Above average — CMS composite of the measures below.
A standard survey is most likely before around July 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pine Creek Care Center during CMS and state inspections, most recent first.
Surveyors found that three residents at risk for falls and requiring varying levels of assistance with ADLs and transfers did not have accessible, functional call light systems as required by their care plans and facility policy. Two residents were observed awake in bed with their call light buttons on the floor under the bed and out of reach, and CNAs confirmed the lights should have been placed within reach. Another resident reported that his call light had been broken for several days, staff interviews indicated the call light frequently malfunctioned, and observation with staff confirmed the system was broken with no alternative call system provided and no documentation in the maintenance log.
Failure to Provide Required Transfer/Discharge and Bed-Hold Notice A resident with severe cognitive impairment, dementia with behavioral disturbance, and escalating agitation was sent to an acute hospital after staff reported combativeness, wandering, and unsafe behaviors. The physician and nursing staff discussed increasing Seroquel with the RP, but the RP refused the medication change and asked that the resident not be sent out until she arrived. The facility completed a Notice of Proposed Transfer/Discharge, but the RP stated bed-hold was never mentioned, and the ADM later stated the resident was not being accepted back. The resident was denied return to the facility.
Three residents did not receive care and services as ordered, including the application of TED stockings and lymphatic compression devices. One resident with endocarditis and muscle weakness was not provided with TED hose or offered the compression device as ordered, while two other residents with conditions such as congestive heart failure and multiple sclerosis were not provided with TED hose or daily weights as prescribed. Staff and nursing leadership confirmed these orders were not followed, and facility policy required adherence to physician orders.
Two residents who required staff assistance for ADLs were found with untrimmed, dirty fingernails, dry and scaly feet, and old food residue in their beards. Staff confirmed these hygiene deficiencies and acknowledged that the residents should have been properly cleaned and groomed, in accordance with their care plans and facility policy.
The facility did not consistently document the administration of hydrocodone-acetaminophen for three residents with orthopedic and spinal injuries, resulting in discrepancies between the Controlled Drug Record and the Medication Administration Record. The DON acknowledged the importance of accurate documentation for controlled drug accountability, but the facility's policy was not followed.
Surveyors found that medication carts contained a loose, unlabeled tablet and were left unlocked and unattended, contrary to facility policy. Additionally, a discontinued medication for a resident with respiratory conditions remained in the medication refrigerator with active medications days after discharge, instead of being promptly removed and stored for disposal as required.
Staff did not deliver bedside water pitchers for two days, resulting in four residents—each at risk for dehydration due to medical conditions and not on fluid restrictions—being left without consistent access to water. Observations and interviews confirmed the absence of water pitchers, with some residents only receiving water at mealtimes. Both nursing and CNA staff acknowledged that water pitchers should have been provided, and facility policy required monitoring and supporting resident hydration.
Licensed nursing staff documented treatments and medications as provided when they were not administered, including TED hose and IV antibiotics, and failed to accurately complete informed consent for a psychotropic medication. Additionally, meal tickets containing resident-identifiable information were disposed of in regular garbage instead of confidential shredding, breaching confidentiality protocols.
A resident with dysphagia and partial paralysis had a G-tube in place, but there was no current physician order or care plan addressing the device. Multiple staff, including an LPN, NP, and DON, confirmed the absence of required documentation and care planning for the G-tube, despite facility policy requiring comprehensive care plans for all medical devices.
A resident with dysphagia and partial paralysis had a physician order for 1:1 supervision and assistance during meals, including cues to slow eating and pre-cut food. Staff were observed leaving the resident unattended during meals, and there was no documentation of required supervision for the past month. Facility policies required following physician orders and providing meal assistance based on individual needs, but these were not followed.
The facility failed to meet professional standards for food storage and service practices, including unlabeled opened food packages, improperly stored food items, and ineffective sanitizer solution. These deficiencies were acknowledged by the Food and Nutrition staff and were in violation of the facility's policies and the U.S. Food and Drug Administration's Food Code.
The facility failed to follow infection control standards, including improper sanitation of a shower chair, washing machine, and vital signs machine, as well as inadequate hand hygiene and labeling of oxygen tubing, nebulizer equipment, and urinals. These failures decreased the facility's potential to prevent the spread of infection.
The facility failed to ensure accurate assessments for two residents, leading to discrepancies in their MDS. One resident's MDS inaccurately indicated one-sided impairment despite both knees being contracted, while another resident's MDS incorrectly noted intermittent catheterization without physician orders. These inaccuracies were confirmed by the MDS Coordinator and nursing staff.
The facility failed to develop and implement accurate baseline care plans for three residents within the required 48-hour timeframe after admission. The residents had various medical devices and needs, including urinary catheters, a PICC line, an abdominal binder, and TED hose, but there were no documented care plans for these items. The Director of Nursing confirmed the omissions, and the facility could not provide a policy for Baseline Care Plans.
The facility failed to update a resident's care plan to include the use of an elopement management bracelet, despite multiple observations of the resident wearing the bracelet. Both the ADON and DON confirmed the care plan was not revised, contrary to facility policy.
The facility failed to implement physician's orders for a resident's use of TED hose and an abdominal binder, and did not properly assess and cover a PICC line. Additionally, an elopement management bracelet was applied to another resident without a physician's order, with no documented communication between staff and the physician.
The facility failed to ensure that a resident with a history of stroke and dysphagia was assisted to an upright position while eating, increasing the risk of aspiration. The resident was observed lying in bed while eating, and staff acknowledged the need for the resident to be sitting up to prevent choking. Interviews with staff confirmed the importance of proper positioning during meals.
The facility failed to ensure all drugs were properly labeled, as an aerosol medication used to treat breathing problems was found inside a disposable plastic cup without any identifying labels in a medication cart. Staff confirmed the medication lacked identification labels and was unable to determine which resident the medication belonged to. The facility's policy requires medications to be labeled with specific information, which was not followed in this instance.
Failure to Maintain Accessible and Functional Call Light Systems for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents had access to functioning call light systems within reach, as required by their care plans and facility policy. For one resident with a neck fracture, dementia, and no capacity to make decisions, the care plan identified risk for falls and directed staff to keep the call light within reach. During observation, this resident was found awake in bed with a neck brace, and the call light button was on the floor under the bed. The resident stated he did not know where his call light was, and a CNA confirmed its location and acknowledged it should have been placed where the resident could reach it. A second resident, with diabetes, polyneuropathy, retinopathy, gait and mobility abnormalities, and muscle weakness, had an MDS showing intact cognition but required varying levels of assistance with ADLs and transfers. The care plan for this resident, which addressed fall risk, included interventions to keep the call light within reach and to educate/remind the resident to call for assistance with all transfers. During observation, this resident was also found awake in bed with the call light button on the floor under the bed and the cord stuck on the bed frame. The resident reported being unable to reach the call light, and a CNA confirmed the situation and stated the call light should always be within the resident’s reach. A third resident, with a history including a left upper arm fracture, diabetes, muscle weakness, and congestive heart failure, had an MDS indicating mostly substantial/maximal assistance needs for ADLs and supervision or assistance for bed mobility and transfers. The care plan for this resident, addressing fall risk, included instructions to educate/remind the resident to call for assistance with all transfers and to keep the call light within reach. Staff interviews revealed that this resident’s call light “usually gets broken” and that staff would try to fix it, but it would break again. The resident reported feeling annoyed and uncomfortable in the room because the call light had been broken for several days and stated that staff were aware but had not fixed it. Observation with a CNA and the Maintenance Supervisor confirmed the call light system was broken, there was no alternative call system in place, and there was no entry in the maintenance logbook documenting the broken call light. The DON stated she expected residents to have working call lights within reach and acknowledged safety concerns when call lights are not working or not within reach.
Failure to Provide Discharge and Bed-Hold Notice
Penalty
Summary
The facility failed to follow the discharge process for a resident who was transferred to an acute hospital, and the resident’s RP was not informed of the intent to discharge or provided notice of bed-hold. The resident had been admitted with multiple diagnoses, including metabolic encephalopathy, dementia with behavioral disturbance, and enterocolitis due to clostridium difficile. The resident’s MDS showed a BIMS score of 4 out of 15, indicating severe cognitive impairment, and also documented delusions and behavioral symptoms such as hitting, scratching, rummaging, and smearing bodily wastes. On the day of the transfer, the resident had escalating behaviors, including combativeness, refusal of care, wandering into other residents’ rooms, taking food and drinks, and entering the nurses’ station to open handbags and take items. The physician ordered the resident sent to acute care due to increased behaviors and safety concerns. Documentation showed staff contacted the RP about the resident’s agitation and discussed increasing Seroquel, and the RP refused the medication change. Staff then sent the resident to the acute hospital for safety reasons. The record also showed the facility completed a Notice of Proposed Transfer/Discharge, but the ADM later stated the resident was discharged rather than transferred and that the RP was not offered bed-hold because the facility had already determined the resident would not be accepted back. The RP stated bed-hold was never mentioned and that she asked the facility not to send the resident out until she arrived. Facility policy required residents and/or representatives to be informed in writing of bed-hold policies at the time of transfer and stated residents must be permitted to return following hospitalization, but the resident’s RP was not provided that notice and the resident was denied return to the facility.
Failure to Follow Physician Orders for Compression Devices and Stockings
Penalty
Summary
The facility failed to provide care and services according to accepted standards of clinical practice for three residents by not following physician orders for the application of Thrombo-Embolic Deterrent (TED) stockings and lymphatic compression devices. One resident, admitted with endocarditis and generalized muscle weakness, had physician orders for TED hose to be applied every morning and removed in the evening, as well as for a lymphatic compression device to be offered after meals. During observation and interview, the resident was found wearing regular socks instead of TED stockings and reported that the compression device had not been offered. The assigned nurse confirmed the devices were not applied as ordered and that the compression device was stored out of sight in the resident's room. Another resident, admitted with congestive heart failure and muscle weakness, had an order for compression stockings to be worn during the day and removed at night, as well as an order for daily weights. Observations revealed the resident was not wearing compression stockings, and record review showed daily weights were not completed as ordered. The Director of Staff Development confirmed the omission of daily weights and the absence of compression stockings during review of the resident's records. A third resident, admitted with muscle weakness and multiple sclerosis, had an order for TED hose to be applied in the morning and removed at bedtime. During observation and interview, the resident was not wearing TED hose and stated she had never been fitted for them while at the facility. The physical therapy assistant and licensed nurse confirmed that TED hose were not available among the resident's belongings and had not been applied. The Director of Nursing and Nurse Practitioner both stated their expectation that staff follow physician orders as written. Facility policy also required that prescribed medication and treatment orders be carried out as prescribed.
Failure to Provide Adequate Hygiene and Grooming for Two Dependent Residents
Penalty
Summary
Two residents who required assistance with activities of daily living (ADLs) were observed to have untrimmed, jagged fingernails with black substances underneath, dry and scaly skin on their feet, and traces of colored-liquid and old, dry food residue in their beards. These findings were confirmed during multiple observations and interviews with facility staff, including the Treatment Nurse, Assistant Director of Nursing, and Director of Nursing. Both residents had documented medical conditions—one with osteoarthritis, generalized muscle weakness, and a left below-knee amputation, and the other with Parkinson's disease and dementia—that necessitated staff assistance for ADLs, as reflected in their care plans. Despite these documented needs, the residents were not provided with adequate hygiene and grooming, as evidenced by their physical condition during the survey. Staff interviews confirmed that the residents should have been cleaned and groomed, and that the lack of hygiene could lead to discomfort, skin irritation, and affect their dignity. Facility policy required appropriate care and services for residents unable to perform ADLs independently, but this was not followed for the two residents in question.
Failure to Accurately Document Controlled Medication Administration
Penalty
Summary
The facility failed to ensure accurate documentation and accountability of controlled medications for three residents who were prescribed hydrocodone-acetaminophen for pain management following orthopedic and spinal injuries. For one resident, the Controlled Drug Record (CDR) indicated a dose was administered, but this was not reflected in the Medication Administration Record (MAR). For another resident, multiple instances were found where the CDR showed administration of the medication, but the MAR did not document these doses. In a third case, there was a discrepancy between the administration times recorded in the CDR and the MAR for the same dose. Interviews with the Director of Nursing confirmed the importance of correct documentation for controlled drug accountability and acknowledged that incorrect records could be associated with medication misuse and drug diversion. The facility's policy required immediate and accurate documentation of controlled medication administration on both the accountability record and the MAR, including date, time, amount administered, and the nurse's signature, but this procedure was not consistently followed.
Medication Storage and Labeling Deficiencies
Penalty
Summary
Surveyors observed multiple deficiencies related to the storage and labeling of medications. During an inspection of a medication cart, a loose, unlabeled white tablet was found at the bottom of a drawer containing blister packs. The nurse present acknowledged that medication carts should not contain loose or unlabeled medications. Additionally, a medication cart was found unlocked and unattended at a nursing station, which was confirmed by both a licensed nurse and the Director of Nursing (DON) as a safety concern and contrary to facility policy. The facility's policy requires all drugs and biologicals to be stored in their original packaging and for medication carts to be locked when not in use. Another deficiency was identified regarding the handling of discontinued medications. A prescription drug belonging to a discharged resident, who had a history of acute respiratory failure with hypoxia and chronic obstructive pulmonary disease, was found stored in the medication refrigerator alongside active medications several days after the resident's discharge. The nurse and DON confirmed that discontinued medications should be removed immediately upon discharge and stored separately for disposal. Facility policy also states that discontinued, outdated, or deteriorated drugs must be placed in designated bins for destruction, which was not followed in this instance.
Failure to Provide Bedside Water Pitchers Results in Hydration Deficiency
Penalty
Summary
The facility failed to provide sufficient hydration to four residents when staff did not deliver bedside water pitchers for two consecutive days. Observations and interviews revealed that these residents, all of whom had medical conditions placing them at risk for dehydration, did not have water pitchers at their bedside tables during multiple checks. Instead, some residents only had partially filled cups or received water only at mealtimes, which was inconsistent with their care plans and facility policy. Resident records indicated that none of the affected residents were on fluid restrictions, and their care plans specifically identified them as being at risk for dehydration. For example, one resident with a history of urinary tract infection, type 2 diabetes, and high blood pressure, who was also prescribed a diuretic, had significantly reduced fluid intake on the days in question compared to her average intake for the month. Other residents with moderate cognitive impairment also lacked bedside water pitchers, and staff interviews confirmed that water pitchers should have been provided regardless of fluid restriction status. Staff interviews further clarified that the night shift was responsible for providing fresh water pitchers, and the day shift was expected to replace any missing pitchers. However, both nursing and CNA staff acknowledged that the absence of water pitchers could lead to adverse outcomes, and the facility's own hydration policy required staff to monitor hydration status and provide supportive measures, including supplemental fluids. The deficiency was directly linked to the failure of staff to ensure water pitchers were consistently available at residents' bedsides.
Inaccurate Documentation and Breach of Resident Confidentiality
Penalty
Summary
Licensed nursing staff documented the administration of treatments and medications that were not actually provided to several residents. For example, one resident with orders for TED hose and a lymphatic compression device was not wearing the devices as ordered, and the nurse confirmed she had not applied them despite documenting otherwise. Similarly, two other residents with orders for TED hose were not wearing them, and the responsible nurse admitted to documenting their application on the MAR when she had not performed the task. In another case, a resident's intravenous antibiotics were documented as administered by a nurse not authorized to do so, and the nurse acknowledged the documentation was inaccurate. The facility also failed to safeguard resident-identifiable information. Meal tickets containing residents' names, room numbers, dietary information, and allergies were disposed of in the regular garbage rather than in a confidential shredding bin. This practice was confirmed by both the dietary worker and the dietary manager, who acknowledged that the tickets contained confidential information and should not have been discarded with regular waste. Additionally, the facility did not accurately complete informed consent documentation for the administration of a psychotropic medication. The consent form for a resident receiving brexpiprazole was signed and witnessed by two nurses, but the section indicating the name of the person giving verbal or phone consent was left blank. The assistant director of nursing confirmed that the consent was incomplete and inaccurate, as the responsible party's name was not documented as required.
Failure to Develop and Implement Care Plan for G-Tube
Penalty
Summary
The facility failed to develop and implement a care plan for a resident who was admitted with diagnoses including dysphagia and partial paralysis to the left side, and who had a G-tube in place. Upon review of the resident's admission record, order summary report, and care plan documentation, it was found that there was no current physician's order or care plan addressing the G-tube, despite its presence. The resident expressed a desire to have the G-tube removed, and during multiple interviews and record reviews with facility staff, it was acknowledged that the necessary documentation and care planning for the G-tube were missing. Further interviews with a licensed nurse, nurse practitioner, and the director of nursing confirmed that there was no current order for the G-tube and no care plan developed, revised, or resolved for its care and treatment. The facility's own policy requires a comprehensive care plan that includes measurable objectives to meet the resident's needs, including medical devices. The lack of a care plan for the G-tube meant the resident's specific needs related to this device were not formally addressed.
Failure to Provide Required Supervision and Assistance During Meals
Penalty
Summary
A resident with diagnoses including dysphagia and partial paralysis to the left side was admitted to the facility and had a physician order for 1:1 supervision during meals, cues to slow eating, and pre-cut food into bite-sized pieces. Observations revealed that the resident was left unattended during meal times, with staff delivering meal trays, positioning the resident, and then leaving. On two separate occasions, the resident was found alone with her meal tray, without the required supervision or assistance. A review of the resident's electronic record showed no documentation of 1:1 supervision for meals over the past 30 days, despite the physician's order. When requested, the facility was unable to provide a policy and procedure defining levels of meal assistance. The facility's existing policies indicated that residents should receive meal assistance according to their individual needs and that physician orders should be followed as prescribed. The nurse practitioner confirmed that staff are expected to follow orders for resident safety.
Deficiencies in Food Storage and Sanitization Practices
Penalty
Summary
The facility failed to meet professional standards for food storage and service practices, as observed during a survey. Opened food packages, such as a bottle of barbecue sauce and various seasonings, were found without labels indicating the date they were opened. This lack of labeling was acknowledged by the Food and Nutrition Assistant (FNA) and the Food and Nutrition Director (FND), who both stated that opened food items should be labeled with the date to determine their shelf life based on storage guidelines. The facility's policy and procedure, as well as posted guidelines, were not followed in these instances. Additionally, several food items, including frozen waffles and bins of sugar and brown rice, were found removed from their original packaging without proper labels identifying the contents. The FNA confirmed that these items should have been labeled to indicate what the product was. This practice is in violation of the facility's policy and the U.S. Food and Drug Administration's Food Code, which requires that food storage containers be identified with the common name of the food to prevent contamination. Furthermore, opened and unsecured packages of meatless meatballs, meatless breaded wings, and oatmeal cookie dough were found in the freezer. The FNA and FND both acknowledged that these bags should be securely closed to prevent cross-contamination and freezer burn. The facility also failed to maintain the proper concentration of quaternary ammonium sanitizer solution, as observed during multiple tests where the solution was found to be below the effective range of 200 to 400 parts per million (ppm). The FND and Dietary Aide (DA) confirmed that the solution needed to be changed more frequently to ensure its effectiveness, as per the facility's policy and procedure.
Infection Control Deficiencies
Penalty
Summary
The facility failed to follow infection control standards of practice in several instances. A shower chair with a brown substance was observed stored in the hallway, and staff did not follow the recommended minimum disinfectant contact time for sanitation of the chair. Additionally, staff did not sanitize the exterior surface of the washing machine, including the door handle, after loading dirty laundry. Staff also failed to perform hand hygiene prior to donning and after doffing personal protective equipment during medication administration. Furthermore, staff did not disinfect the vital signs machine between resident use and after use. Oxygen tubing for three residents was not labeled with a date, and nebulizer equipment for one resident was not labeled with a date or stored in an anti-microbial bag. Lastly, urinals for two residents were not labeled with resident identifiers. These failures decreased the facility's potential to prevent the spread of infection.
Inaccurate Resident Assessments
Penalty
Summary
The facility failed to ensure accurate assessments for two residents, resulting in discrepancies in their Minimum Data Sheets (MDS). Resident 15, who was admitted with multiple diagnoses including hemiplegia and hemiparesis, was observed with both knees contracted and experiencing significant pain. However, the MDS inaccurately indicated impairment on only one side. This inaccuracy was confirmed by the MDS Coordinator, who acknowledged that the assessment should have reflected impairment on both sides, potentially affecting the resident's plan of care. Similarly, Resident 301's MDS inaccurately indicated that the resident was receiving intermittent catheterization, despite no physician orders for such a procedure. This discrepancy was confirmed during a review of the resident's MDS and Order Summary Report (OSR) by the MDS Coordinator and a Licensed Nurse. The Director of Nursing stated that resident assessments are expected to be accurate, as per the facility's policy and procedure on resident assessments.
Failure to Implement Baseline Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement accurate baseline care plans for three residents within the required 48-hour timeframe after admission. Resident 297, admitted with diagnoses including fractures and muscle weakness, had a urinary catheter in place due to urinary retention, but there was no care plan documented for the catheter. Similarly, Resident 301, readmitted with muscle weakness, a fracture, and chronic respiratory failure, also had a urinary catheter without a corresponding care plan documented. These omissions were confirmed during a review of their care plans and physician orders, which indicated the presence of urinary catheters without associated care plans. Resident 307, admitted with lymphoma, benign prostatic hyperplasia, and muscle weakness, had multiple medical devices and needs, including a urinary catheter, a PICC line, an abdominal binder, and TED hose. However, there was no documented care plan for any of these items. During an observation and interview, Resident 307 confirmed the presence of these devices and the lack of use of the abdominal binder and TED hose. The Director of Nursing confirmed the missing care plans for all three residents and acknowledged that the baseline care plans should have included these essential details within the first 24-48 hours of admission. The facility was also unable to provide a policy and procedure for Baseline Care Plans when requested.
Failure to Update Care Plan for Elopement Management Bracelet
Penalty
Summary
The facility failed to revise the care plan for Resident 310 to reflect the placement of an elopement management bracelet. Resident 310, who was admitted with diagnoses including a left hip fracture, dysphagia, and dementia without behavioral disturbance, was observed wearing the bracelet on multiple occasions. However, the care plan dated from 4/4/24 to 4/18/24 did not include this critical update. Certified Nursing Assistant 5 was unaware of the bracelet's purpose, indicating a lack of communication and documentation regarding the resident's care needs. The Assistant Director of Nursing and the Director of Nursing both confirmed that the care plan had not been updated to include the elopement management bracelet, despite the facility's policy requiring care plans to be revised to meet residents' individual needs. This oversight was acknowledged during interviews and record reviews, highlighting a failure to provide consistent nursing interventions for Resident 310.
Failure to Implement Physician's Orders and Unauthorized Use of Elopement Bracelet
Penalty
Summary
The facility failed to ensure services provided met nursing professional standards for two residents. For Resident 307, the physician's orders for the use of thrombo-embolic deterrent hose (TED hose) and an abdominal binder to prevent orthostatic hypotension were not implemented. Additionally, Resident 307's peripherally inserted central catheter (PICC) was not assessed for patency and was not covered with an appropriate dressing. The Assistant Director of Nursing (ADON) confirmed that there were multiple shifts where the orders for TED hose were not documented as executed, and the PICC dressing was observed to be not intact and needed changing. For Resident 310, an elopement management bracelet was applied without a physician's order. The resident's records indicated no risk for elopement, and there was no documented communication between the nursing staff and the physician regarding the application of the bracelet. The Medical Doctor (MD) and Nurse Practitioner (NP) confirmed that there was no documentation or communication about the order for the bracelet in the communication binder, and the MD was unaware of the order. These failures decreased the facility's potential to ensure physician's orders were carried out for residents, as evidenced by the lack of implementation and documentation of prescribed treatments and the application of an elopement management bracelet without proper authorization.
Failure to Assist Resident to Upright Position While Eating
Penalty
Summary
The facility failed to ensure that Resident 28 was assisted to an upright position while eating lunch, which decreased the potential to prevent food aspiration and aspiration pneumonia. Resident 28, who had a history of stroke, dysphagia, and generalized muscle weakness, was observed lying in bed while eating a bowl of soup. When asked, Resident 28 indicated that lying down was not the best position to eat. A Certified Nursing Assistant (CNA) acknowledged that the resident was lying back too much and should be sitting up to eat, and subsequently raised the head of the bed to an upright position. The resident did not express any discomfort with sitting upright. Interviews with the Director of Staff Development (DSD), the Restorative Nursing Assistant Supervisor (RNAS), and the Director of Nursing (DON) confirmed that residents should be sitting up while eating to prevent choking. The facility's policy on Activities of Daily Living (ADLs) indicated that residents who are unable to carry out ADLs independently should receive appropriate support and assistance with dining. A review of a research article highlighted the importance of appropriate posture to prevent aspiration in older adults with dysphagia, emphasizing that the head of the bed should be raised by at least 30 degrees for those who cannot get out of bed.
Failure to Properly Label Medications
Penalty
Summary
The facility failed to ensure all drugs were properly labeled, as observed during a survey at nursing station 1. An aerosol medication used to treat breathing problems was found inside a disposable plastic cup without any identifying labels in medication cart 1. Licensed Nurse 3 confirmed the medication lacked identification labels and was unable to determine which resident the medication belonged to. The Regional Nurse Consultant also confirmed the medication should have been labeled. The Assistant Director of Nursing stated that unlabeled medications should be discarded due to safety issues, as nurses would not be able to identify which resident the medication was intended for. A review of the facility's policy and procedure on medication labeling, revised in February 2023, indicated that medications should be labeled in accordance with federal and state requirements. The policy specifies that labels must include the resident's name, medication name, prescribed dose, route of administration, and appropriate instructions and precautions. The failure to adhere to this policy reduced the facility's potential to ensure safe medication administration for its residents.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Illustrative
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Nursing homes near Roseville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Roseville Care Center | 0 mi | ★★★★★ | 2 | 0 |
| Roseville Point Health & Wellness Center | 0.6 mi | ★★★★★ | 8 | 0 |
| Oak Ridge Healthcare Center | 0.9 mi | ★★★★★ | 2 | 0 |
| Citrus Heights Post Acute | 4.4 mi | ★★★★★ | 1 | 0 |
| Fair Oaks Healthcare Center | 5.1 mi | ★★★★★ | 22 | 0 |
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