Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sequoia Vista during CMS and state inspections, most recent first.
Lost Resident Clothing and Incomplete Inventory Tracking Two residents had clothing go missing, and their personal belongings were not accurately tracked in the IPE. One resident reported missing clothing on arrival, with additional unlabeled items found in the room and missing items not documented. Another resident reported a missing bag of clothing, and a TLF listed several missing shirts and tank tops. The facility policy required resident possessions to be respected, added to the inventory, and protected from loss or theft.
Failure to Complete Annual Abuse Prevention Training. The facility failed to ensure annual abuse prevention training was completed for a CNA, a Dietary Aide, and the HLS. CNA 2 stated she had not received annual abuse training, and record review confirmed the CNA, Dietary Aide, and HLS did not have current annual abuse training documented. Facility records and the abuse, neglect, and exploitation policy indicated staff are to receive abuse education at orientation and annually thereafter.
Staff were not trained on a new IV pump before it was used to administer IV meds. During an observation, RN 2 was preparing an IV antibiotic for a resident when the resident asked whether RN 2 knew how to use the pump, and the DON later stated she also was unsure how to use the new pump and had needed help. Although the facility had started using a new pharmacy and an IV pump in-service was held, only three RNs signed in and RN 2 was not among them.
The facility failed to complete required competency evaluations for multiple CNAs and LVNs upon hire and annually. Record review and staff interviews showed some employees had orientation competency evaluations, but others had none at hire and several had no annual competency evaluations after hire. The DON and DSD confirmed the missing evaluations, and the facility policy stated initial competency is evaluated during orientation and annual competency is based on facility assessment and job performance.
Improper Storage of OTC Medications in Dirty Utility Area: Surveyors observed two cabinets of OTC meds stored in the dirty utility area alongside uncovered vital signs machines. MCSP stated the meds were new and not expired, but said there was nowhere else to store them. The facility P&P required meds to be stored in the pharmacy and/or med rooms with proper sanitation and security.
Pureed Diet Prepared Without Approved Recipe: A dietary staff member prepared pureed lunch items for residents on a pureed diet without following the facility’s approved recipe. He stated he had never seen a recipe book or binder for pureed diets and had not used a recipe, while the CDM confirmed the pureed meat recipe should have been followed and the facility P&P required approved standardized recipes.
Failure to label and date open food items was identified in Freezer 1 during kitchen observation. Open boxes of zucchini, french toast, and sausage were found undated and unlabeled, and the CDM stated stored food items must have received-by and open dates. Facility policy also required all food in storage, refrigeration, and freezers to be labeled and dated.
A facility failed to follow its BAA policy for three residents whose primary language was Spanish. Admission staff presented English-language arbitration forms, and there was no documentation that the agreements were explained in Spanish or that the residents acknowledged understanding them. Two residents with intact cognition and one resident with moderately impaired cognition stated they signed the forms without understanding what they were signing.
Infection control practices were not followed in multiple areas of the facility. Staff stored chemicals on the laundry room floor, left an uncovered trash bin between washers, and placed dirty equipment in clean linen closets. Staff also entered a Contact Precautions room without PPE, a TN failed to clean the bedside table before setting up wound care supplies, and hand hygiene was not performed during a wound dressing change. Infection surveillance records were incomplete for multiple residents, utility rooms were not separated into clean and dirty areas, and residents on different isolation precautions were housed together.
A resident with cognitive impairment had a physician-ordered urology consult, but the RP was not informed of the referral. The RP stated she was unaware of the specialist referral, and record review found no documentation of notification. The SSD said she did not notify the RP, and the DON stated this notification was the responsibility of the licensed nurses.
The facility failed to ensure quarterly care conferences were held for a resident. During record review with the ADON and SSD, the resident’s last two documented care conferences were identified, and the SSD confirmed that quarterly conferences were required but were not occurring for this resident. A care conference policy was requested but not provided.
Medication Not Available for Resident Anxiety Treatment: A resident with an order for BusPIRone HCl for anxiety-related symptoms did not have the medication available in the med cart when an LVN prepared morning meds. The LVN called the pharmacy to reorder it, and the DON stated refills are expected to be requested when one to two days of medication remain, consistent with the facility's medication reordering policy.
Therapeutic diet not served as ordered. A resident with an order for a no added salt, soft and bite sized diet was served a quesadilla cut into large triangles instead of a bite-sized soft item. The CDM stated the portions were too large to be considered bite sized and that the resident should not have been served a quesadilla as part of the soft diet.
A resident with dysuria was started on Bactrim DS even though the urine culture was not completed because of an improper specimen storage/transport issue. The IPC log and MAR showed the antibiotic was given for 7 days, and the IP stated there was no documentation that the urine culture was re-done. The facility policy required monitoring antibiotic response and lab results to determine whether the antibiotic remained indicated or needed adjustment.
A resident refused Pneumococcal, RSV, and TDAP immunizations, but the clinical record did not contain a care plan for the refusal. During record review, the IP stated she could not find a care plan, and the facility policy required documentation of the reason for refusal or medical contraindication in the clinical record.
Nonfunctioning Resident Call Light: A resident who needed staff help with ADLs, including transfers and toileting, reported that her call light had not worked for months and that she had to go into the hallway to get help. During observation, the resident’s bed call light did not light up or make noise, and both a CNA and the AD stated the call light was not working.
The facility allowed a respiratory therapist to provide respiratory care without verifying state licensure, despite a job description and a license verification policy requiring a valid, unrestricted state license. Human Resources hired the therapist and did not complete or document required license verification with the state regulatory agency, later confirming the therapist never held a state license during employment. This failure resulted in an unlicensed individual delivering respiratory services to residents and was cited as a deficiency.
A resident with orders for buspirone, citalopram, and valproic acid repeatedly refused these psychotropic medications over multiple days, as documented on the MAR. Review of progress notes showed no documentation that the physician was notified of these refusals, despite the IDON acknowledging that notification should occur after multiple refusals. The facility’s policy on residents’ rights and treatment requires documenting the refusal, the reason, education provided, and physician notification, but the record lacked evidence that the physician had been informed.
A resident with dementia, anxiety, and recent aggressive behaviors had a new order for Risperdal Consta 37.5 mg IM every 14 days. On the scheduled administration date, the MAR showed the dose was not given, and a progress note documented that the medication was pending pharmacy delivery. The IDON confirmed that the physician was not notified that the ordered antipsychotic dose was unavailable, despite facility policy requiring physician notification and treatment of missed doses as medication errors.
A resident with rheumatoid arthritis was discharged from a hospital on methotrexate 20 mg PO weekly, but when orders were entered into the facility’s system, the drug was incorrectly ordered and administered as 20 mg PO daily. The electronic order entry generated a medication alert stating the dose and frequency exceeded usual weekly dosing, yet staff did not clarify or correct the order, and the consultant pharmacist’s drug regimen reviews noted no recommendations. Over several weeks, the MAR shows daily methotrexate administration, after which the resident developed sore throat, dysphagia, epistaxis, oral and facial swelling, and bloody stool, leading to transfer to the hospital. Hospital records confirmed the resident had been receiving methotrexate daily, diagnosed methotrexate toxicity with pancytopenia, multi-organ dysfunction, sepsis, and acute renal failure, and the resident ultimately died; the death certificate cited acute renal failure and methotrexate toxicity, stating the resident ingested a toxic amount of methotrexate. Facility policy required adherence to the six rights of medication administration, use of drug references, special handling of immunosuppressants, and correction of discrepancies, which were not followed in this case.
A resident with Type 1 DM and hyperglycemia had physician orders for twice-daily Insulin Degludec with instructions to notify the MD for BS readings greater than 250. Review of the MAR showed multiple BS values above 250 over the month, yet there was no documentation that the MD was notified of these elevated results. The care plan directed staff to administer insulin as ordered and report signs and symptoms of hyperglycemia, and facility policy required reporting critical test results to the physician, but the DON confirmed that documentation of MD notification for these high BS readings was not available.
The facility did not complete required annual performance evaluations for two CNAs in accordance with its policy. Both CNAs had their last evaluations documented more than a year earlier, and the HR manager acknowledged that new evaluations should have been completed around their employment anniversary dates. The Administrator confirmed that evaluations are expected yearly, and the written policy states that supervisors must conduct annual performance discussions at or around each employee’s anniversary date, but this was not done, resulting in overdue evaluations.
A resident with metabolic encephalopathy, mobility impairment, and cognitive communication deficit, but cognitively intact per BIMS, reported that an unknown CNA was rough and hurt her back while assisting her on and off the toilet during a p.m. shift when her usual CNA was at lunch. The resident and a family member relayed this allegation of physical abuse to a CNA, who immediately informed an LVN. The LVN admitted she did not report the allegation to the administrator/abuse coordinator or DON as required, stating she was overwhelmed and forgot. The SSD and administrator learned of the allegation only the next day from the family, despite facility policy requiring that all abuse allegations be reported to the administrator and appropriate agencies immediately, and no later than two hours after the allegation is made.
A resident with a history of elopement and moderate cognitive impairment was not monitored or documented every hour as required by her care plan. Staff failed to consistently check her whereabouts, leading to her unsupervised exit from the facility. She was found the next morning by police, suffering from hypothermia and other medical complications, and required hospitalization.
A resident's RP filed a grievance about the resident not receiving a personal bag and sack lunch for dialysis transport and about a bandage on the dialysis port site not being removed after return from dialysis. The DSD said the DON was informed and would follow up, and the grievance log listed the DON as responsible for investigation, but the DON later stated no follow-up or investigation was completed.
A resident involved in a peer altercation sustained visible facial injuries, but the RP and physician were not properly notified as required. Documentation indicated notification, but interviews and record review showed the RP was unaware until a visit. The facility also failed to assess, treat, or monitor the injuries according to policy, and staff were unclear about notification responsibilities.
A resident, assessed as cognitively intact, reported feeling intimidated and bullied by a social worker during a conversation in their room. An LVN present described the social worker's responses as snarky, which did not align with the facility's policy requiring respectful communication with residents.
A resident reported $600 missing, and although staff initiated an internal investigation and notified the resident's family, the facility did not report the alleged misappropriation to the Department of Public Health, Ombudsman, Adult Protective Services, or Law Enforcement within 24 hours as required by policy. The resident was cognitively intact, and staff interviews confirmed the delay in external reporting.
A resident's Inventory of Personal Effects (IPE) was not signed by the resident or their representative at admission, contrary to facility policy requiring all personal items to be inventoried and acknowledged. The Social Service Director confirmed the omission during a review.
A resident with major depressive disorder and social anxiety, who prefers to stay in her room, was forced to leave her room and remain in the hallway in her bed for about an hour during a scheduled deep cleaning, despite her refusal and documented preferences. Multiple staff members confirmed the resident's right to remain in her room was not honored, resulting in significant distress and a violation of her rights.
A resident was not given advance written notice before a new roommate, who exhibited frequent outbursts and confusion, was moved into his room. The facility did not monitor for compatibility as required, resulting in ongoing distress, sleep disruption, and a resident-to-resident altercation. Staff confirmed the lack of documentation and that the two residents were not compatible.
A resident's responsible party filed a grievance about the resident being found in a soiled gown, but did not receive a written decision as required by facility policy. The administrator confirmed the grievance was resolved but could not provide documentation that a written response was given, resulting in a violation of the resident's rights.
A resident with moderate cognitive impairment and a history of exit-seeking behaviors was able to leave the facility unsupervised after staff failed to consistently report and intervene on her attempts to exit. The resident was later found by police outside the facility. Staff interviews and record reviews confirmed that the resident's behaviors were known but not always communicated or addressed according to facility policy.
A resident experienced repeated episodes of low blood pressure after dialysis, with multiple readings below normal limits. Despite the resident and family reporting these concerns and facility policy requiring physician notification and documentation for significant changes, staff did not document interventions or notify the physician. This failure to address and record the resident's change in condition did not meet professional standards of quality.
The facility failed to provide routine nail care for two residents, resulting in untrimmed nails and debris accumulation. Observations and interviews revealed that nail care, scheduled for Sundays, was not performed. One resident, a diabetic, did not receive the required care from a licensed nurse as per facility policy.
The facility did not ensure an RN was on duty for eight hours daily, seven days a week, as required by policy. On specific dates in November, no RN was present for the required duration, confirmed by the HR manager and staff schedules.
The facility did not complete Performance Evaluations for three CNAs, as identified during a review with HR. CNAs hired in 2021, 2022, and 2023 had no evaluations in their files, contrary to the facility's policy requiring HR to notify managers of upcoming evaluations. This oversight could impact staff awareness of areas needing improvement.
A facility failed to ensure proper communication between the Dietary Manager and Registered Dietitian regarding a malfunctioning refrigerator used to store TCS foods. The refrigerator was not maintaining the required temperature, leading to improper storage of foods like pudding cups and milk. The issue was identified but not communicated effectively, resulting in continued use of the faulty refrigerator, which posed a risk of bacterial growth.
The facility failed to maintain sanitary kitchen conditions, use pasteurized eggs, and ensure proper food storage temperatures. Observations revealed unsanitary utensils, non-pasteurized eggs served to residents, uncovered food delivery, and a malfunctioning refrigerator with temperatures above safe levels. Staff acknowledged these issues, which were contrary to the facility's policies.
The facility failed to conduct timely smoking assessments for two residents, resulting in a lack of safety evaluation for smoking. A resident admitted on an unspecified date and another admitted on May 1, 2022, did not receive required quarterly assessments after September 2023. The facility's policy mandated smoking assessments during admission and quarterly MDS assessments to determine supervision needs. This oversight posed a potential risk of burns while smoking.
A medication error rate of 11.63% was observed when an LVN administered medications orally instead of via G-tube as ordered for a resident. The medications, including aspirin, docusate sodium, metformin, Keppra, and Januvia, were crushed and mixed with pudding before being given. The LVN acknowledged the error and the facility's policy requires adherence to the prescribed route of administration.
The facility failed to implement Enhanced Barrier Precautions for residents with indwelling devices, as required by their policy. Observations showed a lack of signage and PPE carts, and staff interviews revealed a lack of awareness about the necessity of these precautions. Despite policy requirements, the facility did not ensure precautions were in place for residents with devices like Foley and dialysis catheters.
A facility failed to ensure accurate informed consent for a psychotropic medication for a resident with severe cognitive impairment. The resident, with a BIMS score of 2, signed their own consent for Zoloft, contrary to the facility's policy requiring a higher cognitive score for self-consent. The DON acknowledged the error, as the policy mandates assessing decision-making capacity.
A resident with schizophrenia and dementia was observed over several days with greasy hair, a strong smell of urine, and wearing the same dirty clothes, with no personal clothing available in her closet. Staff interviews revealed that the resident was often left to perform her own personal care, and her clothing was accidentally discarded. The facility failed to adhere to its policies on maintaining resident dignity and personal belongings.
A resident with lower extremity impairments was unable to participate in group activities due to the unavailability of a Geri-chair, which is necessary for their mobility. Despite the resident's interest in activities, the facility did not provide the necessary equipment consistently, resulting in no participation in group activities for two months. The facility had limited Geri-chairs and no schedule for their use among dependent residents.
A facility failed to notify a resident's family when the resident experienced a change in condition and was transferred to a hospital. The resident was unresponsive on two occasions and taken to the hospital by EMTs. Although the resident was their own Responsible Party (RP), the Director of Nursing (DON) acknowledged that the family should have been informed, as per the facility's policy on Notification of Changes.
The facility failed to provide an ABN to a resident who self-discharged from Medicare Part A and left another resident's ABN incomplete by not checking required option boxes. The Admissions Coordinator acknowledged these oversights, which could lead to the facility being held liable for care costs.
The facility failed to conduct PASRR Level II evaluations for two residents who tested positive for Serious Mental Illness (SMI) in their Level I screenings. Despite the facility's policy requiring a Level II evaluation prior to admission and within 40 days if the resident stays longer than 30 days, these evaluations were not performed, as confirmed by the DON.
A resident was admitted without a diet order, leading to potential unmet nutritional needs. The diet order was documented four days later, indicating a controlled carbohydrate diet. Interviews with the DON and ADON confirmed the absence of a physician-ordered diet upon admission, contrary to the facility's policies requiring immediate care orders, including dietary needs.
A resident experienced unmet communication needs due to the facility's failure to provide necessary hearing services and adaptive equipment. Despite the resident's expressed difficulty in hearing and desire for hearing aids, the Social Service Designee was unaware of any audiology services being used, and the resident had not received a hearing test. This was contrary to the facility's policy requiring access to hearing services.
Lost Resident Clothing and Incomplete Personal Belongings Documentation
Penalty
Summary
The facility failed to follow its policy and procedure for Resident Personal Belongings for two residents when their personal items were lost and not properly documented. One resident stated that clothing went missing when he arrived at the facility and that the shirt he was wearing was not his, but he wore it because it fit. His MDS dated 4/23/26 showed a BIMS score of 14, indicating normal thinking and memory. During a later room review, his inventory of personal effects listed 20 belongings with no missing items documented, but 31 belongings were found in his closet. The LVN stated the resident had five missing belongings that were not documented as missing and four belongings with no name that were not listed on the inventory. The LVN also stated clothing should have been labeled with the resident's name and that the CNA or assigned staff was responsible for updating the inventory and labeling clothing. Another resident stated that a whole bag of clothing was missing and was never found. His MDS also showed a BIMS score of 14. His inventory of personal effects, dated 9/18/25, listed four clothing items with no missing belongings documented. A Theft and Loss Form dated 4/6/26 documented missing items as one red t-shirt with pocket, one navy shirt with pocket, one grey tank top, and one grey shirt with collar. The facility's policy stated that all resident possessions would be treated with respect, additional possessions brought in during the stay would be added to the inventory, and the facility would exercise reasonable care to protect resident property from loss or theft.
Failure to Complete Annual Abuse Prevention Training
Penalty
Summary
Develop and implement policies and procedures to prevent abuse, neglect, and theft. Based on interview and record review, the facility failed to ensure annual abuse prevention training was completed for three of nine sampled employees: CNA 2, a Dietary Aide, and the Housekeeping/Laundry Supervisor. During interview, CNA 2 stated she had not been provided annual abuse training. Review of CNA 2’s employee personnel file with the DSD confirmed annual abuse training had not been completed, and the DSD stated abuse training should be completed upon hire and annually. Review of the Dietary Aide’s personnel file with the HR/Payroll Manager showed the last abuse training was completed on 4/19/24, and the HR/Payroll Manager stated the Dietary Aide did not have annual abuse training completed. Review of the Housekeeping/Laundry Supervisor’s personnel file with the HR/Payroll Manager showed the last abuse training was completed on 12/29/23, and the HR/Payroll Manager stated the Housekeeping/Laundry Supervisor did not have annual abuse training completed. The facility policy titled Abuse, Neglect and Exploitation stated new employees are educated during initial orientation and existing staff receive annual education through planned in-services and as needed.
Staff Not In-Serviced on New IV Pump Use Before Administration
Penalty
Summary
The facility failed to ensure that two of nine RNs, including RN 2 and the DON, received education on the use of a new IV pump before the pumps were used to administer medications. During an observation in Resident 94's room, RN 2 was preparing to give an IV antibiotic when Resident 94 asked whether RN 2 knew how to use the pump and stated that another nurse had not known how to use it the other day. The DON later stated she was not sure how to use the new pump and had needed help from another nurse when she was going to administer IV antibiotics to Resident 94. The DON stated the facility had recently contracted with a new pharmacy that used a different model of IV pump than the prior pharmacy, and that the pharmacy had not in-serviced the RNs on the new pumps at the time they were being used. Although the facility began using the new pharmacy on 5/1/26 and the pharmacy provided an IV pump in-service on 5/12/26, the sign-in sheet showed only three RNs attended, and RN 2 was not listed. The manufacturer’s service manual stated parameter programming requires trained health care professional confirmation of limits and drug therapy to physician directive, and the facility’s training policy required training to be completed before staff independently provide services to residents.
Missing CNA and LVN Competency Evaluations
Penalty
Summary
The facility failed to ensure competency evaluations were completed upon hire and annually for six of seven sampled employees: CNA 2, CNA 3, CNA 1, LVN 1, LVN 2, and LVN 3. During interviews and record review, CNA 2 stated she had worked at the facility since 2024 and had an orientation competency evaluation upon hire, but no competency evaluation within the last year. The DSD reviewed CNA 2's EPF and confirmed an orientation competency evaluation was completed on 11/12/24, but no annual competency evaluation had been completed since then. The DSD also confirmed CNA 3 had an orientation competency evaluation completed on 11/1/24, but no annual competency evaluation since that date. Record review showed CNA 1 had a hire date of 1/27/25 and no competency evaluations completed upon hire or annually, with the orientation competency section left blank. LVN 1 had a hire date of 1/30/23 and no annual competency evaluations completed since hire. LVN 2 had a hire date of 10/20/25 and no orientation competency evaluation completed upon hire, and the DON stated this meant she did not know LVN 2's skill set to provide care to residents. LVN 3 had a hire date of 5/11/26 and no competency evaluations completed upon hire, with the DSD stating the orientation competency was not completed and should have been completed before the orientation process was finished. The facility policy stated initial competency is evaluated during orientation and subsequent or annual competency is evaluated at a frequency determined by the facility assessment, training evaluation, and/or job performance evaluations.
Improper Storage of OTC Medications in Dirty Utility Area
Penalty
Summary
The facility failed to store over-the-counter medications in a clean and sanitary area. During a concurrent observation and interview with Maintenance and Central Supply Personnel in the dirty utility area, surveyors observed four vital signs machines without coverings and two cabinets filled with over-the-counter medications stored in that same dirty area, which was identified by a sign as the "Dirty Side." The personnel stated the medications were new and not expired, and also stated they had nowhere else to store the over-the-counter medications. Review of the facility policy titled "Medication Storage" indicated that medications housed on the premises are to be stored in the pharmacy and/or medication rooms according to manufacturer recommendations and in a manner sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security.
Pureed Diet Prepared Without Following Approved Recipe
Penalty
Summary
The facility failed to ensure a recipe was followed when preparing a pureed diet for nine residents. During a concurrent observation and interview in the kitchen, a dietary staff member prepared lunch items for residents on pureed diets, including spinach and herb and spice roast beef with gravy, and stated he did not follow a pureed recipe. He also stated he had never seen a recipe book or binder for pureed diets and had not followed a recipe when preparing the food. During a concurrent interview and record review, the Certified Dietary Manager reviewed the facility’s 2025 recipe for pureed meats, which directed staff to complete the regular recipe, measure the total number of portions needed, puree the food to a paste consistency before adding liquid, and gradually add warm liquid until the desired consistency was achieved. The recipe also stated the finished item should be smooth, free of lumps, hold its shape, and not be too firm, sticky, or weep. The CDM stated the dietary staff member did not follow a pureed recipe and should have. The facility policy titled Food Preparation stated food shall be prepared by methods that conserve nutritive value, flavor, and appearance and that approved recipes standardized to meet the resident census will be used.
Failure to Label and Date Frozen Food Items
Penalty
Summary
The facility failed to label and date three open boxes of food items in Freezer 1 in the kitchen. During a concurrent observation and interview on 6/1/26 at 9:32 a.m., the Certified Dietary Manager observed open, undated, and unlabeled boxes of zucchini, french toast, and sausage in the freezer. The CDM stated that all stored food items need to be labeled with a received-by date and an open date. Review of the facility policy titled, "Labeling and dating of Foods," dated 2023, indicated that all food items in the storeroom, refrigerator, and freezer need to be labeled and dated, and that newly opened food items must be closed and labeled with an open date and used-by date; produce is to be dated with the received date.
Binding Arbitration Agreements Not Explained in Residents’ Primary Language
Penalty
Summary
The facility failed to follow its Binding Arbitration Agreement policy for three sampled residents when admission staff did not provide documentation and explanation of the agreement in the residents’ primary language. Resident 32, Resident 41, and Resident 80 each had a BAA written in English, and the admission coordinator stated there was no documentation showing the agreement was explained in Spanish for any of them. Each resident stated Spanish was their primary language, and each reported signing the English form without understanding it or without recall of the explanation. Resident 32’s admission record identified Spanish as the primary language, and the MDS showed a BIMS score of 8, indicating moderately impaired cognition. Resident 41’s admission record also identified Spanish as the primary language, and the MDS showed a BIMS score of 14, indicating intact cognition. Resident 80’s admission record identified Spanish as the primary language, and the MDS showed a BIMS score of 14. The facility policy stated the arbitration agreement must be explained in a form and manner the resident understands, including in a language the resident understands, and that the resident or representative must acknowledge understanding.
Infection control practices not followed during resident care and environmental storage
Penalty
Summary
The facility failed to implement infection prevention and control practices in multiple areas of the building and during resident care. In the laundry room, two large plastic containers holding colored liquid were stored on the floor, and an uncovered trash bin was positioned between two washing machines. In two clean linen closets, dirty equipment was stored with and touching clean linen, including a folded chair leaning on clean linens in one closet and wheelchair footrests stored in another. The facility’s environmental services and clean linen policies stated that equipment should be properly stored and that clean linen must be handled and stored in a safe and sanitary manner to prevent contamination. The facility also failed to follow transmission-based precautions and hand hygiene requirements during resident care. Two staff members entered a room posted for Contact Precautions without wearing PPE, even though the posted instructions required hand hygiene, gloves, and gowns on room entry and removal before exit. In another resident’s room, the treatment nurse placed wound dressing supplies on the resident’s bedside table without cleaning or sanitizing the surface first, and during the dressing change did not perform hand hygiene after removing gloves and before putting on clean gloves. The nurse stated she did not perform hand hygiene and acknowledged she should have sanitized the bedside table. The facility’s wound care, hand hygiene, and transmission-based precautions policies required hand hygiene and PPE use as part of these procedures. The infection surveillance process was also incomplete for all 15 sampled residents reviewed in the infection surveillance report. The report listed multiple infections, including sepsis, bacteremia, osteomyelitis, periodontitis, otitis media, skin infections, UTIs, pneumonia, cystitis, and other infections, but did not document signs and symptoms for those cases. The former infection preventionist stated she should have documented the signs and symptoms because that information was part of the surveillance report. In addition, both utility rooms were not properly separated into clean and dirty areas, with one room divided only by red tape and clean equipment present on the dirty side, and the other room containing clean and dirty equipment together without separation. The report also described two occupied isolation rooms with residents on different precautions together in the same room, including one resident on neutropenic precautions sharing a room with another resident who was not wearing the required mask, gown, or gloves, and another room where one resident on Contact Precautions was sharing space with a resident on Enhanced Barrier Precautions.
Failure to Notify Responsible Party of Urology Referral
Penalty
Summary
The facility failed to notify the responsible party for Resident 5 when a referral to a urologist was made. During an interview, the responsible party stated she was not informed of the referral. Resident 5’s physician order dated 4/1/26 directed a urology consult ASAP per the NP. Resident 5’s MDS dated 4/8/26 showed a BIMS score of 4, indicating cognitive impairment. During record review and interviews with the SSD and DON, no documentation could be found showing that the responsible party had been notified of the urology referral. The SSD stated she did not notify the responsible party, and the DON stated the notification was the responsibility of the licensed nurses. Facility policy required the resident and/or resident representative to be notified in advance of care to be furnished and changes to the plan of care, including new treatment, and required notification of the resident’s family member or legal representative when there is a change requiring such notification.
Missed Quarterly Care Conferences
Penalty
Summary
The facility failed to ensure care conferences were conducted at least quarterly for one sampled resident, Resident 6. During a concurrent interview and record review on 6/3/26 at 11:24 a.m. with the ADON and SSD, Resident 6’s documented care conferences were reviewed and showed the last two conferences were held on 3/8/24 and 10/22/25. The ADON stated these were the only documented care conferences found, and the SSD stated care conferences should be conducted quarterly and that Resident 6’s were not. A care conference policy was requested but not provided.
Medication Not Available for Resident Anxiety Treatment
Penalty
Summary
The facility failed to ensure medication was available to administer for one of four sampled residents, Resident 8. Resident 8 had a physician order dated 5/13/26 for BusPIRone HCl 5 mg tablets, with instructions to give 2 tablets by mouth two times a day for inability to relax related to adjustment disorder with mixed anxiety and depressed mood. During a concurrent observation and interview on 6/3/26 at 9:42 a.m., an LVN prepared to give the resident morning medications but stated she was unable to find Resident 8's BusPIRone HCl in the medication cart. During the same observation and interview at 9:44 a.m., the LVN called the facility pharmacy to reorder the medication and was told it would be delivered at noon that day. The DON stated medication refills can be requested through the electronic medical record or by faxing a paper order form to the pharmacy, and that nurses are expected to reorder medication when there is still one to two days' worth left rather than waiting until the medication is depleted. The facility policy on Medication Reordering stated that medications are to be obtained in a timely manner to meet resident needs and that when a nurse observes six or fewer doses left of one kind, that nurse will reorder the medication, time permitting.
Therapeutic Diet Not Served as Ordered
Penalty
Summary
The facility failed to ensure that one sampled resident received the diet ordered by the physician. Resident 20 had an order for a no added salt, soft and bite sized diet, and the care plan directed staff to check trays for accuracy every meal and provide and serve the diet as ordered. During observation in the dining room, Resident 20 was served lunch that included a quesadilla made with melted cheese in a toasted flour tortilla and cut into approximately 3-inch triangles. During a concurrent observation and interview, the Certified Dietary Manager stated Resident 20 received the quesadilla because she did not like beef and it was an alternative meal. The CDM stated the quesadilla should have been cut into smaller pieces and that the portions served were too large to be considered bite sized. The CDM also stated Resident 20 should not have been served a quesadilla as part of her soft diet. Resident 20 finished the meal without eating any of the quesadilla.
Failure to Monitor Antibiotic Use and Follow Up on Urine Culture
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program for one sampled resident, Resident 35. The Infection Prevention and Control Surveillance Log dated 4/18/26 showed Resident 35 had dysuria, the organism on culture was not completed, and treatment with Bactrim DS twice a day for seven days was started. The Medication Administration Record for April 2026 showed Resident 35 received Bactrim DS from 4/19/26 through 4/25/26. The laboratory results report dated 4/17/26 showed the urine culture was not performed because of an improper specimen storage/transportation issue. During interview on 6/3/26, the Infection Preventionist stated there was no documentation that the urine culture was re-done and stated the urine specimen should have been re-collected and sent to the lab. The Infection Preventionist also stated re-collection of the urine specimen and monitoring lab results was the responsibility of the IP and licensed nurses to follow up. The facility policy titled Antibiotic Stewardship Program stated to monitor response to antibiotics and laboratory results when available to determine whether the antibiotic is still indicated or adjustments should be made.
Missing Care Plan for Immunization Refusal
Penalty
Summary
Develop and implement policies and procedures for flu and pneumonia vaccinations was cited after the facility failed to develop a care plan for the refusal of immunizations for one of five sampled residents, Resident 18. Review of the Resident Vaccine Consent Form dated 3/25/26 showed that Resident 18 refused Pneumococcal, RSV, and TDAP immunizations. During a concurrent interview and record review on 6/3/26 at 10:43 a.m., the Infection Preventionist reviewed Resident 18's clinical record and stated she could not find a care plan for the resident's refusal of immunization. The facility policy titled Pneumococcal Vaccine (Series), dated February 2025, stated that the resident or representative retains the right to refuse the immunization and that the facility will document in the clinical record the reason for refusal or the medical contraindication of the immunization.
Nonfunctioning Resident Call Light
Penalty
Summary
The facility failed to ensure that one resident’s call light system was functioning properly. Resident 7’s MDS indicated the resident needed staff assistance with ADLs, including transfers and toileting. During a concurrent observation and interview, Resident 7 stated that the call light system had not been working for months and that she had informed multiple staff about the issue. She stated she had to go out to the hallway to call for help, and when she pushed the call light on her bed, it did not light up in the hallway and did not register any noise. During the same observation, a CNA stated that Resident 7 did not use her call light and instead rolled herself out to the hallway to ask for assistance. The CNA then pushed the resident’s call light and stated it was not working. An Activities Director also stated that Resident 7’s call light was not lighting up in the hallway to indicate the resident needed assistance. The facility policy titled, Call Lights: Accessibility and Timely Response, stated the facility should be equipped with a call light at each resident bedside, toilet, and bathing facility and that staff should report problems with a call light immediately to the supervisor and/or maintenance director.
Unlicensed Respiratory Therapist Allowed to Provide Care
Penalty
Summary
The facility failed to ensure a respiratory therapist was properly licensed by the state before hire and while providing care. Human Resources (HR) records showed the therapist was hired as a respiratory therapist on 7/14/25 and worked in that role until termination on 4/14/26. The termination form documented the reason for termination as failure to possess the licensure or certification required for the position. During interview, HR stated that respiratory therapist licenses were supposed to be verified with the Department of Consumer Affairs prior to employment, but HR could not provide evidence that this therapist’s state license had been verified at hire and confirmed the therapist did not have a state license at the time of hire or termination. The facility’s respiratory therapist job description required a valid, unrestricted state license, and the facility’s undated License Verification policy assigned the HR Director or designee responsibility for maintaining and ensuring the validity and current status of individual licensure, which was not carried out in this case. The report states that this failure resulted in the therapist providing respiratory care to residents without a state license and created the potential to put residents at risk for harm. No additional resident-specific clinical details or medical histories were provided in the report.
Failure to Notify Physician of Repeated Psychotropic Medication Refusals
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician when a resident repeatedly refused prescribed psychotropic medications. Review of the resident’s Order Summary Report showed active orders for buspirone for anxiety twice daily starting 12/25/25, citalopram for depression once daily starting 3/4/26, and valproic acid for psychiatric disorders twice daily starting 3/31/26. The Medication Administration Record for 4/1/26–4/30/26 documented that citalopram was refused on 4/1, 4/5, 4/7, and 4/8, and that buspirone and valproic acid were refused on 4/1, 4/2, 4/4, 4/5, 4/6, 4/7, and 4/8. During an interview and concurrent record review with the Interim Director of Nursing on 4/13/26, the resident’s progress notes from 4/1/26–4/8/26 were examined, and there was no documentation that the physician had been informed of these multiple medication refusals. The IDON stated that the physician should have been notified when the resident refused the medications three times. The facility’s policy titled “Residents’ Rights Regarding Treatment and Advance Directives” requires documentation of what was refused, the reason for refusal, how the resident was educated about consequences, and that the physician was notified of the refusal and the resident’s response. The records did not contain documentation that the physician was notified as required by this policy.
Failure to Notify Physician When Antipsychotic Medication Was Unavailable
Penalty
Summary
The facility failed to ensure physician notification when an ordered antipsychotic medication was not available for a resident with dementia and recent aggressive behaviors. A psychological evaluation and medication recommendation dated 3/30/26 documented that the resident had two recent episodes of significant aggressive acting-out behavior, and recommended increasing Risperdal Consta to 37.5 mg IM every two weeks. The physician’s order summary dated 4/1/26 reflected an order for Risperdal Consta 37.5 mg IM every 14 days in the evening, related to unspecified dementia with anxiety, with a start date of 3/31/26. The MAR for 3/1/26–3/31/26 showed that the Risperdal Consta dose scheduled for 4 p.m. on 3/31 was not administered, with a code indicating to see the progress notes. A progress note entered at 9:27 p.m. on 3/31 documented that the Risperdal Consta dose was pending pharmacy delivery. During interview and concurrent record review, the Interim DON confirmed that the physician was not notified that the medication was unavailable for administration on 3/31 and acknowledged that the physician should have been notified. The facility’s policy on Unavailable Medications states that if a resident misses a scheduled dose, staff must follow procedures for medication errors, including physician and family notification, completion of a medication error report, and monitoring for adverse reactions to omission of the medication.
Fatal Methotrexate Dosing Error and Ignored Medication Alert
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors by not following its Medication Administration policy regarding right dose, right time, and appropriate response to medication alerts. A resident with rheumatoid arthritis was discharged from an acute hospital to the facility with an order for methotrexate 20 mg by mouth every Friday, as documented in the hospital discharge instructions. The resident’s diagnoses included rheumatoid arthritis, shortness of breath, and difficulty walking, and the Minimum Data Set also reflected an active diagnosis of rheumatoid arthritis. Despite this, when the orders were entered into the facility’s system, the Physician’s Order Sheet showed methotrexate 20 mg by mouth every day instead of weekly. When the methotrexate order was entered into the facility’s computer system, a medication alert was generated stating that the order was outside the recommended dose or frequency, specifying that the dosing regimen of 2 tablets daily exceeded the usual dosing regimen of 0.25 mg to 2.5 mg tablets every 7 days and that the daily frequency exceeded the usual weekly frequency. Facility staff interviews indicated that nurses understood medication alerts to mean there was a contraindication or concern requiring contact with the pharmacy or physician to clarify safety, but there was no evidence this alert was acted upon. The Medication Administration Record for November and December showed that the resident received methotrexate 20 mg by mouth daily on multiple dates over several weeks, consistent with the incorrect daily order. The care plan identified methotrexate as a black box warning medication with potential for bone marrow suppression and called for monthly drug regimen review by a pharmacist, yet the pharmacist’s order history and drug regimen review documents showed the methotrexate 20 mg daily order was reviewed on two dates in November with no recommendations and was listed as reviewed without requiring any recommendations. Progress notes documented that in mid-December the resident developed sore throat, difficulty swallowing, epistaxis, lip and chin swelling, and bloody stool. Nursing staff notified the physician, obtained orders including nasal spray, and the resident was sent to the hospital for further evaluation due to ongoing nosebleeds. Hospital emergency documentation recorded that the resident presented with life-threatening cytopenias, critical neutropenia, thrombocytopenia, anemia, acute bleeding, and organ dysfunction, with a diagnosis of methotrexate toxicity with multi-organ involvement and sepsis, and confirmed with the nursing home that the resident had been receiving methotrexate daily, with suspected overdose. The hospital history and physical also documented confirmation from the nursing home that methotrexate was being given daily. The hospital discharge summary described a prolonged course for methotrexate toxicity with severe thrombocytopenia, pancytopenia, septic shock, acute renal failure requiring dialysis, and respiratory failure, after which the resident was transitioned to comfort care and hospice. The death certificate listed acute renal failure, methotrexate toxicity, and rheumatoid arthritis, and stated that the resident ingested a toxic amount of methotrexate. The facility’s Medication Administration policy required medications to be administered as ordered by the physician, in accordance with professional standards, ensuring the six rights including right dosage and right time, use of drug reference material if unfamiliar, special handling of immunosuppressant medications, and reporting and correcting discrepancies, which were not followed in this case. Interviews with facility staff further clarified the actions and inactions leading to the deficiency. The DON stated that the resident was admitted in November and began having swallowing problems and nosebleeds around the middle of December, and that the resident was sent to the hospital due to continued nosebleeds. The DON reported that near the end of December a hospital case manager informed her that the resident appeared to have been receiving methotrexate daily instead of weekly. Upon comparing the facility MAR with the hospital discharge orders, the DON confirmed the resident had been given 20 mg methotrexate daily instead of 20 mg weekly, and that the pharmacy-supplied bubble pack was labeled for daily administration. The nurse who admitted the resident and entered the discharge orders into the facility system stated she entered the orders but could not recall how or why the methotrexate frequency was changed from weekly to daily. The ADON stated that this error could have been caught and was unsure why the system failed. The manufacturer’s black box warning for methotrexate, reviewed by surveyors, emphasized that methotrexate can cause serious, potentially fatal toxic reactions and should only be used by physicians experienced with antimetabolite therapy, underscoring the high-risk nature of the medication that was not properly managed according to facility policy and system alerts.
Failure to Notify Physician of Critically Elevated Blood Glucose Levels
Penalty
Summary
The deficiency involves the facility’s failure to follow a physician’s order and notify the physician when a resident’s blood sugar (BS) exceeded 250. The resident had Type 1 diabetes mellitus with hyperglycemia and physician orders for Insulin Degludec to be administered subcutaneously twice daily, with instructions to hold the insulin if BS was less than 90 and to notify the MD if BS was greater than 250. Review of the Medication Administration Record for the month showed multiple BS readings above 250, including values of 330, 342, 341, 301, 383, and 299 while the resident was on a 23-unit twice-daily dose, and subsequent readings of 335, 372, 252, 257, 325, and 324 after the dose was changed to 28 units twice daily. The resident’s care plan documented that the resident had diabetes mellitus and directed staff to administer Insulin Degludec as ordered and to monitor, document, and report signs and symptoms of hyperglycemia to the MD as needed. During an interview and concurrent record review with the DON, the facility was unable to provide documentation that the MD had been notified of any of the BS results above 250. The DON stated that the nurses should have notified the MD when the BS result was above 250, consistent with the physician’s order. The facility’s undated policy and procedure for Blood Glucose Monitoring stated that it is the policy of the facility to perform blood glucose monitoring for diabetic residents as per physician’s orders and to report critical test results to the physician in a timely manner. Despite these orders and policies, there was no documentation that the physician was notified of the elevated BS values identified in the resident’s record review.
Overdue Annual Performance Evaluations for CNAs
Penalty
Summary
The facility failed to follow its policy and procedure for conducting annual performance evaluations (PEs) for two certified nursing assistants. Review of the employee roster showed both CNAs were hired on 5/1/19. Record review with the Human Resource/Payroll Manager on 3/9/26 showed that each CNA’s last PE was completed on 7/17/24, and the HRPM stated that both should have had PEs completed in July 2025. In an interview, the Administrator confirmed that PEs are supposed to be done yearly. Review of the facility’s undated Performance Evaluations policy indicated that supervisors are to complete, review, and conduct performance discussions annually at or around the employee’s anniversary date, but this was not done for the two CNAs, resulting in overdue performance evaluations. No resident-specific medical history or condition was mentioned in relation to this deficiency.
Failure to Timely Report Resident’s Allegation of Rough Handling During Toileting
Penalty
Summary
The deficiency involves the facility’s failure to ensure an allegation of abuse was promptly reported to the abuse coordinator as required by policy. Resident 1 was admitted with metabolic encephalopathy, difficulty in walking, cognitive communication deficit, bilateral lower extremity range-of-motion impairment, and was wheelchair-bound and dependent for transfers. An MDS dated 1/30/26 documented that the resident was cognitively intact with a BIMS score of 13. On 1/28/26 during the p.m. shift, the resident reported that an unknown CNA who assisted her to and from the restroom while her regular CNA was on lunch had been rough and hurt her back while providing care, which the facility categorized as an allegation of physical abuse. A SOC 341 form dated 1/29/26 documented the resident’s report that an unknown staff member was rough while assisting her to the restroom on the 1/28/26 p.m. shift. Progress notes dated 1/30/26 at 1:57 p.m. indicated that the IDT met to discuss the staff-to-resident alleged abuse that occurred on 1/28/26, and that the resident’s granddaughter had found the resident crying and was told by the resident that a female staff member had been rough and hurt her back while helping her to the bathroom. The resident stated the staff member was not her usual CNA but was helping out during the CNA’s lunch break and was unable to identify the CNA involved. Multiple staff interviews confirmed that the allegation was reported by the resident and her family to CNA 3 during the 1/28/26 p.m. shift, and that CNA 3 relayed the allegation to LVN 1 that same evening. LVN 1 acknowledged that she did not report the allegation to the administrator (abuse coordinator) or the DON, stating she was overwhelmed and it slipped her mind, and further acknowledged it should have been reported right away. The SSD and administrator both stated they did not become aware of the allegation until the following day when the family reported it, and both indicated that staff should have reported the allegation to the abuse coordinator immediately. The facility’s abuse, neglect, and exploitation policy required reporting all alleged violations to the administrator and appropriate agencies immediately, but not later than two hours after the allegation is made when the events involve abuse or result in serious bodily injury, which did not occur in this case.
Failure to Monitor and Document Whereabouts of High-Risk Resident Resulting in Elopement and Hospitalization
Penalty
Summary
A deficiency occurred when the facility failed to monitor and document the hourly whereabouts of a resident identified as high risk for elopement, as required by the resident's care plan. The care plan specified that the resident, who had a history of elopement and impaired safety awareness, should be monitored every hour. However, documentation in the Point of Care Response History showed that staff did not consistently check or record the resident’s whereabouts every hour, with significant gaps between documented checks. Staff interviews confirmed that the resident was last seen in her room in the evening, but was later discovered missing, and staff were unable to determine when or how she exited the facility. The resident involved had diagnoses including schizophrenia, anxiety disorder, and major depressive disorder, and was assessed as having moderate cognitive impairment and the ability to walk. She had a prior history of elopement from the facility. On the night of the incident, staff last observed her in her room, but she was later found to be missing. Despite a search of the facility and notification of the DON and police, the resident was not located until the following morning, when she was found by police approximately a mile away from the facility, exposed to cold weather conditions and without shoes. Medical evaluation after the incident revealed that the resident suffered from hypothermia, leukocytosis with left shift, and metabolic acidosis, requiring hospitalization. The facility’s policy required systematic monitoring and management of residents at risk for elopement, including regular assessment, care planning, and supervision, but these measures were not effectively implemented in this case. Staff interviews and documentation review confirmed that the required hourly monitoring was not performed or recorded as specified in the care plan, directly contributing to the resident’s unsupervised exit and subsequent medical complications.
Failure to Investigate Resident Grievance
Penalty
Summary
The facility failed to follow its policy and procedure titled Resident and Family Grievances when no investigation was completed for a grievance filed by a resident's responsible party. The grievance concerned the resident not being provided a personal bag and a sack lunch when transported to the dialysis center and the bandage on the resident's dialysis port site not being removed after returning from dialysis. During interview, the DSD stated the DON was informed of the grievance and said she would follow up, and the grievance log identified the DON as responsible for investigation. However, the DON later stated no follow-up was done and no investigation was completed, and acknowledged the grievance should have been investigated.
Failure to Notify Responsible Party and Physician of Resident Altercation and Injuries
Penalty
Summary
The facility failed to notify the responsible party (RP) and the physician when a resident was involved in a resident-to-resident altercation and subsequently sustained visible injuries, including a cut under the left eye, bruising on the left cheek, and scabs to the left side of the nose and under the left eyebrow. Despite documentation indicating that the RP was notified, interviews with staff and the RP revealed that the notification did not occur as required. The RP only became aware of the injuries during a visit and was not informed about the altercation or the resulting wounds. Staff interviews further confirmed confusion and lack of clarity regarding who was responsible for notifying the RP, with documentation not matching actual communication events. Additionally, the facility did not assess, treat, or monitor the resident's injuries in accordance with its own policies. The ADON and Administrator were unaware of the full extent of the resident's injuries until they were observed during a visit, and there was no documentation of assessment, treatment, or physician notification regarding the wounds. The facility's policies required notification of changes in condition, accidents, and new treatments, but these procedures were not followed in this instance.
Failure to Treat Resident with Respect and Dignity
Penalty
Summary
A deficiency occurred when a social worker (SW) failed to treat a resident with respect and dignity during a conversation in the resident's room. According to a Licensed Vocational Nurse (LVN) who was present, the SW responded to the resident's questions with a snarky attitude. The resident, who was assessed as cognitively intact with a BIMS score of 15, reported feeling intimidated and bullied by the SW during the interaction. The facility's policy on promoting and maintaining resident dignity requires staff to speak respectfully to residents, which was not followed in this instance.
Failure to Timely Report Alleged Misappropriation of Resident Property
Penalty
Summary
The facility failed to follow its policy and procedure regarding the timely reporting of an alleged misappropriation of resident property for one resident. On 8/10/25, a resident reported $600 missing, and this was documented in the Theft & Loss Form and in the resident's progress notes. The CNA notified the RN supervisor, who assisted in searching for the missing items, and the resident's daughter was informed. The resident, who was cognitively intact as indicated by a BIMS score of 15/15, completed a theft and loss form, which was submitted to Social Services. However, the incident was not reported to the Department of Public Health, Ombudsman, Adult Protective Services, or Law Enforcement within 24 hours as required by facility policy. Interviews with facility staff confirmed that the required notifications were not made within the specified timeframe. The Social Service Director acknowledged that the incident should have been reported to the appropriate authorities, regardless of the family's wishes. The Ombudsman confirmed that their office was not notified, and the Administrator admitted that the delay occurred because the amount of missing money was unclear during the investigation. Review of the facility's policy confirmed the requirement to notify authorities within 24 hours of any suspected misappropriation of resident property.
Failure to Obtain Resident Signature on Inventory of Personal Effects at Admission
Penalty
Summary
The facility failed to follow its policy and procedure regarding the inventory of personal effects for one resident at the time of admission. Specifically, the Inventory of Personal Effects (IPE) form for the resident, dated 4/10/25, was not signed by the resident or their representative, as required by facility policy. During an interview and record review, the Social Service Director confirmed that the IPE should have been signed to indicate that all belongings were properly inventoried upon admission. The facility's policy states that all resident personal items must be inventoried at admission and reviewed by the social services designee and the resident's representative, but this process was not completed as documented.
Resident's Right to Room Choice Not Respected During Deep Cleaning
Penalty
Summary
The facility failed to honor a resident's right to self-determination and choice by not allowing her to remain in her room during a scheduled deep cleaning. The resident, who has a history of major depressive disorder and social anxiety, prefers to stay in her room and avoid social situations, as documented in her care plan and confirmed by multiple staff interviews. Despite her clear preference and refusal to leave, she was removed from her room and placed in the hallway in her bed for approximately one hour while her room was cleaned. This action caused the resident significant distress, including anxiety and being nearly in tears. Interviews with facility staff, including the social service designee, LVN, CNA, housekeeper, DON, and administrator, all confirmed the resident's preference to remain in her room and acknowledged that she should not have been forced to leave. The facility's own policy on resident rights also states that residents have the right to make choices about aspects of their life in the facility that are significant to them, including remaining in their room. The failure to respect the resident's choice resulted in a violation of her rights and caused her emotional discomfort.
Failure to Provide Advance Notice and Monitor Roommate Compatibility
Penalty
Summary
The facility failed to provide advance written notice to a resident prior to assigning a new roommate, as required by policy. The resident was not informed in writing before another resident, who was known to have frequent outbursts and confusion, was moved into his room. Multiple staff members, including the Social Service Assistant, Assistant Director of Nurses, and Licensed Vocational Nurse, confirmed that there was no documented evidence of written notification or monitoring for compatibility following the room change. The facility's policy requires advance notice and monitoring for 72 hours to ensure compatibility, but these steps were not followed or documented. As a result of this failure, the resident experienced significant distress, including inability to sleep due to the new roommate's constant yelling and outbursts. The resident reported the issue to several staff members but stated that nothing was done to address his concerns. Staff interviews confirmed that the two residents were not compatible as roommates, and no monitoring for compatibility was documented in the clinical records. This led to a resident-to-resident altercation and a violation of the resident's rights.
Failure to Provide Written Grievance Decision to Resident's Representative
Penalty
Summary
The facility failed to provide a written grievance decision to a resident's responsible party after a grievance was filed regarding the resident being found in a soiled gown. The responsible party reported submitting the grievance, and a review of the facility's Grievance/Concern Log confirmed the grievance was filed. During interviews and record reviews, the administrator acknowledged that although the grievance was resolved, there was no documented evidence that a written decision was issued to the responsible party. The facility's policy requires that a written decision be provided at the conclusion of the investigation, including specific details such as the date received, investigative steps, findings, confirmation status, corrective actions, and the date the decision was issued. This omission resulted in a violation of the resident's rights.
Failure to Supervise Resident with Exit-Seeking Behaviors Resulting in Elopement
Penalty
Summary
The facility failed to provide adequate supervision for a resident with a known history of attempting to leave the facility unsupervised. The resident, who had moderate cognitive impairment as indicated by a BIMS score of 12, was able to walk 50 feet with minimal assistance and had previously demonstrated exit-seeking behaviors, including leaving the facility and expressing a desire to go to Mexico. Staff interviews confirmed that the resident frequently attempted to leave, set off door alarms, and packed belongings in preparation to exit, with these behaviors occurring approximately every two weeks. Despite these known behaviors, staff did not consistently report the resident's actions to nursing staff as required. On the date of the incident, the resident was discovered missing during a staff lunch break, and after a search of the facility, the police were notified. The resident was subsequently found by police next to a neighboring church. Review of facility policy indicated that residents at risk for elopement should be assessed and have person-centered interventions implemented and communicated to staff, with ongoing monitoring by charge nurses and unit managers. However, the lack of timely reporting and intervention allowed the resident to elope without staff knowledge, resulting in a deficiency related to supervision and accident prevention.
Failure to Address and Document Low Blood Pressure in Resident
Penalty
Summary
Facility staff failed to address a resident's change in condition when the resident repeatedly presented with low blood pressure readings following dialysis treatments. The resident and a family member reported that after returning from dialysis, the resident often felt unwell and requested blood pressure checks, which consistently showed readings below the normal range. Despite these findings, there was no documentation of interventions or physician notification in the resident's medical record, as confirmed by the Director of Staff Development. The facility's grievance log also indicated the resident was dissatisfied with how blood pressure checks were conducted by a CNA. Review of the resident's orders showed no current medication for low blood pressure, and interviews with staff confirmed that the physician should have been notified for systolic blood pressure readings below 100 mm Hg. The facility's policy required nurses to notify the attending physician and document any significant changes in a resident's condition, but this was not done in this case. The lack of intervention and documentation for the resident's persistently low blood pressure constituted a failure to meet professional standards of quality.
Failure to Provide Routine Nail Care
Penalty
Summary
The facility failed to provide adequate nail care for two residents, resulting in both having untrimmed fingernails and dark brown debris under their nails. During observations and interviews, it was noted that the nail care, which was supposed to be performed on Sundays, was not completed for these residents. Certified Nursing Assistants (CNAs) acknowledged the oversight, stating that the residents' nails should have been cleaned and trimmed the previous day. Further interviews revealed that one of the residents was diabetic, and according to the facility's policy, only licensed nurses are responsible for trimming or filing the fingernails of diabetic residents. A Licensed Vocational Nurse (LVN) admitted that nail care was not provided to the diabetic resident on the scheduled day. The facility's policy indicated that routine nail care should be part of the Activities of Daily Living (ADL) care and performed on a regular schedule, which was not adhered to in this instance.
Failure to Schedule RN for Required Hours
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was scheduled and on duty for eight hours a day, seven days a week, as required by their policy. During an interview and record review with the Human Resource Payroll Manager, it was revealed that on specific dates in November 2024, namely the 9th, 23rd, and 24th, there was no RN present in the building for the required duration. This was confirmed by the facility's staff schedule and acknowledged by the HR manager. The facility's policy, titled 'Nursing Services-Registered Nurse (RN),' mandates the utilization of RN services for at least eight consecutive hours per day, seven days a week, which was not adhered to on the mentioned dates.
Failure to Conduct Performance Evaluations for CNAs
Penalty
Summary
The facility failed to complete Performance Evaluations (PEs) for three of eight sampled employees, specifically Certified Nursing Assistants (CNAs) 54, 88, and a terminated CNA. This deficiency was identified during interviews and record reviews conducted on December 5, 2024, with the Human Resources Payroll (HR) department. CNA 54, hired on June 22, 2021, and CNA 88, hired on April 5, 2022, both had no PEs in their files, as confirmed by HR. Similarly, the terminated CNA, hired on June 11, 2023, also lacked a PE in her file. The facility's policy and procedure for the evaluation process indicated that the HR department should notify department managers of upcoming evaluations, and managers or supervisors should inform employees of their evaluations at least one week prior to the due date. However, this process was not followed, leading to the absence of PEs for the mentioned CNAs.
Inadequate Communication Leads to Improper Food Storage
Penalty
Summary
The facility failed to ensure adequate communication between the Dietary Manager and the Registered Dietitian regarding the malfunction of a refrigerator used to store Time Temperature Control for Safety (TCS) foods. On observation, Refrigerator 1, located in the kitchen, was found to be not in good working condition, with an internal thermometer reading 38 degrees Fahrenheit, but the actual temperature of stored pudding cups was between 50.1 and 52 degrees Fahrenheit. The issue was first identified on 11/29/24, but the refrigerator continued to be used to store TCS foods, which were not maintained at the required temperature of 41 degrees Fahrenheit or less. The Lead Cook noted the problem with the refrigerator and reported it to the Plant Operations Manager on the same day. However, the Dietary Manager was not informed until 12/1/24, and the Registered Dietitian was not aware of the issue until 12/2/24. The Administrator received a text about the refrigerator needing a new compressor but did not communicate this to the Dietary Manager or the Registered Dietitian to ensure proper oversight of food safety. As a result, TCS foods continued to be stored in the malfunctioning refrigerator, posing a risk of bacterial growth due to improper temperature control. The facility's policy and procedure on sanitation require correct temperatures for food storage and handling, which was not adhered to in this case. The Food and Drug Administration (FDA) Food Code recommends that TCS foods be stored at a maximum temperature of 41 degrees Fahrenheit. Despite these guidelines, the facility failed to maintain the required standards, leading to the potential for residents' nutritional needs not being met safely.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, as observed during a survey. There was an extensive amount of dry old egg debris on the stove range area, and a #8 scooper with dry old food debris was stored inside the clean utensil drawer. The Dietary Manager acknowledged that the scooper should not have been stored with clean utensils, as it was unsanitary. The facility's policy indicated that all utensils should be kept clean, and all equipment used in food handling should be cleaned and sanitized to prevent contamination. The facility also failed to use pasteurized eggs as required by their policy. Observations revealed a case of shelled eggs in the refrigerator that were not labeled as pasteurized, and staff confirmed that the eggs were not pasteurized. The facility's Food and Service Invoice indicated that the supply of eggs was not pasteurized, and meal tray tickets showed that residents were served eggs over easy, which should have been made with pasteurized eggs according to the facility's policy. Additionally, a Certified Nursing Assistant was observed carrying an uncovered salad and dressing down the hallway to a resident's room, contrary to the facility's policy that required food to be covered during delivery. Furthermore, the facility failed to maintain the cold food storage refrigerator at the required temperature. The refrigerator's internal temperature was found to be above the safe range, with pudding cups measuring 50.1 and 52 degrees Fahrenheit. The Plant Operations Manager confirmed that the refrigerator's compressor needed replacement, and the facility's policy required monitoring of food temperature and refrigeration equipment to ensure safe storage conditions.
Failure to Conduct Timely Smoking Assessments
Penalty
Summary
The facility failed to ensure timely completion of smoking assessments for two residents, Resident 13 and Resident 22, which resulted in a lack of assessment for safety while smoking. Resident 13 was admitted on an unspecified date, and no quarterly smoking assessments were completed after September 13, 2023, despite the requirement for assessments on June 5, 2023, December 6, 2023, March 6, 2024, and September 6, 2024. Similarly, Resident 22, admitted on May 1, 2022, did not have quarterly smoking assessments completed after September 13, 2023, although assessments were due in December 2023, March 2024, and June 2024. The facility's policy required smoking assessments during the admission process and each quarterly or comprehensive MDS assessment process to determine the need for supervision or safety in smoking. The failure to conduct these assessments posed a potential risk of residents being burned while smoking.
Medication Administration Error Due to Incorrect Route
Penalty
Summary
The facility failed to maintain a medication error rate of five percent or less, as evidenced by five medication errors observed out of 43 medication administration opportunities, resulting in an error rate of 11.63 percent. During an observation, a Licensed Vocational Nurse (LVN) administered medications to a resident orally, despite the resident's orders indicating that the medications should be given via a gastrostomy tube (G-tube). The medications involved included chewable aspirin, docusate sodium, metformin, Keppra, and Januvia, all of which were crushed and mixed with pudding before being administered orally. The LVN acknowledged during interviews that the medications should have been administered via G-tube as per the resident's Order Summary Report. The facility's policy and procedure for medication administration, dated January 2024, requires that medications be administered as ordered by the physician and in accordance with professional standards of practice, including verifying the right route of administration. The LVN admitted to not checking the order and failing to contact the physician to change the route of administration prior to giving the medications orally.
Failure to Implement Enhanced Barrier Precautions for Residents with Indwelling Devices
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions for five residents with indwelling devices, which are necessary to prevent the transmission of bacteria. Observations revealed that these residents did not have the required signage or Personal Protective Equipment (PPE) carts outside their rooms, indicating a lack of compliance with infection control protocols. Interviews with staff, including Licensed Vocational Nurses and a Certified Nursing Assistant, highlighted a lack of awareness and understanding regarding the necessity of Enhanced Barrier Precautions for residents with indwelling devices. The facility's policy on Enhanced Barrier Precautions, dated January 2024, mandates that all staff receive training on these precautions and that orders for such precautions be obtained for residents with indwelling medical devices. Despite this policy, the facility did not ensure that the necessary precautions were in place for residents with devices such as Foley catheters and dialysis catheters. The Order Summary Reports for the affected residents indicated the need for regular checks for signs and symptoms of infection, yet the absence of Enhanced Barrier Precautions suggests a failure in policy implementation and staff training.
Failure to Ensure Accurate Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure accurate informed consent for a psychotropic medication for one resident. The resident, who had a severe cognitive impairment with a BIMS score of 2, signed their own informed consent for Zoloft medication. The facility's policy requires a higher cognitive score for a resident to sign their own consent. The Director of Nursing acknowledged that the resident should not have signed the consent due to their cognitive impairment. The facility's policy on informed consent for psychotherapeutic medications emphasizes the need to assess the resident's decision-making capacity, which was not adhered to in this case.
Failure to Maintain Resident Dignity and Personal Care
Penalty
Summary
The facility failed to maintain the dignity and respect of a resident, identified as Resident 10, by not ensuring proper personal care and the availability of personal possessions. Resident 10, who was admitted with diagnoses of schizophrenia and dementia, exhibited moderate cognitive impairment and required partial assistance with personal care tasks. Observations revealed that Resident 10's room was cluttered, her hair was greasy and disheveled, and she emitted a strong smell of urine. Over several days, Resident 10 was observed wearing the same clothes, which were dirty, and she had no clothes or shoes in her closet. Staff interviews indicated that Resident 10 was often left to perform her own personal care, resulting in her unkempt appearance and odor. The facility's policy on resident personal belongings was not adhered to, as Resident 10's personal effects were not maintained in an orderly fashion, and her clothing was reportedly thrown out with the trash by accident. The facility's policy also stated that residents should have at least two sets of clothes, which was not the case for Resident 10. Staff members, including a CNA and the Administrator, acknowledged the lack of clothing and personal care for Resident 10, with the CNA attempting to provide clothing from her own resources. The facility's failure to support Resident 10's right to retain and use personal possessions and to provide necessary personal care compromised her dignity and respect, as outlined in the facility's policies on resident rights and personal belongings.
Failure to Accommodate Resident's Mobility Needs
Penalty
Summary
The facility failed to accommodate a resident's choice to get out of bed daily, which impacted their ability to participate in group activities. The resident, who has impairments in both lower extremities and is dependent on care, expressed a desire to attend activities but was unable to do so due to the unavailability of a Geri-chair, which is necessary for their mobility. Despite the resident's interest in activities such as bingo, nails, and coloring, and their need for assistance to attend these activities, the facility did not provide the necessary equipment consistently. Interviews and record reviews revealed that the resident had not participated in any group activities for the months of November and December, as the facility only had three Geri-chairs, all of which were in use by other residents. The Interim Director of Activities confirmed the lack of participation and the absence of a schedule for Geri-chair use among dependent residents. Observations showed that a Geri-chair was not in use in one room, indicating a potential oversight in resource allocation. The facility's policies emphasize promoting resident self-determination and accommodating individual needs, but these were not adhered to in this case.
Failure to Notify Family of Resident's Hospital Transfer
Penalty
Summary
The facility failed to notify the Responsible Party (RP) for a resident when there was a change in the resident's condition that required admission to an acute care hospital. During a review of the resident's Change in Condition Evaluation (COC) on two separate occasions, it was noted that the resident was unresponsive and transferred to the hospital by Emergency Medical Technicians (EMT). The COC indicated that the resident was their own RP, but the Director of Nursing (DON) confirmed that no family was notified, although they should have been. The facility's policy and procedure on Notification of Changes requires informing the resident, consulting with the resident's physician, and notifying the resident's family or legal representative when there is a significant change, such as a transfer or discharge from the facility.
Failure to Provide and Complete Advanced Beneficiary Notices
Penalty
Summary
The facility failed to provide an Advanced Beneficiary Notice (ABN) to one resident and failed to accurately complete the ABN for another resident. In the first case, Resident 192 was not given the ABN after self-discharging from Medicare Part A before exhausting benefit days and remaining in the facility. The Admissions Coordinator (AC) acknowledged that the ABN should have been provided alongside the Notice of Medicare Non-Coverage (NOMNC), which was issued when the resident requested to be taken off occupational therapy. In the second case, Resident 195's ABN was left incomplete as none of the required option boxes were checked, although the resident had signed the form. The AC confirmed that one of the boxes needed to be checked for the form to be considered complete. The facility's instructions for the Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) specify that the patient must select one option and sign the form to acknowledge understanding. Failure to complete the form correctly could result in the notice being invalidated and the facility being held liable for the care in question.
Failure to Complete PASRR Level II Evaluations
Penalty
Summary
The facility failed to accurately complete the annual pre-admission screening assessment and resident review (PASRR) for two residents, which is a federal requirement to ensure individuals are not incorrectly placed in nursing homes or long-term care instead of a psychiatric setting. Resident 13's PASRR Level I Screening indicated a positive result for Serious Mental Illness (SMI) but negative for Intellectual Disability (ID), Developmental Disability (DD), and Related Condition (RC). However, there was no Level II PASRR performed on Resident 13, as confirmed by the Director of Nursing (DON) during an interview. Similarly, Resident 42's PASRR Level I Screening also indicated a positive result for SMI and negative for ID/DD/RC, yet no Level II PASRR was conducted. The DON acknowledged that a Level II screening should have been performed for Resident 42. The facility's policy and procedure on Resident Assessment - Coordination with PASARR program, dated January 2024, states that a positive Level I screen necessitates a PASARR Level II evaluation prior to admission, and if a resident remains in the facility longer than 30 days, a Level II resident review must be completed within 40 calendar days of admission.
Failure to Obtain Diet Order Upon Admission
Penalty
Summary
The facility failed to obtain a diet order upon admission for a resident, which had the potential to result in unmet nutritional needs. Upon reviewing the resident's Admission Record, it was found that the resident was admitted without a diet order. The Order Summary Report, dated four days after admission, indicated a controlled carbohydrate diet with thin pureed texture and thin consistency was ordered by the facility's physician. This was the first diet order documented for the resident. Interviews with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) revealed that there was no documentation of a physician-ordered diet upon the resident's admission. The ADON acknowledged that the nurse should have contacted the physician to obtain the diet order. The facility's policy and procedure on Admission Orders requires that a physician or other qualified healthcare professional provide written or verbal orders for residents' immediate care, including dietary needs. The facility's policy on Diet Orders specifies that diet orders prescribed by the physician should be communicated to the Food & Nutrition Services Department.
Failure to Provide Hearing Services to Resident
Penalty
Summary
The facility failed to provide appropriate care and services to a resident, identified as Resident 10, to improve her hearing and communication needs. Upon review of Resident 10's Admission Record, it was noted that she was admitted on an unspecified date. During an observation and interview, it was evident that Resident 10 had difficulty hearing, requiring the surveyor to speak loudly and clearly near her ear. Resident 10 expressed a desire for hearing aids to improve her ability to hear. Further interviews revealed that the Social Service Designee (SSD) was unaware if audiology services had been utilized for Resident 10, despite acknowledging her hearing difficulties. It was confirmed that Resident 10 had never undergone a hearing test at the facility. The facility's policy and procedure on Hearing and Vision Services mandates that residents have access to necessary services and adaptive equipment, with the social worker or SSD responsible for assisting residents in obtaining these resources. However, this policy was not followed, resulting in Resident 10's communication needs not being met.
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What surveyors actually found near you
We read the 329 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Visalia
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Westgate Gardens Care Center | 0.6 mi | ★★★★★ | 5 | 0 |
| Linwood Meadows Care Center | 0.6 mi | ★★★★★ | 0 | 0 |
| Kaweah Health Skilled Nursing Center | 2.2 mi | ★★★★★ | 11 | 0 |
| Delta Healthcare & Wellness Center, Lp | 2.4 mi | ★★★★★ | 0 | 0 |
| Visalia Post Acute | 3.7 mi | ★★★★★ | 33 | 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 October 2026) and official state health department websites.