Average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sage Post Acute during CMS and state inspections, most recent first.
A resident with dementia, impaired vision, and moderate fall risk was left unattended in a shower chair after a shower while a CNA left the room to get water. The resident fell to the floor next to the bed, complained of neck and back pain, had rectal bleeding noted, and was later diagnosed at the hospital with an L5 compression fracture. The DON stated CNAs should transfer residents to bed after showering to ensure they are safe and secure before leaving the room.
RN coverage was not provided for at least 8 consecutive hours every day as required. Review of staffing schedules showed multiple days when no RN was scheduled for an 8-hour shift, and the DON stated this could affect resident care because residents need an RN to assess them when there is a change in condition. The facility policy also required an RN to provide at least 8 consecutive hours every 24 hours, 7 days a week.
Advance Directive Discussions Not Documented: The facility failed to document that advance directives were discussed with six residents or their responsible parties. Three residents had severe cognitive impairment and diagnoses including cerebrovascular disease, respiratory failure, and dementia, while three others were cognitively intact with diagnoses including failure to thrive, heart disease, and heart failure. Their POLST forms showed no information about an advance directive, and the SSD confirmed there was no documentation that the discussions and follow-up occurred.
An RN left a resident’s Aspirin 81 mg unattended on top of the med cart after removing it from the original cup, then walked away. In a separate observation, another RN left a different resident’s ferrous sulfate and multivitamin unattended on top of the med cart while assisting the podiatrist in another room. The DON and ADON stated nurses should never leave medications unattended, and the facility policy states no medications are kept on top of the med cart.
Medication errors were found when an LPN administered Alendronate to a resident without following the order and package directions, giving orange juice instead of water and not timing it before the first meal. The facility also administered Amlodipine to two residents even though the bubble packs were missing the HR parameter of 60, and the nurse added the missing information with a marker instead of clarifying it against the physician order. Leadership stated staff must follow the MAR and label instructions, and the policy required medications to be given as prescribed and verified by checking the label three times.
Unpalatable and Overcooked Meal Service: A regular and a puree tray were observed and sampled after the last resident tray was delivered. The citrus barbeque chicken and mixed vegetables on both trays were checked with a calibrated thermometer, and the regular mixed vegetables were noted to be overcooked, lacking color, and bland. The ADM and DM stated the puree food was not palatable and the regular vegetables looked overcooked, despite the facility policy requiring food to be served at appropriate temperatures and with an appetizing appearance.
Kitchen food storage and sanitation were deficient when expired food items were found in refrigerators, freezers, and on a stove, and multiple utensils and pans were observed rusted, dented, chipped, stained, or covered with baked-on food and grease. Cup and food container lids were loose in a drawer, several items were stacked wet instead of air-dried, and the microwave, ovens, and toasters had visible buildup and damage. The ASDM acknowledged the conditions during observation.
A facility failed to maintain an effective infection control program when clean and dirty laundry hampers were stored together in the soiled linen room. A Laundry Worker sanitized dirty hampers and returned them to the same room with dirty hampers because there was no separate space for clean storage, then used the clean hampers in the hallways to collect residents' used linens and clothes. The LS and DON confirmed the practice and stated it created a risk of infection spread.
A resident with cachexia, hypokalemia, dysphagia, and acute kidney failure reported that his wallet had been missing for about 2 weeks and said it contained his money and ID. His inventory list documented 1 wallet among his belongings, but an RN was unaware of the missing item during interview. The facility policy stated it would protect resident valuables from loss or theft and promptly respond to complaints of theft or misappropriation.
A resident with dementia and severely impaired decision-making capacity did not have an IDT care conference for seven months. The MDSC stated the conference should occur quarterly to update the responsible party on the plan of care and allow input, and the DON confirmed it should have been held quarterly to review care, medication changes, and condition changes. The facility policy states the IDT develops care plans and encourages resident or representative participation.
Insufficient square footage in multiple shared resident rooms. Six rooms with multiple occupants were measured below the required 80 sq. ft. per resident, ranging from 72.5 to 76.7 sq. ft. per resident. The report notes that residents and staff did not complain about room size, staff had enough room to work, and there were no reported issues with belongings, privacy, or negative consequences.
A resident with impaired mental status eloped from the facility due to inadequate supervision and a faulty exit alarm on the sliding doors in their room. The resident, who used a wheelchair and had a low BIMS score, was found by a concerned citizen and taken to a police station. Maintenance staff did not keep records of alarm checks, and the charge nurse was aware of the resident's elopement risk. The resident's family had previously raised concerns about the sliding doors.
A facility failed to properly document and reconcile narcotic medications, as evidenced by a resident's hydrocodone-acetaminophen administration lacking proper time documentation and another instance of undocumented medication removal. Additionally, narcotic reconciliation counts were inconsistently completed, with multiple instances of missing signatures on count sheets. Staff interviews confirmed the importance of these procedures for accountability and safety.
The facility failed to implement Enhanced Barrier Precautions (EBP) and maintain proper catheter care for three residents with indwelling urinary catheters. Observations revealed catheter drainage bags were consistently found on the floor, contrary to facility policy and CDC guidelines. Staff, including CNAs and LVNs, were unaware of EBP requirements, and the Director of Nursing and Administrator acknowledged the infection control concerns but were not previously aware of the EBP requirements.
The facility failed to accurately code MDS assessments for two residents, one with a suprapubic catheter and another receiving Plavix, an antiplatelet medication. The MDS for the resident with a catheter did not reflect its presence, while the MDS for the resident on Plavix incorrectly indicated the use of an anticoagulant. These errors were acknowledged by the MDS Coordinator, DON, and Administrator, highlighting a lapse in accurate documentation of residents' medical conditions and treatments.
A facility failed to complete a baseline care plan within 48 hours for a resident with complex medical needs, including heart disease and renal failure. The care plan was marked 'In Progress' and lacked completion in key areas such as dietary status and therapy. Interviews with the DON and an LVN confirmed the oversight, acknowledging the care plan should have been completed within the required timeframe.
A facility failed to update care plans for a resident on anticoagulant medication and two residents with indwelling urinary catheters. Despite being on Eliquis, a resident's care plan lacked monitoring for anticoagulant use. Two other residents with catheters had no care plan updates reflecting their catheter use. The deficiency was due to the failure of admitting nurses and staff to update care plans according to facility policies.
Two residents with indwelling urinary catheters were not properly assessed or documented upon admission and readmission to the facility. Observations confirmed the presence of catheters, but there were no physician's orders or documentation in their care plans or medical records. Staff interviews revealed a lack of communication and documentation regarding catheter care, leading to deficiencies in catheter management.
A facility failed to monitor a resident for side effects of the anticoagulant Eliquis, despite policy requirements. The resident, with a history of pulmonary embolism and heart failure, received Eliquis without documented monitoring for complications like bruising or bleeding. Staff interviews confirmed the lack of monitoring, leading to a deficiency in medication management.
The facility exceeded the acceptable medication error rate, with errors affecting two residents. One resident received the wrong type of multivitamin, while another missed doses of metoprolol and Plavix due to unavailability. The LVNs involved failed to administer medications as prescribed and did not notify the physician of missed doses, as expected by the DON and Administrator.
A resident with hypertension did not receive a scheduled dose of metoprolol due to the medication being unavailable. The LVN contacted the pharmacy but did not inform the physician about the missed dose. The MAR and Progress Notes documented the omission, and interviews with staff highlighted the expectation to notify the physician and monitor the resident's condition.
A facility failed to document the administration of PRN pain medication for a resident, resulting in a deficiency. Despite a policy requiring immediate documentation on the MAR, two LVNs administered hydrocodone-acetaminophen without recording it on the MAR. The resident, admitted with hip pain, had an active order for the medication. Interviews confirmed the importance of timely documentation, which was not followed.
The facility did not meet the required minimum space of 80 square feet per resident in six multiple-resident rooms. Despite this, staff reported no issues in providing care, and residents had no complaints about room sizes. The DON was unaware of the specific requirements, while the Administrator acknowledged the importance of meeting them.
Failure to Supervise Resident After Shower
Penalty
Summary
The facility failed to supervise a resident during and after a shower when the resident was left unsupervised and unattended in a shower chair in her room. The resident had multiple diagnoses including muscle weakness, dementia, and osteoarthritis of the knees, and her assessment showed a BIMS score of 8 out of 15, indicating moderately impaired mental status. Her MDS indicated she required staff supervision or touching assistance with upper body dressing, lower body dressing, showers, and personal hygiene. Her fall risk assessment identified her as at moderate risk for falls due to factors including impaired recall, impaired vision, incontinence, and being confined to bed, and her care plan directed staff to anticipate and meet her needs. According to the CNA, after assisting the resident with a shower and returning her to her room in a shower chair, the CNA left the room to get water while the resident remained in the shower chair. When the CNA returned, the resident was on the floor next to the bed. Nursing progress notes stated the resident was found on the floor in a sitting position next to the shower chair after being left to dress independently following a shower, and she complained of neck and back pain with rectal bleeding noted. The resident was transferred to the hospital, where records showed an L5 compression fracture from the ground-level fall. The DON stated CNAs should transfer residents to bed after showering to ensure they are safe and secure before leaving the room.
RN Coverage Not Provided 8 Hours Daily
Penalty
Summary
The facility failed to provide RN coverage for eight hours a day, seven days a week. During a concurrent interview and record review on 8/12/25 at 9:00 a.m. with the Accounts Payable/Payroll staff and later with the PC, the facility’s licensed staffing schedules for January 2024 through June 2024 were reviewed and showed multiple dates when no RN was scheduled to work eight hours in a day. The dates without the required RN coverage included numerous days in January, February, and March 2024, as well as 4/19/24, 5/16/24, 6/07/24, and 6/13/24. During an interview on 8/14/25 at 12:20 p.m., the DON stated that not having an RN in the facility for eight hours a day would affect the quality of care residents received and that residents needed an RN to assess them if there was a change in condition. The facility’s policy and procedure titled Departmental Supervision, Nursing, revised August 2022, stated that a registered nurse provides at least eight consecutive hours every 24 hours, seven days a week, and that RNs may be scheduled more than eight hours depending on resident acuity needs.
Advance Directive Discussions Not Documented
Penalty
Summary
The facility failed to ensure that residents’ medical records were updated to show documentation that advance directives were discussed with the residents and/or their responsible parties for six of 24 sampled residents. Residents 7, 11, and 16 had significant cognitive impairment documented in their MDS assessments, with diagnoses including cerebrovascular disease, respiratory failure, and dementia. Residents 26, 28, and 37 were documented as cognitively intact and had diagnoses including adult failure to thrive, heart disease, and heart failure. For each of these residents, the POLST form in the record showed no information on the presence of an advance directive. During a concurrent interview and record review, the Social Service Director reviewed the records for Residents 7, 11, 16, 26, 28, and 37 and stated there was no documentation that advance directives were discussed and followed up with the residents and their responsible parties. During interview, the DON stated that advance directives were supposed to be followed up by the SSD and explained that advance directives are important to help ensure the resident’s wishes for medical care are carried out if the resident becomes incapacitated. The facility policy stated that prior to or upon admission, the SSD or designee inquires about written advance directives, offers assistance, and nursing staff documents the offer and the resident’s decision to accept or decline assistance.
Medications Left Unattended on Medication Cart
Penalty
Summary
Medications were left unattended on top of the medication cart during administration for two residents. During an observation and interview, an RN removed Resident 28’s chewable Aspirin 81 mg from the original medication cup, placed it in a medication cup, and then left it unattended on top of the medication cart before walking away through the double doors to the front lobby/facility entrance. The RN stated the medication should have been put back in the medication cart before walking away and acknowledged that leaving it unattended was not safe because someone could pick it up and swallow it. During another observation and interview, an RN left Resident 16’s Ferrous sulfate 325 mg and multivitamin unattended on top of the medication cart and went into Resident 58’s room to assist the podiatrist. The RN identified the medications as belonging to Resident 16 and stated they should have been placed back in the medication cart and not left unattended to prevent other residents from picking them up and swallowing them. Resident 28’s face sheet showed diagnoses of diastolic congestive heart failure, primary hypertension, and atherosclerotic heart disease of the coronary artery. Resident 16’s face sheet showed diagnoses of fracture of femur following insertion of orthopedic implant and osteoporosis. The DON and ADON stated licensed nurses should never leave medications unattended on top of the medication cart, and the facility policy stated no medications are kept on top of the med cart and the cart must remain closed and locked when out of sight.
Medication Administration Errors With Incorrect Alendronate and Incomplete Amlodipine Instructions
Penalty
Summary
Medication administration errors were identified for three residents during observation and record review. The facility failed to keep medication error rates at 5 percent or less when a nurse administered Alendronate to Resident 16 without following the physician’s order, the MAR, or the medication packaging instructions. Resident 16 had diagnoses including osteoporosis and a prior femur fracture with orthopedic implant and joint prosthesis to the left leg. During the observed administration, the nurse gave 30 ml of orange juice instead of a full glass of water and did not follow the instruction to give the medication at least 30 minutes before the first meal. The facility also failed to ensure accurate administration of Amlodipine for Resident 1 and Resident 68 when the medication bubble packs had incomplete heart rate instructions. For both residents, the bubble pack instructions were missing the number 60 for the HR parameter, and the nurse administered the medication without clarifying or reconciling the discrepancy with the physician’s order. Resident 1 had diagnoses including primary hypertension and chronic embolism/thrombosis of the left femoral vein. Resident 68 had diagnoses including essential hypertension, a cardiac pacemaker, and complete atrioventricular block. During interview, the nurse stated the missing HR parameter was added with a black sharpie rather than being clarified or reconciled before administration. Other nursing leadership stated that staff must follow the medication label and MAR instructions, and if labeling is missing or incorrect, the medication should be returned to the pharmacy. The facility policy stated medications are to be administered as prescribed, within required time frames, and the label must be checked three times to verify the right resident, medication, dosage, time, and route.
Unpalatable and Overcooked Meal Service
Penalty
Summary
The facility failed to ensure residents were served palatable, flavorful food and properly cooked vegetables. During observation in the facility conference room, two test trays were presented, one regular texture and one puree texture. In a concurrent observation and interview with the Assistant Dietary Manager and Dietary Manager, both trays were sampled immediately after the last resident tray was delivered. The regular tray contained citrus barbeque chicken and mixed vegetables, and the puree tray contained citrus barbeque chicken and mixed vegetables. Temperatures were taken with the surveyor's calibrated thermometer, showing the pureed citrus barbeque chicken at 147.6 F, the pureed mixed vegetables at 165.4 F, the regular citrus barbeque chicken at 151 F, and the regular mixed vegetables at 141.2 F. The regular mixed vegetables were observed to be overcooked, lacking color, and bland. The pureed citrus barbeque chicken lacked color and was not palatable, and the mixed vegetables were bland. The pureed zucchini felt barely warm in the mouth and tasted bland. The Assistant Dietary Manager and Dietary Manager stated the pureed food was not palatable and the regular mixed vegetables lacked color and looked overcooked. The Assistant Dietary Manager also stated that the vegetables are steamed and do not normally look like that. The facility policy titled Meal Service: Tray Assembly stated residents will receive food at appropriate temperatures and appetizing appearance.
Kitchen Food Storage and Equipment Sanitation Deficiencies
Penalty
Summary
Food was not stored, prepared, and served in a safe and sanitary manner in the kitchen. During observation, multiple expired food items were found, including Parmesan cheese, teriyaki sauce, Greek yogurt, cottage cheese, and whipped cream. The Assistant Dietary Manager stated that food rotation is usually done when deliveries come in on Tuesdays and Thursdays, but was not sure why the expired items were still present. The facility policy required older items to be rotated using FIFO, and the Federal Food Code required refrigerated time/temperature control for safety foods to be consumed, sold, or discarded by the expiration date. Kitchen utensils and equipment were also observed in poor condition. Multiple cup and food container lids were found loose in a drawer and not in original packaging or closed containers. The tray line contained bent, rusted, dented, and food-soiled pans and covers, along with whisks and a masher with faded wood handles and open areas, a bent knife tip, a stained plastic spoon, loaf pans with baked-on food particles, cutting boards with cuts and deep grooves, scratched fry pans, dented pots with baked-on food particles, a pot missing a plastic handle cover, a dented metal bowl, and muffin pans with rusted areas. The ASDM stated that many of these items get a lot of use and would be replaced. Additional observations showed wet items stacked instead of air-dried, including loaf pans, metal mixing bowls, muffin pans, cutting boards, and long pans. The microwave had dark brown spots and stains with a chipped glass turntable. The industrial stove and oven had grease buildup, burnt-on food, dust, rust, and foil with grease and burnt-on food. The conveyor toaster and 2-slice toaster also had crumb buildup, burnt food particles, grease, and peeling black paint. The ASDM stated that some equipment may need to be replaced and that the second oven is used only sometimes.
Laundry Hampers Stored Together in Soiled Linen Room
Penalty
Summary
The facility failed to maintain an effective infection control program when the laundry department did not have a separate space for clean and unclean hampers. During observation in the soiled linen room, a Laundry Worker sanitized a dirty hamper and placed the sanitized hamper together with dirty hampers in the same room. The Laundry Worker stated that after emptying used linens and clothes from the dirty hampers into the washing machine, she sanitized and returned the hampers to the soiled linen room because there was no space to store the clean and sanitized hampers, and that the clean hampers were then brought to the facility hallways to collect residents' used linens and clothes. The Laundry Supervisor confirmed that clean hampers were stored together with dirty hampers in the soiled linen room and stated that mixing clean and dirty hampers created a risk of spread of infection. The DON also stated that storing clean and dirty hampers together in the soiled utility room posed a risk of spread of infection among staff and residents. Facility policy stated that soiled laundry and bedding shall be handled, transported, and processed according to best practices for infection prevention and control.
Resident’s Wallet Not Protected From Loss
Penalty
Summary
The facility failed to ensure Resident 51’s wallet was protected from loss. Resident 51 was admitted with diagnoses including cachexia, hypokalemia, dysphagia, and acute kidney failure, and was his own responsible party. The resident’s inventory list dated 5/3/25 documented that he had 1 wallet among his belongings. During interview, Resident 51 stated his wallet had been missing for about 2 weeks and that he had reported it, but felt no one cared about the issue. He said the wallet contained his money and ID. During a concurrent interview and record review, RN 3 reviewed the inventory list and stated she was not aware of the missing wallet, acknowledged the resident came in with one, and said that if it was missing a form would be completed and the Social Worker notified. The facility policy on investigating incidents of theft and/or misappropriation of resident property stated the facility would exercise reasonable care to protect residents from loss or theft, including safeguarding valuables from easy public access and promptly responding to and investigating complaints of theft or misappropriation of property.
Failure to Hold Required Care Conference
Penalty
Summary
The facility failed to ensure the interdisciplinary team initiated a care conference meeting for one resident for seven months. The resident was admitted with diagnoses that included dementia, and the Minimum Data Set dated 6/23/25 indicated the resident’s short- and long-term memory were impaired and decision-making capacity was severely impaired. The resident’s last care conference was held in December 2024, and the MDS Coordinator stated the care conference should be done quarterly to update the resident’s responsible party on the current plan of care, changes in care, and to allow input into the care plan. During interview, the MDS Coordinator stated that if no care conference was done, the resident had no voice in the plan of care. The DON also stated the resident’s care conference should have been done quarterly and explained that the purpose was to plan the resident’s care, discuss medication changes, changes in condition, and changes in the plan of care. The facility policy stated the interdisciplinary team is responsible for developing resident care plans and that the resident, family, legal representative, guardian, or surrogate are encouraged to participate in development and revisions to the care plan.
Insufficient square footage in multiple shared resident rooms
Penalty
Summary
The facility failed to provide at least 80 square feet per resident in 6 of 45 resident rooms occupied by multiple residents. During an observation with the Maintenance Director, Rooms 5, 23, 26, 28, 29, and 30 were measured and found to have insufficient square footage for the number of beds in each room: Room 5 had two beds and measured 145 sq. ft. for 72.5 sq. ft. per resident; Room 23 had three beds and measured 230 sq. ft. for 76.7 sq. ft. per resident; Room 26 had two beds and measured 220 sq. ft. for 73.3 sq. ft. per resident; Room 28 had three beds and measured 220 sq. ft. for 73.3 sq. ft. per resident; Room 29 had three beds and measured 225.5 sq. ft. for 75.2 sq. ft. per resident; and Room 30 had three beds and measured 220 sq. ft. for 73.3 sq. ft. per resident. The report states that during random observations of care and services, residents and staff did not complain about room size, staff had enough room to do their job, there was sufficient space for care, no heavy equipment was kept in the rooms, each resident had adequate personal space and privacy, and there were no complaints about belongings or negative consequences related to the reduced space.
Resident Elopement Due to Inadequate Supervision and Faulty Exit Alarm
Penalty
Summary
The facility failed to ensure adequate supervision and safety for a resident with impaired mental status, resulting in the resident's elopement. The resident, who had a BIMS score indicating poorly impaired mental status and used a manual wheelchair, was able to leave the facility unsupervised. The resident was later found and brought to a police station by a concerned citizen. The facility's records indicated that the exit alarm on the sliding doors in the resident's room was loosely connected and not functioning at the time of the elopement. Interviews with facility staff revealed that the maintenance staff did not keep records of scheduled checks or maintenance of the exit door alarms, and the alarm string was found disconnected. The charge nurse on duty was aware of the resident's risk for elopement but was informed by another staff member that the resident was missing. The resident's family member had previously expressed concerns about the sliding doors in the resident's room. The facility's policy on safety and supervision emphasized making the environment as free from accident hazards as possible, yet this was not effectively implemented in this case.
Narcotic Documentation and Reconciliation Deficiencies
Penalty
Summary
The facility failed to ensure proper documentation and reconciliation of narcotic medications, as evidenced by the case of a resident who was admitted with a diagnosis of pain in the left hip. The resident had an active order for hydrocodone-acetaminophen to be administered as needed for pain. However, the facility's records showed discrepancies in the documentation of narcotic administration. Specifically, a Licensed Vocational Nurse (LVN) administered the medication but failed to record the time of administration, and another LVN did not document the removal and administration of a dose until prompted by a surveyor. This lack of documentation was acknowledged by the staff involved and highlighted during interviews with the Director of Nursing and the Administrator, who confirmed that staff should follow proper procedures for signing out narcotics. Additionally, the facility did not consistently complete narcotic reconciliation counts as required by their policy. The Controlled Drugs Count Records for a medication room and medication carts showed multiple instances where either no nurse or only one nurse documented the performance of drug counts during shift changes. Interviews with various staff members, including LVNs, the Infection Control Specialist, and the Pharmacist, revealed that the narcotic count sheets were intended to verify the accuracy of narcotic counts and ensure accountability. However, the presence of blank spaces on these sheets indicated that the counts were not consistently completed or verified, leaving the facility unable to prove that narcotics were accounted for. The Director of Nursing and the Administrator both acknowledged the importance of completing and signing narcotic count sheets to track narcotics and prevent unauthorized use. The failure to properly document and reconcile narcotic medications was a significant deficiency, as it compromised the facility's ability to ensure the safe and accurate administration of controlled substances to residents.
Failure to Implement Enhanced Barrier Precautions and Proper Catheter Care
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) and maintain proper catheter care for three residents with indwelling urinary catheters. Observations revealed that catheter drainage bags for Residents #13, #5, and #50 were consistently found resting on the floor, which is against the facility's policy and CDC guidelines. The facility's policy specifies that catheter drainage bags should be kept off the floor to prevent infection, yet this was not adhered to, posing a potential infection control issue. Resident #13 was observed with a catheter drainage bag on the floor multiple times, and there were no signs indicating the need for EBP. The resident's care plan did not address the presence of an indwelling urinary catheter, and staff, including a Licensed Vocational Nurse (LVN), did not take action to correct the situation. Similarly, Resident #5's catheter drainage bag was found on the floor, and staff only wore gloves during care, without implementing EBP. The resident's care plan and orders did not include directives for EBP, and staff were unaware of the requirement. Resident #50 also had a catheter drainage bag on the floor, and staff did not use appropriate PPE during care. Interviews with staff, including CNAs and LVNs, revealed a lack of awareness and education regarding EBP. The Director of Nursing (DON) and the Administrator acknowledged the infection control concerns but were not previously aware of the EBP requirements. This lack of awareness and implementation of EBP contributed to the deficiency in infection prevention and control.
Inaccurate MDS Assessments for Residents with Catheter and Antiplatelet Medication
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for two residents, leading to discrepancies in their medical records. For one resident with a history of urinary retention and a suprapubic catheter, the MDS was inaccurately coded, failing to reflect the presence of an indwelling urinary catheter. This error was acknowledged by the MDS Coordinator, Director of Nursing (DON), and the Administrator, who all confirmed that the MDS should have been coded to indicate the presence of the catheter. The resident's care plan and order summary clearly documented the use of a suprapubic catheter, yet the MDS assessment did not accurately capture this information. In another case, a resident with a history of cerebral infarction was receiving Plavix, an antiplatelet medication. However, the MDS was incorrectly coded to reflect the use of an anticoagulant instead of an antiplatelet medication. The MDS Coordinator admitted to the error, having mistakenly classified Plavix as an anticoagulant. The Administrator and DON both emphasized the importance of following the RAI manual instructions for accurate MDS coding. These inaccuracies in MDS assessments highlight a failure in the facility's processes to ensure accurate documentation of residents' medical conditions and treatments.
Failure to Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to complete a baseline care plan within 48 hours of admission for a resident, as required by their policy. The policy, revised in December 2016, mandates that a baseline plan of care to meet the resident's immediate needs be developed within 48 hours of admission. The resident in question was admitted on May 12, 2024, with a medical history that included atherosclerotic heart disease, end-stage renal disease, dependence on renal dialysis, chronic pain syndrome, and insomnia. However, the baseline care plan for this resident was marked as 'In Progress' and lacked completion in several critical sections, including dietary/nutritional status, therapy, social services, comments and preferences, plan of care, and necessary signatures. Interviews with facility staff, including the Director of Nursing (DON) and a Licensed Vocational Nurse (LVN), confirmed that the baseline care plan was not completed within the required timeframe. The DON acknowledged that the care plan should have been completed within 48 hours of admission, and the LVN admitted that the staff had missed following up on the completion of the care plan. The facility's Administrator also stated that baseline care plans should be initiated at the time of admission and completed within the specified 48-hour period.
Failure to Update Care Plans for Anticoagulant Use and Urinary Catheters
Penalty
Summary
The facility failed to develop a care plan addressing the use of anticoagulant medications for a resident who was admitted with a history of pulmonary embolism and heart failure. Despite the resident being on Eliquis, an anticoagulant, since admission, the care plan did not include any focus area addressing the use of this medication. Interviews with the LVN and the DON confirmed that the care plan should have included monitoring for signs and symptoms of bruising and bleeding due to the anticoagulant use, but it was not updated accordingly. Additionally, the facility did not develop care plans for two residents with indwelling urinary catheters. One resident was readmitted from the hospital with renal failure and hospice services, and although observed with a catheter, the care plan did not reflect this. The DON confirmed that the catheter should have been included in the care plan upon readmission. Similarly, another resident with severe cognitive impairment was observed multiple times with an indwelling urinary catheter, yet the care plan lacked any mention of it. The MDS Coordinator and the DON acknowledged that the admitting nurse should have updated the care plan to include the catheter. The deficiency in care planning was attributed to the failure of the admitting nurses and other responsible staff to update the care plans to reflect the residents' current medical needs, such as anticoagulant use and the presence of urinary catheters. The facility's policies on anticoagulation and catheter care were not adhered to, resulting in incomplete care plans for the affected residents.
Deficiency in Catheter Care and Documentation
Penalty
Summary
The facility failed to ensure proper assessment and documentation for residents with indwelling urinary catheters, affecting two residents. Resident #50 was admitted and readmitted to the facility without any documentation or physician's orders for an indwelling urinary catheter, despite observations confirming its presence. The resident's care plan and medical records did not reflect the catheter, and staff interviews revealed a lack of communication and documentation regarding the catheter's presence and care requirements. Similarly, Resident #13 was readmitted to the facility with an indwelling urinary catheter, but there were no physician's orders or documentation in the resident's care plan or medical records. Observations confirmed the presence of the catheter, and staff interviews highlighted the absence of necessary orders and documentation to guide catheter care. The facility's policy required ongoing assessment and documentation of catheter use, but this was not followed for the affected residents. Interviews with staff, including CNAs, LVNs, the DON, and the Administrator, revealed a breakdown in communication and documentation processes, leading to the deficiency in catheter care and management.
Failure to Monitor Anticoagulant Side Effects
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications by not monitoring for potential side effects related to the use of a prescribed anticoagulant medication. The facility's policy on anticoagulation therapy required staff and physicians to monitor for complications such as excessive bruising, hematuria, hemoptysis, or other evidence of bleeding. However, the care plan for a resident admitted with a history of pulmonary embolism and heart failure did not include a focus area for monitoring the use of the anticoagulant Eliquis. The resident's medication administration records and progress notes lacked documentation of monitoring for side effects from Eliquis, despite the resident receiving the medication twice daily. Interviews with facility staff, including an LVN and the Director of Nursing, confirmed that monitoring should have been documented on the resident's MAR. The facility's failure to adhere to its anticoagulation monitoring policy resulted in a deficiency related to the resident's medication management.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 9.38% during a survey. This deficiency affected two residents during medication administration. One resident was given a multivitamin without added minerals, contrary to the prescribed order for a multivitamin with minerals. The Licensed Vocational Nurse (LVN) responsible for this error acknowledged the mistake during an interview, stating she did not realize the discrepancy at the time of administration. Another resident did not receive their prescribed doses of metoprolol tartrate and Plavix because the medications were unavailable. The LVN involved contacted the pharmacy but did not notify the resident's physician about the missed doses, as required. The Director of Nursing (DON) and the facility's Administrator both confirmed that the nurses were expected to administer medications as ordered and to notify physicians of any missed doses. The DON highlighted the potential risk of a hypertensive crisis due to the missed dose of metoprolol.
Failure to Administer Metoprolol Results in Medication Error
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically by not administering metoprolol to a resident with a history of hypertension. The resident was admitted to the facility with an active order for metoprolol tartrate, 100 mg, to be taken twice daily. During a medication administration observation, it was noted that the medication was not available, and the Licensed Vocational Nurse (LVN) did not administer the 9:00 AM dose. The LVN contacted the pharmacy, which required a new order, but did not notify the resident's physician about the missed dose. The Medication Administration Record (MAR) indicated the missed dose, and the Progress Notes confirmed that the pharmacy had not delivered the medication by the afternoon. Interviews with the LVN, the Director of Nursing (DON), and the physician revealed that the nurse should have monitored the resident's blood pressure and heart rate and informed the physician about the missed dose. The DON and the Administrator both stated that the nurse was expected to notify the physician and document the missed medication administration.
Failure to Document PRN Pain Medication Administration
Penalty
Summary
The facility failed to ensure proper documentation of the administration of as-needed (PRN) pain medication for a resident, leading to a deficiency in maintaining accurate medical records. The facility's policy required that the individual administering medication should initial the Medication Administration Record (MAR) immediately after giving each medication. However, for a resident admitted with a diagnosis of pain in the left hip, there was a lack of documentation on the MAR for doses of hydrocodone-acetaminophen administered on two separate occasions. The resident's care plan included instructions to administer analgesics as per physician's orders, and the resident had an active order for hydrocodone-acetaminophen to be given every four hours as needed for pain. The deficiency was identified when the Controlled Drug Record showed that two Licensed Vocational Nurses (LVNs) had signed for administering the medication, but the corresponding entries were missing from the MAR. LVN #6 admitted to failing to sign the MAR after administering the medication and acknowledged the importance of documenting the time of administration. Similarly, LVN #4 confirmed administering the medication but did not document it on the electronic MAR at the time of administration. Interviews with the Director of Nursing and the Administrator confirmed that staff were educated to document immediately after medication administration, highlighting a lapse in following established procedures.
Deficiency in Resident Room Size Requirements
Penalty
Summary
The facility failed to ensure that multiple-resident bedrooms met the required minimum space of 80 square feet per resident. This deficiency was identified in six rooms out of 45, where the space per resident ranged from 72.5 to 76.7 square feet. The facility's policy mandates that double rooms should provide at least 80 square feet per resident, and single rooms should provide at least 100 square feet. Despite the deficiency, there were no negative consequences or safety concerns noted, and residents were able to move freely around their rooms without obstruction from furniture or equipment. Interviews with staff, including CNAs and an LVN, revealed that the room sizes did not hinder their ability to provide care. The Director of Nursing was unaware of the specific room size requirements but expected rooms to be large enough for care provision and resident movement. The Administrator acknowledged the importance of meeting the 80 square feet per resident requirement to ensure adequate space for residents and staff. Despite the deficiency, no residents expressed concerns about their room sizes.
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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 Hayward
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hayward Hills Health Care Center | 0.1 mi | ★★★★★ | 0 | 0 |
| Hayward Gardens Post Acute | 0.2 mi | ★★★★★ | 13 | 0 |
| Canyon Creek Post-acute | 0.3 mi | ★★★★★ | 2 | 0 |
| Baywood Court Health Center | 0.6 mi | ★★★★★ | 0 | 0 |
| Vista Post Acute | 1.1 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.