Average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Parkway Hills Nursing & Rehabilitation during CMS and state inspections, most recent first.
A resident was admitted with surgically repaired ankle and foot fractures and documented surgical wounds with staples, but no physician orders for wound care were obtained or documented for most of the month following admission, and the TAR showed no wound treatments during that time. Later, a wound care physician was consulted, orders were written, and treatments were documented, with subsequent notes indicating staple removal and resolution of most wounds. The wound care nurse stated it was her responsibility to assess new wounds and contact the physician for orders, acknowledged she did not recall obtaining orders for this resident, and stated she should have done so. The DON confirmed the expectation that the wound care nurse obtain and document physician orders for wound monitoring and treatment, in line with the facility’s clinical protocol requiring documentation of current treatments.
A resident with paraplegia was transferred to a GACH and, shortly after admission, was documented as calm, cooperative, medically cleared to return, and expressing a desire to go back to the original SNF, where an active bed-hold was in place. Despite this, the facility declined to readmit the resident when the hospital attempted to discharge him back, and instead the resident was later discharged to another SNF. In interviews, the AD and Administrator confirmed the decision not to readmit, which conflicted with the facility’s bed-hold and return policy requiring residents seeking to return within the bed-hold period to be allowed back to their previous room and evaluated based on their current condition.
Dietary Manager Lacked Required Qualifications: The facility failed to ensure the DM had the education or experience needed to manage FNS. The DM stated she had no CDM credential, no degree in food service management, and no prior food service manager experience. The HR file contained an unsigned job description requiring a bachelor's degree and CDM credential, but the verification form was blank and the resume listed only a high school education and college coursework. The Admin stated she was unaware the DM did not meet the job qualifications.
A resident with COPD had incomplete oxygen saturation monitoring and documentation while receiving PRN oxygen, with staff stating the readings should have been checked every shift and recorded in the task and pulmonary sections. Another resident was observed on continuous oxygen without a physician's order in the chart, even though staff stated oxygen is a medication and should have been ordered by the physician.
Alternate food items were not prepared to equal nutritive value. A CK prepared a chef salad, grilled cheese sandwich, and cheese quesadilla for residents without using recipes, measuring utensils, or a scale. The CK stated she did not measure or weigh the items, while the RD said ingredients must be measured and weighed so residents receive protein and calories equal to the main entree. Record review showed facility recipes and a Portion Control policy requiring portion control equipment and a diet scale.
Kitchen sanitation and food storage were not maintained as required. Food prep surfaces, a tabletop can opener, and a salt container had visible debris, prepared dinner rolls were not labeled with prep or discard dates, and opened dry goods and soup bases in storage lacked proper labeling and were not fully sealed. Ceiling light fixtures over the food prep area were also observed with rust or dark debris while trays were being prepared.
Failure to assess and document self-administration of bedside meds: a resident with burns to the right eye was self-administering eye irrigation, drops, ointment, and Tegaderm despite a form indicating he was not to self-administer. The TN said he preferred to do his own eye care and may have done it more often than ordered, while the DON stated there was no order or appropriate documentation/assessment for self-administration.
Failure to implement a resident-centered pain care plan: A resident with a cancerous breast tumor and chronic pain had an order for oxycodone every 6 hours, but she reported missing four doses because staff said the facility ran out. The care plan called for administering the pain medication as ordered, yet staff interviews and record review confirmed the intervention was not implemented; the resident was alert, oriented, and aware of her missed doses.
A resident with cancer and chronic pain missed multiple scheduled doses of oxycodone because the medication was not available. The resident said staff told her the facility had run out and she was upset because she was in pain. Staff and hospice staff confirmed the resident’s pain medication was supplied by hospice and that communication was needed to keep the medication available; the DON stated the expectation was to ensure the medication was available for pain control and management.
Controlled meds were signed out in the CDR for several residents, but the MAR did not show the administrations, and the DON confirmed the missing documentation. In addition, expired insulin pens for one resident and expired compounded vancomycin eye drops for another resident were found in the med refrigerator, with the DON stating expired or discontinued meds were expected to be removed or destroyed.
A nurse made three medication administration errors during an observed med pass, resulting in a 10.71% error rate. The nurse crushed methadone, opened duloxetine DR capsules and mixed the contents with applesauce, and gave lansoprazole after breakfast instead of before a meal, contrary to the med information and the facility’s med administration policy.
Improper Storage of Erythromycin Ophthalmic Ointment: A tube of erythromycin ophthalmic ointment for a resident was found in the med refrigerator at 37 F, even though the manufacturer labeled it for storage between 59 F and 77 F. An LPN confirmed the label, the DON stated meds must be stored as directed by the manufacturer, and the CP said the ointment should be kept at room temperature and not frozen because it can become too thick or hard to apply.
Unsafe storage and reheating of outside food: A resident kept multiple opened snacks and fruit in the room without labels or proper containers, and staff gave inconsistent accounts of how outside food was handled. One CNA said she would reheat any outside food for 30 seconds without instructions or a thermometer, while another CNA described labeling requirements. The RD said reheating instructions and a thermometer should be available, and the Admin stated she was unaware food was being reheated without guidance or temperature checks.
Inaccurate BP Documentation on MAR: An LPN entered the wrong BP reading on a resident's MAR after giving antihypertensive medications. The resident had orders to hold losartan and metoprolol if SBP was below 110, but the chart showed a lower BP while the LPN stated he had actually taken a higher BP before administration and mistakenly documented the CNA's later VS instead of his own. The DON confirmed the mismatch, and the facility policy required medical record documentation to be objective, complete, and accurate.
A resident on EBP for a catheter was observed receiving care without the required PPE. Two CNAs changed linens, repositioned and transferred the resident, and provided grooming while one or both staff members were missing gowns and, at times, gloves. The EBP sign outside the room and the facility policy both required gown and glove use for high-contact care activities such as hygiene, transferring, and changing linens.
Resident room space requirements were not met in 4 of 28 rooms after review of the Client Accommodations Analysis and room measurements. Two rooms housed two residents each with 71.5 sq. ft. per resident, one room housed three residents with 73.66 sq. ft. per resident, and one room housed four residents with 76 sq. ft. per resident. Residents in the affected rooms stated their rooms were comfortable and had no concerns, and the survey found no observed adverse effect on resident health, safety, QOC, or QOL.
The facility failed to maintain a safe and homelike environment, with hallway floors taped and missing sections creating tripping hazards, and a wobbly handrail posing risks to residents and staff. Two residents, one using a cane and another with a history of falls, expressed concerns about these conditions. The maintenance director acknowledged the issues, which predated his employment, and admitted to lacking a routine schedule for checking handrails.
The facility failed to staff an RN for at least 8 hours a day for 18 days between January and March 2024. Despite having sufficient LNs and CNAs, the facility could not retain RN services and had no staffing waivers. The DON highlighted the importance of an RN for managing staff and resident care. The absence of an RN had the potential to compromise resident care quality.
A long-term care facility experienced a 50% medication error rate during a medication pass observation. Errors included a nurse failing to administer full doses to a resident via a G-tube, another nurse delaying a resident's morning medications by over three hours, and a third nurse unable to administer a diabetes medication due to unavailability. The errors involved medications critical for managing conditions like seizures, hypertension, and diabetes.
Three residents in a LTC facility experienced significant medication errors. A resident did not receive the full dosage of medications through a G-tube due to improper administration. Another resident's morning medications were administered over three hours late, including critical medications for diabetes and hypertension. A third resident did not receive a diabetes medication because it was unavailable in the medication cart. These errors highlight issues in medication administration and availability.
The facility failed to ensure kitchen staff were competent in operating and documenting the use of low-temperature dishwashers. Observations revealed dishwashers were unsure of proper procedures for taking temperature and chlorine samples, leading to inaccurate logs and potential risks of foodborne illness. The Dietary Manager acknowledged the need for accurate documentation to ensure proper machine functioning.
The facility failed to provide palatable and flavorful meals, potentially affecting residents' meal intake and health. Residents reported issues such as bland, cold, and repetitive food, with some dietary needs not being met. A test tray observation confirmed the lack of seasoning and unsatisfactory texture in meals, highlighting a deficiency in food quality.
The facility failed to store soy sauce and teriyaki glaze as per manufacturer's instructions, requiring refrigeration after opening. Additionally, the low-temperature dishwasher did not reach the necessary rinsing temperature for sanitization, with staff unsure of proper temperature recording procedures. These issues could increase the risk of foodborne illness.
A resident's MDS was inaccurately coded regarding their pneumococcal vaccination status, leading to incorrect data submission to the federal database. Despite consenting to vaccines, the resident did not receive an updated pneumonia vaccine, as confirmed by the IP nurse and the resident. The DON acknowledged the error, stating the MDS should reflect accurate assessment per the RAI manual.
A resident with obstructive sleep apnea had a care plan that was not updated to include specific details about their CPAP machine's settings and cleaning procedures. Observations showed the CPAP machine was present but not in use, and staff interviews confirmed the resident used the machine at night. The facility's policy required detailed care plans, but this was not reflected in the resident's documentation, leading to a deficiency.
Two residents in the facility did not receive necessary assistance with nail care, despite facility policies requiring weekly trimming during showers. One resident, with hemiplegia and hemiparesis, had long, untrimmed nails with debris, while another resident with dementia had long, jagged nails. Staff interviews revealed a lack of action due to uncertainty and fear of causing harm, leading to a deficiency in care.
A resident with obstructive sleep apnea used a CPAP machine without a documented physician's order for its settings, leading to potential inappropriate care. The resident brought her own CPAP machine, and staff were unaware of the preprogrammed settings. The facility's policy required documentation of CPAP settings but lacked guidance on obtaining a physician's order.
A resident with a history of epilepsy and moderate cognitive deficits had an unlabeled medication cup left unattended on their bedside table. A nurse admitted to leaving the medications, which included Clonazepam and Depakote, because the resident did not want to take them immediately. Facility staff acknowledged that medications should not be left unattended due to risks of divergence and choking hazards.
The facility failed to maintain infection control procedures for three residents, including not changing oxygen tubing weekly for two residents and improper storage of a CPAP mask for another. The respiratory therapist was on emergency leave, leading to lapses in changing and labeling oxygen tubing. Additionally, a CPAP mask was not stored in a plastic bag as required, and there was no documentation of its cleaning. These deficiencies increased the risk of infection transmission.
The facility failed to offer and administer updated pneumococcal vaccines to two residents, despite having consent forms and CDC recommendations. One resident, cognitively intact with a history of pneumonia, was not offered the vaccine, while another resident with a G-tube and high-risk status had an incomplete consent form. The DON acknowledged the importance of vaccine administration, but the facility did not follow its policy, leading to the deficiency.
The facility did not meet the minimum square footage requirements for resident rooms, with some rooms providing less than the required 80 square feet per resident. Despite this, there was no observed adverse effect on residents' health or quality of life, and a waiver for the room size variance was recommended.
A resident with functional quadriplegia lacked adequate visual privacy during personal care due to insufficient curtain placement, allowing a roommate to view her when accessing the shared bathroom. The Maintenance Director acknowledged the issue and noted that adding a curtain would be a simple fix.
Failure to Obtain and Document Physician Orders for Surgical Wound Care
Penalty
Summary
The facility failed to obtain and follow treatment orders for a resident’s surgical foot and ankle wounds. The resident was admitted with a lateral malleolus fracture that had been surgically repaired, and nursing documentation on the day after admission noted surgical wounds with staples on the right foot and ankle. The physician’s History and Physical confirmed admission following a fall and ankle fracture with surgical repair. However, review of the physician’s orders from admission through late in the month showed no treatment orders for the surgical wounds during that period, and the Treatment Administration Record (TAR) documented that no wound treatments were performed for the surgical sites during most of the month. A wound care physician was consulted by the primary care physician later in the month to evaluate and treat the surgical wounds, and wound care orders were then written and carried out as documented on the TAR for the remaining days of the month. A subsequent wound care physician note indicated that surgical staples had been removed and most of the wounds had resolved, with instructions to continue wound care. The wound care nurse reported that she had assessed the resident’s skin and wounds at admission and five days a week thereafter, acknowledged that it was her responsibility to contact the physician for treatment orders, and stated she did not remember calling for such orders. She further stated that she should have obtained treatment orders so nurses would know to monitor for signs of infection or other problems. The DON stated her expectation that the wound care nurse obtain physician orders to monitor and treat wounds and that written physician orders should have been present in the medical record as evidence that treatments were provided, consistent with the facility’s clinical protocol requiring documentation of current treatments.
Failure to Readmit Hospitalized Resident Despite Active Bed-Hold and Clearance
Penalty
Summary
The facility failed to permit a resident to return after hospitalization despite an active bed-hold and the resident’s expressed desire to return, resulting in a deficiency related to transfer/discharge practices. The resident, who had paraplegia and was originally admitted to the facility on an unspecified date, was transferred to a general acute care hospital (GACH) on 3/28/26. According to the GACH Case Manager Interdisciplinary Note dated 3/30/26, the resident was calm, cooperative, medically cleared for discharge back to the skilled nursing facility, and stated that he wanted to return there. The resident had an active bed-hold at the facility at that time. Despite this, the facility did not accept the resident back. The GACH Nursing Note dated 4/3/26 documented that the resident was instead discharged to a different skilled nursing facility four days after being initially cleared for discharge back to the original facility. In an interview on 4/9/26, the Admissions Director stated that the GACH attempted to send the resident back, but the facility decided not to readmit him. In a subsequent telephone interview on 4/14/26, the Administrator confirmed that the facility decided not to readmit the resident from the GACH. This decision was inconsistent with the facility’s “Bed-Holds and Returns” policy, revised October 2022, which states that residents with a bed-hold who seek to return within the bed-hold period are allowed to return to their previous room and that post-hospitalization return decisions for residents with clinical or behavioral concerns are to be based on their current condition at the time of transfer.
Dietary Manager Lacked Required Qualifications
Penalty
Summary
The facility failed to ensure the Dietary Manager had the required education or experience to effectively manage the Food Service department. During interview, the Dietary Manager stated she had been employed in the role for approximately 18 months, did not have a degree in food service management, did not hold a Certified Dietary Manager credential, and did not have prior experience as a food service manager at another facility. She stated she had been promoted into the position by a previous manager. Record review showed an undated, unsigned job description for Certified Dietary Manager stating the position required a bachelor's degree in nutrition, dietary management, or a related field and required a Certified Dietary Manager credential. The employee file also contained an undated, unsigned License or Certification Verification Form that was blank and did not include a license or certification number. The Dietary Manager's resume listed only a high school education and current college coursework as of February 2022, with no course of study, graduation date, credential, or license listed. The Administrator stated she was unaware the Dietary Manager did not have a license or certificate to meet the job qualifications and acknowledged the lack of training and education had the potential to impact the quality of food service provided to residents.
Oxygen Monitoring and Order Deficiencies
Penalty
Summary
The facility failed to ensure oxygen saturation levels were routinely monitored and documented for a resident with COPD who had an order for oxygen 2 liters per minute via nasal cannula as needed to keep oxygen saturation above 90%. Resident 3 was observed receiving oxygen in bed, and the record review showed oxygen saturation documentation was incomplete in the task sheet and absent from the pulmonary section of the electronic record. Staff interviews indicated oxygen saturation levels should have been checked every shift, documented in both the task and pulmonary sections, and recorded before oxygen was applied when needed, but the pulmonary documentation was not saving due to a system glitch that staff had just realized. Resident 3 stated he normally gets 2 liters of oxygen and demonstrated use of a portable pulse oximeter. When he was off oxygen for three minutes, his saturation was 89%, after which he reapplied the nasal cannula. The DON and LN 17 stated the saturation levels were important to determine whether the resident required oxygen and that the physician would need those documented values to assess pulmonary status and change orders as needed. The record review showed oxygen saturation was documented only 22 times out of 51 opportunities in the task sheet review period, with many readings taken on room air and no documented evidence for some dates when the resident was observed receiving oxygen. The facility also failed to obtain a physician's order before administering oxygen to Resident 7. Resident 7, who had COPD, was observed on oxygen at 3 liters per minute via nasal cannula, and staff stated she was always on oxygen or had been placed on oxygen after a change in condition. However, the clinical record contained no physician's order for oxygen, while a pulmonary monitoring form indicated continuous oxygen at 3 liters per minute for COPD. An LPN and the DON both stated oxygen is considered a medication and should not be administered without a physician's order, but the record reviewed did not contain such an order.
Alternate Food Items Not Prepared to Equal Nutritive Value
Penalty
Summary
The facility failed to ensure that alternate food items were of equal nutritive value. During an observation of the kitchen tray line, a chef salad was prepared and placed on a resident tray, along with a grilled cheese sandwich and a cheese quesadilla prepared as alternate items for residents. The chef salad was assembled with a hard boiled egg, lettuce, cheese, turkey, and ham. The grilled cheese sandwich was made from two slices of white bread and two slices of what appeared to be American cheese, then grilled in butter. The quesadilla was made from a medium flour tortilla and a handful of shredded cheese, then browned in an oiled pan. No recipes or measuring utensils were visible or in use during preparation. During interview, the CK stated the alternate food items were offered daily if residents did not like the main menu items, but she had not used a recipe and had not measured or weighed the items. She stated she should have measured or weighed the cheese and meat for the salads and sandwiches, but did not have a scale. The RD stated it was important to measure and weigh ingredients for all recipes so residents received protein and calories equal to the main entree, and demonstrated a food scale for the CK. Record review showed facility recipes specifying exact amounts for the chef salad, grilled cheese, and cheese quesadilla, and a facility policy titled Portion Control stating portion control equipment and a diet scale must be used to ensure portions served equal menu portion sizes.
Kitchen sanitation, labeling, and food storage deficiencies
Penalty
Summary
Kitchen sanitation and food storage were not maintained in accordance with professional standards during a kitchen tour and related interviews. Food preparation areas, including the tile ledge near the hand wash sink, a chemical dispenser box, and a window ledge over a utility sink, were observed with a thick dark greasy substance. A tabletop can opener and its holder had embedded food debris, and a plastic container of salt stored over the food preparation area had dried food debris on the outside. The CK stated the area should have been clean and the can opener and salt container should have been removed from service and cleaned. Food items were also observed without required labeling and dating. A covered metal bowl containing about 25 dinner rolls had no label showing when the rolls were prepared or when to discard them. In the storeroom, a large opened bag of oatmeal had no label and was not sealed, and two buckets of chicken and beef base had manufacturer labels only, with no opened date or discard date; their lids were not fully closed. Ceiling light fixtures over the food prep area were also observed with rust or dark solid debris on the metal ends while trays were being prepared for lunch. The DM stated she was responsible for sanitation and food storage in the kitchen, and the RD stated she had not identified the sanitation, labeling, or food safety problems during her recent audit.
Failure to Assess and Document Self-Administration of Eye Medications
Penalty
Summary
The facility failed to ensure the interdisciplinary team assessed and documented whether self-administration of medications kept at bedside was clinically appropriate for a resident with second-degree burns, including to the right eye. The resident stated he sometimes ran out of Tegaderm, lubricating eye ointment, and eye drops, and explained that he self-administered his eye treatment by irrigating his eye with saline, using Refresh Tears eye drops, applying moxifloxacin eye drops, then GenTeal Tears eye ointment, and finally Tegaderm. He stated he had been self-administering this treatment four times daily for about a year and that he sometimes did not wait between eye drops. The Treatment Nurse stated the resident preferred to self-administer his ointment and wound care, informed staff when supplies were low, and may have performed the treatment more often than prescribed. The resident’s record included a Self-Administration of Medications form dated 10/6/22 that indicated he was not to self-administer medications. The DON stated the resident was not supposed to self-administer, there was no order for it, and he should not have medications at bedside. The DON also stated the resident should not have been self-administering without appropriate documentation and assessment because staff would not know whether he was doing it correctly or following physician orders. Facility policies stated the IDT must assess cognitive and physical abilities to determine whether self-administration is safe and clinically appropriate, and that residents may self-administer only if the attending physician and interdisciplinary care planning team determine they have the decision-making capacity to do so safely.
Failure to Implement Pain Care Plan
Penalty
Summary
The facility failed to ensure a comprehensive resident-centered care plan was implemented for a resident with diagnoses including a cancerous tumor of the right breast and chronic pain. The resident was readmitted to the facility with a physician's order for oxycodone every six hours for pain management, and the care plan identified chronic pain with an intervention to administer oxycodone as ordered. During an observation and interview, the resident stated she had missed four doses of her pain medication because staff told her the facility had run out, and she stated she was upset because she was in pain. Record review and staff interviews confirmed the pain care plan interventions were not implemented. The resident's H&P indicated she had the capacity to understand and make decisions. A CNA who cared for the resident stated she was alert, oriented, knew what was going on, and talked often about her pain and missing doses of pain medication. An LN familiar with the resident reviewed the pain care plan and stated the interventions to administer pain medications were not implemented. The DON stated the expectation was to implement the resident's care plan to manage her pain.
Pain Medication Not Available for Resident With Chronic Pain
Penalty
Summary
The facility failed to ensure a pain medication was available for a resident with cancerous tumor of the right breast and chronic pain who was readmitted with an order for oxycodone every six hours for pain management. During an observation and interview, the resident stated she had missed four doses of her pain medication because staff told her the facility had run out, and she said she was upset because she was in pain. The resident’s H&P indicated she had the capacity to understand and make decisions, and staff described her as alert, oriented, and aware of when her pain medication was due. Record review showed the resident did not receive three scheduled doses of pain medication on 9/19/25 at 11 P.M., 9/20/25 at 5 A.M., and 9/20/25 at 11 A.M. because the medication was not available. A CNA stated the resident talked often about her pain and that she had mentioned missing doses of her pain medication. An LN stated the resident was in hospice, that hospice supplied her medications, and that communication with hospice was important to ensure pain medications were ordered and available. The hospice LN stated the facility should have informed hospice when pain medication was running low so the medications could be delivered and available. The DON stated the expectation was to make sure pain medications were available for the resident for pain control and management.
Missing controlled medication documentation and expired medications in storage
Penalty
Summary
Safe and effective pharmaceutical services were not maintained when controlled medications were signed out of the controlled drug record (CDR) for five sampled residents, but the administrations were not documented on the Medication Administration Record (MAR). For Resident 27, hydrocodone-acetaminophen 5/325 mg was signed out on one occasion without MAR documentation. For Resident 6, hydrocodone-acetaminophen 5/325 mg was signed out on three occasions without MAR documentation. For Resident 52, oxycodone 5 mg was signed out on four occasions without MAR documentation. For Resident 26, oxycodone 5 mg was signed out on one occasion without MAR documentation. For Resident 19, morphine 100 mg/5 mL was signed out on three occasions without MAR documentation. The DON reviewed the records and confirmed the missing MAR entries for each resident. The DON stated the CDR and MAR documentation should match and explained that nursing staff were expected to document on the MAR first, then document on the CDR after administering the medication. The DON also stated proper documentation was important to avoid drug diversion and to ensure medication errors were not occurring and to make sure efficacy of the medication pre and post administration. A review of the facility policy titled Controlled Substances, revised 11/22, indicated that an individual controlled substance record is made for each resident receiving a controlled substance and includes the date and time of administration. Expired medications were also found in the medication refrigerator in one medication room. Four boxes of regular insulin prefilled pens for Resident 7 were observed with manufacturer expiration dates of 3/18/25 and 7/1/25, and two bottles of compounded vancomycin eye drops for Resident 29 were labeled with an expiration date of 8/28/25. LN 17 confirmed the expiration dates. The DON stated nursing staff were expected to immediately destroy expired medications or remove discontinued medications from the refrigerator, and the facility policy on Medication Labeling and Storage stated that discontinued or outdated medications are to be handled through instructions from the dispensing pharmacy.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure the medication error rate remained below five percent. During observation of medication administration for one resident, three medication errors were identified out of 28 opportunities, resulting in a 10.71% error rate. The resident involved was receiving multiple medications crushed and mixed with applesauce, and the nurse prepared and administered 11 medications during the observed pass. During the observation, the nurse crushed methadone tablets before administration and opened duloxetine delayed-release capsules, poured the granules into applesauce, and gave them to the resident. The nurse also administered lansoprazole in the 9 o'clock hour after breakfast, even though the medication information indicated it should be given 30 to 60 minutes before a meal. The consultant pharmacist stated duloxetine should not be opened, methadone should not be crushed, and lansoprazole should generally be given before breakfast or the first meal of the day. The facility policy stated medications are to be administered in a safe and timely manner, and as prescribed.
Improper Storage of Erythromycin Ophthalmic Ointment
Penalty
Summary
The facility failed to ensure a medication was stored under proper temperature controls in one of one Medication Rooms. During a concurrent observation and interview on 9/21/25 at 10:05 A.M., a tube of erythromycin ophthalmic ointment for Resident 29 was found in the medication refrigerator, which was 37 F. The medication's manufacturer labeling indicated it should be stored between 59 F and 77 F, and LN 17 confirmed the labeling and stated it would have to be stored outside. During an interview on 9/22/25 at 1:44 P.M., the DON stated medications have to be stored how the drug manufacturer says and that improper storage can affect the medication. During a telephone interview on 9/24/25 at 1:58 P.M., the CP stated erythromycin ophthalmic ointment should be stored at room temperature and should not be frozen because it can become too thick or hard to apply. The facility's policy titled Medication Labeling and Storage, revised 2/2023, stated the facility stores all medications under proper temperature controls.
Unsafe Storage and Reheating of Outside Food
Penalty
Summary
The facility failed to ensure resident food brought into the facility from outside sources was stored appropriately and that procedures were in place for safe reheating of those foods. During an observation with Resident 24, the resident’s bedside table was covered with large bags of candy, cookies, and other opened food items, and a blanket at the foot of the bed had ripe bananas and a small brown bag from a fast food restaurant on top of it. None of the foods were in plastic bags, and none had labels with dates, the resident’s name, or room number. Resident 24 stated that food from the kitchen was sometimes cold, so friends and family brought food from outside to keep in the room, and the facility had not offered bins or containers for storage. Staff interviews showed inconsistent and unsafe handling of outside food. A CNA stated that if residents wanted outside food reheated, she would use the microwave for 30 seconds regardless of the food item, without instructions or a thermometer to check temperature. Another CNA stated food brought in from outside should be labeled with the resident’s name, room number, and date received. The RD stated reheating instructions should be posted on the resident refrigerator and microwave and that a thermometer should be available to check food temperatures. The Administrator stated she was not aware foods from home were being reheated without instructions or temperature checks and acknowledged that residents storing foods in their rooms posed a food safety issue and potentially a pest management issue.
Inaccurate BP Documentation on MAR
Penalty
Summary
The facility failed to maintain accurately documented records when the wrong blood pressure reading was entered on the Medication Administration Record for one resident. Resident 9 had active orders for losartan 25 mg daily for hypertension, to be held if systolic blood pressure was less than 110, and metoprolol 25 mg twice daily for hypertension, to be held if systolic blood pressure was less than 110 or heart rate was less than 60. Her clinical record showed a blood pressure of 103/59, yet she received both her losartan dose and her 9:00 A.M. metoprolol dose despite the hold parameters in the physician's orders. During interview, the LPN stated he measured the resident's blood pressure before giving the blood pressure medications and had handwritten the reading on a sheet of paper, but he accidentally entered the CNA's vital signs instead of his own. The LPN stated the resident's blood pressure was 118/68 at 9:00 A.M. The DON confirmed that the LPN took the resident's blood pressure before administering the medications and that the electronically recorded blood pressure was actually the CNA's reading taken later at 11:25 A.M. The facility's policy stated that documentation in the medical record must be objective, complete, and accurate.
Failure to Use Required PPE During EBP Care
Penalty
Summary
The facility failed to implement proper infection control practices for one sampled resident who was on enhanced barrier precautions (EBP) because of a catheter. During an observation on 9/21/25 at 9:28 A.M., CNA 2 and CNA 3 were seen caring for the resident outside his room while he was being changed and repositioned in a wheelchair. Both CNAs had gloves on, CNA 3 had a mask on, but neither wore a gown. CNA 2 was observed brushing the resident’s hair and putting a baseball cap on him without gloves, and CNA 3 was observed changing linens from the resident’s bed. CNA 2 was also observed pushing the resident’s wheelchair with bare hands as the resident was transferred out of his room. The EBP sign posted outside the room stated that staff must wear gloves and a gown for high-contact resident care activities, including transferring, changing linens, and providing hygiene. During interviews, LN 1 stated the CNAs should have worn gowns while changing linens and transferring the resident, and CNA 2 stated that staff were supposed to gown up when caring for residents on EBP. The Infection Preventionist stated staff were expected to wear gloves, gown, and a mask when changing linens and transferring a resident on EBP. The facility policy titled Enhanced Barrier Precautions also listed providing hygiene or grooming, transferring, and changing linens as examples of high-contact resident care activities requiring gown and gloves.
Resident Room Space Requirement Not Met
Penalty
Summary
The facility failed to provide the minimum required room space of 80 square feet per resident in 4 of 28 resident rooms based on the Client Accommodations Analysis and observation of resident room measurements. Rooms 2 and 4 each housed two residents in 143 total square feet, providing 71.5 square feet per resident. Room 6 housed three residents in 221 square feet, providing 73.66 square feet per resident. Room 21 housed four residents in 304 square feet, providing 76 square feet per resident. Residents in the affected rooms were interviewed and stated their rooms were comfortable and that they had no concerns. The report states that the variation in room size requirements was not observed to adversely affect resident health, safety, quality of care, or quality of life during the survey.
Unsafe and Unhomelike Environment Due to Poor Flooring and Handrail Conditions
Penalty
Summary
The facility failed to provide a safe and homelike environment for its residents, as evidenced by several deficiencies observed during a survey. The hallway floors were found to be in poor condition, with gray duct tape used to secure the flooring and missing sections creating uneven surfaces. This was particularly concerning for residents with mobility issues, such as one resident who used a cane and expressed concern about the potential for injury due to the unstable flooring. Another resident, with a history of falling, also expressed fear about the missing flooring near their room. The maintenance director acknowledged the taped flooring and missing sections, noting that these issues predated his employment. Additionally, a handrail outside a resident's room was observed to be wobbly and secured with a loose screw, posing a risk to residents and staff. A CNA confirmed the handrail's instability and the danger posed by the uneven flooring. The maintenance director admitted to not having a routine schedule for checking handrails and was unaware of the issue until it was pointed out. The facility's policy on providing a safe and homelike environment was not adhered to, as evidenced by these observations.
Failure to Staff RN for Required Hours
Penalty
Summary
The facility failed to staff a Registered Nurse (RN) for at least 8 hours a day for 18 days between January 1, 2024, and March 31, 2024. This deficiency was identified through a review of the PBJ Staffing Data Report and CASPER Report 1705, which indicated that no RN hours were recorded for 19 days within the specified period. The Staffing Coordinator confirmed that on specific dates in January, February, and March, there was no RN scheduled for at least 8 hours. Despite having sufficient Licensed Nurses (LNs) and Certified Nursing Assistants (CNAs) on those days, the facility was unable to retain RN services and had no waivers for staffing. Attempts to use registry RNs were made, but the registry was found to be undependable. The Director of Nursing (DON) emphasized the necessity of having an RN on duty for at least 8 hours daily to manage staff, oversee resident care, and administer intravenous medications. The facility's policy on staffing mandates providing a sufficient number of skilled staff to meet resident care plans and facility assessments. The absence of an RN for the required hours had the potential to result in inadequate supervision and compromised quality of care for residents.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to prevent medication errors of less than 5% during a medication pass observation involving three licensed nurses and three residents. Licensed Nurse 1 (LN 1) administered medications to Resident 37 via a gastronomy tube but omitted one medication and failed to administer the full dose of several medications. The medications were not fully dissolved, leaving remnants in the medication cups, which resulted in Resident 37 not receiving the complete dosage necessary for managing health complications such as seizures, hypertension, and anxiety. Licensed Nurse 2 (LN 2) did not administer Resident 31's morning medications as scheduled, resulting in a delay of over three hours. This included medications for diabetes, high blood pressure, depression, and nutritional supplements. The delay was attributed to LN 2's incorrect assumption that Resident 31 was with the rehabilitation therapy team, which was not the case. The delay in medication administration was highlighted by the electronic medication administration record, which indicated the medications were late. Licensed Nurse 3 (LN 3) was unable to administer Resident 33's Januvia, a medication for diabetes management, because it was not available in the medication cart. LN 3 was unaware if the medication had been ordered and needed to notify the pharmacy for delivery. The Director of Nursing emphasized the importance of administering medications according to the facility's policy to prevent complications and ensure resident safety. The facility's medication error rate was calculated at 50%, significantly exceeding the acceptable threshold.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that three residents were free from significant medication errors. For Resident 37, a Licensed Nurse (LN) administered medications through a gastronomy tube but omitted one medication and did not ensure the full dose of medications was administered. The nurse was unsure of the medication being administered due to similar unlabeled medication cups and mixed all medications with the same syringe, leading to undissolved medication remnants. This resulted in Resident 37 not receiving the full dosage of medications necessary for managing epilepsy, hypertension, and mood stability. Resident 31 did not receive morning medications as scheduled because the nurse missed administering them, believing the resident was with the rehabilitation therapy team. The medications were administered more than three hours late, which included critical medications for diabetes, high blood pressure, and depression. The delay in administration was not acceptable, as it could lead to complications such as a hypertensive crisis or uncontrolled blood sugar levels. For Resident 33, the nurse was unable to administer Januvia, a medication for diabetes management, because it was not available in the medication cart. The nurse was unaware if the medication had been ordered and needed to notify the pharmacy for delivery. The absence of this medication could lead to hyperglycemia, highlighting the importance of ensuring medication availability and adherence to the facility's medication administration policy.
Incompetency in Dishwasher Operation and Documentation
Penalty
Summary
The facility failed to ensure that kitchen staff, specifically dishwashers, were competent in operating, documenting, and checking the water temperatures of two low-temperature dishwashers. This deficiency was identified through observations, interviews, and record reviews. During an observation, a dishwasher was seen taking a chlorine sample from the water exit site instead of directly from the dishes, and was unsure of where to take the temperature reading for the log. The temperature logged was 120 degrees Fahrenheit, but upon demonstration, the machine's thermometer showed 115 degrees Fahrenheit, and an independent reading showed 110 degrees Fahrenheit. The dishwasher was unaware of the appropriate temperature required. Further observations with the Dietary Manager revealed that the dishwashers were likely not taking accurate temperature readings, as the log showed consistent numbers despite different measurements. The Dietary Manager acknowledged that the machine was not reaching the appropriate temperature for rinsing and that manual washing would be necessary. Another dishwasher was also observed taking a chlorine sample incorrectly and was unaware of the proper procedure. The Dietary Manager admitted that the dishwashers should understand the importance of taking accurate temperatures and chlorine samples to ensure the machine's proper functioning and prevent foodborne illness.
Deficiency in Food Quality and Palatability
Penalty
Summary
The facility failed to ensure that food served to residents was palatable and flavorful, which could potentially decrease meal intake and contribute to weight loss among residents. During a dining observation and interviews with residents, several concerns were raised about the quality of the food. Residents reported issues such as grilled cheese sandwiches not being cooked properly, dry macaroni and cheese, bland meat, cold food, and repetitive menu items like broccoli. Additionally, a vegetarian resident was served fish, and another resident on a renal diet received salty food. The facility's menu for the day included roast turkey with gravy and other items, but residents expressed dissatisfaction with the taste and temperature of the meals. A test tray observation conducted with the Dietary Manager (DM) and Registered Dietician (RD) revealed that the food served was bland and lacked seasoning. The temperatures of the dishes were taken, and while they were within safe ranges, the taste and texture were not satisfactory. The pureed diet meals had more seasoning compared to the regular diet meals. The DM acknowledged the importance of residents enjoying their meals to prevent weight loss and negative health impacts. The facility's policy on resident food preferences indicated that a variety of foods should be offered at each meal, but the observations and resident feedback suggested that this was not being effectively implemented.
Improper Food Storage and Dishwasher Temperature Issues
Penalty
Summary
The facility failed to store soy sauce and teriyaki glaze according to the manufacturer's recommendations, which required refrigeration after opening. During an observation and interview with the Dietary Manager (DM), it was found that opened containers of these sauces were stored in the dry storeroom, contrary to the instructions on the labels. The DM admitted to being unaware of the need for refrigeration for soy-based sauces and disposed of the sauces upon realizing the mistake. The facility's policy on food storage emphasized the importance of checking food labels to prevent serving spoiled or contaminated food, which could lead to foodborne illness. Additionally, the facility did not ensure that the low-temperature dishwasher reached the appropriate rinsing temperature for sanitization. An observation and interview with Dishwasher (DW) 11 revealed confusion about where to take temperature readings, with the DW incorrectly using a chlorine test strip for this purpose. The recorded temperature was below the required 120 degrees Fahrenheit, with independent measurements confirming this discrepancy. The DM acknowledged that the dishwashers might not have been taking accurate temperature readings and were likely recording incorrect data. The facility's policy required maintaining a temperature log to ensure the dishwashing machine operated within the manufacturer's guidelines to prevent the spread of foodborne illness through contaminated dishes.
Inaccurate MDS Coding for Resident's Vaccination Status
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for a resident's vaccination status, leading to the submission of incorrect information to the federal database. Resident 31, who was readmitted to the facility with a history of congestive heart failure, was found to have an inaccurately coded MDS regarding their pneumococcal vaccination status. The resident's MDS indicated that their pneumococcal vaccination was up to date, despite the fact that an updated pneumonia vaccine had not been administered, as confirmed by the Infection Prevention (IP) nurse during a record review. Interviews and record reviews revealed that Resident 31 had consented to receive vaccines during the 2023-2024 vaccine season but was not offered or given an updated pneumonia vaccine. The resident confirmed receiving COVID-19 and flu vaccines but not the pneumonia vaccine. The Director of Nursing (DON) acknowledged the error, stating that the MDS should reflect an accurate assessment per the Resident Assessment Instrument (RAI) manual, which specifies coding the pneumococcal vaccination status as not up to date if the vaccine was not administered.
Failure to Update CPAP Care Plan for Resident with Sleep Apnea
Penalty
Summary
The facility failed to update a resident-centered care plan for a resident with obstructive sleep apnea who required the use of a CPAP machine. The resident was admitted with a diagnosis of obstructive sleep apnea, and during an observation, the CPAP machine was noted to be present but not in use, with the mask placed on the bed. Interviews with staff revealed that the resident applied the CPAP mask at night and removed it in the morning. A review of the care plan by the Minimum Data Set Nurse revealed that it lacked specific details regarding the CPAP machine's settings and the cleaning procedures for the tubing and mask. The facility's policy on comprehensive person-centered care plans emphasized the need for detailed interventions derived from thorough assessments, but this was not reflected in the resident's care plan. The absence of documentation for these critical aspects of care indicated that they were not being addressed, leading to a deficiency in providing appropriate care and treatment for the resident.
Failure to Provide Adequate Nail Care for Residents
Penalty
Summary
The facility failed to provide adequate assistance with nail care for two residents, Resident 43 and Resident 30, which was identified during a survey. Resident 43, who was admitted with hemiplegia and hemiparesis, had intact cognition but required substantial assistance with personal hygiene due to functional limitations in the upper extremity. Observations revealed that Resident 43 had long, untrimmed fingernails with debris underneath, and the resident reported that no one had cut his nails for a long time. Despite the facility's policy requiring weekly nail care, staff interviews indicated a lack of action due to uncertainty about the resident's health condition and fear of causing harm. Resident 30, diagnosed with dementia and muscle weakness, also had long and jagged fingernails. The resident expressed a desire for assistance with nail trimming, but observations over several days showed no change in the condition of the nails. Interviews with staff revealed that nail care was expected to be provided during shower days, but this was not done for Resident 30. The facility's policy allowed CNAs to trim fingernails unless the resident had diabetes, yet the necessary care was not provided. The facility's policy and procedure documents indicated that nail care should be performed weekly with showers and as needed. However, the failure to adhere to these guidelines resulted in the deficiency, as both residents did not receive the required assistance with nail care, potentially affecting their dignity and increasing the risk of infection and injury.
Lack of Physician's Order for CPAP Settings
Penalty
Summary
The facility failed to ensure a physician's order for the settings of a continuous positive airway pressure (CPAP) machine for a resident diagnosed with obstructive sleep apnea. The resident, who brought her own CPAP machine from home, did not have a documented physician's order specifying the CPAP settings. During an observation, the CPAP machine was seen on a plastic container beside the resident's bed, with the mask placed on the bed. Interviews with the licensed nurse and respiratory therapist revealed that the CPAP was used during sleep hours at preprogrammed settings, but there was no knowledge of what those settings were, nor was there an order to verify them. The resident expressed concern that staff might alter the CPAP settings, as they were not documented in the physician's order. The Director of Nurses confirmed that CPAP settings should be included in the physician's order to ensure staff are aware of the correct settings. A review of the facility's policy and procedure on CPAP/BIPAP support indicated the need to document mode and settings in the resident's medical record, but it did not provide guidance on obtaining a physician's order for the CPAP machine prior to its use.
Unsecured Medication at Resident's Bedside
Penalty
Summary
The facility failed to ensure that medications for a resident were secured and locked during a medication storage inspection. During an observation, a clear medication cup containing six medications was found unlabeled and unattended on the bedside table of a resident who had been readmitted to the facility with a history of epilepsy and moderate cognitive deficits. The resident stated that a licensed nurse had left the medication cup on the table for later consumption. A certified nursing assistant confirmed witnessing the medication cup on the table and noted that medications should not be left unattended for safety reasons. The licensed nurse admitted to leaving the medications at the resident's bedside because the resident did not want to take them at that time, and the nurse did not want to delay administering medications to other residents. The medications included Clonazepam, fenofibrate, fish oil, a multivitamin, vitamin D, and Depakote. Another licensed nurse and the Director of Nursing both stated that medications should not be left unattended due to the risk of medication divergence, potential medication errors, and the possibility of causing a choking hazard. The facility's policy on medication storage requires that all drugs and biologicals be stored in a safe, secure, and orderly manner.
Infection Control Deficiencies in Oxygen Tubing and CPAP Mask Management
Penalty
Summary
The facility failed to implement and maintain infection control procedures for three residents, leading to potential risks of infection. For Residents 27 and 34, the facility did not adhere to its policy of changing oxygen tubing weekly. Resident 27, who has chronic respiratory failure, COPD, and congestive heart failure, was observed with oxygen tubing labeled from two weeks prior, and there was no consistent labeling or changing of the tubing. Similarly, Resident 34, with diagnoses including congestive heart failure and chronic respiratory failure, had oxygen tubing that was not changed weekly as required. The respiratory therapist, who was responsible for changing the tubing, was on emergency leave, and the task was not adequately covered by other staff, leading to lapses in the procedure. Resident 6, diagnosed with obstructive sleep apnea, had issues with the storage and maintenance of their CPAP mask. The mask was observed on the floor and not stored in a plastic bag as per infection control guidelines. The licensed nurse stated that the mask should be stored in a plastic bag when not in use, but the resident reportedly refused this practice, although the resident later denied such a refusal. The respiratory therapist did not document the cleaning of the CPAP mask and tubing, which was supposed to occur weekly, further contributing to the deficiency. The facility's policies and procedures, including those for infection control and CPAP/BIPAP support, were not adequately followed, leading to these deficiencies. The lack of proper labeling, changing, and storage of medical equipment increased the risk of infection transmission among residents and staff. Interviews with staff, including the respiratory therapist, licensed nurse, and director of nursing, confirmed the expectations and importance of these procedures, highlighting the lapses in adherence to the facility's infection control policies.
Failure to Administer Pneumococcal Vaccines
Penalty
Summary
The facility failed to offer and administer an updated pneumococcal vaccine to two residents, Resident 31 and Resident 37, as per the Centers for Disease Control (CDC) recommendations. Resident 31, who was cognitively intact and had a history of congestive heart failure and pneumonia, was readmitted to the facility and had a consent form dated for the vaccine season. However, the vaccine was not administered, and the resident confirmed that he was not offered the updated pneumonia vaccine, although he would have consented if it had been offered. Resident 37, who had a history of epilepsy and required nutritional and medication administration through a G-tube, was also not offered the updated pneumonia vaccine. The consent form for Resident 37 was incomplete, with no indication of consent or refusal for the pneumonia vaccine. The Infection Prevention (IP) nurse acknowledged that the vaccine was not offered due to the incomplete consent form, despite the resident's high-risk status for pneumonia infections due to his health condition. The Director of Nursing (DON) confirmed the importance of offering and administering vaccines to all residents if consented. The facility's policy, revised in October 2023, stated that pneumococcal vaccines should be administered unless medically contraindicated, already given, or refused, in accordance with CDC recommendations. However, the failure to adhere to this policy resulted in the deficiency noted in the report.
Room Size Deficiency in Resident Accommodations
Penalty
Summary
The facility failed to provide the minimum required square footage per resident in four of its 28 resident rooms. Specifically, rooms designated for two residents only provided 71.5 square feet per resident, falling short of the 80 square feet requirement. Additionally, a room accommodating three residents offered only 73.66 square feet per resident, and a room with four residents provided 76 square feet per resident. Despite these deficiencies, the variations in room size were not observed to adversely affect the residents' health, safety, quality of care, or quality of life during the survey. The Department recommended the continuance of the room size variance/waiver for the affected rooms.
Inadequate Privacy Curtains Compromise Resident Privacy
Penalty
Summary
The facility failed to provide adequate visual privacy for a resident, identified as Resident 1, who was admitted with conditions including heart failure and functional quadriplegia, necessitating assistance with personal care. During an observation and interview, it was noted that the privacy curtain for Resident 1's bed did not extend to separate the walkway to the shared bathroom, allowing other residents to potentially view Resident 1 during personal care activities. Resident 1 expressed concerns about the lack of privacy, stating that if her roommate needed to use the bathroom while she was receiving care, the roommate would have a full view of her body due to the inadequate curtain placement. The roommate, identified as Resident 2, confirmed that accessing the bathroom required entering Resident 1's privacy curtain area, which would result in a clear view of Resident 1 during personal care. The Maintenance Director acknowledged the issue, stating that the current curtain setup did not prevent other residents from accessing the shared bathroom without breaching Resident 1's privacy. The director also mentioned that adding a curtain between Resident 1's bed and the walkway to the bathroom would be a simple solution. The facility's policy on confidentiality and personal privacy, revised in October 2017, emphasizes the importance of protecting residents' privacy during personal care, which was not upheld in this instance.
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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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Nursing homes near La Mesa
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Arbor Hills Nursing Center | 0 mi | ★★★★★ | 8 | 0 |
| Country Manor La Mesa Healthcare Center | 0.6 mi | ★★★★★ | 0 | 0 |
| Grossmont Gardens Healthcare Center | 0.6 mi | — | 22 | 0 |
| Community Care Center | 1.2 mi | ★★★★★ | 12 | 0 |
| Grossmont Hospital D/p Snf | 1.2 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.