Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Providence Holy Cross Med Ctr D/p Snf during CMS and state inspections, most recent first.
The facility failed to properly manage IV therapy for two residents. One resident had an unlabeled D5 NS infusion running without complete MAR documentation, and staff could not identify who started it or when it began. Another resident’s PIV dressing was not labeled with the insertion date, and the flush port was left without a disinfecting cap. Staff and facility policy both indicated that IV fluids, PIV dressings, and access ports should be labeled and maintained per protocol.
Food items were observed past discard dates or missing required labels in the kitchen and Sub-Acute pantry freezer. Pre-cut vegetables and burger patties were kept beyond their date-out, diced carrots had no date-in/date-out label, and three cups of water were left uncovered and unlabeled in the freezer. The FNDS and DFNS stated the items should have been discarded or properly covered and labeled per facility policy.
A resident with PEG TF, comatose status, and a history of ventilator-associated pneumonia had an order for aspiration precautions, but no care plan was developed for those precautions. During observation, the resident was receiving TF while the bed was at 26 degrees with no staff present, and an CNA later adjusted the bed to 30 degrees. The MDSC confirmed the aspiration precaution care plan was missing.
A resident with status epilepticus, chronic respiratory failure, tracheotomy, and PEG tube placement was identified as high risk for falls and dependent on staff for care and mobility. Staff observed the resident in bed with the bed elevated and an amber alert light indicating it was not in the low position; RN stated the bed should have been lowered, but it was left high while the resident was unattended. The DON confirmed the resident's seizure history and that the bed should always be kept in the lowest position, and the facility policy included bed in low position as a fall prevention strategy.
Tube feeding positioning was not maintained at the required angle for two residents receiving EF. One resident with a PEG, chronic respiratory failure, tracheotomy, and aspiration pneumonia was observed receiving continuous TF with the HOB at 26 degrees, despite a care plan and physician orders for aspiration precautions. A second resident with PEG status and ventilator-associated pneumonia was also observed receiving TF with the HOB at 26 degrees, and the MDSC stated no aspiration precautions care plan had been developed even though it should have been added on readmission.
Failure to change a resident’s bubble humidifier per P&P. A resident with severe cognitive and communication impairment, MS, Parkinson’s disease, and oxygen therapy had a bubble humidifier dated 3/12/2026. RN stated it should be changed every 3 days or sooner if the water level was below 25%, while RT stated tubing and humidifier were changed weekly, and the respiratory record did not show when they were last changed.
A resident with status epilepticus, chronic respiratory failure, tracheotomy, and PEG tube placement received IV Zosyn at the wrong flow rate after an RN set the pump based on preprogrammed settings instead of the MD order. The IV bag was not labeled with the ordered rate, the first dose ran over 4 hours instead of 30 minutes, and the next dose was given late. The DON and another RN stated meds from the E-kit must be labeled and administered per the MD order, including the flow rate.
Medication labeling and insulin storage were not handled correctly. An RN prepared IV piperacillin-tazobactam for a resident with a UTI, but the IV bag label did not include the ordered flow rate even though the pump was running at a set rate. In a separate finding, a Humulin R vial for a resident with diabetes remained in the med cart past its 31-day storage period and should have been discarded.
Incomplete CNA Repositioning Documentation: A resident with chronic respiratory failure, ventilator dependence, and severe neurological impairment was care planned for q2h repositioning due to pressure injury risk, but CNA documentation did not consistently show the required turning schedule. During record review, the CNA stated he missed charting a repositioning entry and acknowledged that if it was not documented, it did not happen; the CE confirmed CNAs are expected to document repositioning in the EHR on the q2h schedule.
An LVN failed to disinfect a computer mouse after it fell on the floor during medication prep for two residents and continued using it while reviewing the MAR, removing meds from bubble packs, crushing them, and administering them by GT. One resident had acute respiratory failure, tracheostomy, and PEG placement; the other had communicating hydrocephalus, tracheostomy, pneumonia, and PEG placement and was in a persistent vegetative state. The LVN stated he used hand hygiene but did not disinfect the mouse, and an RN confirmed the facility policies were not followed.
Failure to Screen for and Offer Pneumococcal Vaccination: A resident with chronic respiratory failure, tracheostomy, asthma, and GT placement had a history of PCV7 immunizations, but the IP relied on CAIR2 and did not complete further CDC-based screening. After reviewing the CDC tool, the IP stated the resident qualified for PCV15, PCV20, or PCV21 but did not receive additional pneumococcal vaccine doses. RN confirmed the facility’s vaccine screening, education, consent, and administration process was not followed.
Incomplete Daily Staffing Posting: The facility failed to post daily staffing information showing the total number of staff and actual hours worked for the 7 p.m. to 7 a.m. shift. Surveyors observed a staffing form at the nursing station that listed the census but did not include night shift staffing totals or actual hours for RNs, LVNs, and CNAs, and staff interviews showed the night shift information was not being completed consistently.
After a repair to the oxygen gas line, the facility failed to have a certified medical gas verifier test and confirm the safety and purity of the oxygen before returning it to service for 24 residents dependent on mechanical ventilation. Instead, the system was deemed safe by the Facilities Director, who was not certified for this task, and no post-repair quality testing was performed, despite the residents' critical reliance on the oxygen supply.
The facility did not establish or implement standardized protocols for identifying infection signs and symptoms or for applying evidence-based criteria, such as Loeb's minimum criteria, before starting antibiotics. A resident was prescribed levofloxacin for a UTI based only on increased heart rate and fever, which did not meet the required criteria. Staff interviews revealed inconsistent use and documentation of antibiotic stewardship practices, and facility policies lacked clear guidance on these processes.
Two residents receiving subcutaneous insulin and heparin did not have their injection sites rotated as required by professional standards, manufacturer guidelines, and facility policy. Nursing staff repeatedly administered injections in the same anatomical areas, and this practice was confirmed through record review and staff interviews. Both residents were dependent on staff for care and had significant medical conditions, but proper site rotation was not performed.
Three residents receiving enteral feeding experienced deficiencies, including failure to label and change medication syringes daily, not replacing a water flush bag within the recommended 24-hour period, and not ensuring the prescribed amount of tube feeding formula was delivered. Nursing staff confirmed these lapses, and facility policies and manufacturer guidelines for infection control and accurate nutrition delivery were not followed.
Surveyors found that oxygen tubing for two residents was in contact with the floor, a humidification bottle for a resident on oxygen therapy was not labeled or documented as changed per protocol, and a Yankauer suction tool was not dated or replaced as required. Staff confirmed these lapses, and facility policies for infection control and equipment maintenance were not followed.
Two residents received repeated subcutaneous injections of insulin and heparin in the same anatomical sites without proper rotation, contrary to facility policy, standards of practice, and manufacturer guidelines. Nursing staff and documentation confirmed that injection sites were not rotated as required, resulting in significant medication errors for both residents.
Surveyors found that kitchen staff failed to store towels, food items, and personal property according to facility policy, with towels left out in the tray line area, expired and unlabeled food in refrigerators, and personal items stored next to food and utensils. Additionally, refrigerator and freezer temperatures were repeatedly out of range without corrective actions documented, all of which contributed to unsafe food storage and preparation practices.
Staff and medical providers entered the room of a resident with CRPA and MDRA without donning required gowns, despite posted contact isolation instructions and facility policy. The resident was dependent on staff for care and had orders for contact isolation due to infectious bacteria. Facility staff confirmed that policy required gowns for anyone entering the room, regardless of anticipated contact.
A resident with severe cognitive impairment and an indwelling urinary catheter had their catheter drainage bag left uncovered and visible from the hallway. Staff confirmed that the drainage bag should have been covered with a dignity bag, as required by the resident's care plan and facility policy, to protect privacy and dignity.
A resident with severe cognitive impairment and multiple medical conditions had their Seroquel dose increased without obtaining new informed consent, as required by facility policy. Nursing staff confirmed that the last consent on file was for a lower dose, and that consent should be obtained for any dose change of psychotropic medications.
A resident with severe cognitive impairment, non-verbal status, and total dependence for ADLs was found to have their call light out of reach, hanging on an enteral feeding pole. Nursing staff confirmed the oversight, stating the call light should have been placed within reach after care, in accordance with facility policy.
Two residents were placed in physical restraints, including mittens and soft wrist restraints, without the required pre-restraint assessments or documentation of least restrictive alternatives. Staff interviews and record reviews confirmed that facility policy requiring assessment and documentation before restraint use was not followed.
A resident with a suprapubic catheter was found with a urinary drainage bag positioned so that the catheter tubing had a dependent loop, contrary to facility policy and standard infection prevention practices. Staff confirmed that catheter tubing should be free of loops to ensure proper urine flow and reduce infection risk.
A resident with diabetes and respiratory failure was administered insulin lispro without a documented indication in the medication order. While the order for insulin glargine included an appropriate diagnosis, the lispro order did not specify a reason, which was confirmed by nursing staff and found to be inconsistent with facility policy requiring the indication for all medications.
A medication cart inspection found that a resident's vitamin B12 bubble pack had a broken seal and was taped closed after medication was removed, instead of being discarded as required. An RN and the nurse manager confirmed this was not in line with facility policy, which mandates immediate disposal of contaminated medications to prevent errors.
The facility did not have standardized protocols for identifying infection signs and symptoms or for applying evidence-based criteria before starting antibiotics. A resident was given levofloxacin for a UTI without meeting the required clinical criteria, and staff interviews confirmed the absence of a consistent process for reviewing antibiotic use. The facility's policy lacked clear guidance on using tracking tools and national standards for antibiotic initiation.
A resident with respiratory failure and seizure disorders, who was unable to communicate effectively, did not have documentation in the medical record that the pneumococcal vaccine was offered or that education was provided to the family or decision-maker. Although a nurse obtained consent from the family, the discussion and vaccine order were not documented as required by facility policy.
A resident with severe cognitive impairment and a tracheostomy, who had physician orders for bilateral hand mittens and soft wrist restraints to prevent self-injury, was observed using these restraints. However, the MDS assessments on multiple occasions failed to accurately document the use of restraints, with staff acknowledging incorrect coding despite ongoing restraint use and valid orders.
A resident with an indwelling urinary catheter and on blood thinner medication experienced hematuria for several days without the physician being notified. This led to an emergency hospital transfer where the resident was diagnosed with septic shock, a UTI, and pneumonia.
A resident with an indwelling urinary catheter and on blood thinner medication experienced continued hematuria without the physician being notified, leading to emergency hospitalization and diagnoses of septic shock, UTI, and pneumonia. The facility failed to follow its policies on change of condition notification and catheter care.
The facility failed to ensure that residents were free from physical restraints unless needed for medical treatment. Specifically, the facility did not complete an assessment for the risk of entrapment prior to the use of four bed siderails (SR) in the raised position for three residents. Additionally, the facility did not obtain a physician's order or informed consent for the use of these restraints and bed alarms.
The facility failed to develop and implement care plans for the use of bed alarms and side rails for several residents, including those with respiratory failure, quadriplegia, traumatic brain injury, and ischemic stroke. The absence of care plans for these devices and medications was confirmed by staff, violating the facility's policy requiring interdisciplinary care plans within seven days of admission.
The facility failed to provide consistent pressure ulcer care for three residents, leading to missing wound assessments, measurements, pictures, and care plan reviews. The RN responsible was on vacation, and the facility was short-staffed, resulting in the omission of necessary wound care documentation and assessments. The Nurse Manager confirmed the importance of timely assessments and reporting to monitor wound progression and involve the interdisciplinary team when necessary.
The facility failed to properly label enteral feeding bottles and water flush bags for three residents, leading to potential risks of complications. The deficiencies included missing dates, times, and prescribed rates, which were necessary to ensure the correct administration of feedings and water flushes.
The facility failed to ensure the safe and appropriate use of bed side rails for three residents by not conducting risk assessments, not reviewing risks and benefits with representatives, and not obtaining informed consent. Residents were observed with four side rails up without proper documentation or physician's orders, contrary to facility policy and manufacturer's guidelines.
The facility failed to follow proper sanitation and food handling practices, including a Food Service Attendant not wearing a hair restraint, unlabeled and undated open food items, and an open package of cheese without an open date. These deficiencies had the potential to place six out of 43 residents at risk for foodborne illnesses.
The facility failed to implement its antimicrobial stewardship policy for a resident when clindamycin was ordered indefinitely and not monitored for 77 days. The resident had a history of multidrug-resistant infections, and the antibiotic was administered multiple times without a stop date. Staff acknowledged the oversight, which was against the facility's policy to optimize antibiotic therapy and prevent resistance.
The facility failed to honor the residents' right to a dignified existence by not covering a resident's urinary catheter drainage bag and by having a CNA stand over another resident while feeding them. Both actions were against the facility's policies and procedures.
The facility failed to ensure the safe administration of IV fluids for two residents by not labeling IV dressings with the date of insertion or the nurse's initials, leading to potential complications such as infection.
A resident with respiratory failure and a history of traumatic brain injury did not receive necessary respiratory care as the t-piece was not connected to the oxygen regulator, risking respiratory distress. The oversight was confirmed by staff and highlighted a failure to follow the facility's respiratory protocol.
The facility failed to ensure a licensed nurse did not leave an insulin pen unattended and did not accurately document a controlled drug record for a resident. The insulin pen was left on a WOW while the nurse entered a resident's room. Additionally, discrepancies were found in the controlled-drug record for a resident's Lacosamide (Vimpat) medication, which were not identified and reported as required by the facility's policy.
The facility failed to ensure PRN orders for psychotropic medications were necessary and limited to a specific duration for two residents. One resident was prescribed lorazepam without a stop date, and another had a PRN order exceeding the 14-day limit, contrary to the facility's policy and consultant pharmacist's recommendations.
The facility staff failed to implement its infection control program for two residents. A suction canister for one resident was not replaced per policy, and urinal bottles for another resident were not labeled as required. These deficiencies were confirmed through observations and interviews with staff.
The facility failed to ensure timely transmission of MDS assessments to CMS for four residents, resulting in assessments remaining in an exported status without successful validation and acceptance. The previous MDSC left abruptly without completing the necessary transmission process or providing a handoff report, leading to potential delays in care and services.
The facility failed to ensure the MDS accurately reflected a resident's use of a mitten restraint, despite the presence of an order and informed consent. This inaccuracy was confirmed by the DON and could potentially delay necessary care.
IV Fluids and Peripheral Line Labeling Not Maintained
Penalty
Summary
The facility failed to ensure safe, appropriate administration of IV fluids for two residents by not following labeling and documentation practices for parenteral fluids and peripheral IV sites. For one resident, the physician ordered continuous D5 NS IV infusion at 75 mL/hr. During observation, the resident was lying in bed with a family member present, and an IV pump was infusing an unlabeled bag of D5 NS at the ordered rate with approximately 300 mL remaining in the bag. The resident’s MAR showed the last documented administration of D5 NS on 3/22/2026 at 2:12 p.m., and the clinical educator stated there was no documented evidence of who started the infusion, when it began, or how much fluid the resident received because the fluids were not labeled and the administration was not documented. Staff interviews confirmed that the D5 NS bag should have been labeled with the resident’s name, date, and flow rate as part of medication administration. The facility’s medication administration policy stated that medications must be accurately administered and documented, that all medications are appropriately labeled, and that IV solutions are documented every time a new bag is hung and at every rate change. The nurse who was caring for the resident stated the bag was already being administered when she arrived and that she did not know who started the unlabeled infusion. For the second resident, the record showed an order for insertion of a peripheral IV and standard flushing of the line. During observation, the resident had a left forearm peripheral IV wrapped with gauze dressing. At the bedside, the RN stated the peripheral IV had no label showing the date of insertion and the flush port had no green disinfecting cap. The clinical educator stated the dressing should be labeled with the insertion date and that a passive disinfection cap should be used on access ports between intermittent infusions or medication administration. The facility’s vascular access policy stated the dressing will be labeled with the date of insertion and that a passive disinfection cap should be placed on access ports when available.
Food Items Kept Past Discard Dates and Improperly Labeled
Penalty
Summary
Food was not stored, prepared, and served in accordance with professional standards of practice for food service safety. During a concurrent observation and interview in the kitchen, surveyors observed pre-cut green bell peppers with a good-thru date of 3/20/2026, chopped green onions with a date-out of 3/21/2026, diced carrots with no date-in or date-out label, and burger patties with a date-in of 3/18/2026 and a date-out of 3/22/2026. The Food and Nutrition Dietary Supervisor stated the green bell peppers, green onions, and burger patties should have been disposed of, and stated the diced carrots should have been labeled with date-in and date-out for food safety. During a concurrent observation and interview in the Sub-Acute pantry freezer, surveyors observed three cups of water uncovered and without date-in or date-out labels. The Food and Nutrition Dietary Supervisor stated the cups should have had a cover or lid and been labeled with a date, and stated they should have been covered to prevent contaminants from getting into the water. The Director of Food and Nutrition Services later stated that date-out is the expiration date and that items beyond that date should be discarded, and that the facility follows a tighter 3-day shelf-life schedule and must follow its policy. The facility policy stated that foods past the use-by, sell-by, best-by, or enjoy-by date should be discarded and that unused portions and open packages should be covered, labeled, and dated.
Failure to Care Plan Aspiration Precautions for Resident with TF
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for aspiration precautions for Resident 39, who was admitted with diagnoses including sepsis, ventilator-associated pneumonia, and PEG status. The resident’s MDS indicated the resident was comatose, dependent with rolling left and right while in bed, and had a feeding tube while residing at the facility. A physician order dated 7/30/2025 directed aspiration precautions to be implemented per department/hospital protocol. During observation on 3/23/2026, Resident 39 was lying in bed with the TF pump running, and the bed angle display showed 26 degrees with no staff present in the room. During interview, CNA 1 stated the resident’s bed angle was 26 degrees, did not know how long it had been at that angle, and adjusted it to 30 degrees, stating it should be 30 degrees or more. During record review and interview, the MDS Coordinator stated there was no care plan developed for aspiration precautions and that it should have been added when the resident was readmitted. The facility’s policy for continuous enteral tube feeding indicated the head of bed should be elevated to at least 30 degrees to prevent aspiration, and the facility’s sub-acute assessment policy stated the MDS, CAA, and care plan were to be completed within 14 days and amended within 21 days of admission.
Bed Left Elevated for High-Fall-Risk Resident
Penalty
Summary
The facility failed to provide an environment free of accident hazards and adequate supervision and assistance to prevent falls and injury for one resident. The resident had diagnoses including status epilepticus, chronic respiratory failure, tracheotomy, and PEG tube placement. The resident's MDS indicated the resident rarely or never could make herself understood or understand others and was dependent on staff for oral and personal hygiene, toileting, bathing, dressing, and mobility. The resident was also identified as high risk for falls, and the care plan included fall precautions and seizure precautions, including keeping the bed in the low position. During observation, the resident was found lying in bed while the bed was elevated to the high position and a flashing amber light projected a bed symbol onto the floor. RN 6 stated the light indicated the bed was elevated and that the bed should have been lowered to the lowest position, but it was not. RN 6 also stated the resident was left unattended with the bed in the high position. The DON stated the resident had a history of seizures and the bed should always be in the lowest position to prevent falls from a higher position. The facility's fall prevention policy stated to implement resident-specific fall prevention strategies, including bed in low position.
Tube Feeding Positioning Not Maintained
Penalty
Summary
The facility failed to ensure that residents receiving enteral feeding received appropriate care and services to prevent complications by not maintaining the head of bed (HOB) at greater than 30 degrees during tube feeding for two sampled residents. For one resident, the history and physical documented diagnoses including status epilepticus, chronic respiratory failure, tracheotomy, PEG placement, and aspiration pneumonia, and the resident was noted to eat nothing by mouth. The care plan for enteral nutrition included elevating the HOB to a semi-recumbent position between 30 and 45 degrees, and the physician ordered continuous tube feeding with aspiration precautions. During observation, the resident was found lying in bed with the tube feeding pump running while the bed angle display showed 26 degrees and no staff were present in the room. An RN later stated that when a resident is receiving tube feeding, the HOB should be elevated to 30 degrees to prevent aspiration and that all staff are responsible for ensuring this, but the resident’s HOB was not elevated enough. Another RN reviewed the facility policy and stated that residents on continuous tube feeding should not be lying flat and that the policy indicates the HOB should be elevated to 30 degrees; the RN confirmed the policy was not followed when the resident’s HOB was at 26 degrees. For the second resident, the history and physical documented sepsis, ventilator-associated pneumonia, and PEG status, and the MDS indicated the resident was comatose, dependent for rolling, and had a feeding tube. The physician ordered aspiration precautions per protocol. During observation, the resident was receiving tube feeding while the bed angle display showed 26 degrees and no staff were present. A CNA stated the resident had been at 26 degrees and should be at 30 degrees or more. The MDS coordinator stated there was no care plan developed for aspiration precautions and that it should have been added on readmission, with interventions including elevating the HOB at least 30 degrees to prevent aspiration.
Failure to Change Bubble Humidifier per Policy
Penalty
Summary
Resident 2, who was admitted with diagnoses including a gunshot wound to the abdomen, MS, and Parkinson’s disease, had severe communication and cognitive impairment and was receiving oxygen therapy in the facility. The resident’s care plan for invasive mechanical ventilation called for proper humidification equipment checks, provision of humidification, and regular replacement of closed suction equipment to prevent infection. During observation and interview, RN 5 stated the resident’s bubble humidifier was dated 3/12/2026 and that it should be changed every 3 days or sooner if it was less than 25%. During later interview and record review, RT 1 stated oxygen tubing and the bubble humidifier were changed every Wednesday, but the resident’s respiratory daily documentation from 3/17/2026 to 3/27/2026 did not show when the oxygen tubing and bubble humidifier were last changed. The facility’s P&P stated the bubble humidifier is changed when the water level is at 25% or every 3 days.
IV Antibiotic Given at Wrong Rate and Late
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when IV piperacillin-tazobactam (Zosyn) was not administered according to the physician’s ordered flow rate and time schedule. The resident had diagnoses that included status epilepticus, chronic respiratory failure, tracheotomy, and PEG tube placement, and was dependent on staff for multiple activities of daily living. The resident’s care plan for infection noted a fever and included an intervention to administer ordered antimicrobial therapy promptly. A physician ordered piperacillin-tazobactam 4.5 grams in 50 mL sodium chloride 0.9% as an IV bolus at a flow rate of 100 mL per hour over 30 minutes, followed by maintenance dosing four hours later for UTI. The medication record showed the first dose was administered by an RN from the E-kit and the maintenance dose was later given at 5 p.m. During observation, the resident’s IV pump was running at 21.3 mL/hr, and the IV bag had a handwritten label for Zosyn 4.5 g with a start date and time, but no flow rate was listed on the bag. During interviews, the RN stated she mixed and labeled the medication, set the IV pump to 21.3 mL/hr based on the pump’s preprogrammed settings, and began administration. She stated the flow rate should have been determined from the physician’s order and included on the label. The DON and another RN stated medications removed from the E-kit are to be labeled and administered according to the physician’s order, including the flow rate. Follow-up interviews confirmed the first dose was infused over four hours instead of 30 minutes and the second dose was administered four hours late, and the RN identified this as a medication error that delayed treatment for the UTI.
Medication Labeling and Insulin Storage Deficiencies
Penalty
Summary
Drugs and biologicals were not consistently labeled in accordance with accepted professional principles during IV medication administration for a resident with a history that included status epilepticus, chronic respiratory failure, tracheotomy, PEG placement, and dependence on staff for most care. The resident was being treated for a UTI and had an order for piperacillin-tazobactam 4.5 grams in 50 mL sodium chloride 0.9% to be given IV at a flow rate of 100 mL per hour for a one-time bolus over thirty minutes, followed by maintenance dosing. During observation, the resident was in bed with an IV pump running at 21.3 mL/hr, and the attached IV bag had a handwritten label identifying Zosyn 4.5 g with a start date and time, but the label did not include the flow rate. Approximately half of the solution remained in the bag. During interview, the RN who prepared the medication stated she removed the first dose from the E-kit, mixed it, labeled the IV bag, set the pump to 21.3 mL/hr, and started the infusion. She stated that the flow rate is part of the physician's order and should have been indicated on the label, but it was not. She also stated that labeling the medication with the flow rate was important to ensure the medication was administered per the physician's ordered rate. The DON and another RN stated the facility process was for the licensed nurse to label medication from the E-kit and compare the physician's order with the medication label, and that the flow rate should be indicated on the label. The facility also failed to ensure Humulin R was discarded after its 31-day storage period. A resident with diagnoses including acute on chronic respiratory failure after trauma, cervical spine fracture, diabetes, and motor vehicle accident had an order for insulin regular (Humulin R) injection vial 0 to 12 units subcutaneously per correctional scale. During observation in the medication cart, the resident's Humulin R vial was found with a filled date of 2/3/2026, opened date of 2/14/2026, and expiration date of 3/17/2026. The RN stated it should have been discarded on 3/17/2026 and should not have been in use. The CE and DPACS stated Humulin R should only be stored for 31 days and should be removed from the medication cart and discarded after that period.
Incomplete CNA Repositioning Documentation
Penalty
Summary
The facility failed to ensure medical records were maintained in accordance with professional standards when Resident 20’s CNA documentation did not consistently reflect repositioning every 2 hours. Resident 20 was admitted with chronic hypoxemic respiratory failure, ventilator dependence, and chronic neurological encephalopathy. The resident’s MDS indicated the resident was comatose, dependent for ADLs and mobility, and at risk for pressure ulcers/injuries. The care plan for wounds, added on 1/27/2026, directed repositioning every 2 hours and as needed. During interview and record review, CNA 3 reviewed the resident’s flowsheet data and stated he documented the resident lying supine at 8:05 p.m., again at 9:30 p.m., then at 2:30 a.m. after providing a bath, at 3:00 a.m. right-side lying, and at 5:20 a.m. supine. CNA 3 stated he missed the 12:00 a.m. documentation and said the resident had been left side lying but it was not charted. He stated he was supposed to chart every 2 hours to show turning and repositioning and that if it was not documented, it did not happen. The Clinical Educator stated CNAs document repositioning every 2 hours in the electronic record and that turning/repositioning is documented around 8-10-12-2-4-6 within the timeframe the policy is being followed. The facility policy on clinical documentation stated that documentation must accurately and effectively communicate information pertinent to each resident’s care and include care and treatment of the resident.
Failure to Disinfect Mouse During Medication Preparation
Penalty
Summary
The facility failed to maintain its infection prevention and control program when LVN 1 did not disinfect a computer mouse after it fell on the floor during medication preparation and before continuing to use it. The deficiency involved medication administration for two residents, Resident 24 and Resident 19, both of whom had significant medical conditions and were dependent on staff for care. Resident 24 had diagnoses including acute respiratory failure, tracheostomy, and PEG placement, and was rarely/never able to make herself understood or understand others. Resident 19 had diagnoses including communicating hydrocephalus, tracheostomy, pneumonia, and PEG placement, and was in a persistent vegetative state/no discernible consciousness. During observation, LVN 1 prepared Resident 24's medications in the hallway outside the resident's room while using a computer on a workstation on wheels to review the MAR and scroll through physician's orders with a wired mouse. The mouse dropped on the floor two times during the preparation. LVN 1 used hand sanitizer on his hands after placing the mouse back on the WOW, but did not disinfect the mouse, then continued using it while removing medications from bubble packs, placing them into cups, crushing them, and administering them by GT in the resident's room. LVN 1 then began preparing medications for Resident 19 and again used the same mouse during medication preparation. During the second medication administration observation, the mouse dropped on the floor one time while LVN 1 prepared Resident 19's medications. LVN 1 again used hand sanitizer on his hands after placing the mouse back on the WOW, but did not disinfect the mouse before continuing to use it while preparing and administering the medications by GT. In follow-up interview, LVN 1 stated he performed hand hygiene but did not disinfect the mouse and acknowledged he should have disinfected it, noting the potential for cross contamination and transferring germs from the floor to the WOW and the residents' medications. RN 1 also reviewed the facility's medication administration and infection control policies and stated LVN 1 should have disinfected the mouse and that the facility policies were not followed.
Failure to Screen for and Offer Pneumococcal Vaccination
Penalty
Summary
The facility failed to screen for, offer, and administer the pneumococcal vaccine for one sampled resident. Resident 5 was admitted on 9/7/2025 and had diagnoses including chronic respiratory failure, tracheostomy, asthma, and gastrostomy tube placement. The resident’s MDS dated 12/15/2025 indicated he could make himself understood and understand others, but he was dependent on staff for personal hygiene, toileting, bathing, dressing, and mobility. Resident 5’s immunization record showed four doses of PCV7 given between 12/26/2003 and 12/26/2006. During a concurrent interview and record review on 3/26/2026, the Infection Preventionist stated she screens residents at admission and annually using CAIR2 and a CDC tool to determine whether additional vaccines are needed. She stated CAIR2 showed Resident 5’s pneumococcal vaccination was complete, so she did not further screen him. After reviewing the CDC tool, she stated Resident 5 qualified for and should have received PCV15, PCV20, or PCV21, but did not receive any further doses. During a concurrent interview and record review, RN 1 reviewed the facility vaccination policy and stated the process is to screen for and offer vaccinations at admission and as needed, obtain consent, educate on risks and benefits, and administer vaccines with a physician’s order. RN 1 stated that when Resident 5 qualified for and did not receive further pneumococcal vaccine doses, the facility policy and procedure was not followed. The facility’s policy stated pneumococcal vaccines are to be offered and administered to each resident of the Sub-Acute Unit and that CDC guidelines are to be followed.
Incomplete Daily Staffing Posting
Penalty
Summary
The facility failed to post the daily staffing information that included the total number of staff and the actual hours worked per shift for the 7 p.m. to 7 a.m. night shift on four of four days reviewed for the Sufficient and Competent Staffing task. During an observation on 3/23/2026 at 7:46 a.m., surveyors observed a posting titled "STAFFING FOR TODAY" at the nursing station that was dated 3/20/2026 and showed a census of 46, but it did not list the total number of staff for the night shift or the actual worked hours for RNs, LVNs, and CNAs per shift. During interviews and record review, RN 2 stated the facility could not find staffing postings for 3/21/2026 and 3/22/2026 and said the posting did not have night shift information because there was no secretary at night. An Administrative Assistant stated she completed the census, date, and number of staff on duty for the day shift only, and that was all she filled out on the form. RN 3 stated the form was used to post staffing information, that the secretary usually pre-filled it out for the night shift, and that night shift charge nurses had not filled it out. The Director of Post Acute Care Services stated the night shift charge nurse inputted the staffing posting information and that the facility did not have a policy for staffing posting information, but followed CMS staffing posting requirements.
Failure to Verify Oxygen Purity After Medical Gas Line Repair
Penalty
Summary
The facility failed to ensure that all 24 residents who were dependent on mechanical ventilators received oxygen that was verified to be free of contaminants after a repair to the medical gas line system. On the date of the incident, an oxygen alarm was triggered in the Subacute Unit, which led to the discovery of a broken oxygen line. The facility's census at the time included 24 residents in the Subacute Unit who were reliant on mechanical ventilation for respiratory support. Following the repair of the oxygen line by a contracted service, the facility returned the oxygen gas line to service without conducting required quality testing or verification by a certified medical gas verifier. Interviews with facility staff, including the Facilities Director and the Regional Compliance Officer, confirmed that no certified medical gas verifier was called to inspect, test, or verify the oxygen gas line after the repair. The Facilities Director, who is not certified as a medical gas verifier, made the decision to return the system to service based on his own judgment and background in electrical and biomedical engineering. The last documented oxygen gas quality testing had been performed over a month prior, and annual testing was the facility's standard practice. No documentation was available to confirm the safety, purity, or integrity of the medical gas system following the repair. The residents affected by this deficiency had significant medical histories, including chronic respiratory failure, traumatic brain injury, stroke, anoxic brain injury, and other conditions requiring continuous mechanical ventilation. Many had tracheostomies and feeding tubes, and were entirely dependent on the facility's oxygen supply for survival. Despite the critical nature of their conditions, the facility did not follow required protocols for post-repair verification of the medical gas system, as outlined in NFPA 99, which mandates thorough leak testing, purging, and functional testing by a certified third-party verifier after any repair or modification to a medical gas piping system.
Failure to Implement Effective Antibiotic Stewardship Protocols
Penalty
Summary
The facility failed to fully develop and implement an effective antibiotic stewardship program (ASP) as part of its Infection Prevention and Control Program (IPCP). Specifically, the facility did not establish protocols to identify signs and symptoms of infections among residents to assess whether they met evidence-based national standard criteria, such as Loeb's minimum criteria, before initiating antibiotic treatment. The facility also did not have a standardized process for using the antibiotic tracking sheet or for documenting the use of Loeb's criteria in their policies and procedures. A resident was admitted with multiple diagnoses, including acute hypoxic respiratory condition and hyperlipidemia, and was dependent on staff for several activities of daily living. The resident was prescribed levofloxacin for a urinary tract infection (UTI), but the only documented symptoms were increased heart rate and fever. According to the Infection Preventionist (IP), these symptoms alone did not meet Loeb's minimum criteria for initiating antibiotics for a UTI in residents without a urinary catheter. The IP acknowledged that there was no protocol in place to ensure that Loeb's criteria were consistently applied or documented when antibiotics were prescribed. Interviews with staff revealed a lack of awareness and use of standardized criteria for antibiotic initiation. The IP and Registered Nurse (RN) involved did not consistently use or document evidence-based criteria when reviewing or initiating antibiotic orders. The facility's policies and procedures on antimicrobial stewardship did not specify the use of the antibiotic tracking sheet or Loeb's criteria, and the Manager of Infection Prevention was not aware of the CMS requirements for antibiotic stewardship regulation.
Failure to Rotate Subcutaneous Injection Sites for Insulin and Heparin
Penalty
Summary
The facility failed to provide care in accordance with professional standards for two residents who were receiving subcutaneous injections of insulin and heparin. For one resident with a history of craniotomy, hypertension, and chronic respiratory failure, records showed that heparin injections were repeatedly administered in the same anatomical sites, specifically the left and right upper quadrants, without proper rotation. Both the Minimum Data Set Nurse and a Registered Nurse confirmed that the administration sites were not rotated as required by standards of practice and the manufacturer's guidelines, which state that injection sites must be rotated to prevent adverse skin reactions. The facility's own policy also mandates rotation of injection sites for subcutaneous medications. Similarly, another resident with a history of stroke, tracheostomy, and ventilator-dependent respiratory failure received insulin glargine injections in the same sites, specifically the left lower quadrant and left upper arm, over multiple administrations. Interviews with nursing staff and review of records confirmed that injection sites were not rotated for this resident either, contrary to both manufacturer guidelines and facility policy. The staff acknowledged that failure to rotate sites could lead to skin complications and affect medication absorption. Both residents were dependent on staff for medication administration and had significant cognitive or physical impairments, requiring total or substantial assistance with activities of daily living. The lack of site rotation for subcutaneous injections was directly observed in medication administration records and confirmed by staff interviews, demonstrating a failure to adhere to professional standards and facility policy for medication administration.
Deficient Practices in Enteral Feeding Care and Infection Control
Penalty
Summary
The facility failed to provide appropriate care and services for residents receiving enteral feeding, resulting in several deficiencies related to infection control and accurate delivery of prescribed nutrition. For one resident with a feeding tube, the medication syringe used for administering medications was not labeled with the date it was to be changed, contrary to facility practice and infection prevention protocols. Both the registered nurse and the infection preventionist confirmed that syringes are to be changed daily and labeled accordingly, and the absence of a date on the syringe was identified during observation and interview. Another resident with a percutaneous endoscopic gastrostomy tube had a water flush bag that was not changed within the 24-hour period recommended by the manufacturer's guidelines. Observations and interviews with nursing staff confirmed that the water flush bag had been hanging for more than 24 hours, and both the licensed vocational nurse and registered nurse acknowledged that this practice could lead to contamination. The infection preventionist also stated that the water flush bag should have been changed according to the manufacturer's instructions, as outlined in the facility's procedures. A third resident receiving continuous tube feeding did not receive the accurate amount of tube feeding formula as ordered by the physician. Review of the resident's intake flowsheet and direct observation revealed a discrepancy between the amount of formula delivered and the amount that should have been administered according to the prescribed rate and duration. Nursing staff were unable to provide documentation accounting for the difference, and there were no new orders to hold or adjust the feeding. Facility policy required monitoring and documentation to ensure accurate delivery of enteral nutrition, which was not followed in this instance.
Failure to Maintain Respiratory Equipment and Adhere to Infection Control Practices
Penalty
Summary
The facility failed to maintain safe and appropriate respiratory care for three residents by not adhering to infection control practices and equipment maintenance protocols. For two residents with tracheostomies and on continuous oxygen therapy, surveyors observed that the oxygen tubing was in direct contact with the floor. Both the Infection Preventionist and nursing staff confirmed that oxygen tubing should not touch the floor due to contamination risks, and facility policy required proper infection control practices to be followed. In another instance, a resident receiving humidified oxygen therapy via a T-piece had an oxygen humidification bottle that was not labeled with the date it was last changed. Staff interviews revealed that humidification bottles are required to be changed every three days and must be labeled accordingly, but there was no documentation or label present to indicate when the bottle was last replaced. The absence of labeling and documentation was confirmed by both the respiratory therapist and nurse manager, who stated that this omission was not in line with facility policy and created uncertainty about the maintenance of the equipment. Additionally, a resident's Yankauer suction tool was found to be open, containing yellow secretions, and not labeled with the date it was opened or needed to be changed. Nursing staff acknowledged that the Yankauer should be changed daily or as needed and must be dated, but in this case, there was no way to determine when it was last replaced. Facility procedures required regular changing and dating of such equipment, but these were not followed, as confirmed by staff interviews and policy review.
Failure to Rotate Injection Sites for Insulin and Heparin Administration
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors by not rotating subcutaneous injection sites for insulin and heparin, as required by standards of practice and manufacturer guidelines. For two residents, staff repeatedly administered injections in the same anatomical locations over an extended period. Documentation and interviews confirmed that the same sites were used for multiple administrations, rather than rotating among recommended areas such as the abdomen, upper arms, or thighs. One resident, who had a history of craniotomy, hypertension, chronic respiratory failure, and was non-verbal with severely impaired cognition, received heparin injections for DVT prophylaxis. Review of medication administration records showed that heparin was repeatedly injected into the same abdominal quadrants without rotation. Both the Minimum Data Set Nurse and a Registered Nurse confirmed that this practice did not follow facility policy, standards of practice, or manufacturer instructions, all of which require site rotation to prevent adverse skin reactions and ensure proper medication absorption. Another resident, with a history of stroke, tracheostomy, ventilator dependence, and severely impaired cognition, received insulin glargine injections. Records indicated that insulin was administered multiple times in the same anatomical sites, such as the left lower quadrant and left upper arm, without rotation. Staff interviews and review of manufacturer guidelines confirmed that injection sites should have been rotated for each administration. Facility policies also specified the requirement for site rotation, and the failure to do so was acknowledged as a medication error by nursing staff.
Deficient Food Storage, Labeling, and Sanitation Practices in Kitchen
Penalty
Summary
The facility failed to maintain safe and sanitary food storage and preparation practices in the kitchen, as evidenced by several observed deficiencies. Towels used for sanitizing were not stored according to facility standards; some were left on carts in the tray line area rather than being placed in clean towel bins, sanitizer buckets, or dirty towel bins. Staff acknowledged that these towels could be contaminated and should not have been left out, as this practice could lead to cross contamination. The facility did not have a specific policy for towel use, but staff confirmed that towels should only be in sanitization buckets when in the kitchen. Food items in the walk-in refrigerators were not consistently labeled or stored according to facility policy. Expired prepackaged sandwiches were found in the refrigerator, and a pan of cooked meat was left partially uncovered and unlabeled. Additionally, a container of sour cream had an illegible expiration date, and staff could not confirm its safety. The facility's policy requires all food to be labeled, dated, and rotated using the first-in, first-out method, with expired or unlabeled items to be discarded, but these procedures were not followed. Personal property of staff, including a cell phone, headphone case, and an uncovered serrated knife, was found stored on a cart next to food items in the kitchen. Staff admitted that personal items should be kept in lockers and that knives should be covered and stored properly. Furthermore, refrigerator and freezer temperature logs showed that several units were repeatedly out of the acceptable temperature range, with no corrective actions documented. This included both excessively high and low temperatures, which were not addressed as required by facility policy.
Failure to Follow Contact Precautions for Resident on Isolation
Penalty
Summary
The facility failed to implement and maintain its infection prevention and control program by not ensuring that staff and medical providers followed contact precautions for a resident on contact isolation. Specifically, a registered nurse, nurse practitioner, and medical doctor entered the room of a resident with a diagnosis of carbapenem-resistant pseudomonas aeruginosa (CRPA) and multidrug-resistant pseudomonas aeruginosa (MDRA) without donning gowns, despite a posted contact isolation sign instructing all staff and visitors to wear gowns and gloves before entry. The staff members did not wear gowns because they believed it was unnecessary since they did not intend to touch the resident. The resident involved had a complex medical history, including prostate cancer, chronic respiratory failure with a tracheostomy, and a percutaneous endoscopic gastrostomy tube. The resident was dependent on staff for all activities of daily living and had limited ability to communicate. Physician orders were in place for contact isolation due to the presence of CRPA and MDRA, both of which are infectious bacteria that require strict adherence to contact precautions to prevent transmission. Interviews with facility staff, including the infection preventionist and nurse manager, confirmed that the facility's policy required anyone entering the room of a resident on contact isolation to wear a gown, regardless of whether direct contact with the resident or environment was anticipated. The failure of the RN, NP, and MD to don gowns was acknowledged as a violation of facility policy and procedures regarding contact isolation, as outlined in the facility's infection control policies.
Failure to Cover Urinary Catheter Drainage Bag Compromises Resident Dignity
Penalty
Summary
A deficiency was identified when a resident with an indwelling urinary catheter had their catheter drainage bag left uncovered and visible from the hallway. The resident, who had a history of respiratory failure, cerebrovascular accident, hypertension, and neurogenic bladder dysfunction, was severely cognitively impaired and required extensive assistance with daily activities. The resident's care plan specifically included an intervention to provide a privacy bag for the catheter drainage bag, but this was not implemented at the time of observation. During the observation, a Licensed Vocational Nurse confirmed that the drainage bag should have been covered with a dignity bag to protect the resident's privacy. A Registered Nurse also stated that maintaining dignity includes covering urinary drainage bags. Facility policies reviewed indicated that the use of a dignity cover is required to protect resident privacy and dignity, and that residents have the right to considerate, compassionate, and respectful care. The failure to cover the drainage bag was directly observed and acknowledged by staff as not meeting these standards.
Failure to Obtain Informed Consent for Psychotropic Medication Dose Increase
Penalty
Summary
The facility failed to obtain informed consent prior to increasing the dose of Seroquel, a psychotropic medication, for one resident. The resident, who had a history of respiratory failure, tracheostomy, hypertension, and diabetes mellitus, was cognitively impaired and required significant assistance with daily activities. The resident was taking antipsychotic medication for psychosis, which manifested as agitation and pulling out medical devices. The medication order was changed to increase the nightly dose of Seroquel from 50 mg to 75 mg, but the facility did not obtain a new informed consent for the increased dose. Interviews with nursing staff confirmed that the last documented consent was for the previous 50 mg dose, and that facility policy required informed consent for any new psychotropic medication order or dose increase. Staff acknowledged that consent should be verified with the resident's family, especially given the resident's impaired decision-making capacity, to ensure understanding of the risks and benefits. Review of facility policies further supported the requirement for informed consent prior to the use or dose change of psychotropic medications.
Failure to Ensure Call Light Within Reach for Non-Verbal Resident
Penalty
Summary
A deficiency occurred when staff failed to ensure that a call light was within reach for a resident who was non-verbal, had a tracheostomy, severely impaired cognition, and required total assistance with all activities of daily living. The resident's call light was observed hanging on the enteral feeding pole, out of the resident's reach, during a room observation. Both a Licensed Vocational Nurse and a Certified Nursing Assistant confirmed that the call light was not placed within reach, with the CNA stating she had forgotten to do so after providing morning care. The facility's policy requires that call lights be within reach of residents at all times to ensure safety and timely assistance. The resident involved had significant medical needs, including a history of craniotomy, hypertension, chronic respiratory failure, and was assessed as having severely impaired cognition. Despite these needs, staff did not follow the facility's policy regarding call light placement, as confirmed by interviews with nursing staff and the Infection Preventionist. The failure to place the call light within reach was directly observed and acknowledged by staff, constituting a failure to reasonably accommodate the resident's needs and preferences.
Failure to Complete Restraint Assessments Prior to Use
Penalty
Summary
The facility failed to ensure that two residents were free from the use of physical restraints without proper assessment and documentation. For one resident with acute respiratory failure, traumatic brain injury, and schizophrenia, a right-hand peek-a-boo mitten was applied to prevent self-harm or injury by pulling at medical devices. However, there was no restraint assessment completed prior to the application of the mitten, as confirmed by both the Minimum Data Set Nurse (MDSN) and the Nurse Manager (NM). The facility's policy required a restraint assessment and documentation of least restrictive alternatives before restraint use, but this was not followed. Another resident with a history of stroke, tracheostomy, and ventilator-dependent respiratory failure was subjected to bilateral soft wrist restraints and peek-a-boo mittens after previously removing a tracheostomy. Similar to the first case, there was no restraint assessment completed prior to the application of these devices. The MDSN and NM both confirmed that the required pre-restraint assessment and documentation of unsuccessful least restrictive interventions were not performed, despite the facility's policy mandating these steps. In both cases, the lack of a pre-restraint assessment and failure to attempt or document less restrictive interventions were identified through record review, staff interviews, and policy review. The facility's own policy outlined the need for assessment, documentation, and the use of least restrictive alternatives, but these procedures were not followed for either resident prior to the application of physical restraints.
Failure to Maintain Catheter Tubing Without Dependent Loops
Penalty
Summary
A resident with a history of neurogenic bladder, gastrostomy, and tracheostomy, who required total assistance with all activities of daily living and had an indwelling suprapubic catheter, was observed to have a urinary drainage bag hanging on the side of the bed with a dependent loop in the catheter tubing. The resident's medical records confirmed the presence of a physician's order for suprapubic catheter care every shift and as needed, with specific instructions for catheter maintenance. During the observation, a registered nurse confirmed the presence of the dependent loop and acknowledged that the tubing should be positioned to avoid such loops to ensure free urine flow. Further interviews with facility staff, including the Infection Preventionist, confirmed that facility policy and standard infection prevention practices require catheter tubing to be free of kinks or loops to prevent obstruction of urine flow. The facility's policy on urinary catheter care specifically states that the urinary collection bag should always be positioned below the bladder without dependent loops or kinks. The failure to maintain the catheter tubing in accordance with these guidelines constituted a deficiency in providing appropriate care and services to prevent urinary tract infections.
Insulin Order Lacked Required Indication
Penalty
Summary
A deficiency was identified when a resident was found to be receiving a hypoglycemic medication, specifically insulin lispro, without a documented indication for its use. The resident had a history of respiratory failure and diabetes mellitus and was admitted to the facility with these diagnoses. Review of the resident's records showed that while the order for insulin glargine included an indication for diabetes, the order for insulin lispro did not specify a reason for administration. This omission was confirmed during interviews with nursing staff, who acknowledged that the medication order lacked the required indication. Further review of the facility's policy on medication administration and monitoring revealed that staff are required to observe the seven rights of medication administration, which includes ensuring the right reason (indication) is documented. The absence of an indication for insulin lispro in the resident's medication order was inconsistent with both facility policy and standard medication administration practices, as confirmed by staff interviews and record review.
Improper Handling and Storage of Medication Bubble Pack
Penalty
Summary
A deficiency was identified when a medication cart inspection revealed that a resident's cyanocobalamin (vitamin B12) bubble pack had a broken seal and was covered with clear plastic tape. The registered nurse present confirmed that the process for dispensing medication from a bubble pack requires licensed nurses to compare the medication label with the medication administration record (MAR) before dispensing. If a medication is dispensed by accident, it should be immediately discarded in the designated bin inside the medication room, not taped back into the bubble pack. In this case, medications from two slots in the bubble pack had been removed and then taped back, rather than being discarded as required. The nurse manager confirmed awareness of the issue and reiterated that taping a dispensed medication back into the bubble pack is not acceptable, as it could result in contamination and uncertainty about whether the correct medication was returned. The facility's policy and procedure on medication storage states that contaminated or improperly sealed medications must be immediately removed and disposed of. The failure to follow these procedures resulted in the presence of a contaminated medication in the medication cart, creating the potential for medication errors.
Failure to Implement Effective Antibiotic Stewardship Program
Penalty
Summary
The facility failed to fully develop and implement an effective antibiotic stewardship program (ASP) as part of its Infection Prevention and Control Program. Specifically, the facility did not establish protocols to identify signs and symptoms of infections among residents to assess whether they met evidence-based national standard criteria, such as Loeb's minimum criteria, before initiating antibiotic treatment. The facility's policy and procedure on antimicrobial stewardship did not include guidance on the use of antibiotic tracking sheets or the application of Loeb's criteria, and staff interviews confirmed that there was no standardized protocol in place for these processes. A resident was readmitted with multiple diagnoses and was dependent on staff for several activities of daily living. The resident was prescribed levofloxacin for a urinary tract infection (UTI), but review of the resident's clinical presentation showed only increased heart rate and fever, which did not meet Loeb's minimum criteria for initiating antibiotics for UTI in residents without a urinary catheter. The Infection Preventionist (IP) acknowledged that the resident did not meet the criteria and that this was not documented or communicated according to a standardized protocol, as the facility's policy did not specify these requirements. Further interviews revealed that staff, including a registered nurse covering for the IP, did not use any standardized criteria when reviewing antibiotic use. The Manager of Infection Prevention was unaware of CMS requirements for antibiotic stewardship and confirmed that the facility's ASP was not fully aligned with regulatory expectations. The facility's policy stated the intent to optimize antibiotic therapy but lacked specific protocols for evaluating and documenting the appropriateness of antibiotic use.
Failure to Document Pneumococcal Vaccine Offer and Education
Penalty
Summary
The facility failed to document that the pneumococcal vaccine was offered to a resident and that education regarding the vaccine was provided to the resident's family or decision-maker, as required by the facility's policy and procedures. Specifically, for a resident admitted with respiratory failure and seizure disorders, who was rarely able to make herself understood or understand others, there was no documentation in the medical record indicating that the vaccine was offered or that education was provided to the family or legal representative. The Infection Preventionist confirmed the absence of documentation during a review of the resident's records. Further investigation revealed that a registered nurse, who was covering for the Infection Preventionist, had discussed the vaccine with the resident's family member and obtained consent for administration but failed to document this discussion or enter the vaccine order as required. The facility's policy mandates that education about the benefits and potential side effects of the pneumococcal vaccine be provided and documented, and that the offer of immunization be recorded in the resident's medical record. This lapse in documentation was confirmed through interviews and record reviews with facility staff.
Failure to Accurately Document Physical Restraint Use in MDS Assessment
Penalty
Summary
The facility failed to ensure that a resident's Minimum Data Set (MDS) accurately reflected the use of physical restraints. Specifically, a resident with a history of respiratory failure, tracheostomy, hypertension, and diabetes mellitus, who was cognitively impaired and required significant assistance with activities of daily living, had physician orders for bilateral hand mittens and soft wrist restraints to prevent self-injury by pulling at medical devices. Despite these orders and the actual use of restraints, the MDS assessments on multiple occasions did not correctly indicate the use of restraints, with some assessments coded as 'not used' when restraints were in place and in use daily. Observations and interviews confirmed that the resident was using both mittens and wrist restraints, and staff acknowledged the purpose was to prevent the resident from interfering with their oxygen and tracheostomy equipment. The MDS nurse admitted that the MDS Section P: Restraints and Alarms was not coded correctly on at least two assessment dates, despite the presence of restraint orders and ongoing use. Facility policy and CMS procedures require that the MDS accurately reflect the resident's status, but this was not followed, resulting in inaccurate documentation of restraint use for the resident.
Failure to Notify Physician of Resident's Hematuria
Penalty
Summary
The facility failed to notify the physician about a resident's continued hematuria while on blood thinner medication. The resident, who had an indwelling urinary catheter and was on Apixaban, experienced hematuria from January 12 to January 15, 2024. Despite the presence of blood clots and the resident's deteriorating condition, the attending physician was not informed, which led to a delay in appropriate medical intervention. On January 15, 2024, the resident required an emergency transfer to a general acute care hospital due to elevated body temperature, abdominal distention, and significant hematuria. Upon arrival at the hospital, the resident was diagnosed with septic shock, a urinary tract infection, and pneumonia. The hospital records indicated that the resident had a high fever, rapid heart rate, and dark red urine with a foul odor. Interviews with the Nurse Manager and the attending physician confirmed that the physician was not notified of the resident's ongoing hematuria, which was a significant change in condition. The facility's policies required prompt notification of the physician for such changes, but this protocol was not followed, contributing to the resident's severe health decline.
Failure to Notify Physician of Resident's Hematuria
Penalty
Summary
The facility failed to ensure that a resident with an indwelling urinary catheter (IUC) and on blood thinner medication received appropriate care to prevent complications. The resident, who had severe cognitive impairment and was dependent on staff for all activities of daily living, was admitted with an IUC and was on Apixaban for atrial fibrillation. Despite orders to monitor for hematuria and manage continuous bladder irrigation (CBI) to prevent clot formation, the resident continued to have hematuria from 1/12/2024 to 1/15/2024 without the physician being notified of the ongoing bleeding, which was a significant change in condition. This lack of communication led to the resident's condition worsening, requiring emergency transfer to a hospital where the resident was diagnosed with septic shock, UTI, and pneumonia. The resident's medical records indicated that the urine characteristics were described as red, light, and with clots on multiple occasions, yet the physician was not informed. The facility's policy required notifying the physician of any significant change in the resident's condition, including marked changes in vital signs or symptoms. However, the licensed nurses failed to inform the physician about the resident's continued hematuria, which was critical given the resident's anticoagulant therapy and the potential for severe complications. Interviews with the Nurse Manager and the physician confirmed that the physician was not notified about the resident's ongoing hematuria, which would have prompted a reassessment of the resident's medication and possibly an earlier transfer to the hospital. The facility's failure to adhere to its policies on change of condition notification and indwelling urinary catheter care and management directly contributed to the resident's emergency hospitalization and subsequent diagnoses of severe infections and septic shock.
Failure to Ensure Residents are Free from Physical Restraints
Penalty
Summary
The facility failed to ensure that residents were free from physical restraints unless needed for medical treatment. Specifically, the facility did not complete an assessment for the risk of entrapment prior to the use of four bed siderails (SR) in the raised position for three residents. Additionally, the facility did not obtain a physician's order or informed consent for the use of these restraints and bed alarms. These deficiencies were observed in three out of four sampled residents during the review of physical restraints care area. For Resident 24, the facility did not have an assessment, physician's order, or informed consent for the use of four bed siderails in the raised position. The resident had severe cognitive impairment and was totally dependent on staff for all activities of daily living. Despite being at medium risk for falls and high risk for injury, the facility did not document any assessment for possible entrapment with the use of the siderails. Staff interviews confirmed that the siderails were used for the resident's safety, but the necessary documentation and consents were missing. Resident 23, who had a history of post-traumatic cervical-spine injury and quadriplegia, was also found with four siderails in the raised position and a bed alarm in place without the required physician's order or informed consent. The resident was at medium risk for falls and high risk for injury. Similarly, Resident 5, who had a history of alcohol abuse and multiple brain hemorrhages, was found with four siderails in the raised position and a bed alarm without the necessary documentation. Staff interviews revealed a lack of understanding regarding the need for physician's orders and informed consents for the use of these restraints, which were implemented to prevent falls and injuries.
Failure to Develop and Implement Care Plans for Bed Alarms, Side Rails, and Medications
Penalty
Summary
The facility failed to develop and implement care plans for the use of bed alarms and side rails for several residents. Resident 23, who was admitted with respiratory failure and quadriplegia, was observed with four side rails raised and a bed alarm in place, but no care plan was created for these devices. Similarly, Resident 5, admitted with a history of alcohol abuse and multiple brain hemorrhages, was also observed with four side rails raised and a bed alarm in place without a corresponding care plan. Both the Licensed Vocational Nurses and the Nurse Manager confirmed the absence of care plans for these residents, which is against the facility's policy that mandates an interdisciplinary care plan within seven days of admission. Resident 24, who had a traumatic brain injury and was dependent on staff for all activities of daily living, was also found to have four side rails raised without a care plan. The Infection Preventionist and the Nurse Clinician verified the absence of a care plan for the use of side rails. The facility's policy requires accurate clinical documentation and the creation of an interdisciplinary care plan within seven days of admission, which was not followed in this case. Additionally, Resident 37, admitted with ischemic stroke and dependent on a ventilator, did not have care plans addressing the use of apixaban (Eliquis) and an indwelling urinary catheter. The Nurse Manager confirmed the absence of these care plans, stating that without them, the facility could not set treatment goals or implement necessary interventions. The facility's policy emphasizes the importance of clinical documentation and interdisciplinary care plans, which were not adhered to in these instances.
Failure to Provide Consistent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide care consistent with professional standards of practice to prevent pressure ulcers/injuries for three residents. Resident 23, who was admitted with a history of sacral decubiti ulcers and venous insufficiency, had missing wound assessments, measurements, pictures, and care plan reviews during specific weeks. The Registered Nurse (RN) responsible for these assessments was on vacation, and the facility was short-staffed, leading to the omission of necessary wound care documentation and assessments. The Nurse Manager confirmed the importance of timely assessments and reporting to monitor wound progression and involve the interdisciplinary team when necessary. Resident 27, admitted with a diagnosis of respiratory failure and a history of diabetes mellitus and obesity, also had missing wound assessments, measurements, and care plan reviews for several weeks. The RN acknowledged the importance of following weekly wound assessments and documentation to track wound progression and inform the doctor or wound specialist if there was a worsening of the pressure injury. The Nurse Manager reiterated that the treatment nurses should perform weekly wound assessments, including taking pictures and reviewing the pressure injury care plan, to monitor the wound's condition. Resident 14, admitted with a diagnosis of respiratory failure and a history of diabetes mellitus and massive intraparenchymal hemorrhage, had missing assessments and pictures for moisture-associated skin damage (MASD) during a specific week. The RN stated that they do not measure the wound but take weekly pictures for MASD. The Nurse Manager emphasized the importance of timely assessment and reporting to monitor the wound for worsening or healing and involve the interdisciplinary team and attending physician when necessary. The facility's policy and procedure for pressure injury and skin breakdown assessment and prevention were not consistently followed, leading to the potential for development and worsening of pressure ulcers/injuries for the residents involved.
Failure to Properly Label Enteral Feeding Equipment
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent complications of enteral feeding for three residents. For Resident 24, the enteral feeding bottle was not labeled with the correct date and time it was started, and the water flush bag lacked the date and time it was started and the prescribed rate. This was verified by Registered Nurse 2 and the Nurse Manager, who confirmed that the labeling was necessary to ensure the formula was not expired and the water flush bag was discarded after 24 hours as per the facility's procedure. Resident 24 had severe cognitive impairment and was totally dependent on staff for all activities of daily living (ADLs). The resident's physician's orders included specific instructions for hydration and continuous tube feeding, which were not properly followed due to the labeling deficiencies. For Resident 26, the enteral feeding bottle did not indicate the rate prescribed by the physician, and the water flush bag was not labeled with the resident's name, room number, rate prescribed by the physician, and the date and time it was hung. Licensed Vocational Nurse 3 verified these deficiencies and stated that all tube feeding formulas and water flush bags should be properly labeled to ensure the correct amount of feeding and water flushes were administered. Resident 26 had severe cognitive impairment, was non-verbal, and totally dependent on staff for all ADLs. The resident's physician's orders included specific instructions for hydration and continuous tube feeding, which were not properly followed due to the labeling deficiencies. For Resident 191, similar deficiencies were observed. The enteral feeding bottle did not indicate the rate prescribed by the physician, and the water flush bag was not labeled with the resident's name, room number, rate prescribed by the physician, and the date and time it was hung. Licensed Vocational Nurse 3 verified these deficiencies and emphasized the importance of proper labeling. Resident 191 had severe cognitive impairment, was unable to follow commands, and was totally dependent on staff for all ADLs. The resident's physician's orders included specific instructions for tube feeding and water flushes, which were not properly followed due to the labeling deficiencies.
Failure to Ensure Safe Use of Bed Side Rails
Penalty
Summary
The facility failed to ensure the safe and appropriate use of bed side rails for three residents. For Resident 24, the facility did not conduct an assessment for the risk of entrapment, did not review the risks and benefits of side rails with the resident's representative, and did not obtain informed consent. The resident was observed with four side rails up, and staff stated this was for the resident's safety to prevent falls. However, there was no physician's order or care plan indicating the use of side rails, and the facility did not consider side rails as restraints, contrary to their policy and manufacturer's guidelines. For Resident 23, the facility also failed to assess the risk of entrapment, did not review the risks and benefits with the resident's representative, and did not obtain informed consent. The resident was observed with four side rails up, and staff acknowledged that a physician's order and consent should have been obtained. The facility's policy and manufacturer's guidelines were not followed, which required evaluation for entrapment risk and proper documentation. Similarly, for Resident 5, the facility did not conduct an assessment for entrapment risk, did not review the risks and benefits with the resident's representative, and did not obtain informed consent. The resident was observed with four side rails up, and staff confirmed there was no physician's order or documented assessment. The facility's policy and manufacturer's guidelines were again not adhered to, which emphasized the need for proper evaluation and documentation to prevent serious injury or death.
Failure to Follow Proper Sanitation and Food Handling Practices
Penalty
Summary
The facility failed to follow proper sanitation and food handling practices in three specific instances. First, a Food Service Attendant (FSA) was observed working in the food production line without wearing a hair restraint. During an interview, the FSA confirmed that he was not wearing a hair restraint and acknowledged the importance of doing so to prevent hair from falling into the food. The facility's policy requires all employees in food production, storage, and serving areas to wear hair restraints to avoid food contamination and maintain a professional appearance. This policy was not adhered to in this instance. Second, an observation of refrigerator 1-2 revealed open food items not in their original packaging and placed in clear storage bags without labels or dates. The Kitchen Supervisor (KS) confirmed that these items were pieces of cheddar cheese and stated that all food items not in their original packaging must be labeled with the specific name, the date they were opened, and the initials of the food service attendant who opened them. Third, an open package of low moisture part-skim mozzarella cheese was found without an open date. The KS confirmed that the cheese should have been labeled with an open date to ensure it is used before it expires. The facility's policy mandates that all foods be labeled and dated appropriately to ensure proper storage and safety of the food supply. These deficiencies had the potential to place six out of 43 residents at risk for foodborne illnesses.
Failure to Implement Antimicrobial Stewardship Policy
Penalty
Summary
The facility failed to implement its antimicrobial stewardship (AMS) policy and procedures for a resident when clindamycin was ordered indefinitely and the facility did not monitor the antibiotic use for 77 days. The resident, who had a history of multidrug-resistant pseudomonas proteus and MRSA, was admitted on 12/28/2023. The physician's order dated 1/29/2024 indicated clindamycin 1% gel to be applied twice daily for chronic respiratory failure, with the length of therapy marked as indefinite. The Medication Administration Record (MAR) showed that the antibiotic was administered multiple times from January to April 2024 without a stop date or monitoring as part of the AMS program. During interviews, the Infection Preventionist and Nurse Manager acknowledged that antibiotics should not be used indefinitely and should have a stop date to prevent antibiotic resistance. They confirmed that Resident 2's clindamycin use should have been included in the AMS program to ensure proper monitoring and documentation. The facility's policy, last revised in June 2023, emphasized the importance of optimizing antibiotic therapy to improve clinical outcomes and minimize unintended consequences such as drug resistance. However, the facility did not adhere to this policy, leading to the deficiency in monitoring antibiotic use for the resident.
Failure to Honor Residents' Dignity
Penalty
Summary
The facility failed to honor the residents' right to a dignified existence for two sampled residents. For Resident 23, the facility did not ensure that the resident's indwelling urinary catheter drainage bag was covered with a dignity bag, making the urine visible to visitors and other residents' family members. This was observed during a visit where the drainage bag was hanging visibly from the bed without a dignity cover. Both the Licensed Vocational Nurse and the Nurse Manager confirmed that the drainage bag should have been covered to protect the resident's privacy and dignity, as per the facility's policy and procedure. For Resident 238, the facility failed to ensure that a Certified Nursing Assistant (CNA) was not standing over the resident while assisting with feeding. The CNA was observed standing over the resident, who had a history of cerebrovascular accident and was non-verbal, while feeding them. The CNA acknowledged that they should have been seated at eye level to convey respect and maintain the resident's dignity. The Nurse Manager also confirmed that the CNA should have been seated to ensure proper monitoring of the resident during feeding, as outlined in the facility's feeding procedure manual.
Failure to Label IV Dressings
Penalty
Summary
The facility failed to ensure the safe and appropriate administration of intravenous (IV) fluids for two residents, leading to potential complications. Resident 21, admitted with diagnoses including respiratory failure and a history of sepsis, had an unlabeled peripheral IV line on their right arm. The IV dressing lacked the date of insertion or the initials of the nurse who inserted or changed it. This oversight was confirmed by both a respiratory therapist and a registered nurse, who acknowledged that the absence of labeling could result in staff not knowing when to change the dressing or start a new line, potentially leading to infection. Similarly, Resident 238, admitted with diagnoses including respiratory failure and a history of pulmonary embolism and septic shock, also had an unlabeled peripheral IV line on their right hand. A certified nursing assistant and a licensed vocational nurse both confirmed that the IV dressing was not dated or initialed. They recognized that this failure could prevent staff from knowing when to change the dressing or start a new line, increasing the risk of infection. The facility's policy on vascular access management, which requires dressings to be labeled with the date of insertion and changed every seven days or sooner if soiled, was not followed. The nurse manager confirmed that the lack of labeling could lead to missed dressing care or new insertions, potentially resulting in complications such as phlebitis and cellulitis.
Failure to Provide Necessary Respiratory Care
Penalty
Summary
The facility failed to provide necessary respiratory care and services in accordance with professional standards of practice for Resident 34. The resident, who was admitted with a diagnosis of respiratory failure and had a history of traumatic brain injury, required oxygen therapy to maintain oxygen saturation levels above 92%. However, during an observation, it was found that the resident's t-piece was not connected to the oxygen regulator, which is essential for delivering the prescribed oxygen concentration. This oversight was confirmed by Registered Nurse 1, who acknowledged that the t-piece should have been connected to the oxygen regulator with the humidifier to administer the required oxygen concentration. The failure to connect the t-piece could lead to respiratory distress for the resident. Further interviews revealed that the Nurse Manager stated the respiratory therapist should have ensured the t-piece was reconnected to the oxygen regulator after providing a breathing treatment. The facility's policy on respiratory protocol, last reviewed in June 2019, indicated the need for proper assessment and connection of respiratory equipment. The deficiency in reconnecting the t-piece to the oxygen regulator was deemed unsafe and had the potential to cause respiratory compromise for Resident 34.
Medication Management Deficiencies
Penalty
Summary
The facility failed to ensure that a licensed nurse did not leave an insulin pen unattended on top of a computer on wheels (WOW). During an observation, a Licensed Vocational Nurse (LVN) placed an insulin pen on the WOW and walked away, leaving it unattended while entering a resident's room. The LVN acknowledged that the insulin pen should have remained with her at all times for safety. The facility's policy indicated that medications must remain with the administering staff at all times and not be left unattended. Additionally, the facility failed to ensure accurate documentation of a controlled drug record for a resident. The resident, admitted with respiratory failure and seizure disorder, had a physician's order for Lacosamide (Vimpat) to be administered via g-tube. A review of the controlled-drug record revealed discrepancies in the documented amounts of the medication administered and the remaining amount. Both a Registered Nurse (RN) and the Nurse Manager confirmed the inaccuracies and stated that the discrepancy should have been identified and reported per the facility's policy. The facility's policy required a physical inventory of all controlled medications at each shift change and immediate reporting of any discrepancies to the Director of Nursing.
Failure to Limit PRN Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that PRN orders for psychotropic medications were only used when necessary and limited to a specific duration for two residents. Resident 23 was admitted with a history of respiratory failure, post-traumatic cervical-spine injury, quadriplegia, and septic shock. The resident had an active diagnosis of depression and was prescribed lorazepam 0.5 mg every 6 hours PRN for anxiety without a specified stop date. Despite recommendations from the consultant pharmacist to specify a stop date, the order remained open-ended, and the facility did not follow up on the pharmacist's recommendation. The Nurse Manager confirmed that the lorazepam order did not have a stop date and acknowledged that psychotropic drugs should only be prescribed for a 14-day duration to avoid unnecessary use and potential side effects. Resident 5 was admitted with a diagnosis of gastrointestinal bleed and had a history of agitation and delirium. The resident was prescribed lorazepam 1 tablet every 12 hours PRN for anxiety, with a start date and a stop date extending beyond the 14-day limit. The Nurse Manager confirmed that the lorazepam order for Resident 5 exceeded the 14-day duration and acknowledged the risk of prolonged use of psychotropic medications. The consultant pharmacist had reviewed the medications and recommended specifying a stop date, but this recommendation was not implemented. The facility's policy on psychotropic drugs indicated that PRN psychotropic medications should have a start and stop date for 14 days initially, followed by re-evaluation by a physician. However, this policy was not adhered to in the cases of Residents 23 and 5, leading to the potential for unnecessary use of psychotropic drugs and associated adverse consequences. The failure to follow the consultant pharmacist's recommendations and the facility's own policy resulted in a deficiency in the management of PRN psychotropic medications for these residents.
Failure to Implement Infection Control Program
Penalty
Summary
The facility staff failed to implement its infection control program for two residents. For Resident 5, the suction canister, which was labeled with the date 4/5/2024, was not discarded and replaced per facility policy. The policy required the suction canister to be changed weekly to prevent the growth and transmission of infection. During an observation and interview, it was confirmed that the suction canister should have been changed on 4/12/2024, but it was not. The Nurse Manager confirmed that the canister should be changed weekly to prevent bacterial growth that could cause infections in vulnerable residents. For Resident 3, the urinal bottle was not labeled with the resident's name, date, and room number as required by the facility's policy. During an observation and interview, two unlabeled urinal bottles were found hanging on the left side rail of the resident's bed. The Certified Nursing Assistant confirmed that the urinals should be labeled to prevent interchanging and potential infection. The Nurse Manager also confirmed that the urinals should be labeled to prevent switching with other residents and to know when to change them. The facility's infection control policy emphasized the importance of labeling to minimize the risk of disease transmission.
Failure to Transmit MDS Assessments Timely
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments were successfully transmitted timely to the Centers for Medicare and Medicaid Services (CMS) for four out of 14 sampled residents. This deficiency was identified during interviews and record reviews, revealing that the MDS assessments for Residents 12, 18, 23, and 27 were not successfully transmitted and accepted by CMS. The Minimum Data Set Coordinator (MDSC) verified that the assessments remained in an exported status and had not been reconciled, resulting in no CMS final validation reports for the assessments. The previous MDSC had left abruptly without completing the necessary transmission process or providing a handoff report of pending assessments, leading to this issue. Resident 12 was originally admitted on 12/6/2021 and readmitted on 11/22/2022 with diagnoses including traumatic brain injury, cardiac arrest, and PEG placement. The resident's MDS assessments dated 3/1/2023, 6/1/2023, 9/1/2023, and 12/1/2023 were not successfully transmitted to CMS. The MDSC confirmed that the validation reports for these assessments were not reconciled, and the assessments were not accepted by CMS. The Nurse Manager (NM) also verified the status of these assessments and acknowledged the lack of a handoff report from the previous MDSC. Resident 18, admitted on 9/25/2020 and readmitted on 6/2/2023, had diagnoses including chronic respiratory failure, tracheostomy, and PEG placement. The resident's MDS assessments dated 12/4/2022, 3/4/2023, 8/29/2023, and 11/29/2023 were also not successfully transmitted to CMS. Similar to Resident 12, the MDSC and NM confirmed that the validation reports were not reconciled, and the assessments were not accepted. Additionally, Residents 23 and 27, both with diagnoses of respiratory failure, had their MDS assessments in an exported status without successful transmission and acceptance by CMS. The MDSC acknowledged the importance of reconciling and submitting the MDS assessments timely to ensure proper billing and provision of necessary care and services for the residents.
Inaccurate MDS Documentation for Resident Restraint Use
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) accurately reflected the resident's status for one of the sampled residents, specifically Resident 24. The MDS did not document the use of a mitten restraint, which was applied to prevent the resident from self-harm by pulling out medical devices. Resident 24 had a history of traumatic brain injury, dysphagia, PEG placement, and chronic respiratory failure, and was totally dependent on staff for all activities of daily living. Despite the presence of an order for the mitten restraint and informed consent from the family, the MDS assessment did not reflect this restraint use, which was confirmed by the Director of Nursing (DON) during a review of the resident's records. Observations and interviews with nursing staff confirmed that the mitten restraint was in use for Resident 24's safety. The DON acknowledged that the MDS was inaccurately coded, which could potentially delay the provision of necessary care. The facility's failure to document the restraint use in the MDS assessment is a deficiency that could negatively impact the resident's plan of care and the delivery of services.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Mission Hills
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ararat Nursing Facility | 0 mi | ★★★★★ | 25 | 1 |
| Granada Hills Convalescent | 1.6 mi | ★★★★★ | 19 | 0 |
| The Grove Post-acute Care Center | 1.6 mi | ★★★★★ | 41 | 0 |
| Rinaldi Convalescent Hospital | 1.7 mi | ★★★★★ | 42 | 0 |
| Astoria Healthcare Center | 2.4 mi | ★★★★★ | 24 | 2 |
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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.