confirmed by staff interviews and medical record review.
Two residents did not receive pharmaceutical services in accordance with facility policy: one resident's insulin injection sites were not documented on the MAR, and another resident was given crushed oral medications by an LVN without a physician's order. Both the DON and pharmacy consultant confirmed these actions were not consistent with required procedures.
Surveyors found that medication storage areas and carts were not maintained in a clean and sanitary manner, with personal and unrelated items stored alongside medications, oral and external medications stored together, and medication carts left unlocked and unattended. Additionally, some medications were not labeled with opened dates and discontinued medications were not properly disposed of, all in violation of facility policy.
Surveyors found that kitchen utensils, including scoops and measuring cups, were not properly cleaned and were stored while still wet, contrary to facility policy and USDA Food Code requirements. The kitchen hood was also observed with black, dirt residue, despite scheduled cleaning. The Dietary Services Supervisor confirmed these sanitation lapses, which affected food prepared for most residents.
The facility's Facility Assessment did not include active involvement from direct care staff, residents, or their representatives, and failed to address necessary resources for weekends, recruitment and retention of direct care staff, or a contingency plan for staffing needs. The Administrator confirmed the assessment was not updated per the latest CMS guidance.
Surveyors identified multiple infection control deficiencies, including inaccurate infection surveillance documentation, improper storage of personal items on clean linen carts, mishandling of clean linens by staff, and failure of a hospice aide to perform hand hygiene after handling soiled linens before providing care to a resident with cognitive impairment. These actions were acknowledged by facility leadership as not compliant with infection control policies.
Several residents using side rails had inaccurate or incomplete entrapment assessments, with discrepancies found between documented measurements and actual findings during surveyor re-assessment. Facility staff acknowledged that original assessments did not match current measurements, and in some cases, assessment forms were incomplete or based on similar rather than actual beds. These failures did not align with facility policy and had the potential to negatively impact resident safety.
A resident's care plan was not updated to reflect the current size of their suprapubic indwelling urinary catheter after a new catheter was inserted. Staff and leadership confirmed that the care plan still referenced outdated catheter information, contrary to facility policy requiring timely updates based on changes in a resident's condition.
The facility did not post daily nurse staffing information in a publicly accessible area. The DON confirmed that staffing records were kept in a binder at the nursing station and were not available for residents, staff, or visitors to view.
Surveyors observed that the facility's outside garbage dumpster had its lid partially propped open by garbage bags, preventing it from fully closing. This was confirmed by the Maintenance Supervisor, despite facility policy and FDA Food Code requirements for tight-fitting lids to prevent pest and rodent entry.
A resident's medical record was found to be incomplete, with missing documentation by licensed nurses for the administration of prescribed topical antifungal treatments and wound care. The DON confirmed the omissions during a review and stated that undocumented treatments are considered not completed, in accordance with facility policy requiring complete and accurate charting.
Surveyors found that Room A was occupied by five residents, exceeding the allowed maximum of four residents per room. The administrator confirmed the over-occupancy and acknowledged the room's insufficient square footage.
A five-bed room was found to provide only 78.4 square feet per resident, which is below the required 80 square feet. The Administrator confirmed the room's measurements and acknowledged the deficiency during an interview.
The facility failed to ensure the IP was knowledgeable about updated CDC guidelines for pneumococcal immunization and CMS guidelines for enhanced barrier precautions. The IP continued to administer only PPSV 23 vaccines and did not implement enhanced barrier precautions for residents with chronic wounds or indwelling medical devices, including a resident with a Stage 4 pressure ulcer and an infected surgical wound.
The facility failed to offer PCV 15/PCV 20 immunizations to 20 residents in accordance with updated CDC guidelines, only providing PPSV 23 due to outdated policies and lack of awareness. Medical records lacked documentation of offering the updated vaccines, and the facility did not have a tracking system for pneumococcal vaccine history.
The facility failed to notify five residents or their representatives in writing about their rights to a bed hold policy upon transfer to an acute care hospital. This deficiency was identified through interviews, medical record reviews, and a review of the facility's policies and procedures. The facility lacked a specific bed hold notification form, relying only on a notice of transfer or discharge form, which did not fulfill the requirement for informing residents or their representatives about the bed hold policy.
The facility failed to ensure accurate MDS assessments for 11 residents regarding their pneumococcal vaccination status, leading to discrepancies in immunization records and improper documentation. Interviews and medical record reviews confirmed that residents were not offered the appropriate vaccines as per updated guidelines.
The facility failed to follow physician's orders for a resident's abduction pillow, knee immobilizer, and bowel management medication. Additionally, the facility did not ensure proper collaboration with hospice care teams for two residents, including participation in Quarterly IDT meetings and review of care plans.
The facility failed to ensure food safety and sanitary requirements in the kitchen, with unsanitary cutting boards and equipment, expired food items, improper food temperature checks, personal belongings stored in the kitchen, poor hand hygiene, uncovered food transportation, and incorrect diet texture for a resident. These failures posed a risk of foodborne illnesses to residents.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with indwelling urinary catheters and gastrostomy tubes (GT), did not ensure proper hand hygiene practices, and improperly stored medical equipment. Staff interviews and observations confirmed these deficiencies, which were acknowledged by the Infection Preventionist (IP) and the Director of Nursing (DON).
The facility failed to ensure staff provided care and promoted dignity for three residents. Two CNAs were observed standing over residents while assisting with meals, and another CNA transported a resident from the shower room with her body partially uncovered, compromising her dignity.
The facility failed to inform two residents about the risks associated with the use of bed side rails, specifically regarding the entrapment assessment for Zone 6. Both residents had beds that failed the Zone 6 measurement, but there was no documentation showing that they were informed of this specific risk. The facility's policies require residents to be informed of their care and treatment options, but this was not adhered to in these cases.
The facility failed to ensure a resident's call light was within reach, as observed during an initial tour. The resident required dependent assistance for bed mobility and transfers, and the call light was found on the floor. The CNA admitted to not noticing the call light, and the DON confirmed that call lights should always be within reach.
The facility failed to honor a resident's documented food preferences by serving him rice, which he had not eaten for two years and explicitly disliked. This discrepancy was confirmed by the Social Services Director and acknowledged by the Director of Nursing.
The facility failed to inform and provide written information about advance directives to a resident and did not ensure that copies of advance directives were readily available in the medical records of two other residents. The Social Services Director confirmed these deficiencies, and the Director of Nursing acknowledged the findings.
The facility failed to provide a resident and/or their representative with the required written notification of a transfer to an acute care hospital, as mandated by the facility's policy. The resident, who had the capacity to understand and make decisions, was transferred without receiving the necessary written notice, including details and appeal rights.
A facility failed to provide a summary of the baseline care plan to a newly admitted resident. Despite discussing physical therapy, there was no documented evidence that the resident was informed or given a summary of her baseline care plan, contrary to the facility's policy.
The facility failed to develop a care plan to address a resident's noncompliance with a physician's order to use a hip abduction pillow while in bed. Despite the resident's capacity to understand and make decisions, and her expressed right to remove the pillow, the care plan did not reflect this issue, leading to inconsistent care.
The facility failed to provide an individualized and ongoing activity program for a resident with severe cognitive impairment, leading to potential social isolation and frustration. Despite the care plan requiring daily activities and sensory stimulation, the resident was often observed lying awake in bed without engagement, and the Activity Attendance Record showed significant gaps in activity provision.
The facility failed to provide necessary catheter care for two residents, leading to potential risks for UTIs. One resident's catheter care was not documented every shift, and another resident's catheter bag was changed weekly against CDC guidelines. Staff acknowledged these deficiencies.
The facility failed to meet the nutritional needs of a resident who consumed less than 50% of their meal tray. Despite the resident's history of weight fluctuations and a physician's order for a regular diet with a large protein portion, staff did not offer an alternative meal as required. This oversight was confirmed by both the DON and the RD.
The facility failed to ensure proper care for three residents with gastrostomy tubes (GT). A CNA was observed turning off a GT feeding machine, which is outside their scope of practice. Additionally, the GT tubing for three residents was not labeled, which is necessary to ensure daily changes. Both the DSD and DON confirmed these deficiencies.
Menu Preferences Not Honored for Residents Requesting Hispanic Foods
Penalty
Summary
The facility failed to ensure the regular posted menu reflected residents’ food preferences for one sampled resident and one nonsampled resident. Review of the facility’s menu policy showed menus were to be developed in advance, posted, and reflect religious, cultural, and ethnic preferences when reasonable. However, the facility did not have a separate posted Hispanic menu, and the dietary supervisor confirmed the menu was not posted. The dietary records showed eight of 30 residents preferred Hispanic food, and facility leadership stated eight of 35 residents preferred Hispanic food. Resident interviews and observations showed the affected residents were not consistently served according to their preferences. One resident stated he preferred regular food but was repeatedly given Hispanic food, which he did not like, and he appeared upset when served chile relleno again at lunch. Another resident was observed looking for staff to request tortillas to go with beans that had been served. The lunch menu for that day listed roast beef, mashed potatoes, spinach au gratin, Caesar salad, fruit mix, and crumble cake, but did not include chile relleno or beans. Staff and the RD stated the facility did not have a separate Hispanic menu, and the RD said residents who preferred Hispanic food received items from an alternate menu, while leadership stated the facility prepared whatever was available to make Hispanic food.
Food Preferences Not Honored for Multiple Residents
Penalty
Summary
The facility failed to ensure resident food preferences were honored for Resident 2, who stated he did not want to receive only Hispanic food and preferred regular menu items. Resident 2 had capacity to understand and make decisions, and his resident council minutes documented that he requested a variety of foods, not only Hispanic food. Despite this, the dietary department documented that he was being served Hispanic alternatives because he had refused the daily menu items, and the facility stated it would provide the regular menu items again. During observation, Resident 2 was served chile relleno, beans with broth, salad, and dessert instead of the posted lunch menu of herb and spice roast beef with gravy, mashed potatoes, spinach au gratin, Caesar salad, fruit mix, and crumble cake. After the resident expressed concern, the DSS brought him the regular menu meal. The facility also failed to honor food preferences for Residents 18, 29, and 30, who all stated they preferred Mexican food. Resident 29, who had capacity to understand and make decisions, had a diet card listing Mexican food and fish and chicken only, but he reported he was rarely served Mexican meals, did not like beef, and was repeatedly served milk despite stating it caused diarrhea. Resident 30, who also had capacity, had a diet card listing Mexican food and a dislike for pork, yet he reported he continued to receive meals containing pork and lasagna. Resident 18 stated he liked Mexican food and said he had to ask for it, but he never knew what he would be served. During the resident council meeting with Spanish-speaking residents, Resident 29 stated he liked Mexican food but rarely received it and did not understand why staff repeatedly asked for preferences but continued serving foods he did not want. Resident 30 stated he had informed staff he disliked pork and lasagna but still received those foods. The CDM reviewed the facility’s frozen Mexican food list and stated those items were served to residents who requested Mexican food, but the list was not posted for residents to see. The hallway menu posted outside the dining room showed only one meal with Mexican food items for Week 1.
Kitchen Sanitation and Food Storage Deficiencies
Penalty
Summary
The facility failed to ensure sanitary requirements were met in the kitchen for the 30 of 35 residents receiving food prepared there. During observation, a stainless-steel tray was seen stacked while still wet, and the kitchen staff member confirmed it should have been air dried before storage. The report also noted an outside vendor technician with a full beard inside the kitchen who was not wearing a beard restraint, and the staff member acknowledged that the beard restraint should have been worn. Food storage practices were also observed to be out of compliance. An open bottle of teriyaki sauce was found in the dry storage area even though the bottle instructions indicated it should be refrigerated after opening. In the refrigerator used for food brought in from outside, a plastic container of watermelon dated 5/24/26 was present, along with a blue plastic cup of rice pudding that was not labeled with a date. The RN verified that the watermelon should have been discarded and that the rice pudding should have been labeled. Kitchen equipment and food-contact surfaces were observed in poor condition. A brown, white, and green cutting board was heavily marred with whitish discoloration, a plastic blender had a hairline crack and whitish discoloration, and a scoop in a plastic container had dried food residue and water marks. The kitchen staff member verified each of these findings and stated the cutting boards and blender needed replacement and the scoop needed to be cleaned again.
Hospice services were not coordinated and a post-discharge hospice visit occurred
Penalty
Summary
The facility failed to ensure coordinated hospice services for two residents receiving hospice care. For one resident, the facility’s records showed hospice RN visits were scheduled on specific dates in May, but the resident was actually visited on different dates, and the resident’s medical record did not contain the hospice RN progress notes for those visits. The resident’s history and physical stated the resident had no capacity to understand and make decisions, and the resident had been admitted to Hospice A under a physician’s order. For that same resident, the hospice plan of care was not incorporated into the facility care plan. The hospice medication list in the record included medications such as acetaminophen, Dulcolax, ipratropium-albuterol, morphine sulfate, senna-tabs, Zofran, oxygen, cholecalciferol, and mirtazapine, but the list did not show medication dosages. The facility’s order summary did not show active physician orders for morphine or oxygen, and the record did not show that Hospice A was notified or consulted before the facility discontinued those orders. For the second resident, hospice services had been discontinued by physician order because hospice care was no longer appropriate, but the hospice flow sheet showed a CHHA visit occurred after hospice discharge. During interview, facility staff verified hospice services had ended and confirmed the post-discharge hospice visit was documented in the record.
Infection Control Failures in Laundry, Fountain Monitoring, Surveillance, and Hand Hygiene
Penalty
Summary
The facility failed to maintain infection control practices related to the processing of soiled laundry. During a laundry area inspection, one industrial washer and dryer were observed with four buckets of laundry solutions feeding into the washer. The Maintenance Supervisor stated the washer used both high-temperature and low-temperature cycles with chemicals to disinfect soiled laundry, and Housekeeping/Laundry Staff 1 stated washer setting seven was the only setting that used bleach and was for heavily soiled laundry and items with infectious waste such as C. difficile. The temperature gauge behind the washer was not functional, the water-heater in the laundry area was unplugged, and the water-heater in a closet outside the laundry room was set to 150 degrees F with the pipe temperature at 145 degrees F. The Administrator stated he researched the laundry products and was unable to find that any of the products being used, other than bleach, were disinfectants. The facility also failed to ensure the decorative fountain was monitored and maintained to minimize the growth and spread of waterborne pathogens and other contaminants. The facility’s Legionella policy identified the decorative fountain as an area where Legionella and other opportunistic waterborne pathogens could grow and spread, and the water management binder showed a weekly log for adding Trichloro-s-triazinetrione tablets and documenting whether the fountain was emptied and free of debris and bacterial growth. The log did not show that fountain water was tested to ensure appropriate chemical levels were reached. The Administrator stated the Maintenance Supervisor tested the fountain weekly but did not document it on the log. During observation, the Maintenance Supervisor stated he put in half a tablet over the weekend and a partially dissolved tablet was seen in the fountain. The tablet container label directed use of two eight-ounce tablets per 10,000 gallons of pool water every week and to ensure a free available chlorine level of 1 to 4 ppm. The Maintenance Supervisor used test strips labeled for QAC, verified they were QAC strips, and the test result showed zero ppm of QAC. The facility also maintained inaccurate infection surveillance for a resident who received gentamicin drops and Levaquin for a right ear infection. The Infection Surveillance Data Collection Form dated 2/11/26 showed the resident was started on gentamicin sulfate ophthalmic solution 0.3% drops for a right ear infection and Levaquin 500 mg by mouth daily for seven days. The form originally listed the antibiotic as prophylaxis for an ear infection, then changed it to treatment. The form stated the resident’s symptoms met three of four required criteria and therefore did not meet criteria for an infection, and the medical record did not show additional symptoms to determine whether true infection criteria were met. The IP/DSD reviewed the form and the medical record and verified the resident’s symptoms did not meet criteria for a true infection, and that the incorrect data was reported to the QA committee. The facility also failed to ensure staff offered hand hygiene to residents before meal service. During a dining observation, CNAs were seen passing meal trays to residents in the dining room while residents waited for lunch. CNAs 1, 3, and 4 were not observed offering hand hygiene to residents before meal trays were served. Resident 2 stated staff did not offer hand hygiene right before lunch. CNA 1 stated he did not offer hand hygiene and was unsure whether it had been offered by anyone else. CNA 3 stated he did not offer hand hygiene and did not see any other staff offering it before the meal was served. CNA 4 stated she did not offer hand hygiene before passing meal trays or before feeding residents. The IP/DSD acknowledged that staff should have offered hand hygiene to residents right before the meal was served.
Room A Environment Not Maintained in Clean and Functional Condition
Penalty
Summary
The facility failed to maintain a clean and functional environment in Room A. During observation inside the room, three ceiling air vents were noted to have black substances surrounding the vent surfaces, a tile in the shared restroom for Room A was lifted, and two cabinets used for residents' clothing were missing knobs. During a concurrent interview, the Maintenance Supervisor verified these findings and stated that no log was kept to document when the ceiling vents in Room A were last cleaned.
Psychotropic Medication Monitoring Not Properly Documented
Penalty
Summary
The facility failed to ensure two sampled residents were monitored appropriately for psychotropic medication use. For one resident, the record showed orders to monitor blood pressure while lying down and while sitting for orthostatic hypotension every week after starting risperidone for schizoaffective disorder. The facility’s policy required blood pressure to be obtained in both positions and to document any refusal, the reason, and the intervention taken, with physician notification if refusal continued. For that resident, the MAR documented identical blood pressure readings in the lying and seated positions on three separate weekly checks. During interview, an LVN stated the resident refused the monitoring and that the nurse did not want to leave the MAR blank, but the medical record did not show the refusal. The LVN also stated the physician was not notified of the refusal. An RN stated orthostatic monitoring was intended to check for adverse reactions from the antipsychotic medication and that refusal should be addressed and reported if it continued. For the second resident, the MAR showed sertraline for major depressive disorder and divalproex for major depressive disorder, with behavior monitoring tied to documented manifestations. However, the manifestations being monitored did not match the behaviors documented in the resident’s record. Staff interviews identified the monitored behaviors as statements that nobody helped with pain management and feeling life was stuck, while the charted manifestations were "overly concerned with health" and "negative view of himself." The resident was also observed talking to himself, sleeping in bed, and sitting in bed eating breakfast during the survey.
Failure to Provide Written Transfer and Bed-Hold Notices
Penalty
Summary
The facility failed to provide written notification to Resident 38 and/or the resident's representative of the transfer, the reason for the transfer, and the facility's bed hold policy when the resident was transferred to the acute care hospital. Resident 38 was admitted to the facility with no capacity to understand and make decisions, and the medical record showed an order on 5/13/26 to send the resident to the acute care hospital for GT replacement. A progress note documented that the resident was sent to the hospital that morning. The closed record review showed a Notice of Transfer/Discharge dated 5/13/26 that listed the acute care hospital as the transfer location and stated the reason for transfer was for the resident's welfare and because the resident's needs could not be met in the facility. However, the signature line for the resident or resident's representative was blank, and the medical record did not show that the written notice was provided. The facility's policy stated that the resident or resident representative is to be notified in writing of impending transfer or discharge and the reason for the move, and that a copy of the notice is sent to the State Long Term Care Ombudsman. The facility also did not show that Resident 38 or the resident's representative was notified in writing of the bed hold policy at the time of transfer. The facility's bed hold policy required written information about bed-hold rights to be provided in advance and again at the time of transfer, or within 24 hours for an emergency transfer, and documentation of multiple attempts if the representative could not be reached. The IP/DSD and the Social Services/Activity Director both verified they could not locate documentation showing the Notice of Transfer/Discharge or the bed-hold policy was mailed or sent to the resident or representative when the resident was transferred.
Care Plan Not Updated for Nail Trimming Related to Nose Lesion Picking
Penalty
Summary
The facility failed to revise Resident 20’s comprehensive plan of care to reflect her current care needs and interventions related to a basal cell carcinoma lesion on the left side of her nose. The resident’s care plan, revised 7/11/25, identified the nose lesion and documented episodes of the resident picking at the area, with interventions to educate her not to pick or scratch her nose and to explain risk benefits, but it did not include regular trimming of her fingernails. During observation, Resident 20 was seen with a dark red wound on the bridge of her nose and long fingernails on both hands. CNA 1 stated the resident had a history of skin cancer and frequently picked at the wound, which tended to bleed. LVN 2 later observed the resident with pointy fingernails on the right hand and brown-colored residue, measured the nails, and stated that because of the resident’s habit of picking at the nasal wound, her fingernails should have been trimmed regularly and that nail trimming should have been included in the care plan. Resident 20’s record also showed memory problems, moderately impaired cognitive skills for daily decision making, dependence on staff for ADLs, and an H&P stating she had no capacity to understand and make decisions.
Failure to Follow Orders and Provide Ordered Skin and Supportive Care
Penalty
Summary
The facility failed to provide treatment and care according to orders, resident preferences, and goals for Resident 20 and Resident 7. Resident 20 had diagnoses including basal cell carcinoma of the skin of the nose and was dependent on staff for activities of daily living. During observation, she was lying on a stretcher with a dark red wound on the bridge of her nose and long fingernails on both hands. Staff stated she had a habit of picking at the wound, which tended to bleed. On assessment, her fingernails were measured and the right hand nails were pointy; staff acknowledged that her fingernails should have been trimmed regularly because the pointy nails could continue trauma to the wound site and delay healing. Resident 7 was observed in bed wearing bilateral heel protectors and bilateral hand rolls, but the medical record did not contain physician orders for either device and the care plan did not address their use. Staff observed the devices in use during multiple encounters, and one RN stated she was unaware the heel protectors and hand rolls were being applied. The RN verified that any device applied to a resident should have a physician's order and be included in the care plan, and confirmed the record contained no orders or care plan for the heel protectors or hand rolls.
GT Care Not Properly Performed
Penalty
Summary
Appropriate care and services were not provided for a resident with a GT. Resident 27 was readmitted to the facility and had diagnoses including status post GT placement; the H&P dated 4/18/26 also stated the resident had no capacity to understand and make decisions. During a medication administration observation on 6/2/26 at 1615 hours, LVN 1 was observed administering medications via the resident’s GT when the GT tubing fell to the floor. LVN 1 picked the tubing up from the floor and placed it back onto the resident’s GT pole. After the medication administration, LVN 1 placed the syringe used to administer medications into a plastic bag without cleaning it and left the resident’s room. When asked about the tubing falling to the floor, LVN 1 stated he would change the cap of the tubing. On 6/5/26 at 1233 hours, LVN 1 verified these findings during a telephone interview.
Medication Disposal, Controlled Substance Access, Enteral Storage, and Stool Softener Administration
Penalty
Summary
The facility failed to provide necessary pharmaceutical services to ensure accurate medication administration and proper control of stored medications. During an inspection of the medication storage room, three unknown pills were observed sitting on the edge of the medication disposal container, and RN 1 verified they had not been disposed of properly. During inspection of the narcotic destruction storage area, the IP was observed retrieving a key to the narcotic destruction cabinet from a personal purse in an open office. RN 1 stated that she, the IP, and the Administrator each had a key to the cabinet, which contained bubble packs of medications including Keflex, hydrocodone-acetaminophen, clonazepam, and morphine. RN 1 stated the Administrator had a key in case the cabinet needed to be opened when she or the IP were not in the facility. The facility also stored enteral feeding products without a thermometer or temperature log in the closet where Jevity and nutritional supplements were kept, even though the products were labeled for storage in a cool, dry place and to avoid excessive heat. In addition, Resident 27, who had no capacity to understand or make decisions, was ordered docusate sodium 100 mg, two tablets twice daily, with instructions to hold the medication when the resident had loose stools. Review of the resident’s CNA bowel documentation showed 19 loose bowel movements in April 2026 and 17 loose bowel movements in May 2026, yet the MAR showed the docusate sodium was not held when the resident had loose stools. LVN 1 stated the CNAs were not reporting when the resident had loose stools, and RN 1 acknowledged the findings.
Inaccurate POLST and MDS Coding in Resident Record
Penalty
Summary
Resident 28’s medical record was inaccurate in multiple areas. The resident’s POLST showed Family Member 1 as the Health Care Agent, but the record did not contain an Advance Directive naming a Health Care Agent. Instead, the document filed behind the POLST was a Durable Power of Attorney for Financial Management, which did not designate a Health Care Agent. That document only included a nomination of Family Member 1 to be considered by a court as guardian or conservator if one were appointed, and the record did not contain any court documents showing a guardian or conservator had been appointed. During interview and record review, the SS/AD acknowledged the DPOA was for financial matters only and verified the POLST was incorrect. Resident 28 also had inaccurate MDS coding related to hospice services. The physician’s orders showed hospice services were discontinued, but the facility did not complete a comprehensive Significant Change MDS or a comprehensive Annual MDS within 14 days after hospice was discontinued. In addition, a later MDS assessment incorrectly indicated the resident had received hospice care within the prior 14 days, even though hospice had already been discontinued. The IP/DSD and QA Nurse reviewed the record and verified hospice services had ended and that the required comprehensive MDS assessment had not been completed within the expected timeframe.
Antibiotic Stewardship Not Followed for Ear Infection
Penalty
Summary
The facility failed to implement its antibiotic stewardship program for one resident who received gentamicin drops and Levaquin for a right ear infection. Review of the Monthly Antibiotic Log for February 2026 showed the resident received both antibiotics for a HAI. The resident’s Infection Surveillance Data Collection Form dated 2/11/26 documented gentamicin sulfate ophthalmic solution 0.3% drops for a right ear infection, with the original notation of prophylaxis crossed out and changed to treatment, and Levaquin 500 mg by mouth daily for seven days for the same infection. The surveillance form showed the resident’s symptoms met three of four required criteria and therefore did not meet infection criteria. Medical record review did not show additional symptoms to support that a true infection criteria was met. During an interview and concurrent record review on 6/4/26, the IP/DSD stated the resident received antibiotics for a right ear infection that met criteria, but after reviewing the surveillance form and medical record, verified the resident’s symptoms did not meet criteria and that the physician was not notified to reassess the need for continued antibiotic therapy.
Improper Maintenance and Cleaning of Wrist BP Machine
Penalty
Summary
The facility failed to ensure a resident care device was maintained in a safe operating condition when an LVN was observed using a Velcro wrist blood pressure machine during medication administration. The device was used on multiple residents, but the LVN stated the manual was not kept in the medication cart, and the machine was cleaned with Clorox wipes rather than according to the manufacturer's instruction to clean it with a soft dry cloth. The manufacturer's instructions also stated the device was to be serviced by the manufacturer, but the RN stated that if the machine malfunctioned, a new machine would be purchased. The RN further stated staff were trained using a BP tower and verified there was no documented evidence that staff were trained on the proper use, cleaning, or maintenance of the wrist Velcro blood pressure machine used on multiple residents.
Incomplete Medical Record Documentation for Resident with Change in Condition
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for one resident, as required by its own policies and accepted professional standards. Specifically, the Elopement Evaluation form for the resident, dated 5/2/25, was found to have several sections left blank, including those addressing the pattern and impact of wandering behavior, risk identification, goals, interventions, and clinical suggestions. This incomplete documentation was confirmed during a review of the closed medical record with the Director of Nursing (DON), who acknowledged that the form should have been fully completed. Additionally, the resident experienced a change in condition, including agitation, physical aggression, striking out at staff, and attempts to leave the facility, as documented on the eINTERACT tool. However, there was no documentation in the medical record indicating that the resident was monitored for this change in condition during the 0700-1500 hours shift on 5/3/25. The DON verified that the required progress note for monitoring during this period was missing. The facility administrator also acknowledged these findings.
Failure to Document and Assess Skin During AFO Application for Resident with Limited ROM
Penalty
Summary
The facility failed to provide appropriate care to maintain or improve range of motion (ROM) for a resident with contractures in both lower extremities. Despite a physician's order for the application of bilateral ankle-foot orthoses (AFOs) for four hours daily, five times a week, the order was not consistently followed. Documentation was lacking regarding the exact times the AFOs were applied and removed, and there was no evidence that skin assessments were performed or recorded when the AFOs were in use. The resident's care plan addressed the use of AFOs to prevent decline in ROM, but did not include interventions for skin assessment during device application. Interviews with restorative nursing assistants (RNAs), a licensed vocational nurse (LVN), and an occupational therapist (OT) confirmed that while the AFOs were applied, there was no documentation of the timing or skin assessments. The facility's policy on restorative nursing care emphasized maintaining good body alignment and proper positioning, but did not specify skin assessment procedures. The director of nursing (DON) verified the findings, confirming the lack of documentation and absence of skin assessment protocols related to the use of AFOs for the resident.
Failure to Implement Fall Prevention Intervention as Ordered
Penalty
Summary
The facility failed to implement a physician's order to place a floor mat on the left side of a resident's bed, as part of fall prevention interventions. During an initial tour, the resident was observed in bed with the bed in the lowest position, but no floor mat was present on the left side. The resident's care plan, physician's order, and facility policy all indicated the need for a floor mat due to the resident's high risk for falls and tendency to lean to the left. The resident had severe cognitive impairment and was unable to make decisions, further emphasizing the need for adherence to safety interventions. Interviews with facility staff, including an LVN and the DON, confirmed awareness of the physician's order and the absence of the floor mat at the time of observation. The LVN acknowledged that the floor mat should have been in place for safety reasons, and the DON verified the findings. The failure to follow the prescribed intervention constituted a deficiency in providing necessary care and services to prevent accidents.
Failure to Provide Safe and Appropriate Oxygen Therapy
Penalty
Summary
The facility failed to provide necessary and appropriate respiratory care and services for three residents who were receiving oxygen therapy. Observations revealed that the nasal cannula oxygen tubing for all three residents was touching the floor, which was confirmed by staff during interviews. Additionally, for two of the residents, the facility did not follow the physician's orders regarding the prescribed oxygen flow rates. Specifically, one resident was observed receiving oxygen at a rate different from the physician's order, and another resident's oxygen therapy was not administered as ordered for their respiratory condition. Medical record reviews indicated that the affected residents had care plans and physician orders specifying the need for continuous oxygen therapy due to conditions such as oxygen desaturation and respiratory acidosis. The care plans also included interventions to administer oxygen as ordered and to monitor oxygen saturation levels. Despite these documented needs and orders, the facility did not ensure that the oxygen therapy was provided according to the physician's instructions, nor did it maintain the cleanliness and safety of the oxygen delivery equipment as required by facility policy.
Failure to Document Insulin Injection Sites and Crush Medications Without Physician Order
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for two residents by not ensuring proper medication administration and documentation. For one resident with moderate cognitive impairment and diabetes, the facility did not document the injection sites for multiple insulin orders, including Lantus Solostar and Novolog Flexpen, as required by facility policy. The Medication Administration Record (MAR) for the month reviewed did not show any documentation of injection sites for these insulin medications, and both the Director of Nursing (DON) and a registered nurse confirmed the absence of this documentation. The facility's policy required recording the injection site for medications administered by injection, but this was not followed. In a separate incident, another resident with moderate cognitive impairment was observed receiving crushed oral medications without a physician's order to do so. During a medication administration observation, a licensed vocational nurse (LVN) crushed and administered several oral medications to the resident, despite the resident's medical record lacking any physician's order permitting the medications to be crushed. The LVN confirmed that the medications were crushed based on the resident's preference, not on a physician's directive. The DON and the pharmacy consultant both acknowledged that crushing medications should require a physician's order, but this was not obtained in this case. These failures were identified through observation, interviews, and review of medical records and facility policies. The lack of documentation for insulin injection sites and the administration of crushed medications without a physician's order were both contrary to the facility's established policies and procedures, as well as standard pharmaceutical practices.
Medication Storage and Security Deficiencies
Penalty
Summary
Surveyors identified multiple failures in the facility's medication management practices. Medication Storage Room A was found to contain personal items such as a staff member's sweater, desk fans, a resident's box of candies, and a large stuffed toy, all stored alongside medication supplies. An opened diaper package was found near the sink, and both oral and external medications, such as bisacodyl suppositories and saline enema laxatives, were stored together with oral medications. In the medication refrigerator, latanoprost ophthalmic medication was stored with Tubersol injectable solution, and a collection of clear liquid was observed in the freezer basin. These findings were acknowledged and verified by the Director of Staff Development (DSD). Further inspection of Medication Carts A and B revealed additional issues. Medication Cart B was found unlocked and unattended, and contained items with dried residues, such as forceps and wound skin cleanser, as well as unsealed gauze sponges and a bottle of baby powder with dried residue. Medication Cart A contained both oral and external medications stored together, an opened bottle of latanoprost ophthalmic solution without an opened date, and discontinued medications stored in the narcotic locked drawer. The DSD and Director of Nursing (DON) confirmed these findings, which were not in accordance with the facility's policies for medication storage, labeling, and disposal.
Sanitation Deficiencies in Kitchen Utensil Cleaning and Hood Maintenance
Penalty
Summary
Surveyors identified multiple sanitation deficiencies in the facility's kitchen during an inspection. Observations revealed that kitchen utensils, including stainless steel scoops and measuring cups used for food portioning, were not properly cleaned and contained dry, crusted food residue, white residue, and watermarks. Additionally, some utensils and measuring cups were found stored while still wet, indicating they had not been air dried as required by facility policy and USDA Food Code standards. The Dietary Services Supervisor (DSS) confirmed these findings and acknowledged that the utensils should have been rewashed and air dried before storage. Further inspection of the kitchen revealed that the hood over the stove was not maintained in a sanitary condition, as it was observed with black, dirt residue. The DSS stated that the hood was supposed to be cleaned twice a week by dietary staff and serviced by an outside company, but acknowledged that grease residue should not be present due to the risk of contamination and fire hazard. These deficiencies were found in a kitchen that prepared food for the majority of the facility's residents, as indicated by the Diet Type Report.
Facility Assessment Lacks Required Involvement and Staffing Plans
Penalty
Summary
The facility failed to ensure that its Facility Assessment was developed with the active involvement of required individuals, including direct care staff, direct care representatives, residents, residents' representatives, and family members. Review of the Facility Assessment did not show evidence of participation from these groups in the assessment process. Additionally, the assessment did not address the resources necessary to care for residents during weekends or include a plan to maximize recruitment and retention of direct care staff. Furthermore, the Facility Assessment lacked a contingency plan for staffing needs, which is required to ensure adequate staffing during both routine operations and emergencies without activating the facility's emergency plan. During an interview and document review, the Administrator confirmed that the Facility Assessment was not updated to reflect the latest CMS guidance and acknowledged the absence of required involvement and planning elements.
Infection Control Deficiencies in Documentation, Linen Handling, and Hand Hygiene
Penalty
Summary
The facility failed to implement effective infection prevention and control practices as evidenced by multiple deficiencies in documentation, environmental services, linen handling, and hand hygiene. Review of the facility's monthly Infection Prevention and Control Surveillance Logs revealed discrepancies between the surveillance logs and the monthly summary reports for several months, resulting in inaccurate reporting of healthcare-associated infections (HAIs) and community-acquired infections (CAIs). The Infection Preventionist (IP) confirmed that the numbers reported did not match and acknowledged the inaccuracy of the infection data, which is used for tracking and trending infections within the facility. In the laundry area, personal items such as a tumbler cup, bottled water, and lotion were found stored on a clean linen cart, contrary to facility policy requiring clean linens to be protected from environmental contamination. Staff members were observed mishandling clean linens by holding them against their bodies while delivering them to residents' rooms, which was acknowledged by the staff as improper practice. These actions were verified by the Maintenance Supervisor, Director of Nursing (DON), and IP as not compliant with infection control policies. Additionally, a hospice aide was observed providing care to a resident with significant cognitive impairment without performing appropriate hand hygiene. After handling soiled linens with gloved hands, the aide failed to change gloves and perform hand hygiene before touching the resident. The DON confirmed that both facility and hospice staff are required to perform hand hygiene before and after resident care, and acknowledged the failure to follow this protocol.
Inaccurate Bed Entrapment Assessments for Residents Using Side Rails
Penalty
Summary
The facility failed to ensure that entrapment assessments for bed systems were accurate and complete for several residents who used side rails. Specifically, for four residents reviewed, there were discrepancies and inaccuracies in the measurements and zone assessments for bed entrapment risks. The facility's own policies required regular inspection and assessment of bed frames, mattresses, and side rails, including the evaluation of specific entrapment zones as outlined by FDA guidance. However, the assessments documented in the residents' records did not match the actual measurements and findings when re-assessed by staff using the appropriate measurement device. For one resident, the initial entrapment assessment indicated that several zones failed, but a subsequent assessment revealed different measurements and additional failed zones, indicating the original documentation was inaccurate. Another resident's assessment form was incomplete, with critical sections left unmarked, and the zone assessments did not match the findings from a later, more accurate measurement. In both cases, the staff acknowledged that the original assessments were not accurate compared to the re-assessments conducted during the survey. Similar discrepancies were found for two other residents, where the bed inspection measurements and entrapment assessments on file did not align with the actual measurements taken during the survey. In some cases, the beds were measured using a similar bed rather than the actual bed in use, and the results showed differences in mattress length and zone pass/fail status. These failures to accurately assess and document bed system safety had the potential to negatively impact residents by increasing the risk of entrapment.
Failure to Update Care Plan for Suprapubic Catheter Change
Penalty
Summary
The facility failed to ensure that a resident's comprehensive care plan was revised to accurately reflect the current size of the resident's suprapubic indwelling urinary catheter. The resident had a new catheter of size 18 French inserted on 2/7/25, as documented in the urology procedure report. However, the care plan continued to reference previous catheter sizes and did not include the updated information regarding the new catheter size. During interviews and medical record reviews, facility staff, including an RN, the Administrator, and the DON, acknowledged that the care plan had not been updated to reflect the resident's current catheter size. The facility's policy requires ongoing assessment and revision of care plans as resident information and conditions change, but this was not followed in this instance.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post daily nurse staffing information in a location accessible to residents, staff, and visitors. During an inspection of the nursing station and facility bulletin board, the Director of Nursing (DON) confirmed that the daily nurse staffing record was kept in a binder at the nursing station and was not posted for public viewing. The DON was unsure of the correct location for posting this information.
Improper Storage of Garbage in Dumpster
Penalty
Summary
The facility failed to ensure proper storage of garbage in its outside dumpster, as observed during a survey. The dumpster lid was found partially propped open by garbage bags, preventing it from fully closing. This observation was confirmed by the Maintenance Supervisor, who acknowledged that the lid should remain closed at all times. Facility policy requires daily inspection of garbage cans to ensure no debris is present around the area and that lids are closed, in accordance with the FDA Food Code, which mandates tight-fitting lids to prevent pest and rodent entry.
Incomplete Medical Record Documentation for Resident Treatment
Penalty
Summary
The facility failed to maintain an accurate and complete medical record for one resident, as evidenced by missing documentation in the Treatment Administration Record (TAR) for April 2025. Specifically, the TAR lacked entries from licensed nurses for the application of ciclopirox external cream and wound care on two dates, as well as for the application of econazole nitrate external cream on one date. These omissions were identified during a review of the resident's physician's orders, which included specific instructions for topical antifungal treatments to the fingernails due to a fungal infection. During an interview and concurrent medical record review, the Director of Nursing (DON) confirmed the missing documentation and stated that if a licensed nurse did not document a treatment, it was considered not completed. The DON also acknowledged that she was responsible for weekly audits of the Medication Administration Record (MAR) and TAR, as the facility did not have a Medical Record Director or dedicated medical records staff. The facility's policy required objective, complete, and accurate documentation of all treatments and services performed, which was not met in this instance.
Room Exceeds Maximum Resident Occupancy
Penalty
Summary
During an initial tour of Room A, surveyors observed that the room contained five beds, each occupied by a resident, resulting in five residents sharing a single room. The facility administrator confirmed the presence of five residents in Room A and acknowledged that the room did not meet the required square footage for that number of occupants. The administrator also indicated the facility's intention to continue with a room variance waiver for this room. This situation was identified as a failure to comply with regulations limiting the number of residents per room, as Room A exceeded the maximum occupancy allowed.
Insufficient Square Footage Provided in Multi-Resident Room
Penalty
Summary
Room A was observed to be a five-bed room occupied by five residents, with a total area of 392 square feet. This configuration resulted in each resident having 78.4 square feet of space, which is below the required minimum of 80 square feet per resident for multiple occupancy rooms. During an interview, the Administrator confirmed the room's measurements and acknowledged that the space per resident did not meet regulatory requirements. The deficiency was identified during an initial tour and confirmed through direct observation and staff interview.
Failure to Implement Updated Infection Control Guidelines
Penalty
Summary
The facility failed to ensure that the Infection Preventionist (IP) was knowledgeable about the updated CDC guidelines for pneumococcal immunization and the implementation of enhanced barrier precautions. The IP was unaware of the current CDC recommendations for the use of PCV 15 or 20 vaccines and continued to administer only PPSV 23 to residents. This lack of awareness and adherence to updated guidelines was confirmed during an interview and document review with the IP, who admitted to not tracking the type of vaccine needed based on the new guidelines. Additionally, the IP did not implement enhanced barrier precautions for residents with conditions that required such measures, such as chronic wounds or indwelling medical devices, as per the new CMS guidelines effective April 1, 2024. Resident 22, who was readmitted to the facility with a Stage 4 pressure ulcer and an infected left hip surgical wound, was not placed on enhanced barrier precautions. During a wound treatment observation, it was noted that there was no signage or isolation cart with gloves and gowns outside the resident's room, and staff were not performing the necessary hand hygiene or donning gloves and gowns. The IP confirmed that Resident 22 should have been placed on enhanced barrier precautions due to the severity of the wounds but admitted that no residents in the facility were on such precautions. Further interviews with the Director of Nursing (DON) and the Administrator revealed that the facility had residents with indwelling urinary catheters and gastrostomy tubes who were also not placed on enhanced barrier precautions. The DON relied on the IP for current infection control guidelines and was not informed about the new CMS guidelines for enhanced barrier precautions. The Administrator expected the IP to report any new infection prevention and control updates during the quarterly assurance meetings but was unaware that the enhanced barrier precautions were not being implemented for appropriate residents in the facility.
Failure to Offer Updated Pneumococcal Vaccines
Penalty
Summary
The facility failed to offer PCV 15/PCV 20 immunizations to 20 nonsampled residents in accordance with the CDC's updated recommendations. The facility's policies and procedures were outdated, only offering PPSV 23, and did not include the newer PCV 15 or PCV 20 vaccines. This failure was identified through interviews, medical record reviews, and facility document reviews, which showed that residents were not offered the updated vaccines, increasing their risk of being inadequately vaccinated for pneumococcal disease and its associated complications. The medical records of several residents, including Residents 1, 3, 4, 5, 6, 8, 13, 16, 18, 19, 21, 23, 24, 25, 29, 30, 31, and 33, were reviewed and found to lack documentation of being offered PCV 15 or PCV 20 after receiving PPSV 23. The facility's Infection Preventionist (IP) admitted to only offering PPSV 23 due to a lack of awareness of the updated CDC guidelines and the absence of a tracking system for pneumococcal vaccine history. The facility's consent forms and immunization records did not specify the type of pneumococcal vaccine administered, further complicating the tracking and compliance with updated guidelines. Interviews with the IP and the Director of Nursing (DON) confirmed that the facility did not have a system in place to track the specific types of pneumococcal vaccines administered to residents. The IP acknowledged the oversight and the need to update the facility's policies and procedures to align with the CDC's current recommendations. The lack of proper documentation and tracking led to residents not being offered the appropriate vaccines, as per the updated guidelines, thereby failing to ensure their pneumococcal immunization was current and complete.
Failure to Notify Residents of Bed Hold Policy
Penalty
Summary
The facility failed to notify five residents (Residents 10, 22, 32, 35, and 38) or their representatives in writing about their rights to a bed hold policy upon transfer to an acute care hospital. This deficiency was identified through interviews, medical record reviews, and a review of the facility's policies and procedures. The facility's policy, revised in March 2017, mandates that residents or their representatives be informed in writing about the bed hold policy prior to any transfer or therapeutic leave. However, the facility did not adhere to this policy for the residents reviewed, potentially leaving them unaware of their rights to request a bed hold upon transfer. For Resident 10, there was no documented evidence in the General Nurses' Notes for January 2024 that the resident or their representative was provided with information about the bed hold policy upon transfer to Hospital A. Similarly, Resident 22's records for January and March 2024 lacked documentation of bed hold policy notification. The MDS Nurse confirmed these findings during an interview. Resident 35's records for December 2023 and February 2024 also did not show evidence of bed hold policy notification, which was verified by the MDS Nurse and the DON. Resident 32's records indicated a transfer to an acute care hospital on January 17, 2024, but there was no documentation that the resident or their representative was informed about the bed hold policy. This was confirmed by RN 1 and the SSD. Lastly, Resident 38, who was transferred to an acute care hospital on March 26, 2024, also did not receive written notification about the bed hold policy, as verified by the Business Office Manager and the DON. The facility lacked a specific bed hold notification form, relying only on a notice of transfer or discharge form, which did not fulfill the requirement for informing residents or their representatives about the bed hold policy.
Inaccurate MDS Assessments for Pneumococcal Vaccination Status
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessments for 11 of 17 reviewed residents were accurate, specifically regarding the residents' pneumococcal vaccination status. This deficiency was identified through interviews and medical record reviews, revealing that the MDSs inaccurately indicated that residents were up to date with their pneumococcal vaccinations. For instance, Resident 21's MDS was marked as up to date despite not being offered the Pneumococcal Conjugate Vaccine 20 (PCV 20) as required by current guidelines. Similarly, Resident 25's vaccination history was incorrectly documented, and the resident was not offered the appropriate vaccine to be considered up to date. Further investigation showed that several residents, including Residents 3, 16, 19, 23, and 27, had discrepancies in their immunization records. These residents either did not receive the updated pneumococcal vaccines or their records did not accurately reflect the type of vaccine administered. For example, Resident 3's records showed a pneumococcal vaccine was administered in 2020, but it was not clear if the resident was offered the updated PCV 20 or PCV 15 followed by PPSV 23 until much later. Resident 27's records lacked follow-up on vaccination status, and the resident was not offered the pneumococcal vaccine in the facility. Additionally, Residents 15, 18, 31, and 33 had inaccuracies in their MDS documentation regarding their pneumococcal vaccination status. Resident 15's MDS indicated the vaccine was offered and declined, but there was no documented evidence of education or consent. Residents 18, 31, and 33 had their MDSs marked as up to date despite incomplete or unclear vaccination records. Interviews with the Infection Preventionist (IP), Director of Nursing (DON), and MDS Coordinator confirmed these findings, indicating a lack of adherence to updated CDC guidelines and proper documentation practices.
Failure to Follow Physician's Orders and Collaborate with Hospice Care
Penalty
Summary
The facility failed to ensure Resident 22's abduction pillow and bilateral heel protectors were in place while in bed per the physician's orders. Additionally, the facility did not ensure Resident 22 did not wear the left knee immobilizer while in bed, as per the physician's order. The facility also failed to provide other bowel management medication interventions as needed for Resident 22, who was at risk for constipation due to Norco medication. These deficiencies were verified through observations, interviews, and medical record reviews with the LVN and DON, who acknowledged the findings. The facility failed to ensure proper collaboration between the hospice care team and the facility for Residents 20 and 36. For Resident 20, there was no documented evidence that the hospice care team reviewed or acknowledged the resident's care plans. This was confirmed through an interview and medical record review with the IP, who stated that the hospice care team should be updated and informed of the resident's care plans to ensure agreement with the plan of care. For Resident 36, the facility did not ensure a hospice care member participated in the Quarterly IDT meeting. The medical record review showed no documented evidence that the hospice care team was aware of or had signed the updated care plans. The IP verified these findings and stated that the hospice care team should be part of the IDT meeting and review care plans to ensure agreement with the resident's plan of care. The DON also acknowledged that the hospice staff did not sign the care plans or have documented evidence of reviewing them for Residents 20 and 36.
Food Safety and Sanitary Deficiencies in Kitchen
Penalty
Summary
The facility failed to ensure food safety and sanitary requirements were met in the kitchen, leading to multiple deficiencies. Observations revealed that cutting boards and kitchen equipment were in unsanitary conditions, with cutting boards heavily marred and kitchen utensils such as a frying pan, slotted spoon, ice cream scooper, and lime squeezer found with encrusted grease, melted handles, and dried food particles. Additionally, food items were not discarded by their best-by dates, and temperatures of food items were not checked prior to preparation or distribution, with shredded cheddar cheese and fresh green salad found within the danger zone for bacterial growth. Personal belongings were also improperly stored in the kitchen's clean utility room, posing a risk of cross-contamination and infection control issues. Furthermore, kitchen staff failed to maintain proper hand hygiene, as observed when the DSS did not wash hands between sanitizing a preparation table and handling food. Food was also transported uncovered through an outdoor dry storage room, increasing the risk of contamination. Lastly, a resident did not receive the correct diet texture as ordered, with a meal ticket indicating a regular NAS diet but the plate containing mechanical soft turkey. These failures had the potential to cause foodborne illnesses to the medically vulnerable resident population who consumed food prepared in the kitchen.
Failure to Implement Enhanced Barrier Precautions and Proper Infection Control Practices
Penalty
Summary
The facility failed to ensure Enhanced Barrier Precautions (EBP) were practiced for residents with indwelling urinary catheters and gastrostomy tubes (GT). Multiple residents were observed with these medical devices, but there was no evidence of EBP signage or personal protective equipment (PPE) availability in their rooms. Interviews with staff confirmed that EBP was not being observed, and the Infection Preventionist (IP) acknowledged the need for EBP to protect against transmission-based infections. The Director of Nursing (DON) also confirmed the lack of EBP practices in the facility, despite being aware of the requirements for residents with indwelling medical devices and wounds. The facility also failed to ensure proper hand hygiene practices were followed by staff. During a wound treatment observation, a Licensed Vocational Nurse (LVN) was seen changing gloves multiple times without performing hand hygiene in between. This was confirmed by the LVN and the IP, who stated that staff were expected to perform hand hygiene when changing gloves. Additionally, the resident with the wound was not placed on enhanced barrier precautions, which was verified by the IP and acknowledged as necessary due to the resident's condition. Furthermore, the facility did not ensure proper storage and labeling of medical equipment. An opened Yankauer suction tool was observed stored with miscellaneous items and without a label, which was confirmed by the IP as a potential source of infection. The DON acknowledged that the Yankauer suction should be stored separately and labeled with the date opened. Additionally, an LVN was observed administering medication through a GT without wearing a gown, which was against the enhanced barrier precautions required for residents with GTs. This was confirmed by the LVN and the DON, who admitted to misunderstanding the requirements for EBP.
Failure to Promote Dignity and Respect for Residents
Penalty
Summary
The facility failed to ensure the staff provided care and promoted dignity and respect for three residents. CNA 3 and CNA 2 were observed standing over Residents 8 and 35, respectively, while assisting them with meals, contrary to the facility's policy that requires staff to sit at eye level with residents during feeding. Both CNAs acknowledged that they were supposed to sit while feeding the residents. The Director of Staff Development (DSD) and the Director of Nursing (DON) were informed and acknowledged these findings. Additionally, the facility failed to ensure Resident 5's body was fully covered while being transported from the shower room to her room. CNA 4 was observed wheeling Resident 5 in a shower chair with a blanket that did not fully cover her left side, exposing her lower back, hip, and upper thigh. The Administrator confirmed the observation and acknowledged that the resident's dignity was compromised. Resident 5, who was cognitively intact, expressed feeling embarrassed upon learning about the exposure.
Failure to Inform Residents of Bed Side Rail Risks
Penalty
Summary
The facility failed to fully inform two residents or their responsible parties about the risks associated with the use of bed side rails, specifically regarding the entrapment assessment for Zone 6. Resident 9 had a bed that failed the Zone 6 measurement, indicating a potential risk for entrapment. Despite this, neither the resident nor their family was notified of the failed measurement. The resident was observed with a padded left side rail and was able to move their upper extremities. The facility's Administrator confirmed that there was no documented evidence that the resident or their family had been informed of the failed Zone 6 measurement. Similarly, Resident 32 was observed with bilateral half side rails elevated and stated that they did not use the side rails since admission. The resident's bed also failed the Zone 6 measurement, but there was no documentation showing that the resident was informed of this specific risk. The facility's Infection Preventionist (IP) and Administrator both confirmed that the bed inspection process was only conducted annually and that the resident was not specifically informed about the failed Zone 6 measurement. The facility's policies and procedures (P&P) require that residents be informed of their care and treatment options, including the risks and benefits of side rail use. However, in these cases, the facility did not adhere to its own P&P, resulting in a lack of informed consent for the use of side rails. Both the Director of Nursing (DON) and the Administrator acknowledged the findings, confirming that the residents were not fully informed about the specific risks associated with their bed side rails failing the Zone 6 entrapment assessment.
Failure to Ensure Call Light Accessibility
Penalty
Summary
The facility failed to ensure that Resident 37's call light was within reach, which is a violation of their policy and procedure. During an initial tour, the call light was observed on the floor on the right side of the resident's bed. This was confirmed by a CNA who admitted to not noticing the call light on the floor when raising the bed. The Director of Nursing (DON) stated that the expectation is for call lights to be answered within two minutes and always be within the resident's reach. Resident 37 was admitted to the facility with no capacity to understand and make decisions, as indicated in their health and physical examination. The resident's Minimum Data Set (MDS) showed that they required dependent assistance for rolling in bed and transferring from bed to chair, meaning the helper would do all the effort. This failure to provide reasonable accommodation had the potential to negatively impact the resident's psychosocial well-being or result in a delay in providing care and services.
Failure to Honor Resident's Food Preferences
Penalty
Summary
The facility failed to honor Resident 26's food preferences, which were clearly documented in both the resident's meal tray ticket and nutritional assessment. During a dining observation, Resident 26 was served white rice, despite his stated and documented preference against it. The resident confirmed that he had not eaten rice for two years and did not like it. This discrepancy was verified by the Social Services Director (SSD) during an observation and interview, where the untouched rice on Resident 26's plate was noted. The medical record review showed that Resident 26 had the capacity to understand and make decisions, and his food dislikes were well-documented, including rice. Despite this, the facility's staff failed to adhere to the resident's documented food preferences, as outlined in the facility's policies and procedures. The Director of Nursing (DON) was informed and acknowledged the findings, confirming the failure to comply with the resident's dietary choices.
Failure to Provide and Document Advance Directives
Penalty
Summary
The facility failed to inform and provide written information regarding the rights to formulate advance directives to Resident 35. Despite Resident 35 having the capacity to understand and make decisions, there was no documented evidence that the resident was offered or received information about formulating an advance directive. The Social Services Director (SSD) confirmed that there was no documentation to show that the information was provided to Resident 35 upon admission or at any later time. For Resident 10, the facility did not ensure that a copy of the advance directive was readily available in the resident's medical record. Although Resident 10 had an advance directive, the SSD kept the document in a separate binder in her office drawer, and it was not placed back in the resident's medical record after a hospital visit. The SSD acknowledged that the advance directive should have been accessible in the medical record. Similarly, Resident 12's medical record did not contain a copy of the advance directive, despite the resident's family member informing the SSD that one existed. The SSD failed to follow up with the family to obtain the document. The SSD confirmed that she did not verify if she had followed up to obtain the advance directive, and the Director of Nursing (DON) acknowledged these findings.
Failure to Provide Written Transfer Notification
Penalty
Summary
The facility failed to notify Resident 32 and/or their representative of the transfer to an acute care hospital in writing, as required by the facility's policy and procedure (P&P) on transfer or discharge notice. The P&P mandates a 30-day written notice for transfers or discharges, or as soon as practicable in urgent medical situations, including details such as the reason for transfer, effective date, location, and appeal rights. However, when Resident 32 was transferred from a medical appointment to an acute care hospital, the facility did not provide the required written notification to the resident or their representative. Resident 32, who had the capacity to understand and make decisions, was admitted to the facility and later transferred to the hospital. The facility contacted Resident 32 via cell phone to inquire about the status of the medical appointment, and the resident informed them of the hospital admission. Despite this, the facility did not follow through with the written notification process. Interviews with the Social Services Director (SSD) and the Director of Nursing (DON) confirmed the oversight, with the SSD acknowledging the failure to provide the necessary written notice.
Failure to Provide Baseline Care Plan Summary
Penalty
Summary
The facility failed to provide a summary of the baseline care plan for a newly admitted resident, identified as Resident 441. During an initial tour, Resident 441 mentioned that while the Social Services Director (SSD) discussed physical therapy for walking and returning home, there was no discussion or provision of a summary of her baseline care plan. A review of Resident 441's medical records confirmed that there was no documented evidence showing that she was informed or provided with a summary of her baseline care plan. The facility's policy requires that residents and their representatives be given a summary of the baseline care plan, which includes initial goals, medications, dietary instructions, services, treatments, and any updates to the comprehensive care plan. However, this was not adhered to in the case of Resident 441. Interviews with the Director of Staff Development (DSD) and the Director of Nursing (DON) revealed that the care plan should be completed within 24 hours of admission, and a care plan meeting should be conducted within 72 hours. The DON confirmed that the facility did not routinely provide copies of the summary baseline care plan to residents unless requested, although residents were informed of their care. The DON verified that there was no documentation to show that Resident 441 was provided with a copy of the summary baseline care plan, highlighting a lapse in the facility's adherence to its own policies and procedures.
Failure to Address Resident's Noncompliance with Physician's Order
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan to address the individual care needs of Resident 22. Despite a physician's order dated 3/19/24, requiring the application of a hip abduction pillow at all times while in bed, the care plan did not include a problem to address Resident 22's noncompliance with this order. Medical record reviews and observations revealed that Resident 22 had episodes of removing the abduction pillow, and this noncompliance was not documented in the care plan. The resident, who had the capacity to understand and make decisions, expressed her right to remove the pillow, leading to frequent visual checks by the staff to ensure her safety and comfort. During an observation on 4/3/24, the abduction pillow was found removed and placed at the side of Resident 22's bed. Both LVN 1 and the DON confirmed that the pillow should have been in place as per the physician's order. The DON acknowledged that Resident 22 had episodes of noncompliance and verified that there was no care plan problem addressing this issue. This oversight posed a risk of not providing appropriate, consistent, and individualized care to Resident 22.
Failure to Provide Individualized Activity Program
Penalty
Summary
The facility failed to provide an individualized and ongoing activity program to meet the needs and interests of Resident 11. Despite the facility's policy stating that activities should be based on a comprehensive resident-centered assessment and preferences, Resident 11 was observed multiple times lying awake in bed without any engagement or stimulation. Interviews with the resident's representative and a CNA confirmed that the facility did not provide activities for Resident 11, relying instead on the resident's family to provide music and turn on the television during visits. The medical record review showed that Resident 11 had severe cognitive impairment and required prompts and cues to participate in activities, yet the facility did not adhere to the care plan interventions, which included providing room visits and sensory stimulation three times a week. The Activity Attendance Record for March and April 2024 showed significant gaps in activity provision, with no activities recorded from April 1 to April 4, 2024, and inconsistent activity engagement throughout March 2024. The Activity Director and the DON both acknowledged the findings, verifying that Resident 11 was not provided with the necessary daily activities as identified in the activity assessment and care plan. This failure had the potential to cause Resident 11 to experience feelings of social isolation and frustration.
Deficiencies in Catheter Care and Adherence to Guidelines
Penalty
Summary
The facility failed to ensure that two residents with indwelling urinary catheters received the necessary care to prevent urinary tract infections (UTIs). For Resident 35, the facility did not document catheter care every shift as required. Observations showed that the resident's catheter tubing contained cloudy urine with white particles, and there was no standing order for catheter care every shift. Interviews with staff confirmed the lack of documentation and standing orders for catheter care, which was acknowledged by the Director of Nursing (DON). The resident's medical records also lacked evidence of consistent catheter care documentation, despite the care plan indicating it should be done every shift and as needed. For Resident 20, the facility did not follow the CDC's guidelines for catheter maintenance. The resident had a physician's order to change the Foley catheter bag weekly, which contradicts the CDC's recommendation to change catheters and drainage bags based on clinical indications rather than at fixed intervals. The Infection Preventionist (IP) and the DON confirmed that the weekly changes increased the risk of infection and acknowledged that the facility's policy should align with the CDC's guidelines. The resident's medical records showed that the catheter bag was changed weekly, as per the physician's order, but this practice was not in line with best practices for infection control. These deficiencies in catheter care and adherence to guidelines had the potential to put both residents at risk for UTIs. The facility's failure to document catheter care consistently and to follow evidence-based guidelines for catheter maintenance were significant lapses in ensuring the residents' health and safety. The DON and other staff members acknowledged these issues during interviews, highlighting the need for improved practices and adherence to established protocols.
Failure to Ensure Nutritional Needs Met
Penalty
Summary
The facility failed to ensure the nutritional needs of Resident 32 were met. During an observation, it was noted that Resident 32 consumed less than 50% of his meal tray, which included white bread with herbs, zesty lasagna, green beans, a banana, boost, chicken noodle soup, a cookie, grape juice, and water. The staff member (IP) responsible for removing the meal tray did not offer an alternative meal to Resident 32, despite verifying that the resident had eaten less than 50% of the meal. This oversight was confirmed during a follow-up interview with the IP, who acknowledged the failure to offer an alternative meal as required by the facility's protocol. Resident 32 had a history of weight fluctuations, as evidenced by the medical record review showing weights ranging from 168 lbs to 180 lbs over a few months. The resident was cognitively intact and had a physician's order for a regular diet with a large protein portion. Despite these directives, the failure to offer an alternative meal when the resident consumed less than 50% of the provided meal tray was a significant lapse in ensuring the resident's nutritional status. Both the DON and the RD confirmed that the staff should have offered an alternative meal to maintain the resident's nutritional health.
Failure to Ensure Proper Care for Residents with Gastrostomy Tubes
Penalty
Summary
The facility failed to ensure that three residents with gastrostomy tubes (GT) received appropriate care. Specifically, a Certified Nursing Assistant (CNA) was observed turning off a resident's GT feeding machine, which is outside the scope of practice for a CNA. The CNA admitted to turning the machine on and off to assist the charge nurse, despite knowing it was not within their scope of practice. Both the Director of Staff Development (DSD) and the Director of Nursing (DON) confirmed that only licensed nurses are authorized to operate the GT feeding machines. Additionally, the facility failed to label the GT tubing for three residents, which is necessary to ensure the tubing is changed daily. During an initial tour, it was observed that the GT tubing for these residents was not labeled. A Licensed Vocational Nurse (LVN) verified the absence of labels and acknowledged that the tubing should be labeled to ensure it is changed every 24 hours. The DON confirmed that the charge nurses are expected to change and label the GT feeding, syringe, and tubing every 24 hours, but this was not done for the three residents in question.
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What surveyors actually found near you
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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.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Anaheim
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Harbor Villa Care Center | 1.6 mi | ★★★★★ | 24 | 0 |
| La Palma Nursing Center | 1.8 mi | ★★★★★ | 1 | 0 |
| Leisure Court Nursing Center | 1.8 mi | ★★★★★ | 4 | 0 |
| Gordon Lane Care Center | 2.4 mi | ★★★★★ | 2 | 0 |
| Sun Mar Nursing Center | 2.5 mi | ★★★★★ | 1 | 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 August 2026) and official state health department websites.