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 Elizabeth Healthcare Center during CMS and state inspections, most recent first.
Food safety and sanitation guidelines were not followed in the kitchen. An RD was observed without a beard restraint despite the facility dress code requiring facial hair to be covered. Kitchen equipment and utensils were also found in poor condition, including heavily marred cutting boards and wet stacked pans. In addition, several meat items in the reach-in refrigerator were past the facility’s thawing and use-by timeframe and were discarded.
Infection control practices were not maintained for multiple residents on TBP and EBP. A CNA hung a face shield outside a resident’s room without disinfecting it first, and the room trash can was overflowing with used PPE. For another resident on EBP with respiratory equipment and suction orders, a protective face mask was left on the nightstand near the nebulizer supplies. The clean linen curtain was left open, and a resident on EBP with an indwelling catheter had no EBP signage or isolation cart with PPE at the doorway while family members provided care without PPE.
Two residents with indwelling urinary catheters were observed with drainage bags left uncovered and visible in their rooms instead of being placed in dignity/privacy bags. One resident had a cognitive communication deficit and the other had urinary retention; both had physician orders for bedside catheter drainage. The DON and an LVN confirmed the bags were not enclosed, and the DON verified the findings.
Failure to assess bilateral bolster pillows as a possible physical restraint. A resident with limited mobility, stroke-related weakness, and a recent femur fracture was placed in bed bolster pillows after a fall. The resident stated the pillows restricted movement, prevented repositioning, interfered with sleep, and could not be removed by the resident. RN verified no restraint assessment was completed to determine whether the pillows functioned as a restraint, and there was no physician order for restraint use.
The facility failed to ensure PASRR Level 1 screenings were accurate for two residents. One resident had documented depression and PTSD, and another had documented mood disorder and PTSD, but both PASRR forms stated there was no diagnosed mental illness and were marked negative for PASRR Level 2 mental health evaluation. The DSD verified the diagnoses and confirmed the screenings were inaccurate.
A resident’s care plan was not revised after a physician changed the GT feeding rate and water flush orders. The plan still showed an older Jevity 1.5 regimen and flush amounts, and an RN confirmed it had not been updated to match the new order; the DON stated the licensed nurse should have updated the plan when the order was received.
A resident with impaired cognition, dependence for ADLs, and a physician order for a low air loss mattress was observed lying on the mattress in static mode with the pressure setting between 80 to 160 pounds, even though the resident weighed 93 pounds. Facility policy required the LPN to adjust the LAL mattress based on the resident’s weight and/or comfort, and staff confirmed the setting should be based on weight and comfort; the DSD/IP and DON verified the finding.
A resident with a GT feeding order and cognitive communication deficit was observed receiving Jevity 1.5 via pump, but the formula container was not labeled with the resident's name, infusion rate, date, time, or nurse initials as required by facility policy. The DON verified the missing label during observation and confirmed the nurse should have labeled the feeding when it was hung.
A resident with an order for IV hydration received inconsistent IV care and documentation. The IV bag was later found still hanging at the bedside and appeared full, with tubing not attached to the resident, no tubing cap, and no clear documentation that the IV had been started or discontinued. The DON and RN verified the MAR and intake records did not accurately reflect the ordered IV therapy or the resident’s fluid intake.
The facility failed to provide ordered respiratory care for two residents. One resident with COPD and respiratory failure was observed in the dining room without continuous O2 as ordered, and the DON later administered it there. Another resident was observed on O2 via NC with tubing and connectors that were not dated, which staff verified should have been dated.
A facility failed to have an RN onsite on the night shift to provide respiratory care for residents with oxygen titration orders. The facility assessment listed respiratory conditions it could care for, but the staffing plan showed no RN on nights, and the DON confirmed LVNs worked that shift and could not adjust oxygen liter flow or concentration in non-emergent situations. Two residents had orders and care plans requiring oxygen saturation monitoring and oxygen administration or titration based on saturation levels, and the DON verified no nurse onsite could provide those services at night.
A resident with ESRD and dependence on renal dialysis did not receive ordered daily meds, including ascorbic acid, cholecalciferol, cyanocobalamin, furosemide, and zinc sulfate, on multiple days when the MAR coded the resident absent for dialysis. The RN and DON verified the MAR findings and stated the meds should have been given when the resident returned from the dialysis center or adjusted around the dialysis schedule.
A resident was given hydrocodone-acetaminophen for severe pain even though the resident reported moderate pain on the facility pain scale. The MAR, care plan, and staff interviews showed the ordered pain scale was not followed; RN confirmed the opioid should not have been administered for a pain level of 6 and that acetaminophen or a provider call would have been appropriate. The resident also reported constipation and discomfort associated with taking hydrocodone.
Surveyors found expired skin care supplies in Treatment Cart A and the central supply room, including opened bottles of Stomahesive protective powder and Skin-Prep protective spray. Surveyors also observed a plastic bag with hydrophilic cream and zinc oxide cream left on a resident’s nightstand even though the resident’s record did not show physician orders for either cream. The resident had a cognitive communication deficit, and an LVN and RN both confirmed the creams should not have been left at bedside without orders.
Inaccurate medical record documentation was found for two residents. One resident's H&P was uploaded into another resident's electronic chart, and staff confirmed it should not have been there. Another resident's restraint/enabling device/safety device evaluation listed a low air loss mattress even though there was no current physician order for it, and staff verified the prior order had been discontinued.
Equipment Cleaning and Glucometer Calibration Deficiencies: The facility failed to clean and sanitize the ice machine per the manufacturer’s instructions, with the bin cleaned monthly instead of weekly as directed. The facility also failed to document daily glucometer calibration and QC for glucometers in Medication Cart A and Cart B, with missing results and absent control checks on two days, which an LVN verified during inspection.
Two residents with diabetes did not receive the required monitoring for signs and symptoms of hypoglycemia and hyperglycemia as outlined in their care plans. Nursing staff and the DON confirmed that the necessary assessments and documentation were not completed, despite the residents being at high risk for blood glucose fluctuations.
A resident who sustained a fall and subsequent femoral fracture did not have the possible cause of injury documented in the facility's initial investigation, and there was no evidence of IDT collaboration or meeting following the change in condition, as confirmed by the DON.
Nursing staff did not accurately document the administration of a controlled substance for a resident, as hydrocodone-acetaminophen tablets were signed out in the Controlled Drug Record but not recorded on the Medication Administration Record, contrary to facility policy. Staff and the DON confirmed the discrepancy during interviews and record reviews.
A resident with impaired mobility and incontinence waited nearly an hour for assistance after activating the call light following a bowel movement. Two CNAs responded but did not provide immediate care, instead turning off the call light and leaving to find the assigned CNA, resulting in a significant delay. The resident, who was cognitively intact, expressed distress over the prolonged wait and lack of timely care.
A resident received narcotic pain medications without documented evidence that nonpharmacological interventions (NPIs) were attempted first, despite physician orders requiring NPIs such as repositioning, relaxation, and distraction before medication administration. Nursing staff and the DON confirmed that NPIs should have been implemented and documented, but this was not reflected in the resident's medical record.
A resident received IV fluids at a rate higher than ordered, with the IV bag and administration set lacking required labeling. After the infusion was completed, the clamp remained open and the empty IV bag was not removed from the pole, leaving air in the tubing and the set still attached to the resident. Facility policy for IV administration and documentation was not followed.
Surveyors found that two residents did not have their respiratory equipment, including a Yankauer suction tip and nebulizer tubing, stored in bags or labeled with dates as required by facility policy. Staff confirmed the equipment was left exposed to air and undated, contrary to infection control protocols.
The facility did not adequately protect resident-identifiable information or maintain medical records according to professional standards, as observed by surveyors.
The facility failed to ensure three residents were free from unnecessary restraints, using Tab and pad alarms without obtaining necessary physician's orders, informed consent, or completing restraint assessments. A resident was observed with a Tab alarm without an active order or consent, while another had a pad alarm without documentation. A third resident had a Tab alarm with an order but no consent. Staff confirmed these deficiencies, indicating non-compliance with facility policies.
The facility failed to develop and implement comprehensive care plans for four residents, leading to deficiencies in their care. A resident refused essential care without a corresponding care plan, another experienced significant weight loss due to lack of meal assistance, a third lacked a care plan for oxygen and CPAP use, and a fourth had a care plan that did not address prescribed insulin use. These omissions risked the residents' receipt of appropriate and individualized care.
A resident's GT was not flushed between the last three of eight medications administered by an LVN, contrary to facility policy and NIH guidelines. This oversight could disrupt medication flow and clog the GT. The DON confirmed the findings.
A facility failed to implement the RD's recommendations for a resident who experienced severe weight loss. The RD's suggestions to fortify the diet and provide nutritional supplements were not communicated to the physician or documented in the medical record. This oversight was confirmed through interviews and record reviews, highlighting a lapse in following the facility's Nutrition Care Management policy.
A resident did not receive appropriate respiratory care due to incomplete physician orders for CPAP use and maintenance. The CPAP lacked a schedule for application and removal, and there was no documentation of its use over a specific period. Additionally, the CPAP cleaning instructions were incorrect, as the device did not have a humidified container but a filter, which was not cleaned due to the absence of a proper order.
A resident with spine fractures did not receive appropriate pain management as staff failed to assess pain levels or offer alternatives before administering oxycodone. The resident experienced delays and expressed frustration over the lack of assessment, which was confirmed by the DON.
The facility failed to ensure accurate documentation of controlled medications and secure storage of medication carts. A resident's oxycodone administration was not documented, and narcotic sheets lacked required signatures. Additionally, a medication cart was left unlocked, accessible to unauthorized individuals. These issues were confirmed by the DON and an LVN.
The facility failed to ensure two residents were free from unnecessary psychotropic medications. One resident lacked a specific goal to monitor the effectiveness of mirtazapine, while another did not have documented non-pharmacological interventions for escitalopram use. The facility's policies required psychotropic drug reviews and non-pharmacological interventions, but these were not followed, leading to deficiencies in medication management.
A facility's medication error rate was found to be 19.35%, exceeding the acceptable limit of 5%. An LVN failed to administer full dosages of six out of eight prescribed medications to a resident via GT, leaving medication residue in the cups. The DON confirmed these findings, highlighting a significant deficiency in medication administration practices.
The facility failed to properly label and store medications, as observed during an inspection. An LVN confirmed that a single-use Puracol wound dressing was improperly stored for reuse, and a jar of zinc oxide skin protectant lacked an expiration date. The DON verified these findings, indicating non-compliance with the facility's policies on medication access and storage.
The facility failed to maintain accurate medical records for two residents. One resident's POLST was not updated to reflect an existing advance directive, while another resident's wound care treatments were not properly documented in the TAR. Staff confirmed these documentation lapses, which could impact resident care.
The facility failed to maintain infection control practices, including not testing water temperatures as per policy, neglecting hand hygiene after glove removal, and not disinfecting medication vials before use. These deficiencies were acknowledged by staff and management.
A resident requested bilateral grab bars to assist with repositioning in bed, but the facility failed to follow up on this request. The resident expressed frustration as the request was not communicated to the physician. An LVN informed an RN, but no further action was taken, resulting in the resident's needs not being met.
A resident's privacy was compromised during medication administration via GT when an LVN failed to fully close the privacy curtain, leaving the resident exposed to the hallway. The incident was observed, and both the LVN and DON confirmed the lack of privacy.
A resident with severe cognitive impairment was sexually abused by another resident who had a history of inappropriate behavior. Despite this history, the facility did not take adequate precautions, leading to the incident. The facility's investigation confirmed the abuse, highlighting a deficiency in protecting residents from such incidents.
A resident's pressure injury worsened from Stage 1 to unstageable due to the facility's failure to ensure follow-up care by a wound specialist. Despite a physician's order, the wound specialist only evaluated the resident once, and no further visits were documented. Interviews confirmed the lack of follow-up, with the wound specialist being on vacation.
Food Safety and Sanitation Deficiencies in Kitchen
Penalty
Summary
Food safety and sanitation guidelines were not followed in the kitchen. During an observation and concurrent interview, the Registered Dietitian was seen in the kitchen without a beard restraint, despite the facility’s dress code requiring all facial hair to be covered with a beard restraint. The CDM Dietary Resource confirmed the RD was not wearing a beard restraint and stated that facial hair was expected to be covered while in the kitchen. Kitchen utensils and equipment were also observed in unsanitary condition. Four heavily marred cutting boards were seen during the initial kitchen tour, and four metal pans were observed stacked wet with dripping water during a later tour. The CDM Dietary Resource confirmed the wet pans, and the DSS confirmed the cutting boards had deep cuts and should have had a smooth surface. In addition, the meat thawing process was not followed: three sleeves of ground turkey, one box of diced beef, and one box of ground beef were found in the reach-in refrigerator past the facility’s three-day defrost and cook date. The items were verified as past due and were discarded.
Infection Control and Precaution Practices Not Maintained
Penalty
Summary
The facility failed to maintain infection control practices for residents on transmission-based precautions and enhanced barrier precautions. For Resident 63, who had physician orders for droplet and contact precautions and a care plan directing staff to follow transmission-based precautions, CNA 1 was observed removing PPE after providing care and hanging the face shield on a hook outside the room without disinfecting it first. During the same observation, the trash can inside the resident’s room was overflowing with used PPE. CNA 1 stated she had provided care before removing the face shield and acknowledged she did not disinfect it because there was no disinfectant by the isolation cart. For Resident 35, who had an order for enhanced barrier precautions related to known and risk of MDRO and had an indwelling medical device and respiratory treatments ordered, the resident’s nightstand was observed with a suction machine, nebulizer equipment, and a protective face mask placed near the nebulizer medication receptacle. LVN 2 verified the exposed face mask was present on the nightstand and stated it should have been disposed of appropriately. The resident’s record also showed orders for suctioning as needed and scheduled and PRN nebulizer treatments. The facility also failed to maintain clean linen storage and enhanced barrier precaution setup. The clean linen closet curtain was observed left open on two separate observations, and the DON and DSD/IP both verified the curtain was open. The DSD/IP stated the curtain should be closed to prevent contamination of clean linen. In addition, Resident 65, who had an indwelling urinary catheter and an order for enhanced barrier precautions due to MDRO risk, was observed in the room with family members present and not wearing PPE while wiping the resident’s face. There was no EBP signage and no isolation cart with PPE at the doorway, and LVN 3 and the DON verified those items were missing.
Uncovered Catheter Drainage Bags
Penalty
Summary
The facility failed to promote dignity and respect for two sampled residents with indwelling urinary catheters. During an initial tour, Resident 14 was observed lying in bed with the catheter drainage bag placed in a basin, with urine visible to others. Resident 14’s medical record showed a cognitive communication deficit and a physician’s order for an indwelling catheter attached to the bedside. When the observation was reviewed with the DON, the DON verified that the resident’s urine was visible from the drainage bag and stated the bag should have been enclosed in a urinary dignity bag for privacy. Resident 65 was also observed in bed with the urinary catheter drainage bag uncovered on the side of the bed, containing 100 ml of yellowish urine. The resident’s record showed a diagnosis of urinary retention and a physician’s order for an indwelling catheter attached to the bedside. During interview, LVN 3 confirmed that Resident 65 had a urinary catheter drainage bag and no privacy bag. The DON later stated the facility provided privacy bags to all residents with indwelling urinary catheters and verified the findings.
Failure to Assess Bilateral Bolster Pillows as a Possible Physical Restraint
Penalty
Summary
The facility failed to determine whether bilateral bolster pillows used for Resident 12 functioned as a physical restraint. Resident 12 had a history of limited mobility, musculoskeletal impairment, fatigue, impaired balance, acute stroke with right-sided weakness, and a recent closed fracture of the right femur with generalized weakness. After Resident 12 sustained a fall from bed, the facility implemented bilateral bed bolster pillows to define the bed perimeter and maintain spatial awareness, and a physician's order dated 3/1/26 was present for the bolster pillows. During observation and interview, Resident 12 was seen lying in bed with the bilateral bolster pillows attached. Resident 12 stated the pillows prevented him from repositioning himself, restricted his movement, and kept him from sleeping well at night; he also stated he could not remove the pillows. RN 1 reviewed the record and verified that a physical restraint assessment had not been conducted to determine whether the bolster pillows could be easily removed by the resident and whether they restricted freedom of movement, and RN 1 verified there was no physician's order for the use of a physical restraint for Resident 12.
Inaccurate PASRR Level 1 Screenings for Two Residents
Penalty
Summary
The facility failed to ensure that PASRR Level 1 screening information was accurate for two residents reviewed for PASRR. Resident 7 had medical record documentation showing diagnoses of depression and PTSD, including a psychological consult and progress note and a care plan problem focused on moderate risk for depression and re-traumatization related to PTSD. However, the PASRR Level 1 screening for Resident 7 stated that the resident had no diagnosed mental illness and was negative for mental illness, with no PASRR Level 2 mental health evaluation required for that reason. Resident 56 also had documentation in the medical record showing a diagnosis of mood disorder and a care plan problem related to a history of PTSD and potential mood problems. Despite this, the PASRR Level 1 screening for Resident 56 stated that the resident had no diagnosis of mental illness and was negative for mental illness, with no PASRR Level 2 mental health evaluation required for that reason. In interviews and concurrent record review, the DSD verified that both residents had the documented mental health diagnoses and that the PASRR Level 1 screenings were inaccurate.
Care Plan Not Updated for Changed Enteral Feeding Orders
Penalty
Summary
The facility failed to ensure Resident 14’s Plan of Care was revised to reflect a physician’s order dated 3/16/26 that changed the resident’s enteral feeding rate and enteral water flush. The report states that Resident 14 was admitted and later readmitted to the facility, and her H&P dated 3/10/26 documented a cognitive communication deficit. The physician’s order directed Jevity 1.5 via GT to infuse at 60 ml/hour over 20 hours or until the volume limit was completed, with GT tubing flushed with 20-30 ml of water before and after medications and 30 ml of water every four hours. Resident 14’s care plan, which had a nutritional problem or potential nutritional problem initiated on 3/3/26, still listed the enteral regimen as Jevity 1.5 at 70 ml for twenty hours and water flushes of 175 ml every four hours. During interview and record review, RN 1 verified that the care plan had not been updated to match the changed physician’s order. The DON stated the licensed nurse should have updated the Plan of Care when the order for enteral feeding and water flushes was received.
Low Air Loss Mattress Set Incorrectly for Resident
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not ensured for a resident who had a physician order for a low air loss mattress related to wound care management. The resident had no capacity to understand and make decisions, had memory problems and severely impaired cognitive skills for daily decision making, was dependent on staff for activities of daily living, and had a weight of 93 pounds. Facility policy stated that licensed nurses were to adjust low air loss mattress settings based on the resident’s weight and/or comfort and follow manufacturer guidelines. During observations, the resident was found lying on her back on a low air loss mattress that was set on static mode, with the normal pressure level set between 80 to 160 pounds, despite the resident weighing 93 pounds. The mattress manual stated the static mode provides a firm surface for transfers or repositioning and prevents bottoming out when in a sitting position. Staff interviews confirmed that licensed nurses were responsible for checking the setting daily and that the setting should be based on the resident’s weight and comfort; the DSD/IP and DON verified the findings.
Enteral Feeding Labeling Not Documented
Penalty
Summary
The facility failed to provide appropriate treatment and services for Resident 14, who had a cognitive communication deficit and physician orders for Jevity 1.5 via gastrostomy tube at 60 mL/hour over 20 hours or until the volume limit was completed. During an initial tour on 3/17/26, Resident 14 was observed lying in bed with Jevity 1.5 infusing through an enteral pump, and the formula container had little less than 400 mL remaining. The container label did not have the resident's name, infusion rate, date, time, or the nurse's initials documented. Review of the facility policy titled Enteral Feeding showed that enteral feedings were to be provided according to physician orders and that the nurse was to document initials, date, and time the formula was hung or administered, and initial that the label was checked against the order. During a concurrent interview, the DON verified that the feeding formula was not labeled as required and stated it should have been labeled by the licensed nurse when hung according to facility policy. The DON later acknowledged the findings during an interview.
Failure to Administer and Document Ordered IV Fluids
Penalty
Summary
The facility failed to provide the necessary care and services to maintain IV therapy for one resident with hydration orders. Resident 63 had a physician order dated 3/15/26 for one liter of sodium chloride 0.9% to infuse at 60 ml/hr intravenously for IV hydration and nutrition secondary to constipation for one day, with an order to discontinue the IV when completed. The record did not show any physician order discontinuing the sodium chloride solution before completion, and the resident’s IV MAR did not show an initial on the PM shift when the IV was ordered to begin. The resident’s IV bag was later observed still hanging beside the bed and appeared full, with the tubing connected but not attached to the resident for administration. The tubing had no label and no protective cap on the port. During interview, the resident stated he thought he had received the IV the night before because he was constipated, and he did not realize the IV bag was still at his bedside. The DON confirmed the IV bag and tubing findings and stated the tubing should have been covered with a protective cap for infection control. Review of the IV MAR, intake records, task records, and progress notes showed inconsistent documentation of the IV therapy and no documentation that the IV fluids were discontinued. RN 1 verified the IV MAR did not show an initial indicating the IV therapy was started as ordered, and the DON stated she was not sure why the bag was still in the room and appeared not to have infused to the resident. The DON also verified that the resident’s intake should have been documented accurately, including oral intake, fluids given by staff, and IV fluids during the shift.
Failure to Provide Ordered Oxygen Therapy and Date Oxygen Tubing
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident with COPD and respiratory failure when a physician’s order required continuous oxygen at 2 LPM via nasal cannula. Resident 34 had an order dated 10/30/25 for oxygen at 2 LPM continuously every shift, and the care plan included giving oxygen therapy as ordered. During observation on 3/17/26, Resident 34 was seen in the dining room eating lunch in a wheelchair without oxygen, and LVN 4 verified the resident did not have oxygen when entering the dining room. The DON later verified that Resident 34 had no oxygen when he came to the dining room and that she administered the oxygen while the resident was still there. The facility also failed to ensure oxygen tubing was dated for Resident 65. Resident 65 was observed in bed with oxygen connected to a concentrator at 2 LPM via nasal cannula, but the connector and all oxygen tubing were not dated. LVN 3 verified the tubing should have been dated, and the DON stated staff were supposed to date the oxygen tubing using yellow stickers. Resident 65 had a physician’s order for oxygen at 2 LPM via nasal cannula continuously every shift.
No RN Onsite on Night Shift for Oxygen Titration Orders
Penalty
Summary
The facility failed to ensure a staff member was onsite during the night shift who could provide respiratory care and services to residents with oxygen titration orders. The California Code of Regulations review showed LVNs may not perform the initial setup, change out, or replacement of a breathing circuit or adjustment of oxygen liter flow or oxygen concentration. The facility assessment showed the facility cared for residents with respiratory conditions including acute and chronic respiratory failure, COPD, hypoxemia, sleep apnea, asthma, cystic fibrosis, and dependence on supplemental oxygen therapy, and the staffing plan listed no RN assigned to the night shift. The order listing report showed 13 residents had active physician orders for supplemental oxygen continuously and/or as needed, including two residents whose orders required titration as needed. One resident had orders to monitor oxygen saturation every shift and to apply oxygen via nasal cannula at 2 liters per minute if oxygen saturation was less than 90%; the resident’s care plan included monitoring oxygen saturation and administering oxygen at that rate if saturation dropped below 90%. The resident had been admitted for pneumonia and bilateral pleural effusion and was documented as having the capacity to understand and make decisions. Another resident had diagnoses including aspiration pneumonitis and a history of COPD, with orders to monitor oxygen saturation every shift, to apply oxygen via nasal cannula at 2 liters per minute if saturation was less than 90%, and to use an oxygen mask at 5 liters per minute as needed when asleep. During interview, the DON verified the facility’s assessment was accurate regarding RN staffing on the night shift and stated the facility had not had an RN assigned to work the night shift for the last year. The DON stated LVNs worked the night shift and could provide basic respiratory tasks and administer oxygen in emergent situations, but could not adjust or titrate oxygen liter flow or oxygen concentration in non-emergent situations. The DON verified that on the night shift the facility did not have a nurse onsite who could provide respiratory services to residents with oxygen titration orders.
Medication Administration Not Aligned With Dialysis Schedule
Penalty
Summary
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist was not met when the facility failed to administer one resident’s medications according to physician orders during scheduled dialysis appointments. The resident had diagnoses including End Stage Renal Disease and dependence on renal dialysis, and the H&P noted a limited capacity to make decisions. The physician’s orders included a dialysis schedule for Tuesdays, Thursdays, and Saturdays, along with daily orders for ascorbic acid, zinc sulfate, cholecalciferol, cyanocobalamin, and furosemide. Review of the MAR for March 2026 showed these medications were not administered on multiple dates when the resident was marked absent from the facility, and there was no documentation that the medications were given at another time. During interview and concurrent record review, the RN verified the findings and stated the resident should have received the medications when returning from the dialysis center. The DON also verified the findings and stated the resident’s medication administration times should have been adjusted according to the dialysis schedule, with medications given before or after scheduled dialysis appointments.
Pain Medication Given Outside Ordered Pain Scale
Penalty
Summary
The facility failed to ensure appropriate pain medication was provided for one resident who was reviewed for unnecessary medications. Resident 63 had orders dated 3/11/26 for hydrocodone-acetaminophen 5-325 mg, 1 tablet by mouth every 4 hours as needed for severe pain, acetaminophen 325 mg, 2 tablets by mouth every 4 hours as needed for pain, and pain monitoring every shift using a scale in which 4-6 was moderate pain and 7-10 was severe pain. The resident’s MAR showed hydrocodone-acetaminophen was administered on 3/13/26 at 2146 when the resident reported pain level 6, which was moderate pain. The resident’s care plan included a focus for risk of pain or discomfort with interventions to administer analgesia as ordered and follow the pain scale, and a focus for potential fluid deficit related to constipation. During interview, the resident stated he became constipated and was uncomfortable, and said he did not really want to take hydrocodone because it made him constipated. RN 1 verified the medication should not have been given for moderate pain and stated acetaminophen should have been given or the physician could have been called for the proper medication prescription. The DON stated the expectation was for the licensed nurse to assess pain, medicate according to the pain scale, and follow the physician’s orders as prescribed.
Expired Supplies and Unordered Skin Creams Left Accessible
Penalty
Summary
The facility failed to ensure expired supplies were removed from Treatment Cart A and the central supply room. During an inspection of Treatment Cart A with an LVN, surveyors observed one opened bottle of Stomahesive protective powder with an expired date. During a separate inspection of the central supply room with the same LVN, surveyors observed one opened bottle of Skin-Prep protective spray with an expired date. The facility’s policy stated contaminated items or items in containers that are cracked, soiled, or without secure closures are to be immediately removed from stock and disposed of. The facility also failed to ensure hydrophilic cream and zinc oxide cream were not left unattended on top of Resident 14’s nightstand. Resident 14 had a cognitive communication deficit. Review of the resident’s order summary failed to show physician’s orders for either cream. During an initial tour, surveyors observed a plastic bag containing the hydrophilic cream and zinc oxide cream on the resident’s nightstand. An LVN confirmed the creams were there and stated the facility policy required a physician’s order for skin treatment and an order for medications left at bedside. An RN later verified the medical record did not contain orders for the creams and stated they should not have been left at the bedside for safety.
Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to ensure the medical record was accurately maintained for two sampled residents. For Resident 12, the H&P examination was uploaded into Resident 2's electronic health record. During the medical record review, Resident 12's H&P examination was observed in Resident 2's electronic record, and the MRD confirmed that Resident 12's H&P should not have been in Resident 2's chart. The facility also failed to accurately complete Resident 21's Restraint/Enabling Device/Safety Device Evaluation. The evaluation dated 2/2/26 listed a low air loss mattress for comfort under the recommended device, but Resident 21's Order Summary Report did not show a physician's order for a low air loss mattress. RN 1 verified there was no physician order for the mattress, and the DSD/IP acknowledged the assessment included the mattress even though the prior order had been discontinued on 11/18/24.
Equipment Cleaning and Glucometer Calibration Deficiencies
Penalty
Summary
The facility failed to maintain essential equipment in safe operating condition by not cleaning and sanitizing the ice machine according to the manufacturer’s instructions. The facility’s policy for ice machine cleaning stated the internal components were to be cleaned monthly or per manufacturer recommendations, and the cleaning log showed the ice machine was cleaned once a month. However, the manufacturer’s service manual stated the interior of the ice storage bin, which is in contact with ice, should be cleaned and sanitized regularly and sanitized once a week with a commercial food-grade sanitizer. During interview, the Director of Maintenance described a cleaning process that included turning off the machine, emptying the ice, washing the bin with soap and water, and later sanitizing it with Sani Tech, with this procedure completed two times per quarter and the third month handled by a service company. The RD Dietary Resource verified the log reflected monthly cleaning and that the manufacturer’s instructions called for weekly cleaning. The facility also failed to ensure glucometers in Medication Cart A and Cart B were calibrated and had quality control performed for two days in October 2025. The facility’s policy required licensed nurses to calibrate glucometers daily and document the results in the glucometer logbook. Review of the Blood Glucose Monitoring Quality Control Log showed no documented evidence that the glucometers were calibrated or had quality control checks on 10/19 and 10/20/25, and the normal and high control results were not observed on the glucometers with serial numbers 1040-4347198 and 1040-4469963. During inspection of Medication Cart A, LVN 3 verified the findings and stated the 11-7 shift nurses calibrated the glucometer and performed the quality control test. LVN 3 later acknowledged the findings and stated it was important to calibrate the glucometers to ensure accurate blood sugar readings for residents.
Failure to Implement Diabetes Monitoring Interventions
Penalty
Summary
The facility failed to implement care plan interventions for two residents with diabetes mellitus, specifically regarding the monitoring, documentation, and reporting of signs and symptoms of hypoglycemia and hyperglycemia. For both residents, the care plans included detailed interventions to monitor for symptoms such as sweating, tremor, increased heart rate, confusion, and other indicators of blood glucose fluctuations. Despite these documented interventions, medical record reviews revealed no evidence that the required monitoring was performed or documented for either resident during their stays. Interviews with nursing staff and the Director of Nursing confirmed that the monitoring for hypoglycemia and hyperglycemia was not conducted as outlined in the residents' care plans. Both residents were identified as being at high risk for blood sugar fluctuations due to their diagnoses of diabetes, with one also having diabetic chronic kidney disease. The lack of monitoring was acknowledged by staff, who stated that licensed nurses should have performed and documented these assessments as part of the residents' individualized care plans.
Failure to Investigate Fall and Collaborate After Resident Injury
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident remained free from accident hazards and did not provide adequate supervision to prevent accidents. Specifically, after a resident experienced a fall from bed, the facility's investigative report did not include a possible cause for the injury in the initial investigation statement, despite the facility being aware of the cause. The Director of Nursing (DON) confirmed that the cause of the fracture should have been documented in the investigation statement, but it was omitted. Additionally, after the resident was found to have sustained an acute, displaced comminuted distal femoral shaft fracture as revealed by a radiology report, there was no documented evidence that the Interdisciplinary Team (IDT) collaborated or held a meeting to review the resident's change in condition. The DON verified that the IDT meeting and documentation should have occurred following the x-ray results, but this did not happen.
Failure to Document Controlled Substance Administration in Medication Records
Penalty
Summary
The facility failed to implement its pharmaceutical procedures for controlled substances when nursing staff did not ensure accurate accountability for a resident's medication. Specifically, hydrocodone-acetaminophen tablets were signed out of the Controlled Drug Record (CDR) for a resident on multiple occasions, but there was no corresponding documentation of administration on the Medication Administration Record (MAR) for those dates and times. The facility's policy requires that controlled medications be documented both in the CDR and the MAR, but this process was not followed. Interviews with nursing staff and the Director of Nursing confirmed that the expected procedure is to document the administration of controlled medications in both the CDR and the MAR. Review of the resident's records verified that the medication was signed out in the CDR but not recorded as administered in the MAR, despite an active order for the medication during the relevant period. The discrepancy was acknowledged by staff during interviews and concurrent record reviews.
Failure to Provide Timely Incontinence Care Following Call Light Activation
Penalty
Summary
A deficiency occurred when staff failed to provide timely assistance to a resident who required help with incontinence care. The resident, who was cognitively intact and had a care plan addressing bowel and bladder incontinence due to impaired mobility and general weakness, activated the call light after a bowel movement. Despite the facility's policy requiring call lights to be answered within a reasonable time and care needs to be met before turning off the call light, the resident waited nearly an hour before being attended to. Two CNAs responded to the call light but did not provide immediate care; instead, they turned off the call light and left the room to locate the assigned CNA, delaying the resident's care further. Interviews confirmed that the CNAs were aware of the resident's need but did not act promptly, and the assigned CNA only provided care after being informed at the nurses' station. The Director of Nursing verified that the response time was not acceptable and that the CNAs should have provided care immediately rather than leaving the resident unattended. The resident expressed distress over the delay, stating she had not been changed since early morning and was upset by the lack of timely assistance.
Failure to Document and Implement Nonpharmacological Interventions Prior to Administering Narcotic Pain Medications
Penalty
Summary
The facility failed to ensure that nonpharmacological interventions (NPIs) were consistently implemented and documented prior to administering narcotic pain medications to a resident. Medical record review showed that the resident had physician orders for NPIs such as repositioning, dim lighting, relaxation, distraction, music, and massage to be attempted before administering hydrocodone-acetaminophen or Ultracet for moderate to severe pain. Despite these orders, there was no documented evidence that NPIs were attempted before administering these medications on several occasions. Interviews with nursing staff and the Director of Nursing confirmed that NPIs should have been implemented and documented prior to giving pain medication, but the resident's medical record did not reflect this practice on the specified dates. The lack of documentation and implementation of NPIs prior to administering narcotic medications constituted a failure to prevent unnecessary medication use for the resident reviewed.
Failure to Safely Administer and Document IV Fluids
Penalty
Summary
The facility failed to administer intravenous (IV) fluids in accordance with professional standards of practice and physician orders for a resident who lacked capacity to make decisions. Specifically, the IV fluids were administered at a rate of 80 ml per hour instead of the ordered 60 ml per hour. Additionally, the IV fluid bag was not labeled with the date and time it was hung, and the administration set was not labeled as required by facility policy. When the infusion was completed, the clamp was not closed, and the empty IV container was not removed from the IV pole, leaving air in the tubing and the administration set still attached to the resident's IV access. These deficiencies were confirmed through observation, interview, and medical record review. The nurse responsible for the resident's care was unable to state when the IV solution was hung, and the Director of Nursing verified that the IV fluids were not administered as ordered and that labeling requirements were not followed. The facility's policies required IV solutions and administration sets to be labeled with date, time, and nurse's initials, and for the clamp to be closed and the container removed when empty, but these procedures were not followed in this instance.
Failure to Properly Store and Date Respiratory Equipment
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents by not adhering to its own policies regarding the storage and maintenance of respiratory equipment. For one resident who required suctioning for increased oral secretions, the Yankauer suction tip was observed exposed to air and not enclosed in a bag, and was placed on top of a suction canister containing fluid. Both the suction tip and canister were undated. Facility staff confirmed that the equipment was not stored as required for infection control, and the Director of Nursing stated that the expectation was for the equipment to be bagged and dated. For another resident receiving multiple nebulized medications, the nebulizer tubing was found left uncovered on the nightstand and not stored in a bag, with no date label to indicate when the tubing or bag had last been changed. The resident reported that the nurse left the tubing uncovered after the previous treatment. Facility staff verified that the nebulizer administration set should have been enclosed in a labeled bag and dated according to policy. These lapses were observed during surveyor visits and confirmed through staff interviews and review of facility policies.
Failure to Safeguard Resident Information and Maintain Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and/or did not maintain medical records for each resident in accordance with accepted professional standards. This deficiency was identified through surveyor observation or record review, indicating that the required protocols for protecting confidential information or proper documentation of medical records were not followed as expected. No additional details regarding specific residents, their medical history, or the exact nature of the information or records involved are provided in the report.
Failure to Obtain Orders and Consent for Restraint Use
Penalty
Summary
The facility failed to ensure that three residents were free from unnecessary restraints, specifically the use of Tab and pad alarms, without obtaining the necessary physician's orders, informed consent, and completing restraint assessments. Resident 40 was observed with a Tab alarm in bed and wheelchair without an active order, informed consent, or a completed restraint assessment. The Director of Nursing (DON) and Licensed Vocational Nurse (LVN) confirmed the absence of these documents, and the facility's policy was not followed. Resident 38 was found with a pad alarm in both bed and wheelchair, yet there was no informed consent or completed assessment for its use. The DON and LVN were unable to provide documentation to support the use of the alarm, and a Certified Nursing Assistant (CNA) stated the alarm was used due to the resident's attempts to get up unassisted. This indicates a lack of adherence to the facility's policy on restraint use. Resident 12 had a physician's order for a Tab alarm, but there was no informed consent documented. The resident was observed with the alarm in place, and staff confirmed the absence of informed consent. The DON acknowledged the findings, indicating a failure to comply with the facility's policies regarding restraint use, which could compromise the residents' independence and psychosocial well-being.
Deficiencies in Care Planning for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for four residents, leading to deficiencies in their care. Resident 22, who had the capacity to understand and make decisions, refused showers, repositioning, diaper changes, and medications. Despite the facility's policy requiring a care plan to address such refusals, no care plan was developed for Resident 22's refusals, as confirmed by the Director of Staff Development (DSD). Resident 49, who also had decision-making capacity, experienced significant weight loss of 36 pounds in 26 days. The resident had a physician's order for 1:1 meal assistance, but during observations, the resident was seen eating alone and refusing meals without staff assistance. The Licensed Vocational Nurse (LVN) verified that the 1:1 meal assistance was not implemented, contributing to the resident's weight loss. Resident 456, who used oxygen and a CPAP machine, did not have a care plan addressing these needs, despite having physician orders for their use. The Director of Nursing (DON) confirmed the absence of a care plan for these interventions. Similarly, Resident 2, who was prescribed insulin for diabetes management, had a care plan that failed to address the use of insulin, as verified by an LVN. These omissions in care planning placed the residents at risk of not receiving appropriate, consistent, and individualized care.
Failure to Flush GT Between Medications
Penalty
Summary
The facility failed to adhere to professional standards of clinical practice for the administration of medications via gastrostomy tube (GT) for one resident. During an observation of medication administration, it was noted that LVN 4 did not flush the GT between the administration of the last three of eight medications for the resident. This action was contrary to the facility's policy and procedure, which requires flushing the tube with at least 5 ml of water between medications, and the NIH's guidelines, which recommend flushing with 15 ml of water to prevent tube obstruction and ensure proper medication delivery. The resident involved had several medications prescribed to be administered via GT, including aspirin, sodium chloride, cyanocobalamin, multivitamin, Cozaar, Azithromycin, demeclocycline hcl, and acetaminophen. During the administration process, LVN 4 acknowledged missing the flushing step for the last three medications, which could potentially disrupt the flow of medications and clog the GT. The Director of Nursing (DON) verified these findings during an interview, confirming the deviation from the established medication administration protocol.
Failure to Implement RD's Recommendations for Resident's Weight Loss
Penalty
Summary
The facility failed to ensure that the recommendations made by the Registered Dietitian (RD) on December 12, 2024, were communicated to the physician and addressed in the Interdisciplinary Team (IDT) weight variance meeting for a resident who experienced severe weight loss. Resident 49, who had the capacity to understand and make decisions, was admitted to the facility and experienced a significant weight loss of 36 pounds over 26 days. The RD recommended fortifying the current diet order, providing one pack of Arginaid twice daily for 14 days, and administering 30 ml of ProStat daily. However, these recommendations were not communicated to the resident's physician, nor were they documented in the resident's medical record. The medical record review and interviews with the RD and Director of Nursing (DON) confirmed that the RD's recommendations were not followed. The facility's policy and procedure for Nutrition Care Management required that recommendations be communicated via an electronic system and confirmed by a licensed nurse to document the physician's prescription. The failure to follow these procedures resulted in the potential for Resident 49 not receiving the necessary interventions to prevent further weight loss. The DON acknowledged the findings during an interview conducted on December 17, 2024.
Inadequate Respiratory Care and CPAP Maintenance
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, identified as Resident 6, who required the use of a CPAP machine. The physician's order for the CPAP lacked a specific schedule for when the CPAP should be applied and removed, and there was no documentation indicating that the CPAP was used from December 9 to December 11, 2024. Interviews with the LVNs and the DON confirmed that the order was incomplete and should have included specific times for application and removal. Additionally, the resident reported not using the CPAP for two nights, and it was not offered by the staff, despite the resident's moderate cognitive impairment and need for nightly CPAP use to assist with breathing. Furthermore, the facility failed to ensure accurate cleaning and maintenance of the CPAP equipment. The physician's order incorrectly instructed staff to clean a humidified container, which the resident's CPAP did not have. Instead, the CPAP had a filter, which was not cleaned as there was no physician's order for it. The DON acknowledged the error in the physician's order and the lack of documentation for cleaning the CPAP filter. The oversight in cleaning and maintaining the CPAP equipment could have impacted the effectiveness of the device, as noted by the DON.
Failure to Assess and Manage Pain for Resident
Penalty
Summary
The facility failed to adequately assess and manage pain for Resident 354, who was admitted with spine fractures and required pain management. The facility's policy required documentation of pain using a scale of 1-10 and monitoring of pain characteristics, but these procedures were not followed. On December 11, 2024, Resident 354 requested pain medication before physical therapy, but the staff did not assess the resident's pain level or offer nonpharmacological interventions. The resident expressed frustration over the delay and lack of assessment, which had occurred previously. RN 2 acknowledged not assessing the resident's pain level or offering alternatives, and LVN 4 administered oxycodone without evaluating the pain characteristics. The Director of Nursing confirmed these findings. The failure to assess and manage the resident's pain according to the facility's policy potentially caused increased pain and distress for Resident 354.
Deficiencies in Pharmaceutical Services and Medication Security
Penalty
Summary
The facility failed to provide necessary pharmaceutical services by not ensuring accurate and complete documentation of controlled medications for a resident. Specifically, the facility did not document the administration of oxycodone for a resident on a specific date, despite the medication being removed from the narcotic count. This discrepancy was confirmed during an interview with the Director of Nursing (DON), who verified the findings. Additionally, the facility did not ensure that narcotic sheets had the required nurses' initials and signatures during shift changes for one of the medication carts. Multiple entries were missing signatures and initials on various dates, which was confirmed by the DON. Furthermore, a medication cart was left unlocked in an area accessible to residents, staff, or visitors, as observed during an interview with an LVN, who acknowledged the oversight. These failures could lead to medication errors and opportunities for drug diversion or misuse.
Deficiencies in Psychotropic Medication Management
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary psychotropic medications. For Resident 6, there was no specific resident-centered goal to monitor the effectiveness of mirtazapine, an antidepressant prescribed for depression manifested by poor oral intake. Despite the administration of mirtazapine, the resident's meal intake remained low, with numerous episodes of eating less than 50% of meals. The facility's Director of Nursing (DON) acknowledged the lack of a specific order to monitor the effectiveness of mirtazapine for Resident 6. For Resident 49, the facility did not implement or document non-pharmacological interventions for the use of escitalopram (Lexapro), an antidepressant prescribed for depression. Although the care plan included non-pharmacological interventions such as back rubs, redirection, and encouragement to express feelings, there was no evidence that these interventions were implemented or monitored for effectiveness. The Licensed Vocational Nurse (LVN) and the DON confirmed the absence of documentation for these interventions. The facility's policies and procedures required that psychotropic drug use be reviewed by a Psychotropic Drug Review Committee and that non-pharmacological interventions be implemented for residents with psychotropic medication orders. However, these procedures were not followed for Residents 6 and 49, leading to deficiencies in the management and monitoring of their psychotropic medication use.
Medication Administration Errors Observed
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed rate of 19.35%. During a medication administration observation, LVN 4 was found to have made errors in administering medications to Resident 8. Specifically, LVN 4 did not ensure the full dosages of six out of eight prescribed medications were administered as per the physician's orders. The medications involved included aspirin, demeclocycline, Azithromycin, vitamin B12, multivitamins with minerals, and acetaminophen. After administration, medication residue was found in the cups used, indicating incomplete administration. Resident 8, who was admitted to the facility on an unspecified date, had specific physician's orders for medication administration via GT. These orders included aspirin, sodium chloride, cyanocobalamin, multivitamin, Cozaar, Azithromycin, demeclocycline, and acetaminophen. The Director of Nursing (DON) verified the findings during an interview, confirming the medication administration errors made by LVN 4. The failure to administer the full dosages as prescribed had the potential to negatively affect the resident's health.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications and biologicals, as observed during an inspection of the treatment cart. An opened package of Puracol wound dressing, which is intended for single use only, was found with a small cut-out piece inside the treatment cart. The Licensed Vocational Nurse (LVN) stated that if only a small piece was needed, the remaining dressing was placed in a storage bag, dated, and used within 24 hours. However, the LVN confirmed that the package was meant for single use, indicating a failure to adhere to the facility's policy and procedure (P&P) for medication access and storage. Additionally, the treatment cart contained a 16-ounce jar of zinc oxide skin protectant without an expiration date, which was verified by the LVN and subsequently discarded. The facility's P&P for the administration of medications and fluids requires that the expiration date of solutions and medications be ascertained prior to administration. The Director of Nursing (DON) confirmed these findings, highlighting a lapse in the facility's adherence to its own policies and procedures regarding medication labeling and storage.
Inaccurate Medical Records for Two Residents
Penalty
Summary
The facility failed to maintain accurate and complete medical records for two residents, leading to potential unmet healthcare needs. For Resident 456, the POLST was not updated to reflect the existence of an advance directive, despite the resident having the capacity to make decisions and the family being aware of the directive. The SSD confirmed that the POLST should have been updated, but it remained inaccurate, indicating a lapse in ensuring the resident's medical records were current and complete. For Resident 904, the facility did not ensure that the Treatment Administration Record (TAR) was accurately documented. Multiple wound treatment orders were not recorded as completed on specific dates, despite the treatments being administered. LVN 7 and LVN 2 confirmed the missing documentation for various wound care treatments, and the DON acknowledged the requirement for licensed nurses to document after providing ordered treatments. This lack of documentation resulted in incomplete medical records for Resident 904, potentially affecting the resident's care.
Infection Control Deficiencies in Water Management and Hand Hygiene
Penalty
Summary
The facility failed to adhere to its water management program, which is crucial for preventing the growth and spread of Legionella and other opportunistic pathogens. The facility's policies and procedures required regular testing of water temperatures to ensure they were maintained within the desired range of 105 to 120 degrees Fahrenheit. However, there was no documented evidence that these water temperatures were tested monthly as required. This oversight was acknowledged by both the Maintenance Supervisor and the Administrator during interviews. The facility also failed to ensure proper hand hygiene practices among its staff, as outlined in its infection control policies. Several instances were observed where staff members did not perform hand hygiene after removing gloves or after potential contamination. For example, an LVN did not wash hands after removing gloves during wound treatment, and another LVN failed to perform hand hygiene after picking up a sharpie from the floor and after using a computer. These lapses were confirmed by the staff involved and acknowledged by the Infection Preventionist and the Director of Nursing. Additionally, the facility did not follow best practices for infection prevention during medication preparation. An RN was observed preparing an IV medication without disinfecting the vial before connecting it to the solution bag, contrary to CDC guidelines. This failure was confirmed by the RN, who stated that she was trained to disinfect the vial to prevent contamination. The Director of Nursing verified these findings, indicating a systemic issue with adherence to infection control protocols.
Failure to Accommodate Resident's Request for Grab Bars
Penalty
Summary
The facility failed to accommodate the needs and preferences of a resident by not following up on a request for bilateral grab bars. The resident, who was observed awake and sitting up in bed, had turned on the call light and expressed that he had requested the grab bars the previous day to assist with turning or repositioning in bed and sitting in the middle of the bed. The resident felt upset because the staff member did not respond to his request. Licensed Vocational Nurse (LVN) 5 acknowledged the resident's request and stated that it needed to be communicated to the resident's physician. However, LVN 5 only informed Registered Nurse (RN) 1 and did not follow up further. RN 1 confirmed that she had not informed the physician about the resident's request. This lack of communication and follow-up resulted in the resident's needs not being addressed in a timely manner.
Privacy Breach During Medication Administration
Penalty
Summary
The facility failed to ensure the privacy of a resident during medication administration. Specifically, a Licensed Vocational Nurse (LVN) did not completely pull the privacy curtain when administering medications via gastrostomy tube (GT) to a resident. The room door was open, exposing the resident to the hallway where other residents and staff members were passing by. This incident was observed, and the LVN later confirmed that complete privacy was not provided during the procedure. The Director of Nursing (DON) verified these findings during an interview.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from sexual abuse by another resident. On 7/28/24, a CNA observed Resident 2 inappropriately touching Resident 1's genitals. Resident 1, who had severe cognitive impairment and advanced dementia, lacked the capacity to consent to such contact. Despite Resident 2's known history of verbally inappropriate behavior towards staff, the facility did not take adequate precautions to prevent this incident. Resident 1 was admitted to the facility with a diagnosis of advanced dementia and required assistance for most activities of daily living. Resident 2, who was cognitively intact, had a care plan addressing verbally inappropriate behaviors towards staff, but no measures were in place to prevent inappropriate interactions with other residents. On the day of the incident, Resident 2 was seen touching Resident 1's genitals, and despite being stopped by a CNA, Resident 2 returned to Resident 1's bedside shortly after. Interviews with staff and family members confirmed the incident and Resident 2's inappropriate behavior. The facility's investigation substantiated the incident, acknowledging that Resident 2's actions were purposeful and due to a need for sexual gratification. The facility's failure to implement effective measures to prevent such incidents resulted in a deficiency in protecting residents from abuse.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that a resident with a pressure injury received the necessary care and services to prevent the development and worsening of the injury. The resident was initially evaluated to have a Stage 1 pressure injury on the sacral coccyx, which advanced to a Stage 2 pressure injury within a week. Despite a physician's order for a wound care consult, the wound specialist only evaluated the resident once and did not follow up, leading to the injury becoming unstageable. The medical records lacked documented evidence of follow-up visits or reasons for discontinuation of the wound specialist's services. Interviews with the Director of Staff Development/Infection Preventionist (DSD/IP) and the Director of Nursing (DON) confirmed the absence of follow-up visits from the wound specialist. The Wound Specialist Manager verified that the resident had only one initial consultation and no subsequent visits, attributing the lack of follow-up to the wound specialist being on vacation. The DON acknowledged the findings and indicated a need to work with the wound care specialist to address the issue.
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Illustrative
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) |
|---|---|---|---|---|
| The Pavilion At Sunny Hills | 0.4 mi | ★★★★★ | 9 | 0 |
| Greenfield Care Center Of Fullerton, Llc | 0.4 mi | ★★★★★ | 15 | 0 |
| Terrace View Care Center | 0.4 mi | ★★★★★ | 28 | 0 |
| Park Vista At Morningside | 1.2 mi | ★★★★★ | 21 | 0 |
| St. Catherine Healthcare | 2.1 mi | ★★★★★ | 22 | 0 |
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