Average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at St. Catherine Healthcare during CMS and state inspections, most recent first.
The facility failed to properly screen an Activity Volunteer who disclosed on his application that he was a current sex offender registrant. Although a background check showed no criminal findings, the volunteer’s written disclosure was missed by HR, and he was allowed to volunteer with residents despite the facility’s policy requiring screening of all volunteers before working at the facility.
Antibiotic stewardship documentation was incomplete for several residents who received antibiotics for infections that did not meet McGeer's criteria. For one resident, the UTI was incorrectly documented as meeting criteria, and the physician was not followed up with to reassess continued antibiotic therapy. For other residents, the surveillance forms stated the physician was notified and antibiotics were continued, but the records did not show when the notification occurred, including one form completed after the IP had returned to the facility.
Two cognitively intact residents had OTC medications at the bedside without physician orders or self-administration assessments. One resident had Mylanta on the bedside table and said he had taken it previously, while another had open Biofreeze and said he used it on his hand when pain was severe. Staff confirmed neither resident had an order or documented self-administration assessment.
A resident’s Advance Directive was incomplete because it was missing the page identifying the health care agent, and the POLST completed with a family member did not match the resident’s stated wishes for life-sustaining treatment. The record showed the resident had no decision-making capacity, while social services documented that the Advance Directive contradicted the POLST and that the family member wanted to continue the current POLST.
A facility failed to properly document and monitor psychotropic use for two residents. One resident with schizoaffective disorder had repeated angry outbursts, but the record did not show nonpharmacological interventions when the behaviors occurred. Another resident with anxiety had PRN Ativan orders for agitation and angry outbursts, but the record did not show the behaviors were monitored when the medication was given, and other documented behaviors were not addressed with the ordered nonpharmacological interventions or the PRN medication as prescribed.
A resident receiving dialysis had a care plan for renal failure, but the plan was not revised after the resident received a new left upper arm AV fistula. The resident was observed with a chest perma-catheter and reported using it for dialysis, while the record showed AV fistula discharge instructions with restrictions on lifting or straining the access arm. RN 1 verified no interventions were developed for the fistula, and the DON acknowledged the finding.
A facility failed to ensure an LVN and an RN demonstrated required competencies for safe nursing care. An LVN could not show how to calibrate a glucometer during observation, and an RN prepared an IV ertapenem dose for a resident incorrectly by using the full reconstituted amount instead of the ordered 5 ml. The DON stated she was responsible for competency checkoffs for licensed nurses.
An RN failed to prepare and administer a resident’s IV ertapenem at the ordered dose. The resident had CKD and an order for ertapenem 500 mg IV daily for a UTI, but the RN reconstituted a 1 g vial, used the entire 10 mL, and placed it into a 50 mL NS piggyback instead of transferring only 5 mL as labeled. The surveyor stopped the administration before the medication was given.
Medications for three residents were found in a med cart without open dates during an observation by a LVN and surveyor. The bottles included geri-tussin, gabapentin oral solution, and megestrol acetate suspension. The LVN confirmed the issue, and the DON stated that resident-specific meds should be labeled with open dates because some meds are only good for certain days and the open date can help show whether meds are being given correctly.
Dumpster Lid Left Open: The facility failed to ensure one of three outside blue garbage dumpsters was fully closed. During observation, a dumpster lid was seen open, and the DSS later confirmed it was partially propped open with bags of trash. The facility P&P required daily inspection of garbage and trashcans to ensure lids were closed.
A resident with a dialysis access site had repeated BP readings documented on the wrong arm even though the care plan said not to use that arm, and the resident stated staff never took BP there. Another resident’s narcotic record was incomplete because the time of an oxycodone-acetaminophen dose was left blank. Two residents also had incomplete or inaccurate advance directive records: one file was missing a page and did not identify the healthcare agent, and another POLST incorrectly stated the resident had no advance directive even though the resident said one existed at home.
Failure to Complete QAPI Audits and Monitor Corrective Actions: The facility failed to implement its QAPI plan and prior POC for F554 and F761. Surveyors found no records showing Medical Records completed admission chart reviews for new orders or that the RN Supervisor/designee completed weekly then monthly medication cart checks as required. The Administrator stated the audits were part of routine process and did not have documentation to show they were completed.
Infection control practices were not followed when a resident's UTI was recorded as a HAI despite the medical record not supporting the reported symptoms, Medication Cart A had medication spillage and a sticky liquid iron bottle, and an LVN failed to perform hand hygiene and change gloves after touching a resident's surroundings before checking the GT and giving medications.
A facility failed to protect resident privacy when its public survey binder on the nursing station counter contained three confidential resident rosters with resident names and identifiers. The rosters were marked confidential, and the Administrator verified they should not have been included in the binder for public viewing.
A resident with an order for oxygen via nasal cannula PRN for angina, and a history of respiratory failure and hypoxia, was observed with tubing that was not dated or labeled and was not stored in a set-up bag when not in use. The facility’s oxygen policy required dated disposables and labeled bags for cannulas and masks, and an LVN confirmed the tubing was not labeled or properly stored; the DON acknowledged the findings.
A resident who lacked decision-making capacity had an alleged abuse incident reported by a family member, with police involvement and documented right hand discoloration. Facility records showed psychosocial support by Social Services on some days but no comprehensive care plan addressing the alleged abuse was developed, despite facility policy requiring an IDT care plan for each resident. An RN and the DON confirmed that no abuse-related care plan existed, and the DON stated staff did not create one because the allegation was unsubstantiated, no harm was identified, and there was no change in condition, although a care plan was completed for the hand discoloration.
Surveyors found that several residents received supplemental oxygen at higher flow rates than ordered by their physicians, and that documentation of PRN oxygen administration was incomplete or missing. Nursing staff confirmed the discrepancies, and medical record reviews showed that facility policies for oxygen administration and medication documentation were not followed.
A resident in a LTC facility did not receive prescribed medications for two days due to pending delivery, and the facility failed to notify the physician as required by policy. The resident, with a history of diabetes, hypertension, and hyperlipidemia, was not administered critical medications, leading to a high blood sugar reading upon transfer to an acute care facility. The DON confirmed the oversight and acknowledged the lack of physician notification.
The facility failed to implement fall prevention measures for three residents, as their care plans were not followed. Observations revealed that beds were not in the lowest position, and floor mats were improperly placed, increasing fall risks. Staff confirmed these deficiencies, indicating a lack of adherence to safety protocols.
A facility failed to ensure the accuracy of the MAR for a resident, leading to discrepancies in medication administration records. The resident, admitted for respite care, had fluctuating decision-making capacity and was prescribed carvedilol and ezetimibe. Despite the MAR indicating these medications were administered, they were actually pending delivery and not given, as confirmed by the DON.
The facility failed to follow food safety and sanitation protocols, including improper thawing of meats, unsanitary storage of kitchen utensils, and inadequate maintenance of food preparation equipment. Additionally, a food preparation sink lacked an air gap for backflow prevention, posing a risk of food-borne illnesses to residents.
The facility failed to implement its infection control surveillance program effectively, limiting it to residents prescribed antimicrobials and not accurately tracking infections. Additionally, proper infection control practices were not followed for a resident under transmission-based precautions, and hand hygiene was not performed during a GT dressing change. These deficiencies were confirmed by staff interviews.
A resident was found with medications at their bedside without an assessment, physician's order, or care plan for self-administration. The RN acknowledged the error, and the DON confirmed the absence of necessary documentation, despite the resident's capacity to make decisions.
A facility failed to incorporate PASARR Level II recommendations into a resident's care plan. The resident, with schizophrenia, anxiety disorder, and major depressive disorder, required special services as per the PASARR evaluation. However, the facility did not document these recommendations in the care plan, nor was there evidence of an IDT meeting to discuss them. Interviews with the MDS Coordinator and DON confirmed the lack of documentation and follow-up.
A facility failed to ensure proper care for a resident's gastrostomy tube (GT). The GT was not checked for placement before medication administration, nor was it flushed with water between medications or after administration, as per facility policy and physician's orders. An LVN confirmed these lapses during an interview.
A facility failed to monitor a resident's PICC line by not measuring the right upper arm circumference upon admission and during dressing changes. This oversight, confirmed by RN 2, was contrary to physician orders and posed a risk for complications. The facility also did not develop a care plan for the PICC line, which is essential for proper management.
A facility failed to provide adequate dialysis care for a resident by not monitoring fluid intake as per physician's orders and neglecting to assess the dialysis access site before and after treatments. The resident's fluid intake exceeded the prescribed limit on multiple occasions, and there were missing assessments for the dialysis site on several dates. These deficiencies were confirmed by an LVN during a review.
The facility failed to attempt alternative measures before using bed rails for two residents, contrary to its policy. One resident had a physician's order for bed rails as an enabler for mobility, but no alternatives were documented. Another resident had a similar order for grab bars, with no alternatives attempted. An RN confirmed these findings.
A facility failed to ensure a resident had a physician's order for nasal moisturizing spray, which was found in her bedside drawer. The resident was evaluated as safe to self-administer medications and had no cognitive impairment. However, the medical records lacked an order for the nasal spray, as confirmed by an LVN during a review.
The facility failed to ensure safe storage of medications and supplies. An inspection revealed expired supplies and items without manufacturing or expiration dates in the IV Cart, verified by an RN. Additionally, an opened bottle of Gerilanta without an open date was found in Medication Cart 2, confirmed by an LVN. These deficiencies could lead to unsafe medication administration.
A resident with a diagnosis of unspecified protein-calorie malnutrition did not receive a fortified diet as ordered, as the facility failed to add margarine to the resident's meal. The facility's policy required fortification for residents needing additional calories and protein, but this was not followed, as confirmed by the DSS and acknowledged by the DON and Administrator.
A facility failed to follow dietary texture guidelines for a resident with dysphagia, serving a meal that did not meet the required pureed consistency. The resident's lunch tray included runny beans and rice mixed with pureed pork, which did not hold its shape as required. The Dietary Services Supervisor confirmed the inconsistency, and the facility's leadership was informed of the findings.
The facility failed to educate staff and family/visitors on safe food handling of outside food, as per its policy. The DSS did not provide specific education on cooking and cooling temperatures, nor literature on safe practices. The LVN indicated the RD was responsible for discussing guidelines, but no evidence of this was found. The DSD and DON revealed gaps in staff education, with reheating done by kitchen staff and no reheating available after hours, risking foodborne illnesses for residents.
The facility failed to implement its antibiotic stewardship program by not properly assessing infections using McGeer's criteria. Several residents were prescribed antibiotics without meeting the necessary criteria, as evidenced by incomplete Surveillance Data Collection Forms. Interviews with staff confirmed these findings, highlighting a systemic issue in the facility's practices.
A facility failed to obtain informed consent for an increased dosage of diazepam for a resident. The resident's physician noted increased anxiety and pain, leading to a dosage increase from 10 mg to 15 mg. However, consent was only documented for the initial dose. Interviews with an LVN and the DON confirmed the oversight, posing a risk of uninformed medication changes.
A facility failed to obtain and maintain a resident's advance directive in their medical record, despite policy requirements and indications in assessments that such directives existed. The resident had a DNR status and comfort-focused treatment preferences, but the facility did not follow up to secure a copy of the advance directives, as confirmed by interviews with the SSD and DON.
A resident with multiple diagnoses, including Parkinson's disease and cognitive deficits, experienced a fall from a wheelchair. The facility failed to perform neuro-checks at the required intervals as per their 72-hour monitoring protocol. The checks were conducted at irregular intervals, and the resident was later transferred to an acute care hospital. Interviews with staff confirmed the deviation from protocol.
A resident received Norco for severe pain, but the administration was inaccurately documented on the MAR. The medication was taken from the E-kit and given immediately, but the nurse delayed documentation, leading to a discrepancy. This failure to document accurately posed a risk of medical error and treatment delay.
Volunteer Screening Failure
Penalty
Summary
The facility failed to ensure resident safety when it allowed an Activity Volunteer with a prior history of conviction to volunteer with residents. The facility’s Abuse: Prevention and Prohibition Against policy, revised December 2023, stated that it applied to all facility staff, including volunteers, and that all prospective volunteers would be properly screened before working at the facility. The Activity Volunteer’s application dated 8/2/24 showed a handwritten “yes” response to whether the applicant had ever been convicted of a criminal offense, and the application also disclosed that he was currently a sex offender registrant. The facility initiated a background check, which returned no criminal findings. During interviews, the Administrator stated he was not aware the volunteer had disclosed sex offender status on the application, and HR stated she missed that disclosure when reviewing the application. HR also stated that when she later contacted the Activity Volunteer about the sex offender response, he refused to provide details other than that it went back about 20 years.
Antibiotic Stewardship Documentation and Physician Notification Failures
Penalty
Summary
The facility failed to implement its antibiotic stewardship program by not ensuring timely physician notification when several residents received antibiotics for infections that did not meet McGeer's criteria. Review of the facility's Antibiotic Stewardship policy showed the program was intended to promote appropriate antibiotic use and reduce adverse events and antibiotic resistance. Surveyors identified that for Residents 16, 17, 47, 49, and 93, the surveillance documentation showed the infections did not meet criteria, yet the records did not consistently show when the physician was notified that the infections failed to meet criteria. For Resident 47, the UTI Surveillance Data Collection Form indicated symptoms beginning on 1/4/26 and incorrectly showed the UTI met criteria, but the medical record did not support that the resident's symptoms met UTI criteria. The resident received ciprofloxacin from 1/7/26 through 1/17/26, and the record did not show that the physician was notified the infection did not meet criteria or that the need for continued antibiotic therapy was reassessed. The IP and DSD later verified that the form incorrectly showed the UTI met criteria and that the physician was not followed up with to reassess continued antibiotic therapy. For Resident 16, the UTI Surveillance Data Collection Form showed the infection did not meet McGeer's criteria and stated the physician was notified and instructed to continue antibiotics, but it did not show when the physician was notified. The form was completed by the IP after she had been out of the facility and returned in March 2026, after the resident had already completed cephalexin. Similar documentation issues were identified for Resident 17, Resident 49, and Resident 93, whose surveillance forms stated the physician was notified and antibiotics were continued, but did not document when the notification occurred. The IP and DSD verified that these forms failed to show timely physician notification and reassessment of the need for continued antibiotic therapy.
Unassessed Bedside Medications Found for Two Residents
Penalty
Summary
The facility failed to ensure that two residents were assessed for self-administration of medications when medications were found at their bedside without physician orders. Resident 6, who was cognitively intact per the MDS, had a bottle of Mylanta on the bedside table and stated he did not remember who brought it to him and that he had taken it about a week earlier or more. Review of the March 2026 order summary showed no physician's order for Mylanta and no order for self-administration, and staff confirmed there was no consent for self-administration and no documented assessment. Resident 41, who was also cognitively intact per the MDS, had Biofreeze Cool the Pain on the bedside table and stated he brought it with him to the facility and applied it to his hand when it hurt. The order summary showed no physician's order for Biofreeze or for self-administration. Staff verified the medication was open and not sealed, acknowledged it should have been accounted for, and confirmed there was no physician's order or self-administration assessment for the resident.
Incomplete Advance Directive and conflicting POLST
Penalty
Summary
The facility failed to ensure that one resident’s Advance Directive and POLST were complete and consistent. Resident 32’s Advance Directive Durable Power of Attorney for Health Care and Living Will, dated [DATE], showed the resident’s wishes for life-sustaining treatment in several scenarios, including that he would not want CPR, a breathing machine, kidney dialysis, feeding tubes, or artificial nutrition and hydration if unconscious, in a coma, or in a vegetative state with little or no chance of recovery, and would not want life-sustaining treatment if he needed a breathing machine and would be in bed for the rest of his life. The document also stated the resident wanted those preferences followed strictly, even if the decision maker thought otherwise. However, the Advance Directive was missing page two and did not identify who the resident selected as his health care agent. The resident’s POLST, signed by Family Member 1, stated to attempt resuscitation/CPR, provide full treatment with the primary goal of prolonging life, and use long-term artificial nutrition including feeding tubes. The facility record also showed the resident had no capacity to understand and make decisions. Social services documented that the resident’s Advance Healthcare Directive contradicted the POLST and discussed this with Family Member 1, who wanted to continue with the current POLST. The SSD stated Family Member 1 was the resident’s health care agent, but the Advance Directive in the record did not show that designation; a later copy provided by the facility showed a prior, now void Advance Directive listing Family Member 2 as the designated health care agent and Family Member 1 as the alternate.
Unnecessary Psychotropic Medication Monitoring and Documentation Deficiencies
Penalty
Summary
The facility failed to ensure two sampled residents were free from unnecessary psychotropic medication use. For Resident 7, who had no capacity to understand and make decisions and had orders to monitor and document psychotic behaviors evidenced by angry outbursts, the medical record showed episodes of angry outbursts on multiple shifts, but there was no documented evidence of nonpharmacological interventions when those episodes occurred. Resident 7 was also ordered quetiapine 25 mg at bedtime for schizoaffective disorder manifested by angry outburst, and the care plan included documenting behaviors and resident response to interventions, but the record did not show what nonpharmacological interventions were attempted during the outbursts. For Resident 8, the record showed orders to monitor for episodes of anxiety evidenced by agitation and angry outbursts and to administer Ativan 1 mg every eight hours as needed for anxiety with manifested behavior of agitation and angry outbursts. The MAR showed Ativan was given on several occasions, but the medical record did not show the episodes of anxiety were monitored and documented when the medication was administered. The care plan also included nonpharmacological interventions such as redirection, reassurance, a calm approach, and other measures, but the record did not show the manifested behaviors were addressed by either those interventions or by administering Ativan as prescribed. RN 1 and the DON were informed and acknowledged the findings.
Care Plan Not Updated for New AV Fistula
Penalty
Summary
The facility failed to ensure the comprehensive plan of care was revised to reflect the current care needs and interventions for one resident with renal failure who received dialysis. The resident had a care plan problem dated 10/29/24 addressing dialysis needs related to renal failure, and the resident’s history and physical dated 10/10/25 showed the resident could make needs known and make medical decisions. During the initial tour on 3/11/26, the resident was observed with an upper right chest perma-catheter and stated that she goes to dialysis and uses the perma-catheter for dialysis. She also stated that she had a new left upper arm fistula. Review of the resident’s arteriovenous access creation/surgery discharge instructions dated 2/10/26 showed left arm AV fistula creation with instructions not to lift anything or strain the access arm. Review of the care plan showed it was not updated to include interventions or precautions for the new left arm AV fistula. RN 1 verified there were no interventions developed to address the left arm AV fistula, and the DON acknowledged the findings.
Competency Deficiencies in Glucometer Calibration and IV Medication Administration
Penalty
Summary
The facility failed to ensure two licensed nurses reviewed for competency had the specific competencies and standard of practice skill sets needed to provide safe and efficient nursing care. The report states the facility did not ensure LVN 3 was able to demonstrate competency in calibrating a glucometer accucheck machine used to measure blood glucose, and did not ensure RN 2 was able to competently administer the correct IV medication dosage to Resident 101. For LVN 3, the surveyor observed a glucometer quality control process and reviewed the glucometer quality control record with the LVN. When asked to calibrate the glucometer, LVN 3 stated she did not know how to calibrate it and could not recall whether she had been taught. The DON later reviewed LVN 3's file and stated she had provided training and performed the glucometer calibration skills check upon hire, annually, and as needed, but the competency record reviewed did not show that glucometer calibration had been observed or reviewed for LVN 3. For RN 2, the surveyor observed administration of ertapenem IV 500 mg to Resident 101. The pharmacy label directed that 5 ml of the reconstituted medication be transferred into 50 ml NS piggyback and infused over 30 minutes. RN 2 instead diluted the vial with 10 ml NS, aspirated the entire 10 ml amount, and mixed it into the 50 ml NS piggyback. RN 2 stated she would run the whole bag for 30 minutes and acknowledged after being stopped that she should have removed the other 5 ml after dilution. The DON reviewed RN 2's IV skills checklist and stated she was responsible for checking off licensed nurse competencies.
Incorrect IV Antibiotic Dosage Prepared and Observed
Penalty
Summary
RN 2 failed to administer Resident 101’s IV ertapenem at the correct dosage according to the physician’s order during medication administration observation. The facility’s medication administration policy required medications to be given in accordance with the attending physician’s written orders. Resident 101 was readmitted with Stage 1 CKD and had a physician’s order for ertapenem sodium injection solution reconstituted 500 mg IV once daily for a lower UTI, ESBL of the urine, until 3/17/26. During the observation, RN 2 stated she was administering ertapenem 500 mg IV and prepared the medication by diluting the one-gram vial with 10 mL of NS, aspirating the entire 10 mL from the vial, and mixing it into a 50 mL NS piggyback bag. The pharmacy label indicated the vial should be reconstituted and 5 mL (500 mg) transferred into 50 mL NS for infusion over 30 minutes. RN 2 stated she would run the whole bag and was stopped by the surveyor before administration. RN 2 acknowledged she should have removed the other 5 mL after reconstitution. Resident 101’s labs showed elevated BUN and creatinine, and the pharmacy consultant and DON were informed of the findings.
Medications Stored Without Open Dates
Penalty
Summary
The facility failed to provide necessary pharmacy services to ensure proper labeling of medications for three residents. During an observation of Medication Cart A, a LVN and surveyor found that the geri-tussin liquid bottle for one resident, the gabapentin oral solution bottle for another resident, and the megestrol acetate suspension bottle for a third resident were not labeled with an open date. The LVN verified the findings and stated the medications should be labeled with open dates. Medical record review showed that the first resident had an order for geri-tussin oral liquid every six hours as needed for cough, the second resident had an order for gabapentin oral solution every eight hours for neuropathic pain, and the third resident had an order for megestrol acetate suspension once daily for appetite stimulant. The DON stated that house stock medications were tracked by the manufacturer's expiration date and did not need open dates, but that resident-specific medications should be labeled with open dates because some medications are only good for certain days and the open date could also indicate whether medications were being administered properly or correctly regarding the ordered frequency and amount.
Dumpster Lid Left Open
Penalty
Summary
The facility failed to ensure that garbage and refuse were properly disposed for one of three outside garbage dumpsters. During an observation of the dumpsters located on the side of the facility, one blue garbage dumpster was observed with its lid open and not fully closed. A later observation and concurrent interview with the DSS confirmed that the lid of the blue garbage dumpster was partially propped open with bags of trash. The facility's policy for Miscellaneous Areas stated that garbage and trashcans must be inspected daily to ensure no debris is on the ground or surrounding area and that the lids are closed.
Incomplete and inaccurate resident medical record documentation
Penalty
Summary
The facility failed to ensure Resident 5’s medical record accurately reflected the location of the blood pressure access site. Resident 5 had a right chest perma-catheter and a new left upper arm fistula, and the care plan directed staff not to draw blood or take blood pressure in the left arm. However, the March 2026 blood pressure documentation repeatedly recorded readings taken on the left arm. During interview, Resident 5 stated she never allowed nurses to take her blood pressure on the left upper arm, and RN 1 verified the documented left-arm blood pressures were inaccurate. The facility also failed to properly document a narcotic record for Resident 42. Resident 42 had an order for oxycodone-acetaminophen 10-325 mg every four hours as needed for moderate to severe pain, and the MAR showed the medication was administered on 3/10/26 at 1246 hours. When the Narcotic and Hypnotic Record was reviewed, the entry showed the medication was given with an initial, but the time the medication was given was left blank. LVN 3 verified the omission. In addition, the facility failed to maintain complete and accurate advance directive documentation for Residents 32 and 107. Resident 32’s record included a POLST stating the resident had an advance directive dated 2024 and naming Family Member 1 as the legally recognized decision maker, but the Durable Power of Attorney for Health Care and Living Will was missing page two and did not show who was selected as healthcare agent. Resident 107’s POLST stated the resident did not have an advance directive, but the resident told staff she did have one at home, and the SSD stated the POLST should have reflected that an advance directive existed but was not currently available for review.
Failure to Complete QAPI Audits and Monitor Corrective Actions
Penalty
Summary
The facility failed to implement its QAPI plan and the past recertification survey plan of correction for F554 and F761. The survey team identified repeat deficient practices from the prior recertification survey conducted from 9/23/24 to 9/26/24, including F554 and F671. The facility's 2024 Recertification Survey POC, accepted on 11/27/24, stated that Medical Records would perform chart reviews upon admission to check for any new orders and that the DON or designee would report findings to the QA&A Committee monthly for six months. It also stated that the RN Supervisor or designee would randomly check medication carts weekly for eight weeks and then monthly to ensure proper medication storage, with findings reported to the QA&A Committee monthly for six months. On 3/17/26, the survey team reviewed the facility's QAPI binder and supporting documents with the Administrator, who was unable to provide records showing that Medical Records completed chart reviews of new admissions for new orders or that the RN Supervisor or designee completed the medication cart checks as outlined in the POC. The Administrator stated the audits were part of the routine process and did not have records to show they were completed.
Infection Control Lapses in UTI Surveillance, Medication Storage, and Hand Hygiene
Penalty
Summary
The facility failed to ensure infection prevention and control practices were followed in multiple areas. Review of the Infection Prevention and Control Program showed the facility used McGeer's Criteria for infection surveillance and reported infection data to QAPI. For Resident 47, the Infection Prevention and Control Surveillance Log for January 2026 showed antibiotics were started for a HAI UTI, and the Surveillance Data Collection Form stated the resident had urinary urgency and frequency beginning on 1/4/26 and met criteria for a true infection. However, review of the resident's medical record did not show urinary urgency or frequency and did not show that the resident met criteria for a UTI. During interview and record review, the IP and DSD verified the surveillance form showed the UTI met criteria for a HAI infection, but also verified the medical record did not support those symptoms and that the UTI had been incorrectly reported to QAPI as a HAI UTI. The facility also failed to keep Medication Cart A and a liquid iron bottle free of spillage, and failed to follow hand hygiene and glove-changing practices during medication administration. On observation, Medication Cart A's fourth small drawer had multiple medication spillages, and one large bottle of liquid iron supplement had sticky spillage all over it. LVN 3 verified the cart should be maintained clean and free of spillage. During medication administration for Resident 87, LVN 4 performed hand hygiene and donned new gloves, stopped the tube feeding pump, repositioned the resident, and raised the bed, then checked the GT for residual and administered medications without performing hand hygiene or changing gloves after touching the resident's surroundings. LVN 4 acknowledged the lapse, and the IP, DON, and Administrator later acknowledged the findings.
Confidential Resident Rosters Left in Public Survey Binder
Penalty
Summary
The facility failed to protect residents' identifiable information when its Survey Inspection Results binder, placed on top of Nursing Station 1 countertop and posted for public view, contained three confidential resident rosters. Review of the undated binder showed a Concurrent Relicensing and Recertification Survey roster dated 9/24/24 - 9/26/24 with six resident identifiers and names, an Abbreviated Survey dated 7/9/25 with two resident identifiers and names, and an Abbreviated Survey dated 2/5/26 with three resident identifiers and names. The rosters were marked confidential and had "Confidential" printed diagonally across each page in large gray font. During interview and document review, the Administrator verified that the three confidential resident rosters should not have been in the survey binder for public view.
Unlabeled and Improperly Stored Oxygen Tubing
Penalty
Summary
The facility failed to provide necessary respiratory care and services for one sampled resident who had an order for oxygen at 2 LPM via nasal cannula as needed for angina. The resident’s history included respiratory failure, hypoxia, and angina, and the care plan addressed as-needed oxygen therapy related to those conditions. During the initial tour, the resident’s nasal cannula tubing was observed unlabeled and undated, and it was placed on top of the resident’s bed rather than stored in a set-up bag when not in use. The resident stated that the cannula was removed when eating and that there was no set-up bag available to place it in. The facility’s policy for oxygen required oxygen cannulas or masks to be changed at least every seven days, with tubing and other disposables dated in an identifiable fashion, and labeled and dated bags provided for cannulas and masks when not in use. During observation and interview, an LVN confirmed the nasal cannula tubing was not labeled with the date it was changed and was not stored in a set-up bag, and stated it should have been labeled and stored in a bag for cleanliness, sanitation, and infection control purposes. The DON was later informed of and acknowledged the findings.
Failure to Care Plan for Alleged Abuse Incident
Penalty
Summary
The deficiency involves the facility’s failure to develop a comprehensive care plan addressing an alleged abuse incident for one resident. The facility’s care planning policy, revised in 2/2021, requires the IDT to develop a comprehensive care plan for each resident. The resident was admitted on an unspecified date and had an H&P dated 10/17/25 indicating the resident did not have the capacity to understand and make decisions. On 1/9/26, a progress note documented that police arrived around noon after the resident’s wife reported to them that the resident had been abused, bruised, and burned. An eINTERACT Change in Condition Evaluation dated 1/9/26 documented right hand discoloration. Progress notes from 1/9 and 1/13–1/15/26 showed that Social Services provided psychosocial support to the resident. Further review of the medical record showed there was no documentation of psychosocial support from 1/10–1/12/26 following the alleged abuse incident on 1/9/26, and no care plan was developed to address the alleged abuse. During an interview and concurrent record review on 2/3/26, an RN confirmed there was no care plan related to the alleged abuse and stated that a licensed nurse should have created one so staff could monitor the resident and have goals and interventions in place. In a separate interview on 2/3/26, the DON also verified that no care plan was developed for the alleged abuse, explaining that staff did not create an alleged abuse care plan because the allegation was unsubstantiated, no harm was identified, and there was no change in condition. The DON stated that psychosocial support was provided daily by the social worker and that a care plan was completed for the resident’s hand discoloration, but not for the alleged abuse itself.
Failure to Follow Oxygen Administration Orders and Documentation Protocols
Penalty
Summary
The facility failed to follow physician orders and its own policies regarding the administration and documentation of supplemental oxygen for four residents. For three residents, oxygen was administered at higher flow rates than prescribed by their physicians. Specifically, one resident with an order for continuous oxygen at 2 liters per minute (LPM) was observed receiving 5 LPM, while two other residents with orders for 2 LPM PRN were observed receiving 4 LPM and 3 LPM, respectively. Nursing staff confirmed that they had not adjusted the oxygen flow during their shifts, and medical record reviews verified that the physician orders were not followed. For another resident, there was a lack of proper documentation regarding the administration of PRN oxygen. Although the medical record and various nursing summaries indicated that the resident received oxygen daily over a period of several weeks, the Medication Administration Record (MAR) only documented a single instance of PRN oxygen administration. Interviews with nursing staff and the Director of Nursing confirmed that the resident was on continuous oxygen, despite the physician's order specifying PRN use, and that the MAR did not accurately reflect the frequency of administration. These deficiencies were identified through direct observation, interviews with nursing staff, and review of medical records and facility policies. The facility's policies required that oxygen be administered as ordered by the physician and that all medication administration be properly documented. The failure to adhere to these protocols resulted in both inaccurate administration of oxygen and incomplete documentation for the affected residents.
Failure to Administer Medications and Notify Physician
Penalty
Summary
The facility failed to provide necessary care and services for a resident by not administering medications as per the physician's orders on two consecutive days. The medications were not delivered on time, and the facility did not follow its policy to notify the prescriber when medication delivery was delayed. This oversight was identified during a review of the facility's policies and procedures, which stated that the prescriber should be contacted for direction when medication delivery is delayed. The facility's failure to adhere to this policy resulted in the resident not receiving critical medications for conditions such as hypertension, diabetes, and depression. The resident, who had a history of Type II diabetes mellitus, hypertension, and hyperlipidemia, was admitted to the facility and later transferred to an acute care facility. The resident's medical records indicated fluctuating capacity to understand and make decisions. Despite having physician's orders for multiple medications, including antihypertensives, antidiabetics, and antidepressants, the medications were not administered due to pending delivery status. The facility's Medication Administration Record (MAR) and electronic MAR (eMAR) showed that several medications were marked as pending delivery, and there was no documentation of physician notification regarding the missed doses. The Director of Nursing (DON) confirmed that the resident's medications were not administered due to pending delivery and acknowledged that the physician was not notified. The DON also stated that the resident's family was responsible for providing medications, and the facility would order and notify the physician if medications were not brought in a timely manner. However, this process was not followed, and the resident's blood sugar levels were not monitored until the day of transfer to the acute care facility, where a high blood sugar reading was recorded. The failure to administer medications and notify the physician as per the facility's policy had the potential to negatively impact the resident's health condition.
Failure to Implement Fall Prevention Measures for Residents
Penalty
Summary
The facility failed to ensure that three residents remained free from accident hazards, as evidenced by observations and interviews. Resident 3's care plan included interventions such as keeping the bed in the lowest position and using bilateral floor mats. However, during an observation, the bed was not in the lowest position, and the right-side floor mat was folded up against the wall. The Director of Nursing (DON) and the Administrator confirmed these findings, indicating a failure to adhere to the care plan designed to mitigate fall risks. Resident 4's care plan required maintaining a clear pathway free of obstacles to prevent falls. Despite this, an observation revealed that the bedside table was placed on top of the floor mat, with one end of the mat flipped up. RN 1 verified the improper placement of the table and expressed concern about the resident's fall risk due to frequent movement. This situation demonstrated a lack of compliance with the care plan's safety measures. Similarly, Resident 5's care plan included keeping the bed in the lowest position and ensuring a clear pathway. However, the bed was observed not in the lowest position, and the bedside table was placed on top of the floor mat. CNA 2 confirmed these observations and adjusted the bed and table accordingly. The DON acknowledged that the table should not be on the floor mat, highlighting a failure to implement the prescribed interventions to prevent falls.
Inaccurate Medication Administration Record for a Resident
Penalty
Summary
The facility failed to ensure the accuracy of the Medication Administration Record (MAR) for one of the sampled residents, identified as Resident 2. This deficiency was identified through interviews, medical record reviews, and a review of the facility's policies and procedures. The facility's policy on documentation, dated May 2007, requires that a resident's clinical record be a concise and accurate account of treatment and care. However, discrepancies were found in Resident 2's MAR for November 2024. Specifically, medications that were documented as pending delivery were erroneously recorded as administered. Resident 2, who was admitted for respite care, had fluctuating capacity to understand and make decisions. The resident's Order Summary Report indicated prescriptions for carvedilol and ezetimibe. Despite the MAR showing these medications as administered on specific dates, interviews with the Director of Nursing (DON) confirmed that the medications were not actually administered due to pending delivery. This error in documentation was acknowledged by both the DON and the Administrator Assistant during a review of the closed medical record.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to its policies and procedures (P&P) regarding food safety and sanitation in the kitchen, which posed a risk of food-borne illnesses to its residents. The thawing process for meats was not followed correctly, as evidenced by a bag of thawed chicken labeled with an outdated use-by date. The Director of Support Services (DSS) confirmed that the chicken should have been discarded, and an employee admitted to incorrectly labeling the chicken. Additionally, the facility's P&P required daily checks of the refrigerator to discard perishable foods, which were not adequately performed. The facility also failed to maintain kitchen utensils and equipment in sanitary conditions. Observations revealed that storage bins for clean cooking utensils contained dry particles, and the plate warmer had debris and broken plate pieces. The DSS confirmed these findings, and the Maintenance Director stated he had not been informed to clean the plate warmer recently. Furthermore, fans inside refrigerators and freezers were found with fuzzy substances, indicating a lack of regular cleaning, which the DSS verified. The facility did not ensure that food preparation equipment was in good condition. Cutting boards were heavily marred with knife marks, and a spatula was cracked, both of which were confirmed by the DSS. Additionally, a bag of frozen ham with freezer burn was found, indicating improper storage. The facility also failed to provide an air gap for backflow prevention in a food preparation sink, which was used for washing vegetables and fruits. These deficiencies were acknowledged by the Administrator, DON, and DSS.
Infection Control Deficiencies in Surveillance and Practices
Penalty
Summary
The facility failed to implement its infection control surveillance program effectively from January through August 2024. The surveillance was limited to residents prescribed antimicrobials, excluding those with signs and symptoms of infection who met McGeer's criteria but were not on antimicrobial medications. Additionally, the facility did not accurately track and monitor infections for February, May, and June 2024, as evidenced by incomplete documentation on the Infection Prevention and Control Surveillance Log regarding whether residents had healthcare-associated infections (HAI), community-acquired infections (CAI), or did not meet McGeer's criteria. The facility also failed to implement proper infection control practices for a resident under transmission-based precautions. During a medication administration observation, a licensed vocational nurse (LVN) did not don a gown as required for a resident with enhanced barrier precautions for a gastrostomy tube (GT). This oversight was acknowledged by the LVN during an interview, indicating a lapse in adherence to infection control protocols. Furthermore, the facility did not ensure staff performed hand hygiene during a GT dressing change for a resident. An LVN was observed changing gloves multiple times without performing hand hygiene in between, contrary to the facility's infection control policy. The supplies used during the dressing change were also placed on an unsanitized surface, which was not in line with the expected standards. These actions were confirmed by the Infection Preventionist (IP) and the Director of Nursing (DON) during interviews, highlighting a failure to follow established infection control practices.
Failure to Ensure Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure the safe self-administration of medications for one resident, identified as Resident 77. During an observation, medications were found inside a medicine cup at the resident's bedside without an assessment, physician's order, or care plan problem addressing the self-administration of medications. This oversight was confirmed by RN 1, who acknowledged that the medications should not have been left at the bedside. A review of Resident 77's medical records revealed that there was no documented evidence of a physician's order, assessment, or care plan problem for self-administration of medications, despite the resident having the capacity to understand and make decisions as per their H&P examination. The Director of Nursing (DON) verified the absence of these critical documents, indicating a lapse in following the facility's policy and procedure for self-administration of medications.
Failure to Incorporate PASARR Recommendations into Care Plan
Penalty
Summary
The facility failed to ensure that the recommendations from the Preadmission Screening and Resident Review (PASARR) Level II determination were followed and incorporated into the care plan for a resident diagnosed with schizophrenia, anxiety disorder, and major depressive disorder. The resident was admitted and readmitted to the facility, and a PASARR Level II Evaluation was conducted, which recommended special services due to the resident's medical and mental health conditions. However, the facility did not document the incorporation of these recommendations into the resident's care plan, nor was there evidence of an interdisciplinary team (IDT) meeting to discuss the PASARR Level II recommendations. Interviews with the MDS Coordinator and the Director of Nursing (DON) confirmed the lack of documentation and follow-up on the PASARR recommendations. The MDS Coordinator acknowledged that the facility should have obtained and printed the determination results and incorporated them into the resident's care plan. The DON was informed of these findings and acknowledged the deficiency. This oversight had the potential to impact the adequacy of care provided to the resident.
Failure in Gastrostomy Tube Care
Penalty
Summary
The facility failed to provide appropriate care and services related to the use of a gastrostomy tube (GT) for one resident. Specifically, the facility did not ensure that the GT was checked for placement prior to medication administration, nor was it flushed with at least 5 ml of water between each medication as per the facility's policy and procedure (P&P). Additionally, the GT was not flushed with 20 to 30 ml of water following medication administration as per the physician's order. These actions were observed during a medication administration session conducted by an LVN for the resident. The resident involved was admitted to the facility on an unspecified date and readmitted on another unspecified date. A review of the resident's order summary report showed a physician's order dated July 4, 2024, which required checking the tube placement before medication administration and flushing the tubing with 20 to 30 ml of water after medications. During an interview, the LVN verified the findings, confirming the failure to adhere to the established procedures for GT care, which had the potential to affect the resident's health and well-being.
Failure to Monitor PICC Line in Resident
Penalty
Summary
The facility failed to provide necessary care and services related to a PICC line for a resident, identified as Resident 537. Upon admission, the facility did not obtain the measurement of the resident's right upper arm circumference, which is crucial for monitoring potential complications such as deep vein thrombosis. Additionally, the facility did not develop a care plan problem to address the use of the PICC line catheter, which is essential for ensuring proper management and monitoring of the device. During an observation on 9/23/24, Resident 537 was noted to have a PICC line on the right upper arm, covered with a transparent dressing. Despite physician orders requiring daily measurement of the external catheter and site dressing, as well as administration of antibiotics for leukocytosis and MRSA, the medical record lacked documentation of the arm circumference measurements. An interview with RN 2 confirmed that these measurements were not taken, highlighting a lapse in the facility's adherence to care protocols for residents with PICC lines.
Failure to Monitor Dialysis Care and Fluid Restriction
Penalty
Summary
The facility failed to provide adequate dialysis care and services for a resident, identified as Resident 63, who required such services. The deficiencies were identified through observation, interviews, medical record reviews, and a review of the facility's policies and procedures. Specifically, the facility did not monitor Resident 63's fluid intake as per the physician's order, which restricted fluid intake to 1200 ml per 24 hours. The resident's fluid intake exceeded this limit on multiple occasions, with recorded intakes ranging from 1220 ml to 1500 ml on various dates. Additionally, there were several instances where the facility failed to document the resident's fluid intake for specific shifts and dates. Furthermore, the facility did not ensure that Resident 63's dialysis access site was assessed before and after dialysis treatments as required. The medical records lacked documentation of assessments for the dialysis site on several pre- and post-dialysis dates. These failures were acknowledged by LVN 2 during an interview and concurrent medical record review, indicating a lapse in following the facility's policy to maintain the resident's well-being and ensure proper dialysis care.
Failure to Implement Alternatives Before Bed Rail Use
Penalty
Summary
The facility failed to implement alternative measures before resorting to the use of bed rails for two residents, which is a violation of their policy. The policy requires that appropriate alternatives be attempted prior to the installation of bed rails. For Resident 63, who was observed with bilateral bed rails elevated, the medical record review showed a physician's order for the use of bed rails as an enabler for bed mobility and positioning. However, the Bed Rail Safety Evaluation did not document any alternative interventions attempted before the use of bed rails. Similarly, Resident 537 was observed with bilateral bed rails elevated, and the medical record review revealed a physician's order for grab bars as an enabler for bed mobility and positioning. The Bed Rail Safety Evaluation for this resident also lacked documentation of any alternative interventions attempted prior to the use of bed rails. An interview with RN 2 confirmed these findings, indicating a failure to adhere to the facility's policy of attempting alternatives before using bed rails.
Failure to Ensure Physician's Order for Nasal Spray
Penalty
Summary
The facility failed to ensure that a resident was provided medications as ordered by the physician. Specifically, the resident had three bottles of nasal moisturizing spray in her bedside drawer without a physician's order for its use. The facility's policy requires medications to be administered as prescribed by the attending physician, and the resident's medical records did not include an order for the nasal spray. The resident was deemed safe to self-administer medications and had no cognitive impairment, as per evaluations conducted prior to the incident. However, the absence of a physician's order for the nasal spray was confirmed during an interview and medical record review with an LVN.
Medication and Supply Storage Deficiencies
Penalty
Summary
The facility failed to ensure the safe storage of medications and supplies, as observed during an inspection. The IV Cart contained expired supplies and items without manufacturing or expiration dates, including 78 Red Plus Luer Lock Caps, five Vial Mate Adapters, and seven BD Vacutainer Luer Lock Access Devices. Additionally, two BD Blue Insyte Autoguard Winged Catheters were found with past expiration dates. These findings were verified by RN 4. Furthermore, an opened bottle of Gerilanta, a laxative medication, was found in Medication Cart 2 without an open date, as confirmed by LVN 2. These deficiencies had the potential to result in unsafe administration of medications.
Failure to Follow Fortified Diet Plan
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the fortification of food for residents requiring additional caloric and protein intake. Specifically, the facility did not follow the prescribed fortified diet for a resident diagnosed with unspecified protein-calorie malnutrition. The facility's policy outlined that fortification should be done on an individual basis for residents who cannot consume adequate amounts of calories and/or protein. The resident in question had a physician's order for a fortified, puree texture diet with nectar thick consistency, which was not followed as the margarine was not added to the red beans and rice entree as required. During an observation of the lunch meal tray line, it was noted that the dietary staff did not add the necessary margarine to the resident's meal, which was confirmed by the Dietary Services Supervisor (DSS). The DSS acknowledged that the cook should have added the margarine before the tray was delivered. Interviews with the Director of Nursing (DON) and the Administrator confirmed the expectation that residents with fortified diet orders should receive meals prepared according to those specifications. The failure to follow the fortified diet plan was acknowledged by the facility's administration.
Failure to Follow Dietary Texture Guidelines
Penalty
Summary
The facility failed to adhere to dietary texture guidelines for a resident on a pureed diet, as per the facility's policy and procedure. The resident, who was diagnosed with dysphagia affecting the oropharyngeal phase, was prescribed a fortified, pureed diet with nectar thick liquids. During an observation of the lunch meal tray line, it was noted that the resident's meal did not meet the required consistency. Specifically, the beans and rice on the plate were runny and mixed into the pureed pork with gravy, which did not hold its shape as required for a pureed diet. The deficiency was identified during a review of the resident's medical records and a direct observation of the meal service. The Dietary Services Supervisor (DSS) confirmed that the pureed entree should maintain its shape and acknowledged that the beans and rice were not prepared to the correct consistency. The facility's Administrator, Director of Nursing (DON), and DSS were informed of these findings, which highlighted a failure to provide food in a form designed to meet the individual needs of the resident, potentially leading to choking or aspiration.
Deficiency in Safe Food Handling Education for Outside Food
Penalty
Summary
The facility failed to ensure that education was provided to staff and family/visitors on safe food handling of outside food, as per the facility's policy and procedure (P&P). The facility's P&P required that foods brought by family or visitors be accepted by the resident, inspected before storage, and stored and served according to food safety professional standards. However, interviews revealed that the Dietary Services Supervisor (DSS) did not provide specific education on proper cooking and cooling temperatures, nor did she provide literature on safe food handling practices to family/visitors. Additionally, the Licensed Vocational Nurse (LVN) indicated that the Registered Dietitian (RD) or designee was responsible for discussing safe food handling guidelines with visitors, but there was no evidence of this education being provided. Further interviews with the Director of Staff Development (DSD) and Director of Nursing (DON) revealed gaps in staff education regarding safe food handling practices. The DSD stated that she reviewed the facility P&P with staff but did not provide education on safe cooking and cooling temperatures. The DON confirmed that reheating of food was done by kitchen staff, and if residents wanted to consume food after kitchen hours, the facility was unable to reheat it. These deficiencies in education and communication had the potential to cause foodborne illnesses among the medically vulnerable resident population.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement its antibiotic stewardship program effectively, as evidenced by the lack of proper assessment using McGeer's criteria to determine true infections. This deficiency was identified through interviews, medical record reviews, and facility document reviews. The facility's policy, dated September 2017, outlined the need for an Antibiotic Stewardship Program to promote appropriate antibiotic use and optimize infection treatment. However, the facility did not adhere to this policy, as shown by the incomplete assessments on the Surveillance Data Collection Forms for several residents. These forms were intended to assess whether infections met the criteria for community-acquired infection (CAI) or healthcare-associated infection (HAI), but many forms were incomplete or incorrect. The medical records of several residents revealed that antibiotics were prescribed without meeting the necessary criteria. For instance, one resident was prescribed cefuroxime despite only meeting one of the required criteria for infection. Other residents were prescribed antibiotics such as azithromycin, ofloxacin, doxycycline, and vancomycin, but their forms did not indicate whether the infections were CAI, HAI, or did not meet the criteria. Interviews with the Infection Preventionist (IP), Director of Staff Development (DSD), and Director of Nursing (DON) confirmed these findings, indicating a systemic issue in the facility's antibiotic stewardship practices.
Failure to Obtain Informed Consent for Increased Psychotropic Medication Dosage
Penalty
Summary
The facility failed to properly obtain informed consent for the use of psychotropic medications for one of the residents, identified as Resident 23. According to the facility's policy and procedure, informed consent must be obtained before initiating or changing the dosage of psychotropic medications. Resident 23 was admitted to the facility and later seen by a physician who noted increased anxiety and pain, leading to a decision to increase the dose of diazepam from 10 mg to 15 mg twice a day. However, the medical records showed that informed consent was only obtained for the initial 10 mg dose, and there was no documented evidence of consent for the increased 15 mg dose. Interviews with the Licensed Vocational Nurse (LVN 1) and the Director of Nursing (DON) confirmed the oversight. LVN 1 verified the physician's order for the increased dose and acknowledged that informed consent should have been obtained when the dose was increased. The DON was also informed of the findings and verified the lack of documented consent for the increased dosage. This failure posed a risk for Resident 23 and their responsible parties to not be fully informed of the medication changes and potential side effects.
Failure to Maintain Advance Directives in Medical Record
Penalty
Summary
The facility failed to obtain and maintain copies of the advance directive in the medical record for one of the sampled residents, identified as Resident 10. This deficiency was identified through interviews, medical record reviews, and a review of the facility's policies and procedures (P&P) regarding advance directives. According to the facility's P&P, it is required that a resident's advance directives be included in their medical record. However, despite indications in Resident 10's assessments that advance directives existed, the facility did not have a copy of these directives in the resident's medical record. Resident 10 was admitted and readmitted to the facility, with medical records indicating a Do Not Resuscitate (DNR) status and comfort-focused treatment preferences. The resident's social services assessments noted the existence of advance directives and included instructions to obtain a copy for the medical record. However, the facility failed to follow up and secure a copy of the advance directives, as confirmed by interviews with the Social Services Director (SSD) and the Director of Nursing (DON). This oversight had the potential to cause confusion or failure to provide care in accordance with the resident's treatment wishes.
Failure to Conduct Timely Neuro-Checks Post-Fall
Penalty
Summary
The facility failed to adhere to its 72-hour Neuro-check Monitoring process following a fall incident involving a resident. The protocol required neuro-checks to be conducted every 30 minutes for two times, every hour for three times, every two hours for two times, every four hours for four times, and every eight hours for six times. However, the neuro-checks for the resident were only conducted at 0300, 0330, 0630, 0930, and 1230 hours, which did not meet the specified time frames. This lapse in monitoring occurred after the resident fell from a wheelchair and hit their left hip on the floor. The resident, who had been admitted with diagnoses including Parkinson's disease, OPD, lack of coordination, difficulty in walking, cognitive communication deficits, muscle weakness, and osteoarthritis, was transferred to an acute care hospital later that day. Interviews with the LVN and the DON confirmed that the neuro-checks were not performed according to the facility's protocol. The failure to conduct timely neuro-checks had the potential for medical complications to go unnoticed post-fall.
Inaccurate Medication Administration Documentation
Penalty
Summary
The facility failed to ensure the accuracy of medication administration documentation on the Medication Administration Record (MAR) for a resident. The facility's policy and procedure (P&P) for medication administration requires that the individual administering the medication records the administration on the MAR immediately after giving the medication. Additionally, when PRN medications are administered, the date, time, dose, route, complaint, and results achieved must be documented. However, in this case, the documentation was not completed accurately or timely. A resident had a new order for Norco 10 mg/325 mg for severe pain, which was documented in the nurse's notes. The medication was taken from the emergency kit at 1110 hours, but the MAR inaccurately showed the medication was administered at 1230 hours. Interviews with the LVN and the Director of Nursing (DON) revealed that the medication was given immediately after being taken from the E-kit, but the nurse was busy and did not document the administration until later. This discrepancy in documentation posed a risk of error in medical care and delay in treatment.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Nursing homes near Fullerton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Gordon Lane Care Center | 1.2 mi | ★★★★★ | 0 | 0 |
| Terrace View Care Center | 1.7 mi | ★★★★★ | 28 | 0 |
| Greenfield Care Center Of Fullerton, Llc | 1.7 mi | ★★★★★ | 15 | 0 |
| The Pavilion At Sunny Hills | 1.8 mi | ★★★★★ | 9 | 0 |
| Leisure Court Nursing Center | 1.8 mi | ★★★★★ | 4 | 0 |
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