Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pilgrim Place Health Services Center during CMS and state inspections, most recent first.
Inaccurate and inconsistent AD documentation was found for three residents. One resident with psychosis and impaired decision-making capacity had conflicting ADA forms and a blank POLST, while two other residents had chart entries stating both that they had and had not executed an AD. The SSC stated one resident’s financial DPOA did not address medical wishes, another resident had no AD in the chart, and one resident’s ADA and POLST were completed in error or were incomplete.
Two residents had PRN Lorazepam orders without the required 14-day stop date. One resident had an active PRN order for anxiety, and another resident had a similar PRN order that remained active beyond the 14-day limit without physician reassessment. LVN, RN, and DON interviews confirmed that PRN psychotropic orders required a stop date and reassessment if continued.
Improper LAL Mattress Use for Two Residents at Risk for Skin Breakdown Two residents at risk for PI did not receive appropriate LAL mattress support. One resident with a stage 3 coccyx wound was found using a foam topper on a regular mattress after the LALM was removed for an air leak, with no LAL pump attached and no documented follow-up for replacement. Another resident with dependent ADLs and mobility had a LAL mattress set at the maximum 450-lb setting despite weighing 95 lbs, and staff stated the setting was too high for proper pressure redistribution and airflow.
Bed Position and Lift Storage Hazards: The facility failed to keep one resident’s bed in the low position for fall prevention and left a sit-to-stand lift stored in another resident’s bathroom doorway, blocking access. One resident had a hx of falls, impaired cognition, and gait/mobility issues, and was observed with the bed raised about three feet off the floor before later being found on the floor. Another resident with RA, repeated falls, and mobility dependence had the lift placed in the restroom doorway, which the resident said sometimes blocked bathroom access and frustrated them.
Failure to Monitor Indwelling Catheters for Signs of Infection: Two residents with indwelling catheters were observed with cloudy urine and thick sediment in their drainage bags. The IPN stated one catheter needed to be changed or flushed because it was no longer patent or clean, and the other needed to be flushed. Staff interviews and the facility policy indicated catheter care and urine assessment were to occur every shift, including monitoring for cloudiness, sediment, odor, and other signs of infection.
Unsafe Food Storage and Temperature Control: A kitchen storage room contained an uncooked rice container that was not fully closed, multiple unlabeled bags of cereal, and a used vinegar container stored with other products. In the walk-in cooler, several bags of diced potatoes were undated, and during tray line service individualized servings of potato salad were found at 46 and 43 degrees while the facility log did not show a second temperature check after portioning. In a unit refrigerator, resident food from home was found without required dates or complete labeling, including an opened dry seasoning package, a bowl of produce and soy sauce, and a grocery bag marked only with a room and bed number.
Staff were observed without proper masks or with masks worn incorrectly in resident care areas, and the IPN, DSD, and DON were unaware of current masking guidance during respiratory virus season. The facility also had incomplete influenza vaccination tracking for staff and no documented education for some employees. Additional infection control lapses included improper glove use during perineal care, nebulizer equipment and oxygen tubing left out instead of stored, a BP cuff reused without disinfection, failure to don gown and gloves for a resident on EBP, and unlabeled wound and skin cleanser products stored improperly near a shared room.
Antibiotic stewardship monitoring was not followed for several residents when antibiotic orders were reviewed without a completed or accurate SDCF, documented signs and symptoms, or available lab results. An IPN stated antibiotic time-out was not practiced, some orders were not clarified, and one resident’s UTI antibiotic was ordered despite a culture showing susceptibility to a different agent. Another resident had no SDCF completed, and others had incomplete forms or the wrong form used for the infection being treated.
Failure to offer and document FLU vaccination for two residents. One resident had MRSA and sepsis with severe cognitive impairment, and the other had HF and PNA with intact cognition. Record review showed prior-season flu vaccines for both residents, but the current-season consent/declination documentation was incomplete or reflected a declination based on having already received the vaccine. The IPN stated signed consent/declination forms were used as proof that education was provided.
Baseline Care Plan Omitted Psychotropic and Anticoagulant Orders: A resident admitted with a-fib, anxiety disorder, and a history of falls had a baseline care plan that did not include ordered Lorazepam PRN for anxiety or Eliquis for clot prevention. The care plan’s psychotropic and anticoagulant sections were left blank, and RN and DON interviews confirmed these medications should have been reflected in the baseline CP to support staff awareness of the resident’s medication needs and monitoring requirements.
A resident admitted with dementia, depression, and an anxiety disorder had moderately impaired cognition and needed partial/moderate assistance with ADLs and mobility. Review of the care plans found no dementia-specific CP, and RN and DON stated that no individualized plan had been developed or implemented to address cognitive status, behavioral risks, communication needs, or safety concerns.
Failure to Educate Resident on New Pain Medication: An LVN administered a new PRN pain med, Tramadol, to a resident with back fracture diagnoses but did not provide the required education about the med’s name, dose, or potential side effects. The resident questioned whether the medication was new, and the LVN later confirmed it was a new prescribed medication.
A resident with a PICC and saline lock did not receive IV site care in accordance with orders and the facility’s IV therapy policy. Staff failed to assess the need for the saline lock, the saline lock site was covered with an old stained dressing and showed redness, and the PICC dressing was undated. The DON and RN stated the saline lock should have been checked and removed if not needed, and the PICC dressing should have been dated.
A resident with cognitive impairment and chronic skin issues did not receive prescribed diphenhydramine for itching, and hydrocortisone treatment was not continued as ordered. Nursing staff failed to perform required weekly skin assessments or notify the physician when the resident's condition did not improve, resulting in ongoing scratching and multiple open wounds. The facility did not follow its own protocols for wound care, assessment, and physician communication.
Licensed nurses did not complete or document required weekly skin assessments for a resident with multiple open skin scratches from persistent itching. Despite ongoing visible skin issues and physician orders for treatment, there was a lack of documentation and communication regarding the resident's skin condition over several weeks, contrary to facility policy and professional standards.
A resident with diabetes and hypertension was given blister packs containing other residents' medications at discharge, resulting in the ingestion of an unprescribed drug and subsequent hospitalization for adverse symptoms. The error was attributed to a failure in medication reconciliation by the discharge nurse, as confirmed by the DON.
A resident with diabetes and hypertension did not have follow-up pain assessments, change of condition notes, or physician communication documented after receiving pain medication. Both an LVN and the DON confirmed that required documentation was missing from the medical record, despite facility policy mandating complete and timely charting of care and communications.
A resident with moderate cognitive impairment and pathologic fractures in both arms made an accusation of abuse that was not reported to the administrator or authorities as required by the facility's policy. The resident mentioned brittle bones and could not recall reporting staff involvement. The facility's policy mandates immediate reporting of such allegations, but this was not adhered to, as confirmed by the administrator.
A resident developed a stage 3 pressure ulcer due to the facility's failure to update the care plan upon readmission, conduct a pressure injury risk assessment, and properly set a low air loss mattress. The resident's mobility was impaired by bilateral arm fractures, leading to pain and refusal to reposition, which increased the risk of pressure injuries. The lack of coordination among staff and unclear care interventions contributed to the deficiency.
The facility failed to inform two residents or their legal representatives about Advance Directives, violating their rights to formulate an AD. One resident had severe cognitive impairment and lacked decision-making capacity, while the other was moderately impaired but oriented. The Social Services Coordinator did not have the necessary documentation on file, despite facility policies requiring it within 72 hours of admission.
Two residents at high risk for falls did not have their care plans updated after incidents, contrary to facility policy. One resident's care plan was blank despite multiple fall risk assessments, while another resident's care plan lacked necessary safety measures after a fall. The facility's policy requires care plan revisions upon status changes, but this was not followed, leading to deficiencies.
The facility failed to follow safe food storage and handling practices, with unlabeled and undated food items found in the kitchen and resident areas. A resident's cookies were past their sell-by date, and the snack/nourishment refrigerator was at an incorrect temperature. Additionally, the chemical sanitizing solution in the kitchen was below the required concentration for effective sanitization.
The facility failed to maintain its infection prevention and control program, with deficiencies including improper disinfection of a blood pressure monitor, inadequate labeling of urinals, and improper storage of personal care items and staff belongings. These actions posed risks of cross-contamination and infection spread among residents.
A facility failed to accurately complete the MDS for a resident, who was incorrectly documented as taking anticoagulant medication. The ADON admitted the error, emphasizing the importance of MDS accuracy for resident care. The facility's policy requires comprehensive assessments to develop care plans, but this inaccuracy could lead to inappropriate care.
The facility failed to complete and transmit MDS assessments within the required timeframe for two residents, as per CMS guidelines. One resident's discharge MDS was not sent within 14 days, and another resident's admission and discharge MDS were also delayed. The Acting Director of Nursing acknowledged the oversight and the absence of a facility policy for MDS submission, relying on CMS guidelines instead.
A resident admitted with a suprapubic catheter did not have a baseline care plan developed within 48 hours, as required by facility policy. The resident, with multiple diagnoses and dependent on staff for toileting, had no care plans in their medical records. The Acting DON and Infection Preventionist confirmed the oversight, highlighting the importance of such plans for guiding staff care, especially for catheterized residents.
A facility failed to develop a care plan for a resident at risk of elopement, despite the resident's history and physician's order for a wander guard. The resident, with cognitive impairment and mobility issues, had attempted to leave the facility. A nurse confirmed the absence of a care plan, contrary to facility policy.
A resident at high risk for skin breakdown developed a stage 2 pressure ulcer due to inadequate care. Despite a care plan requiring regular repositioning and skin care, the resident was not encouraged to reposition, and wet diapers were not changed promptly. The facility's policy on pressure injury prevention was not followed, leading to the development of the ulcer.
A resident receiving oxygen therapy for COPD did not have the required oxygen use signage on their door, as per facility policy. This oversight was confirmed during an observation and interview with an LVN, highlighting a lapse in safety protocols.
The facility lacked a full-time Director of Nursing (DON) for about eight months, leading to the Assistant Director of Nursing (ADON) taking on multiple roles, including acting DON and Director of Staff Development (DSD). This situation resulted in a backlog of tasks and impacted the quality of care, as the ADON struggled to manage responsibilities effectively.
A resident in an LTC facility experienced a medication error rate of 11.54% due to improper administration of Eliquis and a multiple vitamin, and incorrect technique for Brimonidine Tartrate eye drops. The resident, with a history of anticoagulant use and a hip fracture, refused some medications, which were not administered or reported as required by facility policy.
A resident in an LTC facility did not receive their prescribed Eliquis, a blood thinner, due to a medication error. The resident spat out all medications except Colace, and the LVN failed to re-administer Eliquis or inform the NP about the refusal. The resident's care plan required Eliquis due to their risk for blood clots, but the facility's policy on medication refusal was not followed, potentially increasing the resident's risk of complications.
A facility failed to ensure a call light was within reach for a resident with muscle weakness and a history of falls, as required by care plans and facility policy. The resident, who needed substantial assistance and was wheelchair-bound, had the call light out of reach, confirmed by staff. This oversight was contrary to the facility's policy, which mandates call lights be accessible to residents.
The facility failed to ensure that the DON and RNS, acting as Infection Control Preventionists, had the necessary IP certificates and training. This was discovered during an investigation of a Covid-19 outbreak. The DON and ADM acknowledged the importance of proper training, but neither could provide proof of completed training. Regulatory documents emphasized the need for a full-time IP with adequate training.
The facility failed to provide a homelike environment for all residents by using meal trays that were cracked and peeling. During an observation, the DON and KS found ten trays in poor condition, acknowledging they were unsafe for serving meals. The facility's policy required maintaining a safe and homelike environment, which was not met, potentially affecting residents' quality of life.
Inaccurate and inconsistent advance directive records
Penalty
Summary
The facility failed to ensure that advance directive information was consistent and accurate in the medical records for three sampled residents: Resident 11, Resident 59, and Resident 73. During record review and interview with the Social Services Coordinator, the charts for these residents were reviewed for advance directive documentation, including Advance Directive Acknowledgements, POLST forms, and powers of attorney. The SSC stated that an advance directive is a document in which a resident appoints someone to make medical decisions if the resident can no longer do so. Resident 11’s record contained an Advance Directive Acknowledgement dated 10/17/2024 stating the resident had not executed an AD, and another ADA dated 11/28/2025 stating the resident had executed an AD. The SSC stated there was no copy of an AD in the chart and said the 11/28/2025 ADA was an error. Resident 11 also had a blank POLST form in the chart, and the SSC stated that if the POLST was not filled out or there was no POLST, the resident was a full code. Resident 11’s admission record, H&P, and MDS indicated the resident had unspecified psychosis, did not have decision-making capacity, and had moderately impaired cognitive skills for daily decision making. Resident 59’s chart contained an ADA dated 9/17/2025 stating the resident had not executed an AD and had a Durable Power of Attorney for Health, and another ADA dated 11/13/2025 stating the resident had executed an AD. The chart contained a Durable Financial Power of Attorney dated 2/4/2023, and the SSC stated there was no AD in the chart and that the financial DPOA did not address medical wishes. Resident 59’s H&P stated the resident did not have capacity to make own decisions, and the MDS indicated moderately impaired cognitive skills for daily decision making. Resident 73’s chart contained a blank ADA dated 11/25/2025 signed by RN 1, and a revised copy dated 12/3/2025 completed during the care meeting that indicated the resident had executed an AD while also circling the option stating the resident had not executed an AD. The resident’s chart did not contain a copy of the AD, and the SSC stated the form had been completed in error. Resident 73’s POLST was incomplete, and another POLST dated 10/23/2025, not in the chart, indicated an AD dated 12/24/2009 was available and reviewed and no AD. Resident 73’s MDS indicated independent cognitive skills for daily decision making, and the H&P stated the resident had capacity to make own decisions.
PRN Lorazepam Orders Lacked Required Stop Dates
Penalty
Summary
The facility failed to ensure that physician orders for PRN psychotropic medication included the required 14-day stop date for two residents. Resident 101 was admitted and later re-admitted with diagnoses including muscle weakness, difficulty walking, and anxiety disorder, and the MDS dated 11/26/2025 indicated cognition was intact. Resident 98 was admitted with diagnoses including history of falls, anxiety disorder, and difficulty walking, and the BIMS dated 12/2/2025 indicated cognition was intact. Resident 98’s active OSR dated 12/3/2025 included an order for Lorazepam 1 mg by mouth every 24 hours PRN for anxiety, dated 12/1/2025, but the order did not include a 14-day stop date. Resident 101’s active OSR dated 12/4/2025 included an order for Lorazepam 0.5 mg by mouth every 8 hours PRN for anxiety, dated 11/19/2025, and it also did not include a 14-day stop date. During interviews, LVN 1, RN 1, and the DON stated that PRN psychotropic orders required a 14-day stop date and physician reassessment if continued beyond that period, and RN 1 stated no reassessment had been completed for Resident 101 even though the order remained active beyond the 14-day limit.
Improper LAL Mattress Use for Two Residents at Risk for Skin Breakdown
Penalty
Summary
The facility failed to ensure appropriate treatment and services were provided for two residents who were at risk for skin breakdown and pressure injuries. Resident 54 was admitted with diagnoses including prostate cancer and bone metastasis, had moderate cognitive deficit, and required maximal assistance with rolling and repositioning. The care plan identified risk for skin breakdown and included use of a pressure reducing mattress if necessary, and an active order was in place for a low air loss mattress (LALM) to aid with wound maintenance of a stage 3 coccyx wound. For Resident 54, progress notes documented that the LALM was removed because of an air leak, and the resident was using a foam topper placed on a regular mattress brought by the resident’s wife. During observation, the resident was lying in bed without an LAL pump attached to the bed. The Treatment Nurse stated the resident was not lying on a LALM and was on a mattress topper over a regular mattress, and the Registered Nurse Supervisor stated there was no record of follow-up with the LALM supplier for replacement. The RN Supervisor and DON stated that if the LALM was not functioning, it needed to be replaced within 24 hours or immediately. Resident 87 was admitted with diagnoses including palliative care, muscle wasting and atrophy, and anemia, and had moderately impaired cognition with dependence for ADLs and mobility. The resident had an active order for a LAL mattress, and the most recent recorded weight was 95 lbs. Observation showed the LAL mattress control panel set at 450 lbs., the maximum setting. The Treatment Nurse stated the setting was too high for the resident and that the correct setting should have been between 80 and 130 lbs.; the DON stated mattress settings needed to be adjusted according to the resident’s current weight because settings that were too high could reduce pressure redistribution and airflow.
Bed Position and Lift Storage Hazards
Penalty
Summary
The facility failed to ensure Resident 7’s bed was kept in the low position required for fall prevention. Resident 7 was admitted and later readmitted with diagnoses including anxiety disorder and unspecified abnormalities of gait and mobility, had a history of falls, and was identified on the MDS as having severely impaired cognitive skills for daily decision making and falls since admission/reentry. The record also showed fall risk evaluations indicating the resident was at risk for falling, and the care plan included interventions to follow the facility’s fall protocol and maintain a safe environment. During observation, Resident 7 was found lying in bed with the bed positioned about three feet off the floor. The Infection Preventionist Nurse stated the bed was too high. During a later observation, Resident 7 was found on the floor on the left side of the bed and on top of the floor mat. The IPN stated Resident 7 was a fall risk, that one of the fall prevention interventions was to always keep the bed low, and that the bed should have been lowered immediately. A Registered Nurse Supervisor also stated that keeping the bed at the lowest position was important to prevent falls and head injuries. The facility also failed to ensure a sit-to-stand lift was not stored in Resident 36’s restroom doorway and did not block access to the bathroom. Resident 36 had diagnoses including rheumatoid arthritis, repeated falls, and difficulty walking, and the MDS indicated intact cognition, partial/moderate assistance with ADLs, and dependence with mobility. During observation, the lift was positioned in the bathroom doorway and blocked entry. Resident 36 stated the lift was sometimes left in the bathroom and blocked access, which was frustrating. A CNA stated the lift should not be stored there because it could become a safety hazard and that equipment should never be placed in a manner that created a barrier for residents.
Failure to Monitor Indwelling Catheters for Signs of Infection
Penalty
Summary
The facility failed to provide appropriate treatment and services for two residents with indwelling catheters by not closely assessing and monitoring changes in their catheter condition. Resident 3 was admitted and readmitted with diagnoses including urinary device fitting/adjustment and urinary retention, had a suprapubic catheter care order every shift, and had a care plan to monitor and report signs of UTI such as cloudy or foul-smelling urine. Resident 3 also had a history of MRSA, VRE, and UTI, and was cognitively intact. Resident 48 was admitted with diagnoses including COPD and urinary device fitting/adjustment, had an indwelling Foley catheter, and had an order to monitor the catheter every shift for urine output, hematuria, cloudy or foul-smelling urine, and signs of infection. During observation, Resident 3's suprapubic catheter was draining cloudy urine with thick sediment, and the Infection Preventionist Nurse stated the catheter needed to be changed or flushed because it was no longer patent or clean and the sediment could go back and cause a UTI. During a separate observation, Resident 48's Foley catheter was also draining cloudy urine with thick sediment, and the Infection Preventionist Nurse stated it needed to be flushed. Staff interviews indicated catheter checks should occur every shift and that urine should be assessed for blood, sediment, cloudiness, graininess, and odor, with concerns reported to nursing staff. The facility policy stated catheter care would be performed every shift and as needed by nursing personnel.
Unsafe Food Storage and Temperature Control
Penalty
Summary
The facility failed to follow safe food storage practices in the kitchen by leaving a Cambro container of uncooked brown rice with a facility-generated use-by label on a stainless-steel shelving rack with the teal lid not fully closed, storing multiple unlabeled bags of cornflakes on the top shelf, and keeping a used gallon of vinegar with half the contents remaining on the shelf with other vinegar products. During the observation, the CK stated the rice container should be closed because bugs and dust could get into it and residents could get a stomachache, and stated the unlabeled items should have been labeled when received so staff would know when to use them. In Walk-In Refrigerator Cooler #1, six 10-pound bags of diced potatoes were observed without dates. The CFM stated the bags should have been labeled with a use-by date and that undated food items could cause bacteria to grow and cause food borne illness. During tray line service, individualized servings of potato salad were observed on ice, and two sampled servings had temperatures of 46 and 43 degrees. The EC stated the potato salad should have been 40 degrees or lower to keep it within safe serving temperature to prevent potential bacteria growth. The CK later stated the temperature log reflected the potato salad temperature before it was portioned into individual servings and that no second temperatures were taken after preparation. In the unit refrigerator, a posted sign required all food to be labeled with the patient name and date placed in the fridge, but several items were not dated. These included an opened package of dry Italian seasoning marked only with a resident's name, a bowl containing an avocado, tomatoes, and soy sauce marked only with a resident's name and a note, and a grocery bag marked only with a room and bed number containing food items. LVN 2 stated CNA staff generally placed residents' food from home in the refrigerator and that dating was important because the facility discarded food every Friday. CNA 3 stated food from home had to be labeled with the resident's name, room number, and date placed in the refrigerator because residents sometimes changed rooms and the food could be given to the wrong resident.
Infection control failures with masking, vaccination tracking, PPE use, equipment disinfection, and storage of resident care items
Penalty
Summary
The facility failed to provide an infection prevention and control program when multiple staff members were observed without masks or with masks worn incorrectly during resident care and in resident care areas during a period of higher respiratory virus transmission. On 12/2/25, LVN 4, CNA 6, CNA 7, CNA 8, CNA 9, OT 1, PT 1, the DSD, the IPN, the TN, Housekeeper 1, and activity staff were observed in resident care areas without appropriate masking, including in hallways, the nurse’s station area, therapy areas, resident rooms, and the activity room. The IPN stated resident care areas included hallways, the nurse’s station, and public areas when residents were present. The DSD, IPN, and DON stated they were not aware of the latest masking guidance, and the DON later stated the facility would implement mask use for all staff inside the facility. The facility policy stated it maintained an infection prevention and control program, and CDC and local guidance cited in the report required masking during higher levels of community respiratory virus transmission and throughout the respiratory virus season in healthcare patient-care areas. The facility also failed to track influenza vaccination status and provide related education for staff. CNA 6, OT 1, and PT 1 had no influenza vaccination information documented on the facility’s Staff Influenza 2025 log, and the IPN and DSD stated the rehabilitation department had no vaccine information available. CNA 6 stated he declined influenza vaccine. The IPN later stated the log was incomplete and that the facility needed vaccination status to know who required education, declination forms, and recommended vaccines. The facility’s influenza vaccination policy stated staff medical files would include documentation that staff were provided education regarding the benefits and potential side effects of immunization and whether they received or did not receive the immunization due to contraindication or refusal, while CDC guidance cited in the report identified tracking influenza vaccination among healthcare personnel as an important component of a systematic approach. The report also documented multiple infection control lapses in resident care and equipment handling. CNA 3 and CNA 4 were observed performing perineal care for two residents while using the same gloves after touching curtains, closet handles, and other room surfaces. The IPN stated touching the environment after donning gloves and then using the same gloves placed the resident at risk for infection because the environment could be contaminated with bacteria. A nebulizer mask and oxygen tubing for two residents were observed stored outside of storage bags when not in use, despite the facility policy requiring delivery devices to be kept covered in a plastic bag when not in use. A BP cuff was used on one resident after being used on another resident without being disinfected in between, and LVN 2 stated the cuff had been forgotten and needed disinfection because it was shared between residents. In addition, staff did not don gown and gloves when assisting a resident on enhanced barrier precautions back to bed after the resident was found on the floor, even though the resident had a Foley catheter and was on EBP. The report also noted unlabeled wound cleanser and skin cleanser products stored improperly in and around the PPE cart for two residents on EBP, and the IPN stated the cleanser should have been labeled and stored at the resident’s bedside for individual use.
Antibiotic Stewardship Monitoring Not Followed
Penalty
Summary
The facility failed to follow its Antibiotic Stewardship policy for 4 of 5 sampled residents by not properly reviewing antibiotic orders for appropriateness and not completing the Surveillance Data Collection Form (SDCF) as required. The Infection Prevention Nurse stated the facility was using McGeer's criteria, but also stated that antibiotic time-out was not practiced to review whether antibiotics were indicated by signs, symptoms, and laboratory results. The policy stated that licensed nurses participate in the program through resident assessment and that antibiotic use monitoring includes reviewing response to antibiotics and laboratory results when available, reviewing antibiotic orders obtained upon admission, and reviewing orders from consulting, specialty, or emergency providers. For Resident 51, who was admitted with diagnoses including UTI and metabolic encephalopathy, the order summary showed multiple antibiotic orders for UTI/yeast infection and UTI. The SDCF for UTI with an indwelling catheter was incomplete and did not include signs and symptoms or a urine culture result. During review, the IPN stated the urine culture results were not available in the SDCF and that the lab results needed to be printed. The progress notes documented that the resident complained of slight burning when urinating, but the IPN stated the SDCF had been attempted after the antibiotic order rather than when the order was received. The urine culture for November 2025 could not be found during the review. For Resident 12, who had chronic kidney disease stage 4 and functional urinary incontinence, the resident was ordered Amoxicillin for UTI. The SDCF used was for a UTI with an indwelling catheter even though the resident did not have a catheter, and it did not include signs and symptoms or a urine culture result. The microbiology report showed enterococcus faecalis susceptible to ampicillin or Vancomycin, and the IPN stated the next step would be to call the physician to clarify the antibiotic ordered. For Resident 100, who had metabolic encephalopathy and UTI, Cephalexin was ordered for UTI, but no SDCF was completed and the progress notes did not document signs and symptoms of UTI; the U/A showed no bacteria but positive blood and leukocyte esterase. For Resident 13, who had a history of falling and overactive bladder, Cephalexin was ordered for infection, but the infection was not clarified, the SDCF did not specify the type of infection, and no signs, symptoms, or culture results were documented.
Failure to Offer and Document Influenza Vaccination
Penalty
Summary
The facility failed to ensure influenza vaccination was offered and documented for two sampled residents. Resident 11 was admitted and later readmitted with diagnoses including MRSA infection and sepsis, and the MDS dated 12/3/25 indicated severe cognitive impairment and that the resident did not receive the influenza vaccine at the facility because the resident declined it. Resident 20 was admitted and later readmitted with diagnoses including heart failure and pneumonia, and the MDS indicated intact cognition and that the resident did not get the influenza vaccine at the facility because it was offered and declined. Record review showed Resident 11 had received an influenza vaccination on 10/28/24 and Resident 20 had received one on 2/18/25, but there was no documented evidence that Resident 11 signed a vaccination consent/declination form. Resident 20’s vaccination/declination form was dated 11/11/25 and indicated the resident representative declined the flu vaccine because the resident had already received the flu vaccine. The Infection Prevention Nurse stated that when residents consented or refused vaccinations, a signed consent/declination form was used as proof that education was provided, that Resident 11’s current-season consent/declination had not been completed, and that Resident 20’s flu vaccine from the prior season would require current-season information.
Baseline Care Plan Omitted Psychotropic and Anticoagulant Orders
Penalty
Summary
The facility failed to ensure that Resident 98’s baseline care plan included administration of Lorazepam and Eliquis. Resident 98 was admitted on 12/1/2025 with diagnoses including history of falls, anxiety disorder, and atrial fibrillation. The baseline care plan dated 12/1/2025 did not address that the resident was receiving Lorazepam or Eliquis, and Section D of the care plan, which asked whether the resident was taking a psychotropic medication or an anticoagulant, was left blank. The resident’s order summary showed an active order for Lorazepam 1 mg by mouth every 24 hours as needed for anxiety and Eliquis 2.5 mg by mouth twice daily for clot prevention, both ordered on 12/1/2025. During interview and record review, RN 1 stated these medications should have been included in the baseline care plan to reflect the physician’s orders and to ensure staff were aware of the resident’s medication needs, monitoring requirements, and associated risks during the initial admission period. The DON also stated the orders should have been included in the baseline care plan and that their omission could have led to staff missing important monitoring needs such as sedation, behavior changes, or bleeding.
Missing Dementia Care Plan
Penalty
Summary
The facility failed to develop and/or implement an individualized, person-centered comprehensive care plan for Resident 9 that included measurable objectives, defined time frames, and specific interventions addressing dementia. Resident 9 was admitted with diagnoses including dementia, depression, and an anxiety disorder. The Minimum Data Set dated 9/5/2025 indicated the resident's cognition was moderately impaired and that the resident required partial/moderate assistance with activities of daily living and mobility. A review of Resident 9's care plans on 12/3/2025 found no documented evidence that a dementia-specific care plan had been developed. During a concurrent interview and record review, RN 1 stated that a dementia-specific care plan had not been developed, initiated, or implemented for Resident 9 and said it should have addressed cognitive status, behavioral risks, communication needs, and safety concerns. The DON also stated that an individualized, person-centered dementia care plan with measurable objectives, defined time frames, and targeted interventions was essential.
Failure to Educate Resident on New Pain Medication
Penalty
Summary
The facility failed to provide education for a newly prescribed pain medication for one of five sampled residents, Resident 99, during medication administration. Resident 99 was admitted with diagnoses that included wedge compression fractures of the second lumbar vertebrae and T11-T12, and the history and physical dated 12/5/2025 indicated Resident 99 had capacity to make decisions. On 12/4/2025 at 8:33 AM, LVN 2 administered Tramadol to Resident 99 and told the resident, "here is your pain medication." Resident 99 stated that the resident usually took 2 pills for pain medication when asking for pain medication, asked what medication was being given, and asked whether Tramadol was a new medication. LVN 2 responded that the medication was Tramadol and said the resident would check whether it was new. During a later interview the same morning, LVN 2 stated Tramadol was a new prescribed medication for Resident 99 and stated that when a resident is administered a new medication, education must be provided regarding the name, dose, and potential side effects. The order summary report showed a new order for Tramadol 50 mg by mouth every 12 hours as needed for lower back pain dated 12/3/2025, and the MAR showed Tramadol was administered for the first time on 12/4/2025 at 8:33 AM. Facility policy stated medications are to be administered in accordance with professional standards of practice, and the facility's policy on unnecessary drugs stated residents have the right to be informed of and participate in treatment, including being informed of the benefits, risks, and alternatives before initiating a medication.
IV Site Care and Line Management Not Maintained
Penalty
Summary
The facility failed to ensure Resident 11 received IV treatment and care in accordance with orders and the facility’s Intravenous Therapy policy. Resident 11 was admitted and readmitted with diagnoses including unspecified abnormalities of gait and mobility and repeated falls, had no decision-making capacity per the H&P, and had moderately impaired cognitive skills on the MDS. The admission assessment documented a PICC line IV access in the left antecubital area, but did not indicate a saline lock. The skin evaluation also did not indicate the presence of a PICC or saline lock, although it noted the resident was receiving IV Vancomycin. On observation, Resident 11 had a covered saline lock in the right wrist with an old, stained kerlix dressing around the port and slight redness above and below the site. Resident 11 also had a double lumen PICC in the left upper arm with an intact but undated Opsite dressing. At the bedside was an IV infusion pump with an empty bottle of Vancomycin. During interview, the DON stated the resident had been admitted with the IV lines, did not know why the hospital said to keep the saline lock, and stated the PICC dressing should have a date or be replaced and dated. When the dressing was removed, the saline lock site had a clear dressing dated 11/20/25 with redness extending above and below the IV site, and the DON stated staff should have checked the IV site. RN 1 stated the saline lock should have been removed if there was no need for it since the resident had a PICC, and described the saline lock dressing as tattered with signs of possible phlebitis.
Failure to Provide Ordered Itch Relief and Skin Monitoring
Penalty
Summary
The facility failed to provide appropriate care and services for a resident experiencing persistent itching and multiple open skin scratches, as required by its own policies and procedures. The resident, who had a history of psychosis, mobility issues, and muscle wasting, was admitted with skin integrity problems, including open tears and excoriations related to dry skin and scratching. Despite physician orders for hydrocortisone cream and diphenhydramine to address the itching, the resident did not receive diphenhydramine, and hydrocortisone treatment was not continued after the order ended. Observations revealed the resident continued to scratch, resulting in numerous open wounds across the body, with both healed and new excoriations visible. Nursing staff interviews and record reviews indicated that weekly skin assessments were not performed as required, with the last documented assessment being incomplete and not reflecting the resident's current condition. Licensed nurses and the DON confirmed that there was a lack of ongoing monitoring and documentation of the resident's skin status, and that the physician was not notified when the resident's condition failed to improve. The resident's care plan included interventions for skin integrity, but these were not effectively implemented or followed up, as evidenced by the continued presence of open wounds and persistent itching. Further, there was no evidence of communication with the physician regarding the resident's ongoing symptoms until prompted by the surveyor. The wound consultant had never assessed the resident, and there were no wound consultant notes in the medical record. The facility's policies required daily observation for skin changes and weekly documented assessments, as well as prompt notification of the physician for any lack of improvement, but these protocols were not followed. As a result, the resident remained at risk for infection due to the ongoing skin breakdown and lack of effective intervention.
Failure to Document and Assess Resident's Skin Condition Weekly
Penalty
Summary
Licensed nurses failed to accurately assess and document a resident's skin condition weekly, as required by facility policy and professional standards. The resident, who had a history of unspecified psychosis, mobility issues, and muscle wasting, was admitted with multiple open skin scratches caused by persistent itching. Physician orders were in place for topical treatment of the skin issues, but documentation of ongoing skin assessments was missing from the medical record for a period of over six weeks. Record review revealed that after an initial skin assessment on 8/29/2025, there were no further Licensed Nurse Skin Assessment Forms or other documented skin assessments from 8/30/2025 to 10/15/2025. During this time, the resident continued to experience widespread open skin scratches and excoriations, as observed by nursing staff and confirmed during interviews. Staff noted that the resident's skin condition remained unchanged, with numerous new and healed scratch marks visible on various parts of the body, but there was no documentation of these findings in the medical record. Interviews with nursing staff and the Director of Nursing confirmed that required weekly skin assessments were not completed or documented, and that changes in the resident's skin condition were not communicated to the physician as expected. Facility policies required timely and detailed documentation of skin assessments, including any changes or treatments, but these procedures were not followed for the resident during the identified period.
Resident Provided Incorrect Medications at Discharge
Penalty
Summary
A deficiency occurred when a nurse at discharge provided a resident with blister packs containing medications that belonged to two other residents, rather than the resident's own prescribed medications. The resident, who had a history of diabetes mellitus and hypertension and was determined to have the mental capacity to make medical decisions, ingested pantoprazole (Protonix) before realizing the error. The medication was not prescribed to her, and the error was confirmed by the Director of Nursing as a mistake that should not have happened. Following ingestion of the incorrect medication, the resident experienced adverse symptoms including body aches, vomiting, hives, and elevated blood pressure, which required hospital evaluation and monitoring. The facility's policy required the discharge nurse to ensure medication reconciliation at discharge, but this process was not followed, resulting in the resident receiving and ingesting another resident's medication.
Failure to Document Physician Communication and Change of Condition
Penalty
Summary
The facility failed to adhere to its own documentation policy by not recording key clinical information for a resident with diabetes mellitus and hypertension. Specifically, there was no documentation of a follow-up pain score after the administration of a second dose of pain medication, no record of a change of condition (COC), and no documentation of communication with the physician regarding the resident's status. These omissions were confirmed during interviews and record reviews with both a Licensed Vocational Nurse (LVN) and the Director of Nursing (DON), who acknowledged the absence of required documentation in the resident's chart and Medication Administration Record (MAR). The facility's policy, dated August 2024, requires that all care, observations, and communications, including those with physicians, be documented completely, accurately, and in a timely manner. Despite this, the resident's chart lacked progress notes, COC documentation, and a physician's order for hospital transfer, as well as a follow-up pain assessment after pain medication was administered. These failures were identified during a review of the resident's records and confirmed by facility staff.
Failure to Report Alleged Abuse of a Resident
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident, which violated the resident's rights and potentially delayed an abuse investigation. The resident, who was admitted with diagnoses including myocardial infarction and hemiplegia, had moderate cognitive impairment and required maximal assistance with mobility. The resident's care plan noted an accusation that someone had hurt and broken the resident's arm, but this allegation was not reported to the administrator or the appropriate authorities as required by the facility's policy. The resident had pathologic fractures in both arms, as indicated by radiology and oncology consultations. During interviews, the resident mentioned that a water bottle fell on their arm and acknowledged having brittle bones, but could not recall reporting that a staff member broke their arm. The facility's policy mandates that any suspected or alleged abuse be reported within two hours to the administrator and relevant agencies, but this protocol was not followed in this case, as confirmed by the administrator during the review.
Failure to Prevent Pressure Ulcers in Resident
Penalty
Summary
The facility failed to prevent the development of pressure ulcers in a resident, identified as Resident 1, who was readmitted to the facility. Upon readmission, the facility did not develop a comprehensive care plan to address the resident's risk for pressure injuries, despite the presence of redness on the sacrococcyx area. The care plans in the resident's medical record were outdated and not revised to reflect the resident's current condition. Additionally, there was a lack of coordination among the care team to address the resident's needs, particularly in light of the physician's order for minimal turning due to further fractures. The facility also failed to conduct a pressure injury wound risk assessment upon the resident's readmission. This assessment was crucial as it could have triggered the development of a specific care plan and the implementation of preventive measures, such as the use of an alternating pressure pad. The resident's bilateral arm fractures impaired mobility, leading to pain and refusal to reposition, which further increased the risk of pressure injuries. The lack of a clear plan and communication among staff regarding the resident's care needs contributed to the development of a stage 3 pressure injury. Furthermore, the facility did not ensure the proper use of a low air loss mattress, which was set on static mode instead of alternating mode. This setting was not appropriate for pressure relief and circulation, which are essential for preventing pressure injuries. The staff, including the treatment nurse and director of staff development, were unaware of the correct mattress setting needed for the resident's condition. This oversight, combined with the lack of a comprehensive care plan and risk assessment, resulted in the development of a significant pressure injury on the resident's sacrococcyx area.
Failure to Provide Advance Directive Information
Penalty
Summary
The facility failed to ensure that two residents, Resident 9 and Resident 47, or their legal representatives were informed and provided with written information about Advance Directives (AD). This failure violated the residents' rights to formulate an AD, which specifies health-related actions according to the resident's wishes when they are no longer able to make decisions due to illness or incapacity. Resident 9 was admitted with multiple diagnoses, including hemiplegia and dementia, and was assessed as having severely impaired cognitive status and lacking decision-making capacity. Resident 47, with diagnoses including COPD and sepsis, was moderately impaired cognitively but oriented to person, place, and time. During a review of the residents' medical records, it was found that the Social Services Coordinator (SSC) did not have a copy of the AD or the Acknowledgment Form (AF) for either resident. The SSC stated that the AF, which is provided to residents or their representatives to formulate an AD, must be given within 72 hours of admission. The facility's policies indicated that residents have the right to formulate an AD, and it is the SSC's responsibility to review and follow up on the completion of ADs. However, this process was not completed for Resident 9 and Resident 47, leading to the deficiency.
Failure to Update Care Plans for Fall-Risk Residents
Penalty
Summary
The facility failed to revise and update the care plans for two residents who were assessed as being at risk for falls. Resident 2 was admitted with diagnoses including mild cognitive impairment, metabolic encephalopathy, and abnormal gait and mobility. Despite being identified as high risk for falls in multiple assessments, Resident 2's care plan was not updated to reflect necessary interventions to prevent further falls. The registered nurse acknowledged that the care plan was blank and not updated, which was contrary to the facility's policy requiring care plan revisions upon a resident's status change. Resident 39, who was admitted with repeated falls and other medical conditions, was also identified as being at high risk for falls. Despite this, the care plan was not updated after a fall incident, and necessary safety measures such as safety floor mats were not implemented. The resident experienced a fall while trying to reach for clothing, and the interdisciplinary team noted periods of confusion and forgetfulness due to dementia. The Director of Nursing confirmed that the care plan should have been updated to address the fall and implement more effective strategies. The facility's policy mandates that care plans be reviewed and revised when a resident experiences a status change. This includes notifying relevant staff, discussing intervention options, documenting discussions, and updating care plans with new interventions. However, these procedures were not followed for Residents 2 and 39, leading to deficiencies in their care plans and potentially placing them at risk for further falls.
Deficiencies in Food Storage and Handling Practices
Penalty
Summary
The facility failed to adhere to safe food storage and handling practices in both the kitchen and the snack/nourishment refrigerator, as observed by surveyors. In the kitchen, multiple food items, including spices and vegetables, were found without proper labeling or dating, which is essential for maintaining food quality and preventing foodborne illnesses. Additionally, peeled boiled eggs were found in the walk-in refrigerator without labels, and pork butt meat was improperly stored on the floor of the walk-in freezer. The Executive Chef acknowledged that food items should be labeled with open and use-by dates and stored at least four inches above the floor. In the resident areas, a resident's bedside table contained cookies brought from home that were past their sell-by date, posing a risk of gastrointestinal issues. The Certified Nursing Assistant and Acting Director of Nursing both noted that food brought from home should be labeled and not kept for extended periods to prevent spoilage and potential illness. Furthermore, the snack/nourishment refrigerator was found to have an internal temperature of 31 degrees Fahrenheit, which is below the recommended range, risking the freezing of food items. A pot pie in the refrigerator was also undated, and the Licensed Vocational Nurse confirmed that the refrigerator temperature should be between 36 and 40 degrees Fahrenheit. The facility's policies and procedures were reviewed, revealing that they require proper labeling, dating, and storage of food items to prevent contamination and ensure safety. The chemical sanitizing solution used in the kitchen was also found to be at an incorrect concentration of 50 ppm, below the required 200-300 ppm, which is necessary for effective sanitization. The Executive Chef confirmed that the concentration was insufficient to kill bacteria, further highlighting the facility's failure to maintain professional standards for food service safety.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain its infection prevention and control program, as evidenced by several deficiencies observed during the survey. One significant issue involved the improper cleaning and disinfection of a blood pressure monitor. A Licensed Vocational Nurse (LVN) used the same wrist blood pressure monitor on two residents without disinfecting it between uses. This oversight was acknowledged by the LVN, the Acting Director of Nursing, and the Infection Preventionist, all of whom confirmed that the equipment should have been disinfected to prevent cross-contamination and the spread of infection. Another deficiency was noted in the labeling of urinals for residents. Resident 208's urinal was not properly labeled, leading to a potential mix-up with another resident's urinal. This was identified as an infection control issue by a Certified Nursing Assistant (CNA) and the Infection Preventionist, who emphasized the importance of proper labeling to prevent cross-contamination of infectious diseases. The facility's policy on infection prevention and control supports the need for individual labeling to avoid such risks. Additional issues included the improper storage of personal care items and staff belongings. A used perineal and skin cleanser was found on top of a toilet tank cover in a shared restroom, which posed a risk of cross-contamination. The Infection Preventionist confirmed that personal items should be stored at the bedside to avoid contamination. Furthermore, food and personal belongings of staff were found in the linen closet, which could lead to contamination of clean linens. The Housekeeping Supervisor and the Infection Preventionist both stated that such items should not be stored in the linen closet to maintain a clean and safe environment.
Inaccurate MDS Completion for Resident
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) for a resident was completed accurately, as required by the facility's policy and procedure. This deficiency was identified during an interview and record review involving the Acting Director of Nursing (ADON) and the resident's records. The resident, who had multiple diagnoses including dysphagia, oropharyngeal phase issues, and essential hypertension, was inaccurately documented in the MDS as taking anticoagulant medication, which was not prescribed. The ADON acknowledged the error, stating it was important for the MDS to be accurate as it affects the resident's care. The facility's policy, titled MDS 3.0 Completion, Assessment and Care Planning Policy, mandates a comprehensive assessment process to identify care needs and develop an interdisciplinary care plan. According to federal regulations, the facility is required to conduct a comprehensive, accurate, and standardized assessment of each resident's functional capacity. The failure to accurately complete the MDS for the resident had the potential to result in inappropriate care and services based on the resident's preferences, goals of care, functional and health status, strengths, and needs.
Failure to Timely Transmit MDS Assessments
Penalty
Summary
The facility failed to complete and transmit the quarterly Minimum Data Set (MDS) assessments in a timely manner for two residents, as required by the Centers for Medicare & Medicaid Services (CMS) Resident Assessment Instrument (RAI) manual. For one resident, the MDS was not transmitted within 14 days after discharge from the facility. For another resident, the MDS was not transmitted within 14 days after both admission and discharge. These deficiencies were identified during interviews and record reviews with the Acting Director of Nursing (ADON), who acknowledged the oversight and the lack of a facility policy for MDS submission, relying instead on CMS guidelines. The report highlights that the late completion and transmission of MDS assessments to the CMS Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) system could potentially affect the facility's quality monitoring data. The ADON admitted to forgetting to complete and send the discharge MDS for one resident and failing to submit the admission and discharge MDS for another resident. The facility was unable to provide a copy of the MDS 3.0 Submission Report for the relevant months to confirm the submission of the assessments.
Failure to Implement Baseline Care Plan for Resident with Suprapubic Catheter
Penalty
Summary
The facility failed to develop and implement a baseline care plan for a resident who was admitted with a suprapubic catheter within 48 hours of admission, as required by the facility's policy and procedure. The resident, who had multiple diagnoses including hemiplegia, hemiparesis, acute kidney failure, and required a urinary device, was dependent on staff for toileting hygiene. Despite these needs, the resident's medical records did not contain any care plans, which was confirmed during a review with the Acting Director of Nursing. The absence of a baseline care plan was also noted by the Infection Preventionist, who emphasized the importance of having such a plan to guide staff in providing appropriate care, especially for residents with catheters. The facility's policy, revised in September 2022, mandates that a baseline care plan be developed within 48 hours of admission to ensure effective and person-centered care. However, this requirement was not met for the resident, potentially compromising the continuity of care and communication among staff.
Failure to Implement Elopement Care Plan
Penalty
Summary
The facility failed to develop or implement an individualized person-centered care plan for a resident who was at risk for elopement and had a history of elopement. The resident was admitted with diagnoses including mild cognitive impairment, metabolic encephalopathy, and abnormal gait and mobility. Despite being identified as at risk for elopement in assessments conducted on multiple occasions, and having a physician's order for a wander guard due to exit-seeking behavior, the resident did not have a care plan addressing the risk of elopement. During an interview, a family member confirmed that the resident had previously attempted to leave the facility to return home, and a wander guard was ordered to prevent elopement. However, during an observation, the wander guard was found hanging on the resident's walker rather than being worn. A registered nurse confirmed that the resident was high risk for elopement and acknowledged the absence of a care plan to address this risk, which was necessary for the resident's safety. The facility's policy required the development and implementation of a baseline care plan for each resident, which was not followed in this case.
Failure to Prevent Pressure Ulcer in High-Risk Resident
Penalty
Summary
The facility failed to provide necessary care and services to prevent the development of a pressure ulcer in a resident identified as high risk. Resident 48, who was admitted without pressure ulcers, developed a stage 2 pressure injury on the left buttock. The resident had multiple diagnoses, including end-stage renal disease, endocarditis, and bacteremia, and was assessed as high risk for skin breakdown due to reduced mobility, incontinence, diabetes, coronary artery disease, and aging. The care plan included interventions such as regular repositioning and maintaining skin cleanliness, but these were not adequately implemented. Observations and interviews revealed that Resident 48 was not encouraged or assisted to reposition while in a wheelchair or bed, which contributed to the development of the pressure ulcer. The resident reported that staff did not frequently encourage repositioning and that wet diapers were not changed promptly, leading to prolonged exposure to moisture. The resident was mostly bed-bound and required substantial assistance with activities of daily living, further emphasizing the need for diligent care to prevent skin breakdown. The facility's policy on pressure injury prevention outlined the importance of repositioning every two hours and keeping the skin clean and dry, especially for residents at risk. However, these guidelines were not followed, as evidenced by the resident's statements and the observations made during the survey. The lack of adherence to the facility's policy and the care plan interventions resulted in the development of a pressure ulcer in Resident 48.
Failure to Post Oxygen Use Signage
Penalty
Summary
The facility failed to ensure proper respiratory care and safety for a resident receiving oxygen therapy, as per the facility's policy and professional standards. The resident, who was admitted with chronic obstructive pulmonary disease and a history of repeated falls, required oxygen administration at 2 to 4 liters per minute via nasal cannula for shortness of breath. Despite this requirement, there was no sign posted on the resident's door to indicate that oxygen was in use, which is a necessary precaution to inform staff and visitors and prevent potential fire hazards. During an observation, it was noted that the resident was asleep with the nasal cannula connected to an oxygen machine, yet the required signage was absent. This was confirmed during an interview with an LVN, who acknowledged the importance of the sign for safety reasons. The facility's policy on oxygen administration, revised in March 2022, mandates that oxygen warning signs must be placed on the doors of rooms where oxygen is in use, which was not adhered to in this case.
Absence of Full-Time DON for Eight Months
Penalty
Summary
The facility failed to maintain a full-time Director of Nursing (DON) for a period of approximately eight months, starting from early March 2024. This deficiency was identified during an entrance conference where the Administrator acknowledged the absence of a full-time DON and the ongoing search to fill the position. The previous DON went on medical leave in early March 2024 and subsequently resigned in August 2024. During this period, the Assistant Director of Nursing (ADON) assumed multiple roles, including acting as the DON, Director of Staff Development (DSD), and continuing her official duties as the Minimum Data Set Nurse (MDS). The ADON reported being overwhelmed by these responsibilities, which included conducting applicant interviews, being on-call for nursing duties, and managing new hire orientations and performance evaluations. The ADON's additional responsibilities led to a backlog in tasks such as performance evaluations and hindered her ability to effectively oversee the unit and communicate with residents. The ADON expressed that the overwhelming workload negatively impacted the quality of care and potentially affected both residents and staff. The facility's Quality Assurance Committee records confirmed the DON position remained open, and the job description for the DON highlighted the importance of compliance with regulations and quality clinical care, which was compromised due to the absence of a full-time DON.
Medication Administration Errors and Non-Compliance with Physician Orders
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in an observed error rate of 11.54% during a medication pass for a resident. The errors involved the improper administration of medications, including Eliquis, a blood thinner, and a multiple vitamin, which were not given as per the physician's orders. Additionally, the proper technique for administering Brimonidine Tartrate Ophthalmic Solution was not followed, as the tear duct was not held with gentle pressure after administration. The resident involved had a medical history that included long-term use of an anticoagulant, repeated falls, and a displaced intertrochanteric fracture of the right femur. The resident's care plan specifically indicated the need for administering medications as ordered, particularly Eliquis, due to the risk of poor circulation and blood clotting issues. During the medication pass, the resident refused to take certain medications, and the nurse failed to administer Eliquis and the multiple vitamin, disposing of them instead. Interviews with the nursing staff revealed that the nurse did not inform the nurse practitioner about the refusal of Eliquis and the multiple vitamin, although the refusal of other medications was communicated. The facility's policy on medication refusal requires immediate contact with the prescribing doctor, which was not fully adhered to in this case. The failure to apply pressure to the tear duct after administering eye drops was also acknowledged by the staff as a deviation from the correct procedure.
Failure to Administer Critical Medication
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 109, was free from significant medication errors. During a medication pass observation, it was noted that Resident 109 did not receive their prescribed dose of Eliquis, a blood thinner, as ordered by the physician. The resident spat out all medications except for Colace, and the Licensed Vocational Nurse (LVN 5) did not re-administer the Eliquis or inform the Nurse Practitioner about the refusal of this critical medication. The resident's care plan indicated the necessity of administering Eliquis due to their risk for blood clots, given their medical history of long-term anticoagulant use, repeated falls, and a displaced intertrochanteric fracture of the right femur. The LVN acknowledged the failure to administer Eliquis and did not report the refusal of this medication to the Nurse Practitioner, which was contrary to the facility's policy on medication refusal. The policy required immediate contact with the prescribing doctor in cases of medication refusal, especially for medications critical to the resident's health. The Registered Nurse (RN 1) confirmed that Eliquis should have been administered due to the resident's recent fracture and the need to prevent complications. This oversight had the potential to increase the risk of blood clots for the resident, which could lead to serious medical complications.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call light system was within reach for Resident 25, as required by the resident's care plans and the facility's policy and procedure. Resident 25, who was admitted with multiple diagnoses including muscle weakness, difficulty in walking, and a history of falling, had care plans that specified the call light should be kept within reach at all times. During an observation, it was noted that the call light was looped around the left bed grab bar and was out of reach for Resident 25, who was sitting in a wheelchair on the right side of the bed. This was confirmed by Licensed Vocational Nurse 1, who acknowledged that the call light should always be within reach for the resident's safety. Interviews with staff further highlighted the deficiency. Certified Nursing Assistant 1 stated that the call light should always be within reach and not on the opposite side of the bed, as it could increase the risk of falls. The facility's policy, revised in April 2023, also indicated that staff should ensure the call light is within reach and secured as needed. Despite these guidelines, the call light was not accessible to Resident 25, who required substantial to maximal assistance for activities of daily living and was wheelchair-bound, oriented to time, place, and person.
Inadequate Infection Prevention Training for Acting ICPs
Penalty
Summary
The facility failed to ensure that the Director of Nursing (DON) and the Registered Nurse Supervisor (RNS), who were covering the role of Infection Control Preventionist (ICP), had the necessary Infection Prevention (IP) certificates and completed specialized training in infection prevention and control. This deficiency was identified during a visit to investigate a reported Covid-19 outbreak at the facility. The Administrator (ADM) confirmed that the ICP was on medical leave, and the role was shared between the DON and the part-time RNS. However, neither the DON nor the RNS could provide certificates to verify their completion of the required training. Interviews with the DON and ADM revealed that the DON had been acting as the ICP for several months but could not recall the exact start date. The DON acknowledged the importance of having a properly trained ICP to manage infection control and prevent the spread of diseases like Covid-19. The ADM also emphasized the necessity of a trained ICP to monitor outbreaks and protect residents and staff. A review of regulatory documents from the California Department of Public Health (CDPH) highlighted the requirement for a full-time IP with a minimum of 14 hours of training and ongoing education to stay updated on best practices.
Facility Fails to Provide Homelike Environment Due to Damaged Meal Trays
Penalty
Summary
The facility failed to provide a homelike environment for all 53 residents by not ensuring that meal trays were in good condition. During an observation and interview with the Director of Nursing (DON) and Kitchen Supervisor (KS) in the kitchen area, ten trays were found to have cracks and peeling materials. Both the DON and KS acknowledged that these trays were not appropriate or safe for serving meals to residents. The KS further stated that the facility should not be using broken, cracked, and/or peeling trays and that these trays needed to be disposed of. The facility's policy and procedure titled 'Safe and Homelike Environment,' revised in April 2024, indicated that the facility was responsible for providing a safe, clean, comfortable, and homelike environment in accordance with residents' rights. This included ensuring that resident care equipment, such as meal trays, was kept clean and properly stored. The failure to adhere to this policy resulted in a non-homelike environment, potentially affecting the residents' quality of life.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 3,242 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 Claremont
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Claremont Manor Care Center | 0.2 mi | ★★★★★ | 18 | 0 |
| Mount San Antonio Gardens | 0.6 mi | ★★★★★ | 1 | 0 |
| Claremont Heights Post Acute | 1.1 mi | ★★★★★ | 24 | 0 |
| Claremont Care Center | 1.3 mi | ★★★★★ | 14 | 0 |
| Landmark Medical Center | 1.5 mi | ★★★★★ | 26 | 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.