Average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pelican Ridge Post Acute during CMS and state inspections, most recent first.
A resident on contact isolation for C. diff had active orders for contact precautions and hemodialysis access site monitoring, including dressing changes to a central catheter in the right upper chest. Surveyors observed an RN performing a dressing change in the resident’s room, which was posted with a contact precaution sign and had an isolation cart, while not wearing a gown as required for contact precautions. The RN confirmed awareness of the resident’s contact isolation status and acknowledged that a gown should have been worn, and the DON later confirmed that staff are expected to wear gown and gloves in contact isolation rooms in accordance with infection control practices.
A resident with orders for carvedilol for HTN and midodrine for hypotension had medications inconsistently administered in relation to ordered BP and HR parameters. Review of MARs showed multiple instances where carvedilol was held despite BP/HR not meeting hold criteria or with no vitals documented, and midodrine was both held when BP did not meet the ordered threshold and administered when SBP exceeded the prescribed limit. The DON verified these discrepancies, and the Administrator confirmed that facility policy requires licensed nurses to follow physician orders.
A resident with severe cognitive impairment was started on IV fluid therapy without documentation that her family member was informed of the treatment, its risks, benefits, or alternative options. Nursing staff confirmed the lack of notification and documentation regarding the therapy, and the family member only learned of the IV fluids during a visit.
A resident with severe cognitive impairment was physically abused by another resident with a known history of aggression, resulting in injury. Staff and witness interviews confirmed the incident, but the injured resident was not monitored for 72 hours as required by policy. The aggressive resident had prior episodes of aggression, and documentation of required follow-up, including care conferences and social services consultation, was incomplete.
A resident with severe cognitive impairment and CHF did not have daily weights documented as ordered by the physician, nor was there evidence of refusal. After sustaining a head injury with swelling, the resident's follow-up monitoring and care were not documented, despite facility policy requiring such actions after a change in condition.
A resident with severe cognitive impairment received IV fluids as ordered, but the facility did not develop or implement a care plan to address the use of IV therapy. This omission was confirmed through medical record review and staff interviews, indicating the resident's needs related to IV therapy were not formally addressed.
A resident with terminal CVA and severe cognitive impairment did not have required hospice visits properly documented, as the hospice binder lacked evidence of recent skilled nurse and aide visits. Facility nursing staff did not routinely check or record hospice visits, and hospice staff sometimes failed to sign the binder, leading to a lack of confirmation that ordered hospice care was provided.
A resident with decision-making capacity repeatedly refused ADL care, dialysis, medications, and wound assessments, leading to a surgical wound with sutures going unassessed and untreated for several months. The facility did not develop a care plan to address these refusals, and staff confirmed that the lack of such a plan contributed to missed care and delayed wound management.
A resident's care plan was not updated or reassessed after experiencing two falls, one of which resulted in new skin tears. Despite facility policy and regulatory requirements, the care plan did not reflect the resident's current status or evaluate the effectiveness of interventions. Nursing staff and the DON confirmed the care plan should have been revised following these incidents.
A resident was admitted with a surgical incision and sutures, but the facility did not develop a baseline care plan to address wound care needs as required. The omission was confirmed through medical record review and interviews with the DON and Administrator, resulting in the resident's wound care needs not being met for an extended period.
A resident was admitted with a surgical incision and sutures, but staff failed to assess, monitor, or provide wound care for several months until an outpatient dialysis clinic alerted the facility. The wound and sutures were not addressed in the care plan or progress notes, despite being visible and the resident requiring maximum assistance with ADLs. The DON confirmed that required skin assessments and protocols were not followed.
A resident experienced two falls, but staff did not complete required post-fall assessments, neurological checks, or 72-hour monitoring, and failed to notify the physician and the resident's representative. Facility policy for post-fall care and documentation was not followed, as confirmed by staff interviews and medical record review.
Surveyors found that two residents requiring CPAP therapy did not receive proper respiratory care: one resident's CPAP mask was stored unsanitarily on the floor without a storage bag, and another resident did not have a CPAP machine provided as ordered. Facility staff and leadership confirmed these deficiencies.
Two residents did not receive dialysis care as ordered: one did not attend scheduled hemodialysis sessions at an outpatient center due to unarranged transportation, and another had incorrect documentation of their dialysis access device, with staff and records specifying the wrong type of vascular access. These failures resulted in care not being provided according to physician orders.
The facility did not ensure that nursing staff demonstrated required competencies in skin assessment, resulting in a surgical wound not being assessed or cared for over an extended period. Additionally, a resident did not receive prescribed lidocaine patches for pain management, as staff failed to follow physician orders and facility medication administration policies.
A resident with orders for lidocaine patches for pain management did not receive the prescribed patches on two consecutive days, despite documentation on the MAR indicating administration. The DON confirmed the patches were not applied and remained in the medication cart, and pharmacy records supported that no additional patches were delivered. This resulted in a failure to administer and accurately document pain medication as ordered.
Two residents experienced incomplete and inaccurate documentation in their medical records, including missing and incorrect entries in behavior monitoring and medication administration records. These failures were confirmed by the DON and nursing staff, and contradicted both facility policy and physician orders.
Incomplete informed consent for psychotropic medications: The facility had missing or inaccurate consent documentation for three residents receiving psychotropic meds. One resident's duloxetine consent did not match the physician order and lacked the physician's date, another resident's quetiapine/trazodone consent lacked the resident's signature despite the resident being able to sign, and a third resident's buspirone consent was missing required signatures, with the DON confirming the medication had started before the consent was complete.
Call lights were not kept within reach for three residents. One resident with moderate cognitive impairment and no extremity impairment had a clipped call light hanging off the bed, another resident with moderate cognitive impairment and one-sided extremity impairment had a touch call light on a nightstand he could not reach, and a third resident with decision-making capacity had the call light on the floor. Staff members, including an LVN, RN, and the DON, verified the call lights were not accessible.
A resident with moderately impaired cognitive skills for daily decision making was discharged from Medicare Part A skilled coverage while remaining in the facility, but the record did not show that the written NOMNC or SNF ABN was provided to the resident or representative. The NOMNC and SNF ABN lacked resident/representative signatures, and the BOM confirmed only verbal notification was documented for the NOMNC, with no proof that the written notices were mailed or delivered.
Several residents had psychotropic medication orders, but the MARs and clinical records lacked required documentation for monitoring and related interventions. A resident on buspirone had no documented side-effect monitoring or non-pharmacological interventions, a resident on Risperdal had no AIMS assessment or orthostatic hypotension monitoring, a resident on duloxetine and PRN lorazepam had missing behavior monitoring, non-pharmacological documentation, and no PRN duration, and a resident on quetiapine had no AIMS assessment or orthostatic hypotension monitoring. Staff and the DON verified the missing documentation.
Failure to Care Plan New Heel DTI: A resident developed a DTI on the right heel, but the medical record did not show a care plan was developed for the new skin issue. LVN verified the omission during record review, and the DON stated care plans should be initiated as soon as possible for any change in condition and include goals and interventions specific to the problem.
Failure to Trim Resident’s Fingernails: A resident with moderate cognitive impairment and upper-extremity impairment was dependent on staff for ADL care and had a care plan addressing dry, itchy skin with an intervention to trim and file fingernails as needed. Surveyors observed the resident multiple times with long fingernails on both hands, scratching both arms, and noted dry, flaky skin. The resident said no one had helped trim the fingernails, a CNA confirmed they were long and needed trimming, and the DON verified the observations.
Failure to Provide Ordered Pressure Injury Care and Offloading A resident with diabetes, severe cognitive impairment, and pressure injury risk developed a coccyx pressure injury and a right heel DTI while staff failed to provide the ordered LAL mattress, keep heel protectors in use, or ensure the mattress was set correctly for the resident’s weight. The record also lacked the required shift monitoring, updated care plan, weekly skin assessment, and wound specialist follow-up for the new heel injury. Other residents also did not receive ordered heel offloading devices or properly adjusted LAL mattress settings.
A facility failed to follow GT feeding orders for one resident when the water flush rate was below the ordered amount and the enteral feeding was stopped before the ordered volume was completed. Two other residents receiving continuous tube feedings were observed with the HOB at 20 degrees instead of the ordered 30 to 45 degrees, and staff confirmed the lower positioning during the feedings.
Respiratory care was not consistently provided or documented for several residents receiving O2 or nebulizer therapy. Staff failed to document O2 administration in the MAR for one resident, provided O2 at a higher flow than ordered for another, left a humidifier bottle empty, and did not keep nasal cannulas properly labeled, dated, or stored in set-up bags when not in use. One resident also lacked required O2 signage and a physician order for O2 administration, and a nebulizer storage bag was not changed weekly as expected.
The facility failed to provide accurate dialysis-related care for several residents. A resident with a fluid restriction did not have the order clearly broken down for nursing and dietary staff, fluid intake was inconsistently monitored, and a water pitcher remained at bedside. Dialysis communication forms were incomplete or inaccurate for multiple residents, including missing access assessments and incorrect bruit/thrill documentation. Staff also documented BP on restricted extremities for residents with dialysis access, and one resident’s meds were held on dialysis days without an order to hold or reschedule them.
A facility failed to keep three residents free from unnecessary drugs when meds were given outside ordered parameters and required monitoring was not followed. One resident received metoprolol when BP/HR were below hold parameters and Keflex without documented physician notification for adverse effects; two residents received anticoagulants despite documented bleeding signs, and the records did not show the ordered holds or physician notifications. One resident on apixaban also was not monitored for bleeding as ordered for multiple shifts.
Medication administration errors exceeded the allowed rate, with an observed error rate of 6.9%. An LVN failed to shake nystatin suspension before giving it and instructed a resident to swish and spit instead of swish and swallow as ordered. The same resident’s lansoprazole via GT was not administered because the medication had run out and the nurse had not followed up with the pharmacy.
A resident’s vancomycin, apixaban, and metoprolol doses were repeatedly held on dialysis days without a physician order to hold or reschedule them, and the physician was not notified when the meds were not administered. RN and DON interviews confirmed the missed doses and the lack of hold orders.
The facility failed to keep oral meds separate from external-use products and allowed expired or opened supplies to remain in medication rooms and carts. Staff also found multiple medications and treatment products at residents’ bedsides without documented physician orders, including eye drops, zinc oxide cream, Voltaren gel, dry mouth spray, wound dressing, and saline nasal spray. An RN, LVNs, and the DON acknowledged the findings.
Kitchen sanitation and utensil maintenance deficiencies were identified during survey observation and interview with the DSS. The hood over the stove had black residue, multiple utensils were deformed, chipped, cracked, worn, or peeling, and several items had visible residue or film. Cutting boards were heavily marred with deep grooves, and two clear plastic trays were observed wet and stacked together instead of being air dried.
Multiple infection control failures were observed, including inaccurate HAI surveillance reporting, unsanitary laundry handling, and improper PPE and hand hygiene during resident care. Staff were observed reusing a gown between residents, failing to wear a gown for EBP care, handling a call light without disinfection, performing a blood draw without proper PPE, using a BP cuff without disinfection or hand hygiene, and continuing care after touching curtains without changing gloves or cleaning hands.
Medication documentation and disposal process failures were identified when a resident’s morphine doses were signed out on the CDR but not documented as given on the MAR, and when a medication disposition log showed 31 non-controlled meds disposed of with only one nurse signature instead of two. The DON and MDS Coordinator verified the discrepancies and confirmed the facility’s procedures required matching MAR documentation for controlled meds and two nurse signatures for medication disposal.
The facility failed to ensure its Facility Assessment included active involvement from required individuals, a plan to maximize recruitment and retention of direct care staff, and a contingency plan for staffing needs. During document review, the Administrator verified the assessment lacked input from direct care staff, resident/family representatives, and did not document the required staffing plans, and acknowledged it had not been updated to reflect current CMS guidance.
A resident’s POLST was incomplete because Section D, Information and Signatures, was not filled out. During a concurrent chart review, the SSD verified the omission and stated the resident had a copy of the advance directive in the electronic chart and that the POLST needed to be completed so staff would know how to follow and care for the resident properly. The DON later reviewed and verified the finding.
A resident with multiple complex medical conditions was discharged without documented instructions or education regarding necessary care, including Foley catheter and nephrostomy care. Facility records, including the Post Discharge Plan of Care and Skilled Evaluation Notes, lacked required entries, and staff confirmed that documentation of discharge education was missing.
Two residents with a history of verbal aggression and roommate dissatisfaction were not separated despite repeated complaints and staff awareness, leading to one resident pushing a table that struck the other in the head and caused injury. Staff failed to act on requests for a room change and did not intervene when threats were made, resulting in physical harm.
The facility did not thoroughly investigate an abuse allegation between two residents by failing to interview a roommate who was present during the incident, despite facility policy requiring interviews with all individuals who may have relevant information. The omission was confirmed by both the SSD and Administrator, and the roommate later provided details about the altercation when interviewed by surveyors.
Two residents experienced significant unaddressed weight loss due to the facility's failure to implement timely monitoring, IDT assessment, and required notifications. Despite care plans and physician orders for supplements and weight checks, the facility did not consistently monitor weights, update care plans, or initiate a Change of Condition, resulting in missed interventions for nutrition and hydration.
A facility failed to ensure accurate medical records for a resident's enteral feeding. The resident was ordered Jevity 1.5, but the MAR showed [NAME] Farms 1.4, which the facility did not have. Staff administered Jevity 1.5 but documented it incorrectly, failing to clarify and update the MAR. The DON confirmed these findings.
Two residents with indwelling urinary catheters experienced deficiencies in care at the facility. One resident's catheter drainage bag was observed on the floor, contrary to CDC guidelines, and lacked a care plan for UTI treatment. Another resident experienced frequent catheter leakage, but the physician was not notified, and the catheter size was not clarified. These issues highlight failures in catheter maintenance and communication with physicians.
A resident's POLST indicating a DNR order was not followed when they were found unresponsive, leading to the initiation of CPR. The POLST was not immediately accessible, and CPR was continued at a family member's request, despite the resident's documented wishes. The facility's policy required advance directives to be easily accessible, which was not adhered to.
The facility failed to maintain the nutritive content and palatability of pureed food, as pureed vegetables were held in a hot oven for over an hour, potentially reducing essential nutrients. Additionally, a test tray inspection revealed that the breadstick served was crusty and hard to chew, which was verified by the Kitchen Supervisor and RD Consultant.
The facility failed to ensure food safety and sanitation in the kitchen, as observed during a survey. Opened food items in the freezer were not labeled or dated, leading to freezer burn, and food preparation equipment was not properly air-dried before storage. Additionally, a cutting board was heavily marred, making it difficult to clean and sanitize. The Kitchen Supervisor acknowledged these issues.
The facility failed to conduct regular inspections and entrapment assessments for bed safety, affecting several residents using side rails or halo grab bars. The Maintenance Director did not perform routine checks or assess all necessary zones for entrapment risks, as required by policy. Residents with cognitive impairments and mobility issues were at risk due to these oversights.
The facility's call light system was found to be deficient in multiple rooms, with issues such as non-functioning lights and lack of audible alerts at nursing stations. These deficiencies were confirmed through observations and staff interviews, highlighting a failure to adhere to the facility's policy for reporting and documenting defective call lights.
A resident did not receive necessary medical care due to the facility's failure to coordinate and document appointments with an infectious disease physician and an oncologist. The appointments were either marked as completed without evidence or discontinued without scheduling, as confirmed by staff interviews.
A facility failed to renew informed consent for a resident prescribed Seroquel, as required by the Nursing Facility Resident Informed Consent Protection Act of 2023. The resident, unable to make decisions, had no updated consent for the medication, which was confirmed by an LVN and the DON during a survey.
The facility failed to ensure call lights were within reach for two residents, potentially delaying their ability to request assistance. One resident, capable of using the call light, was found with it clipped to the wall, while another had it under a pillow after a therapy session. Both residents expressed needs that could not be promptly addressed due to the inaccessibility of the call lights.
Failure to Use Required PPE for Resident on Contact Isolation for C. diff
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff followed its infection prevention and control program and CDC guidance for contact precautions for a resident on isolation for Clostridioides difficile (C. diff). The facility’s policy titled “Infection Surveillance” (revised 12/2022) stated that infection surveillance is a core activity of the infection prevention and control program, intended to identify infections and monitor adherence to infection prevention practices to reduce and prevent the spread of infections. CDC guidance for Transmission-Based Contact Precautions (dated 4/2024) requires the use of appropriate PPE, including wearing a gown and gloves for all interactions that may involve contact with the resident or the resident’s environment when the resident has an infection that poses increased risk for contact transmission. Resident 3 was admitted on an unspecified date and had physician orders dated 2/18/26 for contact precautions related to C. diff and for hemodialysis access site monitoring for a central catheter in the right upper chest, with dressing changes at the dialysis center and as needed every shift, and monitoring for signs and symptoms of infection. The resident’s H&P dated 2/25/26 documented that the resident had capacity to make medical decisions. On 3/12/26 at 1617, surveyors observed a contact precaution sign and isolation cart outside the resident’s room, while RN 1 was inside the room kneeling at the bedside performing a dressing change on the resident’s dialysis site without wearing a gown. In a subsequent interview, RN 1 confirmed the resident was on contact isolation for C. diff, acknowledged she was not wearing a gown, and stated she should have worn one, noting that contact precautions include donning a gown and gloves. The DON later verified the resident was on contact isolation for C. diff and stated she expected staff to wear gowns and gloves in contact isolation rooms and that proper PPE use ensures infection control is maintained. The Administrator and DON acknowledged the findings during interview.
Failure to Follow Physician Parameters for Antihypertensive and Vasopressor Medications
Penalty
Summary
Surveyors identified a failure to provide pharmaceutical services in accordance with physician orders for one resident who had capacity and was readmitted to the facility in late November. The facility’s policy on medication administration required that medications be given according to written physician orders. The resident had orders for carvedilol 3.125 mg twice daily for hypertension, to be held only if systolic blood pressure (SBP) was less than 100 mmHg or heart rate was less than 60, and for midodrine (initially 2.5 mg, later increased to 5 mg) twice daily for hypotension, to be held if SBP exceeded specified thresholds (greater than 130 mmHg, later greater than 140 mmHg). Review of the MARs for December and January showed multiple instances where these parameters were not followed. In December, carvedilol was held on several occasions when documented BP and heart rate did not meet the ordered hold parameters, and in multiple instances the drug was held with no vital signs documented at all. Midodrine was held once when the BP was 127/71, which did not meet the ordered hold parameter, and was administered on several occasions when the recorded SBP exceeded the ordered threshold (e.g., SBP 145 and 152). Similar issues continued into January, with carvedilol held when vital signs did not meet hold criteria and with missing heart rate documentation, and midodrine both held without any documented vital signs and administered when SBP was above the ordered limit. During interviews, the DON verified these findings, and the Administrator acknowledged that facility policy required licensed nurses to follow physician orders.
Failure to Inform Resident and Family of IV Therapy and Alternatives
Penalty
Summary
The facility failed to ensure that a resident and her family member were fully informed about the initiation of intravenous (IV) fluid therapy, including the risks, benefits, and alternative treatment options. The resident, who had severe cognitive impairment as indicated by a BIMS score of 6, was started on Dextrose Intravenous Solution 5% per physician orders. Medical record review showed no documentation that the family member was notified about the IV therapy, its potential effects, or provided with alternative options prior to administration. During interviews, the family member confirmed that she was not informed about the IV fluids and only became aware of the therapy upon visiting the resident. Nursing staff verified that the IV fluids were administered and acknowledged the lack of documentation regarding the indication for the therapy and the absence of family notification. The Director of Nursing was made aware of these findings and acknowledged the deficiency.
Failure to Protect Resident from Physical Abuse and Inadequate Post-Incident Monitoring
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident. One resident, who was severely cognitively impaired, was sitting in the activities room when another resident, who had a documented history of aggression, hit the first resident on the right hand, resulting in visible redness. Witnesses, including another resident and an activities assistant, confirmed the incident, and a licensed vocational nurse assessed the injury. However, the medical record did not show evidence that the injured resident was monitored for 72 hours post-incident, as required by facility policy. The resident who committed the abuse had a care plan indicating the use of psychotropic medication for bipolar disorder with a history of verbal and physical aggression. Previous documentation showed this resident had been involved in another physical altercation with a different resident and had multiple episodes of aggression toward staff. Despite these incidents, the medical record lacked documentation of a change in condition, progress notes, or notification to the family and physician for the earlier aggressive episode. Interviews with staff, including CNAs, LVNs, and the DON, confirmed that the resident with a history of aggression was not consistently monitored or documented according to policy after incidents. Additionally, a recommended social services consultation for the aggressive resident was not documented as completed. The facility's failure to follow its own policies for monitoring, documentation, and intervention after abuse incidents contributed to the deficiency.
Failure to Document and Provide Ordered Care Following Change in Condition
Penalty
Summary
The facility failed to provide necessary care and services for a resident with severe cognitive impairment who had a physician's order for daily weights for three days due to CHF. Medical record review showed there was no documentation that daily weights were obtained or that the resident refused to be weighed, as required by the physician's order. Interviews with nursing staff confirmed the absence of documentation regarding the daily weights or any refusals by the resident. Additionally, after the resident sustained a bump on the head resulting in a lump with swelling, the facility did not document monitoring, care, or safety measures provided following the incident. Although the resident was observed with the injury and the physician ordered a hospital evaluation, the resident remained in the facility after paramedics determined transfer was not necessary. There was no evidence in the medical record of follow-up monitoring or documentation of the resident's condition after the injury, despite facility policy requiring such documentation for changes in condition or extraordinary events.
Failure to Develop Care Plan for IV Therapy
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan to address the use of intravenous (IV) fluids for one resident. Medical record review showed that the resident, who had severe cognitive impairment as indicated by a BIMS score of 6, was admitted and subsequently received orders for Dextrose Intravenous Solution 5% and Dextrose Intravenous Solution 5% with multivitamin. The IV fluids were administered as ordered, with documentation confirming administration on specific dates. Despite the administration of IV therapy, there was no evidence in the resident's medical record that a care plan was developed to address this intervention. This was verified during interviews with both an RN and the DON, who acknowledged the absence of a care plan for the resident's IV therapy. The lack of a documented care plan meant that the resident's individual needs related to IV therapy were not formally identified or addressed in the care planning process.
Failure to Coordinate and Document Hospice Services
Penalty
Summary
The facility failed to ensure proper coordination and documentation of hospice services for one resident with a terminal diagnosis of cerebrovascular disease and severe cognitive impairment. The resident had physician orders for hospice care, including skilled nurse visits once a week and hospice aide visits twice a week. However, review of the hospice binder and sign-in sheets revealed that the last documented hospice aide visit was nearly two months prior, and the last skilled nurse visit was several weeks prior to the review. There was no evidence in the hospice binder to confirm that the required visits were being completed as ordered. Interviews with facility nursing staff, including an RN and an LVN, revealed that they did not routinely check or document hospice visits in the resident's records. The RN stated it was not her responsibility to monitor the hospice binder, and the LVN indicated she was unaware of previous hospice visits if she was not on duty. Both acknowledged the importance of documentation and the potential for missed care if visits were not tracked. The hospice case manager also confirmed that while she documented visits in the hospice provider's electronic health record, she did not always sign the facility's hospice binder due to its unavailability and did not record which facility nurse she checked in with during visits. Further, the hospice patient care manager stated that all hospice disciplines were required to sign in the hospice binder after each visit, and that case managers were responsible for ensuring all scheduled visits were completed and documented. The facility's DON expected charge nurses to document hospice visits and to check the hospice binder for compliance. Despite these expectations, there was a lack of documented evidence in the hospice binder to show that the resident received the ordered hospice services, and facility leadership acknowledged these findings during the survey.
Failure to Develop and Implement Care Plan for Resident Refusals
Penalty
Summary
A deficiency was identified when the facility failed to develop and implement a comprehensive, person-centered care plan for a resident who frequently refused multiple aspects of care. The resident, who was admitted with a surgical wound and had the capacity to make decisions, repeatedly refused activities of daily living (ADL) care, dialysis, medications, repositioning, and skin and wound assessments. These refusals were documented in the medical record and confirmed by both the Wound Care Nurse and the Director of Nursing (DON). Despite the resident's ongoing refusals, the care plan did not address these behaviors or outline strategies to manage or respond to the refusals. The lack of a care plan problem related to the resident's refusals resulted in the surgical wound with sutures not being assessed, monitored, or cared for until several months after admission. The wound and sutures were only discovered and addressed after a significant delay, during which the resident also developed other unrelated wounds. Interviews with facility staff, including the Wound Care Nurse and the DON, confirmed that the resident's refusals were not incorporated into the care plan. The DON acknowledged that the absence of a care plan addressing the refusals contributed to the missed assessment and care of the surgical wound. The deficiency was verified through medical record review, staff interviews, and direct observation of the resident refusing care.
Plan Of Correction
F0656 - Develop and Implement Comprehensive Person-Centered Care Plan Immediate Corrective Action: On September 2, 2025, a treatment care plan was developed for Resident #10 for multiple refusals. Residents Affected: On September 2, 2025, the RN Supervisor reviewed all residents with refusals to ensure that care plans were developed, reviewed, updated, and revised. No other residents were affected. Corrective Action: Licensed nurses were in-serviced by the DON, beginning on September 3, 2025, on the process for developing, reviewing, and updating care plans for refusals care plan. Monitoring of Corrective Action: The DON or their designee will review care plans for all new and all wounds in the weekly wound meeting to verify compliance. If deficiencies are identified, the DON or their designee will immediately revise the care plan. The results of these audits will be presented to the QAPI Committee on a quarterly basis for further monitoring and/or action planning as needed. Completion Date: 10/25/2025
Failure to Revise Care Plan After Multiple Falls
Penalty
Summary
The facility failed to revise and reassess the care plan for a resident following two separate fall incidents. The resident, who had a documented risk for falls and a care plan addressing this risk, experienced falls on two occasions, resulting in new skin tears during one of the incidents. Despite these events, the care plan was not updated to reflect the resident's current status or to reassess the effectiveness of existing interventions, as required by facility policy and federal regulations. Interviews with registered nurses and the Director of Nursing confirmed that the care plan was not revised after the falls, and that it should have been updated to guide staff in providing appropriate care. The facility's policies also require documentation and care plan updates following such incidents, but these actions were not taken in this case.
Plan Of Correction
F0657 - Care Plan Timing and Revision Immediate Corrective Action: On 09/25/2025 and 09/26/2025, a fall care plan was developed and updated for Resident #08. Residents Affected: On 09/25/2025, the RN Supervisor reviewed all residents with falls to ensure that care plans were developed, reviewed, updated, and revised. No other residents were affected. Corrective Action: Licensed nurses were in-serviced by the DON, beginning on September 17th, 2025, on the process for developing, reviewing, and updating care plans for falls. Monitoring of Corrective Action: The DON or their designee will review care plans for all new and recent falls during IDT meetings. If deficiencies are identified, the DON or their designee will immediately revise the care plan. The results of these audits will be presented to the QAPI Committee on a quarterly basis for further monitoring and/or action planning as needed. Completion Date: 10/25/2025
Failure to Develop Baseline Care Plan for Surgical Wound
Penalty
Summary
The facility failed to develop and implement a baseline care plan that addressed the specific care needs of a resident who was admitted with a surgical wound. Upon admission, the resident had a surgical incision on the left lateral thoracic region with three sutures, as documented in the transfer orders from the acute care hospital. These orders included instructions to follow the wound team's recommendations and standard nursing protocols for wound care. Despite these clear instructions, the baseline care plan for the resident did not include a problem or interventions related to the surgical wound. There was no evidence that the facility assessed, monitored, or provided wound care for the surgical incision within 48 hours of admission, as required by regulation. The omission was confirmed during interviews and medical record reviews with the Director of Nursing (DON) and the Administrator, who both verified that the baseline care plan did not address the resident's surgical wound with sutures. As a result, the resident's care needs related to the surgical wound were not met from the time of admission until several months later. This failure was identified through medical record review and staff interviews, and it was determined that the lack of a baseline care plan for the surgical wound had the potential to affect the resident's well-being.
Plan Of Correction
F0655 - Baseline Care Plan Immediate Corrective Action: On 09/02/2025, a treatment care plan was developed for Resident #10 Surgical site. Residents Affected: On 09/02/2025, the RN Supervisor reviewed all residents with pressure injuries and surgical sites from wound report to ensure that care plans were developed, reviewed, updated, and revised. No other residents were affected. Corrective Action: Licensed nurses were in-serviced by the DON, beginning on September 3rd, 2025, on the process for developing, reviewing, and updating care plans for surgical sites. Monitoring of Corrective Action: The DON or their designee will review care plans for all new and all wounds in the weekly wound meeting to verify compliance. If deficiencies are identified, the DON or their designee will immediately revise the care plan. The results of these audits will be presented to the QAPI Committee on a quarterly basis for further monitoring and/or action planning as needed. Completion Date: 10/25/2025
Failure to Assess and Provide Care for Surgical Wound with Sutures
Penalty
Summary
A deficiency occurred when the facility failed to assess, monitor, and provide care for a surgical incision with sutures for one resident admitted from an acute care hospital. The resident was admitted with a surgical incision on the left lateral thoracic region, which had three stitches and an intact dressing. Transfer orders from the hospital specified that wound care should follow current recommendations and standard nursing protocols. The admission skin assessment documented the presence of the surgical incision and dressing, but subsequent progress notes indicated that the skin issue had not been evaluated. From admission until several months later, there was no evidence that the facility assessed or monitored the surgical wound, nor was there a baseline care plan developed to address the wound or the presence of sutures. The omission persisted until the resident's outpatient dialysis clinic notified the facility about the sutures, prompting the wound care nurse to assess the site and remove the stitches. Interviews confirmed that the wound was in a location easily visible during routine care, and the resident required maximum assistance with activities of daily living, making the oversight notable. The Director of Nursing verified that licensed nurses were required to perform full skin assessments on admission, readmission, and weekly if no concerns were present, and that direct care staff were expected to assess skin during bathing, changing, or repositioning. The facility's failure to follow these protocols resulted in a delay in identifying and providing care for the surgical incision and sutures, as confirmed by both the DON and the administrator.
Plan Of Correction
F0684-- Quality Of Care Immediate Corrective Action: On 09/02/2025, treatment care was initiated immediately for Resident #10 Surgical site. Residents Affected: On 09/02/2025, the RN Supervisor reviewed all residents' wounds to ensure that treatment care, orders, and care plans were developed, reviewed, updated, and revised. No other residents were affected. Corrective Action: Licensed nurses were in-serviced by the DON, beginning on September 3rd, 2025, on the process for immediately initiating treatment care and orders, developing, reviewing, and updating care plans for wounds and surgical sites. Monitoring of Corrective Action: The DON or their designee will review treatment orders for all new and all wounds in the weekly wound meeting to verify compliance. If deficiencies are identified, the DON or their designee will immediately revise the care plan. The results of these audits will be presented to the QAPI Committee on a quarterly basis for further monitoring and/or action planning as needed. Completion Date: 10/25/2025 Residents Affected: On 09/02/2025, the RN Supervisor reviewed all residents' wounds to ensure that treatment care, orders, and care plans were developed, reviewed, updated, and revised. No other residents were affected. Corrective Action: Licensed nurses were in-serviced by the DON, beginning on September 3rd, 2025, on the process for immediately initiating treatment care and orders, developing, reviewing, and updating care plans for wounds and surgical sites. Monitoring of Corrective Action: The DON or their designee will review treatment orders for all new and all wounds in the weekly wound meeting to verify compliance. If deficiencies are identified, the DON or their designee will immediately revise the care plan. The results of these audits will be presented to the QAPI Committee on a quarterly basis for further monitoring and/or action planning as needed. Completion Date: 10/25/2025 F0684
Failure to Complete Post-Fall Assessments and Notifications
Penalty
Summary
The facility failed to provide necessary care and services to a resident who experienced two falls, as required by federal regulations and the facility's own policies. After the resident was found on the floor on two separate occasions, there was no documented assessment of the resident's change in condition, no neurological assessments, and no post-fall assessments completed. Additionally, the required 72-hour post-fall monitoring and documentation were not performed following either incident. Pain and skin assessments were also missing after the respective falls, and there was no evidence of an interdisciplinary team (IDT) review or update to the resident's care plan. The facility did not notify the resident's physician or the resident's representative after the falls, as mandated by policy. Interviews with nursing staff and the Director of Nursing (DON) confirmed that these notifications and assessments were not completed. The DON and staff provided inconsistent definitions of what constituted a fall, with some initially not considering the incidents as falls due to the resident's behavior of getting up unassisted, despite later acknowledging that being found on the floor should be classified as a fall. Review of the facility's policies indicated clear requirements for post-fall assessment, documentation, and notification, which were not followed in these cases. The lack of proper documentation and follow-up assessments had the potential to delay identification and treatment of possible fall-related injuries and posed a risk for additional falls and injury to the resident. The findings were verified through medical record review and staff interviews, which confirmed the absence of required documentation and follow-up actions after the resident's falls.
Plan Of Correction
F0689 - Free of Accident Hazards/Supervision/Devices Immediate Corrective Action: On 09/23/2025 and 09/25/2025, change of condition, neurocheck, care plan, post fall assessment initiated and MD and responsible party was notified. Residents Affected: On 09/23/2025, the RN Supervisor reviewed all residents with falls to ensure that change of condition, neurochecks, care plan, post fall assessment initiated and MD and responsible party was notified. No other residents were affected. Corrective Action: Licensed nurses were In-serviced by the DON, beginning on September 15th, 2025, on the process for all residents with witnessed or unwitnessed falls. Monitoring of Corrective Action: The DON or their designee will review all witnessed and unwitnessed falls in 24 hours to ensure all steps have been taken. If deficiencies are identified, the DON or their designee will immediately revise the care plan. The results of these audits will be presented to the QAPI Committee on a quarterly basis for further monitoring and/or action planning as needed. Completion Date: 10/25/2025 Corrective Action: Licensed nurses were In-serviced by the DON, beginning on September 15th, 2025, on the process for all residents with witnessed or unwitnessed falls. Monitoring of Corrective Action: The DON or their designee will review all witnessed and unwitnessed falls in 24 hours to ensure all steps have been taken. If deficiencies are identified, the DON or their designee will immediately revise the care plan. The results of these audits will be presented to the QAPI Committee on a quarterly basis for further monitoring and/or action planning as needed. Completion Date: 10/25/2025 F0695 - Respiratory/Tracheostomy Care and Suctioning Immediate Corrective Action: On September 19th, 2025, the RN Supervisor changed the tubing for Resident #4's CPAP and properly labeled/stored the tubing.
Failure to Provide and Maintain CPAP Therapy for Two Residents
Penalty
Summary
The facility failed to provide necessary respiratory care and services for two residents requiring CPAP therapy. For one resident with a physician's order for nightly CPAP use due to sleep apnea, the CPAP mask was observed on the floor, and there was no designated bag available in the room for sanitary storage. During an interview, an LVN confirmed the absence of a storage bag and acknowledged the infection risk associated with the mask being on the floor. The Director of Nursing also verified that the mask should not have been on the floor. For another resident, also with a physician's order and care plan for nightly CPAP use to treat obstructive sleep apnea, there was no CPAP machine present in the room. The resident reported not having received a CPAP machine since admission. Both an RN and the Director of Nursing confirmed the absence of the CPAP machine and that the resident was not receiving the prescribed treatment. These findings were acknowledged by facility leadership.
Plan Of Correction
Residents Affected: On 9/19/2025, all residents on CPAP were observed by the RN Supervisor to verify compliance. No other residents were affected. Corrective Action: Licensed staff were inservice re-educated on respiratory care procedures by the DON on 09/19/2025 on the facility policy and procedure, for oxygen administration/CPAP. Monitoring of Corrective Action: The DON or their designee will perform daily room rounds to verify compliance with the CPAP administration policy and procedure. Identify deficient practices will be corrected by the DON or designee. The results of these audits will be presented to the QAPI Committee on a quarterly basis for further monitoring and/or action planning as needed. Completion Date: 10/25/2025 --- F0698-Dialysis Care and Services Immediate Corrective Action: Resident #10, #18-DON began inservicing licensed nurses on proper documentation pre and post dialysis, correct access site on 09/23/25, and ensuring that resident receive dialysis treatment from outpatient center 09/23/25. Resident #10-DON began inservicing licensed nurses on proper documentation of the dialysis site 09/23/25. Residents Affected: All dialysis residents were assessed and their communication forms were completely filled out with accurate site and information on 09/23/25. No other residents were affected. Corrective Action: Nursing staff were re-educated / in-service by the DON on 09/23/2025 on policy and procedure for dialysis care, ensuring that the resident receive dialysis treatment from outpatient center and proper documentation of the dialysis site. Monitoring of Corrective Action: The DON or their designee will perform weekly audits on dialysis residents to ensure policy and procedure on dialysis care is followed and proper documentation for the access sites, monitoring to ensure that resident receive dialysis treatment from outpatient center.
Failure to Provide and Document Dialysis Care as Ordered
Penalty
Summary
The facility failed to ensure that dialysis care was provided according to physician orders and professional standards for two residents. For one resident, the facility did not ensure that the resident received scheduled hemodialysis treatments at an outpatient dialysis center as ordered by the physician. Medical record reviews and staff interviews confirmed that the resident did not leave the facility for dialysis on multiple scheduled days, and the dialysis center administrator verified that the resident was not dialyzed during the relevant period. The facility's own investigation concluded that the resident missed scheduled dialysis sessions, and the reason for the missed appointments was not documented, though it was noted that transportation could not be arranged. For another resident, the facility failed to accurately assess and document the resident's dialysis access site as ordered by the physician. The resident, who had end-stage renal disease and a Perma-Cath in the left thigh, had physician orders and communication records incorrectly specifying the access device as a Port-A-Cath, which is a different type of vascular access typically implanted in the chest wall. The DON confirmed that the physician's order was incorrect and that the resident's actual access was a Perma-Cath. These failures resulted in the residents not being provided with appropriate care and treatment as ordered by their physicians. The facility's policies required nursing care for dialysis residents to be provided in accordance with physician orders, but this was not followed in these cases, as evidenced by the missed dialysis treatments and incorrect documentation of dialysis access.
Plan Of Correction
Identified deficiencies will be corrected immediately by designee. The results of these audits will be presented to the QAPI Committee on a quarterly basis for further monitoring and/or action planning as needed. Completion Date: 10/25/2025
Deficiencies in Nursing Competency and Medication Administration
Penalty
Summary
The facility failed to ensure that both licensed nurses and CNAs possessed and demonstrated the required competencies and skill sets necessary to provide safe and effective nursing care, specifically in the area of skin assessment. One resident was admitted with a surgical incision that required monitoring and care, as indicated in the transfer orders and admission skin assessment. Despite the presence of a visible surgical wound, the facility staff did not assess, monitor, or provide care for the wound from the date of admission until several months later, when the issue was identified by an outside dialysis clinic. Multiple staff members, including licensed nurses and CNAs, provided care to the resident during this period but failed to perform the required skin assessments or document the condition of the wound. Interviews with the Director of Staff Development (DSD) and the Director of Nursing (DON) confirmed that the facility's competency checklists for both CNAs and licensed nurses did not include skin assessment, even though it was a required competency. Both the DSD and DON acknowledged that the omission of skin assessment from the competency evaluations contributed to the failure of multiple staff members to assess and document the resident's surgical wound as required. The lack of proper assessment and documentation persisted until the wound was finally evaluated and the sutures were removed months after admission. Additionally, the facility failed to follow physician's orders regarding medication administration for another resident. Specifically, the facility did not administer lidocaine patches as prescribed for pain management. Review of facility policies and procedures confirmed that medications are to be administered only upon clear, complete, and signed orders from authorized prescribers, and in accordance with written orders. However, the facility did not comply with these requirements, resulting in the resident not receiving the ordered medication.
Plan Of Correction
F0726 - Competent Nursing Staff Immediate Corrective Action: On 09/02/2025, a treatment care plan was developed for Resident #10 Surgical site. All Licensed Competency Skill Checks were initiated immediately. Residents Affected: On 09/02/2025, the RN Supervisor reviewed all residents with pressure injuries and surgical sites to ensure that care plans were developed, reviewed, updated, and revised. No other residents were affected. Corrective Action: Licensed nurses were in-serviced by the DON, beginning on September 3rd, 2025, on the process for developing, reviewing, and updating care plans for surgical sites, and skills competency. Monitoring of Corrective Action: The DON or their designee will review care plans for all new and all wounds in the weekly wound meeting the same week to verify compliance and continue with skill competency every month. If deficiencies are identified, the DON or their designee will immediately revise the care plan. The results of these audits will be presented to the QAPI Committee on a quarterly basis for further monitoring and/or action planning as needed. Completion Date: 10/25/2025 --- P0755 - Pharmacy Services/Procedures/Pharmacist/Records Immediate Corrective Action: On 09/03/25 - In accordance with the facility's general documentation guidelines, Lidocaine patch administration was recorded on the MAR for Resident #11. All medication errors for the residents identified in the citation were immediately corrected, the physician was notified, and residents were assessed for adverse outcomes. On 09/03/2025 - In accordance with the facility's general documentation guidelines, a count sheet was created to ensure all Lidocaine patches are administered. Residents Affected: On 09/04/2025, the RN Supervisor and designee reviewed the MAR and ensured all Lidocaine patches were administered. No residents were identified as being affected at this time. Corrective Action: All licensed nursing staff were re-educated/inservice on safe medication administration practices, including the "5 Rights" (right resident, right drug, right dose, right route, and right time). Monitoring of Corrective Action: The DON or their designee will perform weekly med pass observations for 12 weeks, focusing on safe practices and documentation accuracy, and review medication disposition record logs to verify compliance. Visual checks will be conducted to ensure patches have been applied to the residents. The results of these audits will be presented to the QAPI Committee on a quarterly basis for further monitoring and/or action planning as needed. Completion Date: 10/25/2025
Failure to Administer and Accurately Document Pain Medication
Penalty
Summary
Resident 11, who had the capacity to make medical decisions, was readmitted to the facility and had physician orders for two types of lidocaine patches: Asperflex Lidocaine 4.0% to be applied to the lower back and Lidoderm 5% to be applied to the right hip, both for pain management. The facility's policies required medications to be administered as prescribed, documented immediately after administration, and not pre-poured or shared between residents. Medical records indicated that the patches were documented as administered and removed at scheduled times on multiple days. However, direct observation and interviews revealed that Resident 11 did not receive the lidocaine patches on two consecutive days, despite documentation on the MAR indicating otherwise. The DON confirmed that the patches were not applied and that the medication cart still contained the full supply of patches, which had not been refilled or used as documented. The discrepancy was further verified by pharmacy records and staff interviews, confirming that the resident did not receive the prescribed pain management as ordered.
Plan Of Correction
- Disposition record logs to verify compliance. Visual checks that patches have been applied to the residents. The results of these audits will be presented to the QAPI Committee on a quarterly basis for further monitoring and/or action planning as needed. Completion Date: 10/25/2025
Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to ensure that medical records were complete and accurate for two residents. For one resident, a physician's order required monitoring and documentation of the number of times the resident attempted to get up unassisted each shift. However, the Monitor Record for this resident had missing entries on several dates and inaccurately recorded zero incidents on days when the resident had actually gotten up unassisted and experienced unwitnessed falls. The Director of Nursing (DON) and a registered nurse confirmed these omissions and inaccuracies, acknowledging that the documentation was not completed as required. For another resident, there were physician's orders for the application and removal of two different lidocaine patches for pain management. The Medication Administration Record (MAR) indicated that the patches were applied and removed as ordered on specific dates and times. However, during an interview, the resident reported not receiving the patches on two days, and the DON confirmed that the patches had not been applied despite being documented as administered on the MAR. These documentation failures were verified through interviews, record reviews, and observations. The facility's own policies required accurate and timely documentation of clinical findings and medication administration, but these were not followed in the cases reviewed. The deficiencies had the potential to result in unmet care needs for the affected residents due to inaccurate medical records.
Plan Of Correction
F0842-Resident Records - Identifiable Information Immediate Corrective Action: On 09/03/25 - In accordance with the facility's general documentation guidelines, Lidocaine patch administration was recorded on the MAR and monitoring getting up unassisted for Resident #8 & #11. All medication errors for the residents identified in the citation were immediately corrected, the physician was notified, and residents were assessed for adverse outcomes. On 09/03/2025 - In accordance with the facility's general documentation guidelines, a count sheet was created to ensure all Lidocaine patches are administered. Residents Affected: On 09/04/2025, the RN Supervisor and designee reviewed the MAR to ensure all Lidocaine patches were administered, complete, accurate, and properly stored. No residents were identified as being affected at this time. Corrective Action: All licensed nursing staff were re-educated/inservice on safe medication administration practices, including the "5 Rights" (right resident, right drug, right dose, right route, and right time). All resident records were audited by the Medical Records Director and DON to verify accuracy, completeness, and proper storage on 09/04/2025. Monitoring of Corrective Action: The DON or their designee will audit 5 random resident records weekly for 4 weeks, then Q2 monthly for 6 months to ensure compliance, focusing on safe practices, documentation accuracy, and proper storage and handling of medication. The results of these audits will be presented to the QAPI Committee on a quarterly basis for further monitoring and/or action planning as needed.
Incomplete informed consent for psychotropic medications
Penalty
Summary
The facility failed to obtain complete and accurate informed consent for psychotropic medications for three residents. The facility's policy required informed consent for medical services that require it, and the report identified missing or incomplete consent documentation for duloxetine, quetiapine, trazodone, and buspirone. The deficiencies involved missing physician dates, missing resident signatures, and missing physician, resident/resident representative, and licensed nurse signatures on consent forms. For one resident with a BIMS score of 9 and a diagnosis of depression manifested by verbalization of sadness, the physician order for duloxetine did not match the medication information written on the informed consent, and the consent lacked a date next to the physician's signature. The resident was receiving duloxetine from the date of the order, and both an RN and the DON confirmed the mismatch between the order and the consent, as well as the missing physician date. For another resident who had capacity to understand and make decisions, the record showed orders for quetiapine for psychosis and trazodone for inability to sleep. The informed consent was signed by the physician but did not contain the resident's signature, and staff and the resident confirmed the resident should have signed her own consent. For a third resident receiving buspirone for anxiety manifested by restlessness, one consent form was undated and lacked all required signatures, while another consent signed by the physician still lacked the resident/resident representative and two licensed nurses' signatures. The DON confirmed the resident had started the medication before the consent was complete and stated the facility had been unable to contact the resident's representative.
Call Lights Not Kept Within Residents’ Reach
Penalty
Summary
The facility failed to provide reasonable accommodations by not keeping call lights within reach for three residents. Facility policy stated call lights should be within the resident’s reach and used to communicate unmet needs. Resident 1 was observed in bed with the call light cord clipped and the button hanging on the left side of the mattress, and the resident stated he needed it to call staff for lotion but could not reach it. LVN 16 later verified the call light was not within Resident 1’s reach. Resident 1’s record showed moderate cognitive impairment and no impairment to the upper or lower extremities, with assistance needs for hygiene, dressing, bathing, and footwear. Resident 2 was observed in bed with a touch call light on the nightstand on the left side of the bed, and the resident stated the table was blocking his view of the door and he could not reach the call light. RN 4 verified the call light was not within reach. Resident 2’s record showed moderate cognitive impairment and impairment on one side of the upper and lower extremities. Resident 8 was observed in bed with the call light on the floor on the right side of the bed, and the resident stated she could not find it and would fall out of bed if she tried to reach it. LVN 1 verified the call light was on the floor and not within reach. Resident 8’s record showed capacity to understand and make decisions, and the care plan included keeping the call light within reach for behavior monitoring related to getting up out of bed unassisted.
Failure to Provide Written Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to provide the written Notice of Medicare Non-coverage (NOMNC) form CMS-10123 and the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) form CMS-10055 for Resident 7, who was reviewed for beneficiary notification. Resident 7 was admitted and later readmitted to the facility, and the MDS assessment showed moderately impaired cognitive skills for daily decision making. The facility’s Beneficiary Notice-Residents discharged Within Last Six Months showed Resident 7 was discharged from Medicare Part A skilled coverage while remaining in the facility, and the SNF Beneficiary Notification Review showed the facility initiated the discharge even though benefit days were not exhausted. The NOMNC for Resident 7 showed the effective date for the end of skilled nursing service coverage, but there was no entry for the resident’s or representative’s signature. The document indicated the representative was notified by telephone and that a copy would be mailed, but the medical record did not show that a written copy was provided. The SNF ABN also lacked the signature of the resident or representative, and the medical record did not show that a copy of the ABN was provided when Resident 7 was discharged from Medicare Part A services and remained in the facility. The Business Office Manager verified that the resident’s representative was verbally notified of the NOMNC, but there was no documentation that the written NOMNC or SNF ABN had been provided.
Psychotropic Medication Monitoring and Documentation Deficiencies
Penalty
Summary
The facility failed to ensure several residents reviewed for unnecessary psychotropic medications were monitored and documented as required. The deficiency involved Residents 3, 8, 86, and 154, whose records showed psychotropic medication orders but lacked required documentation for monitoring, non-pharmacological interventions, or medication parameters. The report states these failures had the potential for adverse effects from the psychotropic medications, inaccuracy of monitoring and assessing, and unnecessary use of the psychotropic medications. Resident 154 had an order for buspirone 5 mg twice daily for anxiety manifested by restlessness. Review of the resident’s monitoring record and MAR for August 2025 failed to show documented evidence of monitoring for side effects of buspirone or documentation of non-pharmacological interventions. An RN and the DON both verified the findings and acknowledged that side effects and non-pharmacological interventions should have been assessed and documented. Resident 3 had an order for Risperdal 0.5 mg at bedtime via GT for schizophrenia manifested by screaming and disruptive noises, with listed non-pharmacological interventions. The record failed to show documented evidence that an AIMS assessment was conducted or that the resident was monitored for orthostatic hypotension. Staff interviews confirmed there was no monitoring of the side effect and that the AIMS assessment was not being done. The DON verified the facility was not monitoring for orthostatic hypotension or conducting an AIMS assessment for Risperdal. Resident 8 had an order for duloxetine 40 mg daily for depression and an order for lorazepam 0.5 mg every six hours as needed for anxiety manifested by agitation, but the PRN order had no duration. The MAR did not show non-pharmacological interventions documented for duloxetine, and it did not show monitoring of behavior for depression. Staff and the DON verified the missing documentation, and the DON stated that if the MAR showed only a signature without a number for the non-pharmacological intervention, it meant the intervention was not done. Resident 86 had an order for quetiapine fumarate 100 mg three times daily for psychosis manifested by agitation, but the record failed to show an AIMS assessment or orthostatic hypotension monitoring. Staff interviews and the DON confirmed those assessments were not being completed.
Failure to Care Plan New Heel DTI
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident 138 after the resident developed a deep tissue injury (DTI) in the right heel. Review of the medical record showed Resident 138 was admitted to the facility and had fluctuating capacity but could make needs known. An eINTERACT Change in Condition Evaluation dated 8/8/25 documented a DTI in the right heel measuring 4 cm by 4 cm, with depth unable to determine. Further review of the medical record did not show documented evidence that a care plan was developed for the new DTI in the right heel. During interview and concurrent record review, LVN 11 verified the resident had the DTI and confirmed the plan of care did not show a care plan developed for the skin issue. LVN 11 stated the care plan should be developed or revised if there was already an existing care plan addressing skin integrity. The DON stated the care plan should be initiated as soon as possible for any change in the resident's condition and should include goals and interventions specific to the change in condition.
Failure to Trim Resident’s Fingernails
Penalty
Summary
The facility failed to provide the necessary care and services for Resident 102 by not ensuring the resident’s long fingernails were trimmed. Resident 102 was admitted with moderate cognitive impairment and impairment on both sides of the upper extremities, and the H&P noted the resident was partially able to make decisions. The care plan identified that the resident was dependent on staff for physical needs, including ADL care, and later added an intervention to trim and file fingernails as needed because of generalized dry and itchy skin and the potential for scratching and skin breakdown. During multiple observations, Resident 102 was seen awake in bed with long fingernails on both hands and was observed scratching both arms with the fingernails. The resident’s bilateral arms were noted to be dry with white flakes. When interviewed, Resident 102 stated no one in the facility had assisted with cutting the fingernails. A CNA verified the fingernails were long and needed trimming, and the DON also observed the long fingernails and scratching and confirmed the findings. The resident representative stated the fingernails had not been trimmed since admission, and the DON later stated CNAs could trim fingernails for residents who were not diabetic and that Resident 102’s fingernails should have been trimmed, especially given the scratching behavior.
Failure to Provide Ordered Pressure Injury Support Surfaces and Heel Offloading
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and to prevent new ulcers from developing for Residents 2, 96, 138, and 71. The report states that the facility did not ensure the ordered low air loss (LAL) mattress was provided for Resident 138 and Resident 2, and did not ensure the mattress settings were accurate to the residents’ weights or used appropriately while the residents were in bed. For Resident 71 and Resident 96, the facility also failed to ensure the LAL mattress settings matched the residents’ weights and comfort needs. Resident 138 had diabetes, severe cognitive impairment, dependence for mobility, and was identified as at risk for pressure injuries. The resident had a stage 1 coccyx pressure injury and later developed a deep tissue injury (DTI) to the right heel. The record showed an order for heel protectors while in bed, but observations repeatedly found the heel protectors not in use and placed on a shelf or chair instead. Staff and family reported the resident’s heels were resting directly on the mattress, and the resident was observed on a regular mattress before later being placed on a LAL mattress. The facility also failed to provide the LAL mattress that was included in the resident’s care plan for wound management and skin maintenance, and when the mattress was eventually observed in use, it was set to 200 pounds for a resident whose recorded weight was 115 pounds. For Resident 138’s right heel DTI, the record failed to show the required monitoring every shift for 72 hours after the change in condition, and there was no documented care plan developed or revised for the new wound. The report also states the weekly skin assessment was not completed after 7/31/25, and there was no documented evidence of a wound care specialist follow-up after the DTI was identified. Staff interviews reflected that CNAs were expected to document skin findings during showers and notify nurses, and nurses were expected to assess and monitor new skin issues, but the record did not show that these steps were completed for the heel injury. Resident 2 also did not receive bilateral heel suspenders as ordered to keep the heels offloaded, and did not receive the LAL mattress called for in the care plan for skin maintenance.
GT Feeding Orders Not Followed and HOB Not Elevated During Tube Feedings
Penalty
Summary
The facility failed to provide appropriate care and services for residents with gastrostomy tubes for three sampled residents. For one resident with no capacity to understand and make decisions, the physician ordered continuous enteral feeding with Nepro at 40 ml per hour for 20 hours and intermittent water flushes at 30 ml per hour for 20 hours. During observation, the resident was receiving the feeding at the ordered rate, but the water flush was running at 25 ml per hour. On a later observation, the Kangaroo pump was turned off even though residual feeding remained, and the LVN verified the resident had not completed the ordered feeding volume and still needed 242 ml to finish it. The DON acknowledged that the enteral feeding needed to continue after 1000 hours until the ordered volume was completed. For a second resident with dysphagia and no capacity to understand and make decisions, the care plan directed staff to elevate the HOB at least 30 to 45 degrees during and 30 minutes after tube feedings. The physician ordered continuous Jevity 1.5 at 60 ml per hour for 20 hours. During observation while the resident was receiving the feeding, the HOB was not elevated between 30 and 45 degrees and was measured at 20 degrees. The LVN confirmed the HOB was at 20 degrees and stated it should have been elevated at least 30 to 45 degrees while the feeding was infusing to prevent aspiration. For a third resident with fluctuating capacity who could make needs known, the care plan for enteral feeding also directed HOB elevation of at least 30 to 45 degrees during and 30 minutes after tube feedings. The physician ordered continuous Glucerna 1.2 at 75 ml per hour from 1400 hours to 1000 hours. During observation, the resident was lying in bed receiving the feeding with the HOB at less than 30 degrees and measured at 20 degrees. A CNA verified the HOB was at 20 degrees while the feeding was infusing, and an RN stated the HOB should be elevated to 30 to 45 degrees during enteral feeding. The DON acknowledged the findings.
Respiratory Care Documentation and Equipment Storage Deficiencies
Penalty
Summary
The facility failed to provide necessary respiratory care services for multiple residents who were receiving oxygen or nebulizer therapy. The report identified that oxygen administration was not documented for one resident who was observed receiving oxygen at 2 liters per minute via nasal cannula on multiple occasions, and staff confirmed the MAR did not show when oxygen was administered. The resident had a physician’s order for oxygen as needed, and a licensed nurse stated the resident was on intermittent oxygen use but had not checked the resident’s oxygen saturation at the time of observation. For another resident, oxygen was observed running at 4 liters per minute even though the physician’s order was for 3 liters per minute, and an empty humidifier bottle dated several days earlier was connected to the oxygen concentrator. A licensed nurse verified both the higher oxygen flow and the empty humidifier bottle, and stated the humidifier should have been replaced weekly. A different resident had oxygen tubing and a second nasal cannula observed outside of proper storage, including one cannula on the floor and another on the nightstand, while the storage bag hanging on the concentrator was dated earlier than the observation. Staff verified the tubing was not stored properly and stated it was supposed to be changed weekly. Additional findings involved residents whose oxygen supplies were not labeled, dated, or accompanied by required signage. One resident’s nasal cannula tubing was observed unlabeled and undated on both a portable tank and concentrator, and staff confirmed it should have been labeled and dated. Another resident had unlabeled and undated nasal cannula in the room, and there was no sign posted to indicate oxygen was in use; the medical record also did not show a physician’s order for the oxygen administration, although a change-in-condition evaluation documented oxygen at 2 liters per minute. The report also noted a resident’s nebulizer storage bag was dated earlier than the observation and had not been changed weekly, and another resident receiving continuous oxygen did not have an oxygen storage bag in the room. Staff and the DON stated the storage bags should be changed weekly and dated, and that nasal cannulas should be stored in the bags when not in use.
Dialysis Care Documentation and Treatment Errors
Penalty
Summary
The facility failed to provide safe, appropriate dialysis care/services for four of five sampled residents reviewed for dialysis. The report states the facility did not monitor fluid intake and did not specify the fluid restriction per physician order for one resident with end-stage renal disease who received hemodialysis three times weekly and had a tunneled Permacath in the right upper chest. The resident’s record showed a fluid restriction order for 1500 ml/24 hours, but the record did not show the exact amount to be provided by nursing staff and dietary services, and fluid intake was inconsistently documented. Staff interviews showed CNA and nursing documentation did not consistently capture intake from meal trays, medication pass, or the water pitcher at bedside, and the DON confirmed the restriction was not broken down for nursing and dietary services. The facility also failed to complete and accurately document dialysis communication forms for multiple residents. For one resident, the pre-dialysis section did not show medications administered before dialysis on multiple dates, and the post-dialysis section incorrectly documented bruit and thrill for a resident with a CVC and did not document bleeding assessments on several occasions. For another resident, the post-hemodialysis information section failed to show completed catheter site assessment documentation on several dates. For a third resident, the post-dialysis section incorrectly marked bruit and thrill for a Permacath, and the dressing assessment section was left blank on two dates. Staff interviews confirmed these forms were incomplete or inaccurate, and the DON stated that if the assessment was not documented then it was not done. The report further states the facility did not follow dialysis-related precautions for blood pressure measurement and medication administration. One resident’s care plan instructed staff not to take blood pressure on the right upper extremity, yet the resident’s blood pressure was documented on the right arm on multiple occasions. Another resident with a left forearm AV fistula had blood pressures documented on the left arm on multiple dates despite a care plan instruction not to use that arm. In addition, one resident received scheduled medications as held on dialysis days without a physician order to hold or reschedule them, and the DON confirmed there were no such orders in the record.
Unnecessary Drug Administration and Incomplete Anticoagulant Monitoring
Penalty
Summary
The facility failed to ensure three sampled residents were free from unnecessary drugs because medications were administered outside of ordered parameters and ordered monitoring was not consistently followed. Resident 2 was ordered metoprolol with instructions to hold it if systolic BP was less than 120 mmHg or HR was less than 60 bpm, yet the MAR showed multiple doses were given when BP was below the ordered parameter and one dose was given when the HR was 58 bpm. Resident 2 was also ordered Keflex with monitoring for adverse effects, but the record showed documentation of adverse reactions on several shifts and did not show physician notification when adverse reactions were documented on other shifts. Resident 5 was ordered enoxaparin with instructions to monitor for signs and symptoms of bleeding and to hold the anticoagulant and notify the MD if bleeding signs were observed. The MAR showed enoxaparin was administered twice daily over the reviewed period, while the bleeding-monitoring section showed multiple shifts where signs and symptoms were documented as present and the anticoagulant should have been held, yet the medication was still given. The record also did not show documented physician notification when bleeding signs and symptoms were observed. Resident 138 was ordered apixaban for DVT prophylaxis and was also ordered to be monitored every shift for signs and symptoms of bleeding, with instructions to hold the anticoagulant and notify the physician if bleeding signs were present. The resident had fluctuating capacity but could make needs known. The MAR showed apixaban was administered repeatedly during the review period, but the bleeding-monitoring documentation was absent for multiple shifts and did not begin until later in the stay. The record also showed apixaban was administered even when bleeding signs and symptoms were documented, and there was no documented evidence that the physician was notified when those signs were observed.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to keep the medication error rate below 5 percent during a medication pass observation, with an observed error rate of 6.9 percent. During observation of LVN 7 administering medications to Resident 138, the nurse prepared nystatin suspension without shaking the bottle as directed on the label and instructed the resident to swish and spit the medication instead of swish and swallow as ordered by the physician. The resident had an order for nystatin suspension 100,000 unit/ml, 5 ml by mouth four times a day for oral thrush, swish and swallow. Resident 138 also had a physician order for lansoprazole delayed release 30 mg, one capsule via GT two times a day for GERD, but the medication was not administered during the observed medication pass. LVN 7 stated the lansoprazole was out and that he had forgotten to follow up with the pharmacy because he was unable to select the reorder option in Point Click Care, and he acknowledged that he had not administered the medication for two days. The DON was later informed and acknowledged the findings.
Medication doses were missed on dialysis days without physician orders or notification
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors when vancomycin, apixaban, and metoprolol scheduled for administration on dialysis days were not given as ordered. Medical record review showed physician orders for vancomycin 125 mg four times daily for 10 days, apixaban 2.5 mg twice daily, metoprolol 25 mg 0.5 tablet twice daily, and hemodialysis on Tuesdays, Thursdays, and Saturdays with a set chair time. The MAR documented multiple instances in July and August 2025 when these medications were held and not administered on dialysis days. Review of the record did not show a physician order to hold or reschedule the medications for dialysis days, and there was no documentation that the physician was notified when the medications were not administered. During interview and concurrent record review, RN 2 verified the medications were not given during dialysis and that no hold orders existed. The DON also verified the findings and stated the medication schedule should have been communicated to the physician so the administration schedule could have been adjusted or the licensed nurses should have obtained a physician order to hold the medications.
Medication Storage and Bedside Medication Control Deficiencies
Penalty
Summary
The facility failed to provide pharmacy services to ensure medications were stored according to its policy and that outdated medications and medical supplies were not available for resident use. The facility’s policy stated orally administered medications are to be kept separate from externally used medications, and outdated, contaminated, or deteriorated medications and supplies are to be removed from stock and disposed of. During inspection of Medication Room A, an eye drop bottle was stored next to acidophilus. In Medication Room B, a saline spray was stored next to vitamin B1 tablets, and expired or outdated items were found, including povidone-iodine swabsticks, injection needles, and disposable syringes. Medication Cart A also contained iron tablets and nitroglycerin sublingual tablets stored together with artificial tear drops. Additional inspections found expired or improperly stored items in Medication Carts B and C. Medication Cart B contained bacitracin zinc ointment strips past expiration and two opened, undated normal saline bottles. Medication Cart C contained an opened rolled gauze bandage package and an opened dressing change kit with chloraprep. Staff members who inspected the carts acknowledged and verified these findings, and the DON was later informed of them. The facility also had medications and treatment products left at the bedside of several residents without corresponding physician orders in the record. Resident 2 had Voltaren gel at the bedside, but the order summary did not show an order for it. Resident 97 had Refresh eyedrops, dry mouth spray, Triad hydrophilic wound dressing, and saline nasal spray at the bedside, with no physician orders found for those items. Resident 23 had zinc oxide cream at the bedside without an order, and Resident 25 had Refresh eyedrops at the bedside without an order. Resident 138, who had fluctuating capacity but could make needs known and had a physician’s order for zinc oxide cream for a coccyx stage 1 pressure injury, also had a tube of zinc oxide paste on the overbed table; staff stated family members had brought the cream and that treatment nurses were responsible for applying it.
Kitchen sanitation and utensil maintenance deficiencies
Penalty
Summary
The kitchen was found to have multiple sanitation and equipment issues during the survey observation and interview with the Dietary Services Supervisor (DSS). The hood over the stove had black, dirt residue, and the DSS stated it was cleaned weekly and last cleaned by an outside company on 5/12/25. The facility’s policy required hoods to be kept free of grease and dust, and the surveyor noted the condition of the hood during the initial kitchen tour. Several kitchen utensils were observed to be in poor condition and not maintained with smooth, cleanable surfaces. The surveyor and DSS observed two deformed stainless steel whisks, eight rubber spatulas with chipped and cracked red handles, and two stainless steel food portioning scoops with gray handles that were worn out and peeling. The DSS acknowledged these findings and stated the worn utensils should have been replaced and discarded. The facility’s policy and the cited food code required utensils to be maintained in good repair and condition. The surveyor also observed kitchenware and utensils that were not clean to sight and touch, including a whisk with white thread-like residue, a dirty spatula with dry yellow residue, a portable can opener with dry white crusted residue on the blade, a slotted scoop with a cloudy film, and several food portioning scoops with dry crusted residue or cloudy film. In addition, all observed cutting boards were fuzzy, heavily marred, and had deep grooves, and two clear plastic trays were wet with visible water inside and stacked on top of each other. The DSS verified these observations and stated the dirty utensils should have been rewashed and the trays should have been air dried to prevent bacteria growth.
Infection Control Failures in Surveillance, Laundry, and Resident Care
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices in multiple areas, including infection surveillance, laundry handling, and resident care activities. The infection preventionist reviewed the facility’s June and July 2025 infection surveillance reports and identified more residents as having HAIs than were reflected on the monthly reports. In June, the infection preventionist identified six residents as HAIs in the urinary tract/kidney infection category, while the report showed five. In July, the infection preventionist identified two residents in the blood/systemic infection category when the report showed one, identified three residents in the other infections category when the report showed two, and identified three residents in the urinary tract/kidney infection category when the report showed two. The infection preventionist stated the screening system did not pick up when residents were indicated as in-house or HAI, and that the resident information entered in Point Click Care would automatically populate the monthly quality assurance report. In the laundry area, a blue basket truck with a spring lift was observed with ripped edges exposing rusty steel. When the spring lift was lifted, the bottom of the basket contained pieces of paper, dryer sheets, a towel, and a sock. Dust was also observed on the AC filters in the clean area and near the folding area. The maintenance director verified these findings and stated the basket truck was used to transport washed clothes from the washers to the dryers. The maintenance director also stated the basket truck should be cleaned daily, the spring lift should have been replaced, and the AC filters should be cleaned daily. Several infection control failures were observed during resident care. CNA 7, while caring for a resident on EBP, assisted that resident with a lunch tray and then went to another resident who was not on EBP, touched the resident’s cup, emptied the urinal, removed gloves and performed hand hygiene, and then assisted the second resident with a lunch tray while still wearing the same gown used for the first resident. CNA 2 assisted with repositioning a resident on EBP for wounds without wearing a gown. LVN 6 picked up a call light from the floor mat in a resident’s room on EBP and clipped it to the bed sheet without disinfecting it. A phlebotomist attempted to draw blood from a resident on EBP for a dialysis access site without wearing a gown, and the phlebotomist’s clothing touched the resident and the linen. LVN 7 placed a BP cuff on a resident without performing hand hygiene or disinfecting the cuff first. LVN 8 closed curtains for two residents while wearing gloves and then proceeded with resident care without removing the gloves, performing hand hygiene, or putting on clean gloves.
Medication Documentation and Disposal Process Failures
Penalty
Summary
The facility failed to follow its pharmaceutical procedures for controlled medications when morphine was signed out on the Controlled Drug Record for one resident but was not documented as administered on the resident’s MAR. Resident 15 had a physician’s order for morphine sulfate oral tablet 15 mg, one tablet by mouth every six hours as needed for severe pain. The Controlled Drug Record showed morphine sulfate 30 mg tablets, half-tablet doses, were removed on multiple occasions, including 7/31/25 at 0630 and 0600, 8/1/25 at 0600, 8/3/25 at 0200, and 8/7/25 at 1430, but the August 2025 MAR did not show documentation that the medication was administered at those times. During interview and record review, LVN 3 verified the MAR did not match the Controlled Drug Record, and the DON confirmed the findings. The facility also failed to follow its medication disposition process for non-controlled medications. Review of the Medication Disposition Record/Pass log showed 31 non-controlled medications were disposed of with only one nurse signature. The MDS Coordinator confirmed the facility’s process required two nurses and two signatures for disposing medications, and verified that only one nurse had signed the log. The DON also confirmed that the Medication Disposition Record/Pass log should have had two nurse signatures.
Facility Assessment Missing Required Staffing and Participation Elements
Penalty
Summary
The facility failed to conduct and document a Facility Assessment that included active involvement of required individuals and addressed staffing resources needed for day-to-day operations and emergencies. The report states that the Facility Assessment did not show direct care staff members, direct care representatives, residents, residents' representatives, or residents' family members were actively involved in developing the assessment. It also did not include a plan to maximize recruitment and retention of direct care staff or a contingency plan for staffing needs. During an interview and concurrent document review on 8/14/25 at 0755 hours, the Administrator verified the Facility Assessment was dated 10/29/24 and confirmed there were no direct care staff, direct care representatives, residents' representatives, or family members actively involved in developing it. The Administrator further verified there was no documentation of a plan to maximize recruitment, no contingency plan for staffing needs, and acknowledged the Facility Assessment had not been updated based on the latest CMS guidance.
Incomplete POLST Documentation
Penalty
Summary
The facility failed to ensure the medical record was complete for one of 28 sampled residents, Resident 8, because the resident’s POLST dated 7/16/25 did not have Section D, Information and Signatures, completed. Resident 8 was admitted to the facility on one date and readmitted on another date. During a concurrent interview and medical record review on 8/13/25, the SSD verified that Section D of the POLST was not filled out and stated the resident had a copy of the advance directive in the electronic chart. The SSD also stated it was important for the POLST to be completed so staff would know how to follow and care for the resident properly. On 8/19/25, the DON was interviewed and informed of the findings, and the DON verified them.
Failure to Document Discharge Instructions for Resident with Complex Care Needs
Penalty
Summary
The facility failed to ensure that discharge instructions were properly documented for one of two sampled residents reviewed for discharge. The resident, who had multiple diagnoses including obstructive uropathy, s/p left nephrostomy, AKI on CKD 3, bladder cancer, hypertension, CVA, and chronic CHF, was determined to have the capacity to understand and make decisions. The resident's Post Discharge Plan of Care and Summary lacked entries in sections related to Foley catheter care and other special care instructions. Additionally, the Skilled Evaluation Notes for several days prior to discharge did not contain any documentation under the Education/Notification section. Interviews with the DON and DSD confirmed that there was no documentation in the resident's progress notes, Post Discharge Plan of Care and Summary, or Skilled Evaluation Notes indicating that the resident was provided with education or instructions regarding their specific care needs, such as Foley catheter and nephrostomy care, prior to discharge. Both the DON and DSD acknowledged that this information should have been documented if provided. The Administrator and DON verified these findings during the review.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse when a conflict between two residents escalated, resulting in one resident pushing an over-bed table that struck the other resident in the head. Prior to the incident, there were documented concerns: one resident had expressed unhappiness with his roommate several days earlier, and staff had observed ongoing verbal aggression between the two. Despite these warning signs, the facility did not take action to separate the residents or address the escalating conflict. Medical record reviews and staff interviews revealed that the resident who was ultimately injured had repeatedly requested a room change and informed both the charge nurse and CNAs about the ongoing issues. Staff, including CNAs and LVNs, were aware of the residents' verbal altercations and the request for a room change, but no action was taken to separate them. On the day of the incident, staff observed the residents engaging in verbal aggression, with one resident making a direct threat to harm the other. The residents were not separated at this point, and the situation escalated to physical violence. After the altercation, the injured resident was assessed and found to have a small movable mass with minimal redness and flaky skin on the head, and later reported ongoing headaches. Interviews with staff and the social services director confirmed that the concerns about the residents' compatibility and safety were not communicated or addressed in a timely manner. The facility's policy required immediate separation of residents in such situations, but this was not followed, resulting in harm to the resident.
Failure to Interview Key Witness in Abuse Investigation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving two residents who had a verbal and physical altercation in their shared room. According to the facility's policy, all individuals who may have knowledge of the incident, including those in the vicinity at the time, should be interviewed as part of a comprehensive investigation. However, the facility's investigation file showed that only the involved residents and staff were interviewed, and the roommate who was present in the room during the incident was not interviewed. This omission was confirmed through interviews with the Social Services Director (SSD) and the Administrator, both of whom indicated that they did not see the need to interview the roommate. Further review revealed that the roommate, when later interviewed by surveyors, stated he was present in the room during the altercation, heard the commotion, and could provide relevant information about the incident, even though his curtain was closed. The facility's failure to interview this roommate, as well as other potentially affected residents, resulted in an incomplete investigation of the abuse allegation, contrary to the facility's own policies and procedures.
Failure to Monitor and Address Significant Weight Loss in Residents
Penalty
Summary
The facility failed to implement a systematic approach to monitor and address significant weight loss in two residents, resulting in deficiencies related to nutrition and hydration status. For one resident with diagnoses including enterocolitis due to clostridium difficile, anemia, and gastro-esophageal reflux disease, there was a severe weight loss of 51 lbs. (23.29%) over six months, 14 lbs. (6.39%) in one month, and 30 lbs. (14%) in another period. Despite physician orders for nutritional supplements, snacks, and weekly weights, the resident was not assessed and monitored by the interdisciplinary team (IDT) in a timely manner. The care plan identified the risk for weight loss, but interventions such as IDT assistance during meals and monitoring were not effectively implemented. Additionally, a Change of Condition (COC) was not initiated when severe weight loss occurred, and there was no documentation of physician or legal representative notification at those times. Another resident with a diagnosis of dysphagia experienced a significant weight loss of 17 lbs. (12.14%) in one month. The care plan included interventions such as multivitamin/mineral supplements, a protein supplement beverage, and weekly weights for three weeks. However, the resident's weights were not monitored as ordered, with a 14-day gap between recorded weights. The resident reported being informed of weight loss but was unaware of the extent and stated there was no discussion about the facility's response to the weight loss. The care plan did not reflect updated goals or interventions regarding the risk for weight loss, and the required monitoring was not completed as ordered by the physician. Interviews with facility staff, including the Registered Dietitian (RD) and Director of Nursing (DON), confirmed that the process for addressing significant weight changes was not followed. The RD acknowledged that the physician was not notified of the severe weight loss, and the DON verified that a COC, including physician and legal representative notification, RD consult, and IDT evaluation, should have been initiated immediately upon identification of significant weight loss. The administrator and DON were made aware of these findings.
Inaccurate Medical Record for Enteral Feeding
Penalty
Summary
The facility failed to ensure the accuracy of the medical record for one of the sampled residents, Resident 2. The deficiency was identified through interviews, medical record reviews, and facility policy and procedure (P&P) reviews. The facility's P&P for medication orders and administration required clarification of orders, proper documentation, and transcription of new orders on the Medication Administration Record (MAR) or Treatment Administration Record (TAR). However, there was a discrepancy in the documentation of enteral feeding orders for Resident 2. The Order Summary Report indicated an order for Jevity 1.5 enteral feeding, but the MARs for January and February showed a different formula, [NAME] Farms 1.4, being administered. This discrepancy was not clarified or corrected in the MAR. Interviews with facility staff revealed that LVN 1 administered Jevity 1.5 but documented it under the [NAME] Farms 1.4 order, failing to clarify the orders. RN 1 confirmed the facility did not have [NAME] Farms 1.4 and had received an order for Jevity 1.5, but the MAR was not updated accordingly. The RD confirmed that Jevity 1.5 was equivalent to [NAME] Farms 1.4, but the facility did not carry the latter. The DON verified these findings, indicating a lapse in ensuring accurate medical records and proper communication among staff regarding medication orders and administration for Resident 2.
Deficiencies in Catheter Care and Physician Notification
Penalty
Summary
The facility failed to provide appropriate care and services to prevent urinary tract infections (UTIs) for two residents with indwelling urinary catheters. For the first resident, the facility did not ensure that the urinary catheter drainage bag was kept off the floor, which is against the CDC's guidelines for preventing catheter-associated urinary tract infections (CAUTI). Observations on two consecutive days showed the drainage bag lying on the floor, and interviews with nursing staff confirmed that this was not in compliance with proper catheter maintenance procedures. Additionally, there was no care plan developed to address the resident's UTI and antibiotic treatment. For the second resident, the facility failed to notify the physician of a change in condition due to frequent leakage of the indwelling urinary catheter. The resident experienced frequent catheter dislodgement and leakage, which required the catheter to be changed more often than usual. Despite the resident's history of using a specific catheter size, the facility did not clarify the appropriate size with the physician, leading to the use of a different size catheter. Interviews with the resident and nursing staff confirmed that the physician had not been informed of the frequent leakage or the change in catheter size. These deficiencies indicate a lack of adherence to established protocols for catheter care and communication with physicians regarding changes in resident conditions. The facility's failure to maintain proper catheter hygiene and notify the physician of significant changes posed a risk for adverse complications related to catheter use.
Failure to Honor Resident's DNR Order
Penalty
Summary
The facility failed to honor a resident's POLST, which indicated a Do Not Attempt Resuscitation (DNR) order. This failure occurred when the resident was found unresponsive and without a pulse, and CPR was initiated despite the resident's documented wishes. The POLST was not immediately accessible, leading to the initiation of resuscitative measures contrary to the resident's directives. The resident had the capacity to make medical decisions, as noted in their health and physical examination. During the incident, a Licensed Vocational Nurse (LVN) stated that CPR was continued even after the POLST was found because a family member requested it. The Director of Nursing (DON) confirmed that the POLST indicated a DNR order and acknowledged that it should have been followed. The facility's policy and procedure on advance directives required that such documents be easily accessible in emergencies, which was not adhered to in this case.
Deficiency in Food Preparation and Palatability
Penalty
Summary
The facility failed to ensure the nutritive content and palatability of pureed food for residents on the American menu. Observations revealed that pureed vegetables were cooked and held in a hot oven for more than one hour before meal service, which could lead to a reduction in essential nutrients such as water-soluble vitamins. The facility's policy on puree food preparation requires that food be prepared in a way that conserves nutritive value, flavor, and appearance. However, the pureed green beans were cooked, pureed, and then kept in a hot oven for an extended period, contrary to these guidelines. The Registered Dietitian (RD) Consultant confirmed that the pureed foods should be cooked to preserve their nutritive value. Additionally, the facility did not ensure that the bread served was palatable, as evidenced by a test tray inspection where the breadstick was found to be crusty and hard to chew. This inspection was conducted with the Kitchen Supervisor and RD Consultant, who verified the findings. The facility's menu for the day included vegetable lasagna, sauteed mixed squash, breadstick and butter, peach dump cake, and a choice of beverage. The hard texture of the breadstick could potentially affect the residents' ability to consume the meal comfortably.
Food Safety and Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to meet food safety and sanitary requirements in the kitchen, as observed during a survey. Specifically, the facility did not ensure proper labeling and dating of opened food items in the freezer. During an inspection, it was found that a plastic bag of frozen cookie dough, a bag of potato hash browns, and a bag of frozen waffles were not labeled with an open date and were observed to have freezer burn. The Kitchen Supervisor acknowledged these findings and confirmed that the items were no longer suitable for consumption. Additionally, the facility did not ensure that food preparation equipment was properly air-dried before storage. During the kitchen tour, five cutting boards were found stored wet in the cutting board rack, which the Kitchen Supervisor confirmed were not air-dried properly. Furthermore, one cutting board was heavily marred with knife marks, making it difficult to clean and sanitize, which could lead to the accumulation of pathogenic microorganisms. The Kitchen Supervisor acknowledged this issue and stated that the equipment would be discarded.
Failure to Conduct Bed Safety Inspections and Entrapment Assessments
Penalty
Summary
The facility failed to conduct regular inspections of bed frames, mattresses, and bed rails for safety, specifically failing to assess the risk of entrapment for several residents. Observations and medical record reviews revealed that the facility did not perform routine bed inspections or entrapment assessments for residents using side rails or halo grab bars. The facility's policy required semi-annual assessments for entrapment risks, but these were not conducted for the sampled residents, leading to potential safety hazards. The Maintenance Director admitted to not conducting routine bed inspections and was unaware of the different zones of entrapment that needed assessment. The Bed System Measurement Device Test Results Worksheets for the residents showed that zones 4, 6, and 7 were not assessed for entrapment risks. Interviews with staff, including CNAs and LVNs, confirmed that entrapment assessments were not performed, and the maintenance department was only called for installation purposes. Residents involved in the deficiency included those with severe cognitive impairments, such as Alzheimer's dementia, and others who were non-ambulatory or had difficulty with bed mobility. Despite having care plans that addressed the use of bed rails and halos for mobility and repositioning, the facility failed to ensure these devices were safe and properly assessed for entrapment risks, as required by their policies and manufacturer guidelines.
Deficient Call Light System in Multiple Rooms
Penalty
Summary
The facility failed to ensure that the call light system was fully operational in several rooms, which could lead to delayed assistance for residents. Specifically, the call lights in Room N and Room O did not light up or sound at the nursing station, and the call light in Resident 16's room was dim and not audible. These deficiencies were confirmed through observations and interviews with staff, including the Assistant Director of Nursing (ADON), Certified Nursing Assistants (CNAs), and Registered Nurses (RNs). The facility's policy and procedure (P&P) required prompt reporting and documentation of defective call lights, but this was not consistently followed. In Room N, the restroom call light failed to light at the door and did not sound at Nursing Station B's call panel. This was verified by CNA 8 and RN 1, who noted the importance of a functioning call light system for both resident and staff safety. Similarly, in Room O, the restroom call light did not light or sound at the nursing station, and attempts to fix the issue by changing the light bulb were unsuccessful. The Maintenance Director acknowledged the need for immediate repairs. Additionally, the call light system for Rooms A to M at Nursing Station A had no audible sound, although the lights were visible on the panel. This issue was observed by CNAs and Licensed Vocational Nurses (LVNs), who noted that the problem had persisted for several days without being reported to the maintenance department. The lack of an audible alert could result in staff not noticing when residents require assistance, especially when they are not present at the nursing station. The facility's failure to maintain a fully functional call light system poses a risk to resident safety and care.
Failure to Coordinate and Document Medical Appointments
Penalty
Summary
The facility failed to provide necessary care and services for a resident, identified as Resident 48, by not coordinating and following up on required medical appointments as per transfer orders from an acute care hospital. The resident was supposed to attend appointments with an infectious disease physician and an oncologist, but there was no documentation that these appointments were completed. The medical record indicated that the appointment with the infectious disease physician was marked as completed, yet there was no evidence that the resident attended. Additionally, the appointment with the oncologist was discontinued without being scheduled or followed up. Interviews with facility staff, including an RN, the SSD, and the DON, confirmed the lack of documentation and follow-up regarding these appointments. The SSD mentioned transportation issues as a reason for missing the infectious disease appointment, and the DON noted that the oncology appointment was not scheduled due to billing issues. However, there was no documentation explaining these issues or any attempts to resolve them, leading to a failure in ensuring the resident received appropriate medical care and treatments.
Failure to Renew Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to properly obtain informed consent for the use of psychotropic medications for a resident who lacked the capacity to make decisions. The resident, who was admitted and readmitted to the facility, was prescribed Seroquel for psychosis. However, the informed consent for this medication was not renewed as required by the Nursing Facility Resident Informed Consent Protection Act of 2023, which mandates that consent be renewed every six months. The last documented consent was obtained more than six months prior to the new order for Seroquel. During interviews and medical record reviews, it was confirmed by both an LVN and the DON that there was no updated informed consent for the use of Seroquel. This oversight meant that the resident's responsible party was not informed about the medication and its potential side effects, as required by the facility's policy and the new legislative requirements. This deficiency was identified during a survey and cross-referenced to F758.
Inaccessible Call Lights for Residents
Penalty
Summary
The facility failed to provide reasonable accommodations for two residents, specifically regarding the accessibility of call lights. During an initial tour, it was observed that Resident 124's call light was clipped to the wall panel and not within reach, despite the resident's ability to use it. Resident 124, who was admitted to the facility with the capacity to make decisions and communicate effectively, complained of leg pain during the observation. The inaccessibility of the call light could potentially delay the resident's ability to request assistance. Similarly, Resident 38 was found with the call light button underneath his pillow, making it unreachable. This resident, who had moderately impaired cognition but no physical impairments to the extremities, required substantial assistance with daily activities. The call light was not repositioned after a physical therapy session, as confirmed by a CNA. On a subsequent observation, the call light remained out of reach, and the resident expressed a need for assistance with moving the bedside table and obtaining water. These observations indicate a failure to ensure that call lights were accessible to residents, potentially impacting their ability to receive timely care.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 2,661 citations issued within 25 miles in the last 12 months — including the 8 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Newport Beach
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Crystal Cove Care Center | 0.1 mi | ★★★★★ | 6 | 0 |
| Newport Nursing And Rehabilitation Center | 0.2 mi | ★★★★★ | 11 | 0 |
| Mesa Verde Post Acute Care Center | 0.9 mi | ★★★★★ | 25 | 0 |
| Victoria Healthcare And Rehabilitation Center | 2 mi | ★★★★★ | 1 | 0 |
| Newport Subacute Healthcare Center | 2.8 mi | ★★★★★ | 50 | 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.