Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sunny Village Care Center during CMS and state inspections, most recent first.
A resident with a physician order for a low bed and floor mattress did not have the mattress in place, another high-fall-risk resident had clutter in the room and no floor mattress or low bed as directed by the care plan, and a third resident was not monitored hourly as required after a fall-risk care plan identified frequent checks. Staff and the DON confirmed the missing floor mattresses and the lack of required monitoring.
A resident with a PEG tube had a GT dressing that was not labeled with a date, despite an order and care plan for daily cleansing and dressing changes, and staff stated the missing date meant the site may not have been cleaned or the dressing changed. In a separate finding, another resident with gastrostomy and dementia was ordered Jevity 1.2 via pump, but the pump was on hold and the feeding container remained nearly full, and an LVN confirmed the resident was not receiving the tube feeding as ordered.
Improper Food Labeling and Scoop Storage: Multiple frozen and dry storage food items were found without required labels showing the item name, open date, and/or use-by date, and a scoop was observed sitting on top of rice in a storage container. The KS stated facility policy requires food items to be labeled and dated and scoop devices to be stored hanging inside the bin rather than on top of the rice.
Open Dumpster Lids: Two of three blue dumpsters in the parking lot had lids left wide open, while the recycling dumpster lid was closed. The MS stated the facility policy required all dumpster lids to remain closed at all times to keep out flies and rodents and prevent disease transfer, and the P&P confirmed the main dumpster cover should always be closed.
Two residents’ arbitration agreements did not include provisions for a neutral arbitrator agreed upon by both parties or a venue convenient to both the residents and the facility. The AA confirmed the missing language, and the DA stated she was not aware these items needed to be included in the agreements.
Infection control failures were observed during incontinent care, catheter care, and oxygen use. Two CNAs used the same gloves while continuing care after bowel and bladder-related cleaning, an RN used paper towels that had contacted a contaminated sink during catheter care, and a resident's nasal cannula tubing was found labeled with an old change date with no record of being changed within the required weekly interval. Staff stated gloves should have been changed, hand hygiene performed, catheter care should not have involved contaminated towels, and oxygen tubing should be changed weekly.
Inaccurate MDS Hearing Assessment: The facility failed to accurately assess a resident’s hearing ability in the MDS. The resident, who had dementia, muscle wasting, and hypotension and was dependent for multiple ADLs, was documented as having adequate hearing despite stating he was hard of hearing and having difficulty hearing the surveyor. An RNS and the DON both confirmed the resident had hearing difficulty, and the DON stated the inaccurate MDS could affect the resident’s care plan and services.
A resident with dementia and impaired hearing had a care plan that did not include an intervention for the RP's refusal to allow an ENT consult. The RP cancelled the ENT appointment, and the resident later stated he was hard of hearing and could not hear the surveyor. The SSD confirmed the refusal, and the DON stated the care plan should have addressed it for continuity of care.
A resident with Language 1 as the primary language and dependence for several ADLs was found with a bedside communication board written in Language 2. The resident stated she could not understand the board and did not use it, while the RN supervisor and DON both acknowledged it should have been in Language 1 so the resident could communicate needs to staff.
Pain medication was not administered as ordered for a resident with a left femur fracture and other orthopedic history. The resident had an order for hydrocodone-acetaminophen 5-325 mg PRN for pain rated 4 to 6 out of 10, but the MAR showed it was given for pain rated 7 and 8 out of 10. RN 2 stated the medication should not have been given for those higher pain levels, and RN 1 and the DON stated pain meds should be administered according to the physician’s order and the resident’s pain level.
Dialysis Access Site Not Assessed or Documented: A resident with ESRD, DM, and a left upper arm AV shunt had orders and a care plan requiring pre- and post-dialysis access site checks and communication with the HD center. However, the Nurses Dialysis Communication Records did not show assessment or documentation of the access site or dressing on multiple dialysis days. The RN supervisor and DON stated licensed nursing staff were expected to assess for redness, swelling, drainage, and dressing status and document the findings on the communication record.
An LVN administered medications to a resident without first checking the resident’s ID band, despite the facility’s med administration policy requiring identity verification before giving meds. The resident had HTN, DM, and acute kidney failure, and was documented as cognitively intact for daily decision making.
Inaccurate MAR Documentation for Oxygen Therapy: A resident with dementia, Parkinson’s disease, and hypertensive heart disease had an order for O2 2 L/min via NC PRN to maintain O2 sat at 92%. Record review showed the resident received oxygen on 11 days, but the MAR did not document any oxygen administration. An LVN and RN both stated the MAR should have reflected the oxygen given and was not accurate or complete.
Residents' Rights were not posted in a prominent or accessible area of the facility. The SSD stated the rights were not displayed and that copies were only given on request at admission, and the Administrator confirmed the rights were not currently posted even though facility policy required them to be posted throughout the facility.
Surveyors found that the facility did not maintain required documentation showing that an outside contractor was performing scheduled preventive maintenance on the HVAC system. The Maintenance Supervisor reported having no logs or reports of semi-annual HVAC service visits and acknowledged that such records should have been kept to monitor compliance and system function. The Administrator also confirmed that copies of HVAC maintenance records were not on file, despite facility policy assigning the maintenance director responsibility for maintaining maintenance schedules and related reports in the maintenance office.
The facility failed to maintain ethical standards and resident rights by purchasing a prescribed continuous glucose monitoring device from a resident for staff training. A cognitively intact resident with type 2 DM and cardiac conditions had an order for blood sugar monitoring using a Brand 1 device. The DON agreed to buy one of the resident’s devices using facility petty cash, documented the transaction with the resident and an LVN, and then used the device in a training session on sensor application. The BOM and Administrator later acknowledged that paying a resident for a prescribed device was not usual practice, that such items should be obtained through a vendor, and that there was no policy permitting such transactions, creating an inappropriate business relationship between the facility and the resident.
A resident with multiple medical conditions experienced an acute behavioral change, leading to a physician's order and care plan update for a psychiatric consult. Despite facility policy requiring prompt notification and follow-up, nursing staff did not inform the psychiatrist or document any actions taken, resulting in a 25-day delay before the consult was completed.
Failure to Ensure Nursing Competency With CGM Use: The DON did not ensure licensed nurses were trained and competent to apply, program, and manage a resident’s Brand 1 CGM device. A resident with DM2 and no cognitive impairment had an order for CGM use, but staff reported they were not properly trained, there was no documented return-demonstration evidence, and the DON stated training was delayed because she believed the resident could manage the device himself and viewed it as a personal device.
A resident with quadriplegia and multiple sclerosis, who was fully dependent on staff for all ADLs, did not have a care plan specifying the need for two-person assistance despite staff and assessment documentation confirming this requirement. The care plan only generally referenced assistance with mobility and ADLs, lacking the detail needed for consistent, individualized care as confirmed by interviews with the LVN and DON.
Three residents were labeled as 'feeders' and addressed with generic terms during meals, contrary to facility policy. This practice, acknowledged by staff as inappropriate, failed to promote dignity and respect for residents with cognitive impairments.
The facility failed to maintain appropriate room temperatures for several residents, with one room being too cold and another too hot, both outside the acceptable range of 71-81°F. Additionally, a resident's report of missing personal belongings was not addressed according to the facility's policy, as the Laundry Staff did not report the issue, and the Administrator was not informed, preventing an immediate search.
The facility failed to provide adequate respiratory care for three residents. A resident was observed without a nasal cannula despite orders for continuous oxygen therapy. Another resident received oxygen at an incorrect rate, not following physician orders. Additionally, a third resident's oxygen tubing was not changed weekly as required, and was improperly stored, potentially leading to respiratory infections.
The facility failed to follow proper food handling practices, including labeling food items and maintaining cleanliness in the kitchen. Observations revealed unlabeled food, dirty equipment, and improper trash placement. Dietary staff did not perform proper hand hygiene, and the facility lacked complete cleaning logs for the ice machine, violating its policies.
A facility failed to obtain informed consent from a resident's representative before administering Seroquel, an antipsychotic medication, to a resident with dementia and psychosis. The resident's medical records lacked the necessary consent form, and staff interviews confirmed the oversight, which violated the facility's policy requiring informed consent for antipsychotic use.
A facility failed to ensure an accurate MDS assessment for a resident by incorrectly documenting the discharge status. Despite multiple records indicating the resident was discharged home with home health services, the MDS was inaccurately recorded as a discharge to a hospital. The MDS Coordinator admitted to the error, which affects the facility's quality of care reporting.
A facility failed to implement a baseline care plan within 48 hours for a resident with dementia and psychosis, who was prescribed Seroquel. The absence of this care plan, confirmed by LVNs, could affect the resident's quality of care by hindering continuity and communication among staff.
The facility failed to provide communication boards for two residents with language barriers, hindering their ability to communicate needs. One resident was observed in pain and unable to communicate effectively with staff due to the absence of a communication board, while another resident's request for assistance was not understood by staff. The facility's policy required communication boards for residents with language barriers, but these were not accessible, as confirmed by the DON.
A resident with Parkinson's disease and limited mobility was found with long, dirty fingernails, indicating a failure in personal hygiene care. The resident's care plan required assistance with grooming, but staff interviews revealed that nail care was neglected, contrary to facility policy. This oversight had the potential to impact the resident's self-esteem and posed a risk for infection.
A facility failed to set a low air loss (LAL) mattress correctly for a resident with a stage 4 pressure ulcer, as per the facility's policy and manufacturer's guidelines. The resident, at high risk for skin breakdown, had the LAL mattress set incorrectly on two occasions, which was not effective for wound management. The settings were not adjusted according to the resident's weight, as confirmed by LVNs during observations.
A resident with an indwelling catheter experienced improper catheter care when a CNA moved the catheter bag above bladder level, risking urine backflow. The resident, cognitively impaired and dependent on assistance, had their catheter bag placed on blankets and held above bladder level, contrary to facility policy. This posed a potential risk for a UTI.
A resident with diabetes mellitus type 2 did not receive Metformin hydrochloride within the prescribed time frame, as it was administered late by an LVN. The medication, ordered to be given with meals, was delayed, potentially affecting the resident's blood sugar management. The facility's policy requires medications to be administered within one hour of the prescribed time, which was not adhered to in this instance.
A facility failed to conduct necessary laboratory tests for a resident with hypertensive heart disease and hyperlipidemia. Despite a Consultant Pharmacist's recommendation for lipid and liver panel tests to monitor the effects of prescribed pravastatin sodium, these tests were not ordered or performed. This oversight was confirmed through record reviews and an interview with a registered nurse, highlighting a lapse in ensuring timely laboratory services.
A resident with dysphagia and dementia was not provided with food that met her dietary preferences, as the pureed food was too thick, causing difficulty in eating. Despite the responsible party informing the Dietary Supervisor, no follow-up action was taken, leading to a deficiency in the facility's adherence to its food quality policy.
Two residents experienced delayed meal service, with lunch trays delivered significantly later than the scheduled time. One resident, with colon cancer, received their meal at 12:45 PM, while another resident, with type 2 diabetes, received theirs at 12:47 PM, despite the scheduled lunch time being 12 noon. The Dietary Supervisor confirmed the delay was unacceptable, as it could affect residents' well-being.
A facility failed to document complete orthostatic blood pressure measurements for a resident on Seroquel, missing several lying position readings. Despite protocols requiring documentation or noting reasons for omissions, the resident's records were incomplete, potentially increasing fall risk. Interviews with nursing staff confirmed the oversight, highlighting a lapse in following the facility's policy on monitoring antipsychotic medication effects.
A CNA failed to change gloves and perform hand hygiene after providing peri-care to a resident with an indwelling catheter, subsequently touching clean bed linens with contaminated gloves. The facility's policy requires hand hygiene after contact with bodily fluids and before moving from a contaminated to a clean site, which was not followed.
A water leak in the kitchen ceiling was observed, with water pooling on the floor near the dishwashing area. The leak was due to a hole in the metal duct for ventilation, which collected rainwater. The issue was reported by kitchen staff, but maintenance rounds were not confirmed. Concerns about food contamination and kitchen usability were raised.
A facility failed to maintain accurate medical records by allowing a CNA to administer a topical cream while an LVN documented the administration in the TAR. The resident, with quadriplegia and multiple sclerosis, required hydrophilic wound dressing for skin maintenance. Despite facility policy requiring licensed nurses to administer and document medications, CNAs were observed applying the cream, and licensed nurses signed the TAR.
A resident's medication, carvedilol, was improperly disposed of by nursing staff at the resident's request, contrary to facility policy. The medication was still in use for managing the resident's heart conditions. The facility's policy requires medications to be disposed of only if unused or expired, which was not adhered to in this case.
A resident, capable of making their own decisions, was transferred to a GACH following a psychiatric emergency evaluation. The facility failed to provide the required written notice of bed hold policy, as mandated by their policy, which should have been given at the time of transfer or within 24 hours in emergencies. The administrator acknowledged the oversight, noting no bed hold order was placed due to the expectation that the resident would not return.
The facility failed to manage medications brought in by a resident's family, lacked documentation for an Ozempic injection site, and improperly stored expired medications. Additionally, temperature monitoring of a medication refrigerator was incomplete, potentially affecting medication efficacy.
A resident reported a missing dose of Ozempic, a diabetes medication, after the facility failed to log or inventory his personal medications. Despite the resident's practice of picking up medications from an outside pharmacy and handing them to the LVN, the facility did not maintain a record from September 2023 to August 2024, contrary to its policy requiring inventory and documentation of personal belongings.
A resident with diabetes and legal blindness was instructed by an RN to self-administer insulin due to the RN's phobia of needles and lack of recent experience with injections. The facility lacked a formal process for assessing nursing staff competency, contributing to this deficiency.
A resident with diabetes and legal blindness self-administered insulin after being instructed by an RN, despite lacking a physician's order or self-administration form. The facility's policy requires only licensed individuals to administer medications, which was not followed, leading to a deficiency.
A facility failed to provide a resident's legal representative with timely access to medical records, violating the resident's rights. Despite a request being made and received, the records were not provided within the facility's policy timeframe. The request was forwarded to the facility's lawyers, but there was no confirmation of the records being sent. This delay impacted the resident's ability to follow up on medical care.
Failure to Provide Fall Precautions and Required Monitoring
Penalty
Summary
The facility failed to provide necessary supervision and assistive devices to prevent accidents for three residents reviewed for falls. The deficiency involved failure to provide floor mattresses for two residents in accordance with their care plans and the facility’s Safety of Residents policy, and failure to monitor another resident more frequently in accordance with the resident’s care plan for risk for fall and injury. Resident 10 was admitted with diagnoses including aftercare following joint replacement surgery, muscle wasting and atrophy, and type 2 diabetes mellitus without complications. The MDS showed the resident had no cognitive impairment for daily decision making and required varying levels of assistance with toileting, transfers, bathing, dressing, oral hygiene, and personal hygiene. A physician order dated 2/16/2026 directed a low bed with floor mattress, but during three observations on 3/24/2026 there was no floor mattress found near the bed or in the room. The resident stated she had never seen a floor mattress next to her bed and staff had not told her about one. A CNA also stated there was no floor mattress in the room, and the LVN and DON confirmed the order required a floor mattress and that it was supposed to have been provided since admission. Resident 89 had diagnoses including hemiplegia, hemiparesis, and other specified disorders of bone density and structure. The MDS showed the resident needed supervision or touching assistance with showering and dressing and setup or clean assistance with eating, oral hygiene, toilet hygiene, and personal hygiene. The resident was assessed as high risk for falls, and after a fall on 3/1/2026, the care plan directed that the bed be kept in the lowest position and floor mattresses be placed on each side of the bed. During observations, the resident’s room contained clutter on the floor, the bed was not in the lowest position, and no floor mattress was present at the bedside. CNA staff, an RNS, and the DON all stated the bed was not low and the floor mattress was not in place as required by the care plan. Resident 8 had diagnoses including history of falling, fracture of the left femur, and Parkinson disease. The MDS showed the resident required partial/moderate assistance with multiple activities including toileting hygiene, bathing, dressing, transfers, and sit-to-stand. The resident was assessed as high risk for falls, and the care plan directed staff to monitor the resident frequently to assess needs, comfort, safety, and whereabouts. After a fall in the restroom, staff interviews showed the resident was last assisted between 8:30 AM and 9:00 AM and was next seen around 10:30 AM after the fall had already occurred. The RNS and DON stated that “frequently” meant every hour and that the monitoring was not done every hour.
GT Dressing Not Dated and Tube Feeding Not Administered as Ordered
Penalty
Summary
Resident 13 had diagnoses including dysphasia, hemiplegia, hemiparesis, and gastrostomy status, and was severely cognitively impaired and dependent on staff for care, including tube feeding. The admission nursing assessment noted slight redness around the left mid-PEG tube. The physician order and care plan directed staff to cleanse the GT site with normal saline, pat dry, and cover with a dry dressing every day. During a concurrent observation and interview, Resident 13's PEG tube dressing was found not labeled with a date, and the treatment nurse stated the dressing should have been labeled with the date when the GT site was cleaned and the dressing changed. The nurse also stated that if the dressing was not dated, it meant the GT site was not cleaned and the dressing was not changed. Resident 52 had diagnoses including gastrostomy and dementia and was severely cognitively impaired, required substantial assistance for eating, and was dependent for multiple activities of daily living. The order summary indicated Jevity 1.2 was to be administered at 40 cc/hour via enteral feeding pump from 2 PM to 10 AM, and the care plan reflected the same schedule. During observation, the feeding pump was on hold and beeping, and the Jevity container dated and timed the prior evening was observed to be almost full. The LVN stated the container should have been less full if the feeding had been running as ordered and stated the resident had only received about 3 hours of feeding since the container was hung. During interview and record review, the LVN confirmed the resident was not receiving the tube feeding as ordered. The DON reviewed the enteral feeding policy, which stated the facility would remain current in and follow accepted best practices in enteral nutrition and that the date and time formula was prepared and the rate of administration should be checked to prevent errors. The DON stated tube feeding is ordered to maintain steady weight and provide nutrition, and that if it is not running as ordered, the resident may not receive adequate nutrition and may experience weight loss, skin breakdown, abnormal labs, and decline in health condition.
Improper Food Labeling and Scoop Storage
Penalty
Summary
The facility failed to follow its food storage handling practices by not properly labeling multiple food items in the freezer and dry storage area. During observation with the Kitchen Supervisor, frozen items including beef patties, pork chops, peanut butter frozen cookie dough, smoked ham, chicken breast fillets, English muffins, and tilapia fish fillets were found without the required labels showing the item name, date opened, and/or use-by date. The tilapia fish fillets had only an open date and no use-by date. A large jar of red jello in the dry storage area also had no label identifying the item name, date prepared, or use-by date. During the same observation, a scoop device was found sitting on top of the rice inside a container of jasmine rice. The Kitchen Supervisor stated that, per facility policy, food items should be labeled with the date opened or prepared, the use-by date, and the specific food name, and that scoop devices should be kept hanging inside the bin rather than placed on top of the rice. Facility policy reviewed by surveyors stated that food items in storage areas must be labeled and dated, newly opened foods must be labeled with an open date and use-by date, prepared foods must be covered, labeled, and dated, and scoop devices used for rice should be placed in the proper location and not on top of the rice.
Open Dumpster Lids
Penalty
Summary
The facility failed to ensure that two of three garbage container lids remained closed in the parking lot dumpster area, as required by its policy and procedure titled "Garbage and Trash." During observation, two blue dumpsters used for kitchen and facility waste were found with their lids wide open, while the recycling dumpster lid was closed. During interview, the Maintenance Supervisor stated that the facility's policy required all dumpster lids to be kept closed at all times to keep out flies and rodents and to prevent transfer of disease. A review of the facility's policy, revised July 2024, confirmed that the main dumpster cover should always be closed.
Arbitration Agreements Lacked Neutral Arbitrator and Convenient Venue Provisions
Penalty
Summary
Facility failed to ensure that the arbitration agreements for two residents included language providing for the use of a neutral arbitrator agreed upon by both parties and the selection of a venue convenient to both parties, as required by the facility’s policy. During review of Resident 51’s admission record, it was noted that the resident was originally admitted on [DATE]. Resident 87’s admission record showed original admission on [DATE]. During a concurrent interview and record review, the Admissions Assistant reviewed both residents’ arbitration agreements, dated 5/18/2023 and 11/26/2024, and confirmed that neither agreement included provisions for a neutral arbitrator agreed upon by both parties or for a venue convenient to both the residents and the facility. The Admissions Assistant stated he was not aware of the specific items that needed to be included and said he would need to speak with the Director of Admissions. The Director of Admissions stated she was not aware that the arbitration agreements needed to include a convenient venue and a neutral arbitrator agreed upon by both parties, and acknowledged that these provisions were important so residents would know there was no bias in the arbitration process.
Infection Control Failures During Incontinent Care, Catheter Care, and Oxygen Tubing Use
Penalty
Summary
The facility failed to observe infection control measures during incontinent care for two residents and during catheter care for one resident. For one resident with diagnoses including UTI, E. coli, and bacteremia, CNA 1 and CNA 2 were observed providing incontinent care and used the same gloves while wiping after a bowel movement, touching the bed pad and bed sheets, turning the resident, and removing a soiled gown before putting on a clean gown. Both CNAs stated they should have changed gloves and performed hand hygiene before continuing care. During catheter care for the same resident, the treatment nurse was observed wetting paper towels in a sink that contained hair, brown particles, and stains on the faucet. The paper towels rubbed against the sink and faucet area and were then used to clean the resident and the drainage system. The nurse stated the towels should not have touched the sink, and the DON stated it was not acceptable for the paper towels used for catheter care to rub against a sink with hair and brown particles. The facility policy for urinary catheter care required aseptic technique when handling or manipulating the drainage system. For another resident with diagnoses including UTI and viral hepatitis B, CNA 3 was observed providing incontinent care, wiping the resident's genital and perianal areas, and then using the same gloves to position the resident and adjust the bed pad and sheets. CNA 3 stated she did not change gloves or perform hand hygiene but should have done so before continuing care. The facility's PPE and hand hygiene policies stated gloves are for one-time use and that hand hygiene is required after contact with bodily fluids and after removing gloves. For a third resident with dementia, Parkinson's disease, and hypertensive heart disease, the resident's nasal cannula tubing was observed connected to a portable oxygen tank and labeled with a date indicating when it was last changed. The tubing had not been documented as changed after that date in the medical record reviewed, and staff stated the tubing should be changed weekly per facility protocol and labeled with the date it was changed. The facility's oxygen administration policy stated oxygen tubing is to be changed weekly.
Inaccurate MDS Hearing Assessment
Penalty
Summary
The facility failed to ensure an accurate assessment of Resident 37’s hearing ability in the MDS. Resident 37 was admitted and later readmitted with diagnoses including dementia, muscle wasting, and hypotension. In the MDS dated [DATE], the resident was assessed as moderately impaired in cognitive skills for daily decision making and dependent for multiple activities of daily living, including oral hygiene, toileting hygiene, bathing, dressing, footwear, and personal hygiene. The same MDS indicated the resident’s hearing was adequate, meaning no difficulty in normal conversation. During a concurrent observation and interview, Resident 37 stated he was hard of hearing and had difficulty hearing the surveyor. An RNS also stated that Resident 37 is hard of hearing. During a later interview and record review, the DON stated the MDS inaccurately reflected the resident’s hearing as adequate and confirmed that Resident 37 does have difficulty hearing during normal conversations. The DON stated that an accurate MDS is important because it can affect the resident’s plan of care and may result in services or treatment not being provided in accordance with the resident’s needs. The facility policy on Resident Assessments stated the assessment form must attest to the accuracy of the MDS and that assessment results are used to develop, review, and revise the comprehensive care plan.
Care Plan Missing Intervention for RP Refusal of ENT Consult
Penalty
Summary
The facility failed to develop an individualized, resident-centered care plan with measurable objectives, timeframes, and interventions for a resident with impaired hearing when the resident's RP refused an ENT consult. Resident 37 was admitted and later readmitted with diagnoses including dementia, muscle wasting, and hypotension. The MDS dated 12/26/2025 indicated the resident was moderately impaired in cognitive skills for daily decision making and was dependent for oral hygiene, toileting hygiene, showering/bathing, upper and lower body dressing, footwear, and personal hygiene. A progress note dated 9/1/2025 at 1:31 PM documented that the RP cancelled the resident's ENT appointment. The care plan for impaired communication related to impaired hearing, revised 3/2026, stated the resident's needs would be attended and met, but it did not include an intervention addressing the RP's refusal for the resident to see an ENT doctor. During observation on 3/23/2026 at 9:30 AM, the resident stated he was hard of hearing and could not hear the surveyor talk. The SSD stated the RP refused the ENT visit, and the DON stated the care plan should have included the RP's refusal so the facility could provide interventions for continuity of care.
Communication Board Not Provided in Resident’s Primary Language
Penalty
Summary
The facility failed to ensure that one sampled resident, who was admitted and later readmitted with diagnoses including a history of falls, left femur fracture, and Parkinson disease, had a communication board in a language the resident could understand. The resident’s admission record identified Language 1 as the primary language, and the H&P stated the resident had the capacity to understand and make decisions. The MDS showed the resident was dependent for multiple ADLs, including transfers, toileting hygiene, bathing, dressing, and footwear. During a bedside observation and interview, a communication board written in Language 2 was present, but the resident stated she did not use it because she did not understand it and that she spoke Language 1. The resident also stated there were not many people in the facility she could communicate with. A RN supervisor stated the board was written in Language 2 and should have been in Language 1, and that the resident would not be able to communicate needs to staff with the current board. The DON also stated the resident should have been provided a Language 1 communication board so she could communicate her needs. The facility policy stated that persons with limited English proficiency should be identified and that the facility should be capable of communicating information efficiently, including providing a communication board at the bedside if needed.
Pain Medication Given Outside Ordered Pain Range
Penalty
Summary
Safe, appropriate pain management was not provided for Resident 106, who was admitted with diagnoses including a left femur fracture, presence of a left artificial hip joint, muscle wasting, and atrophy. On admission, the resident was alert and oriented to name only, required extensive assistance with bathing, toileting, and ambulation, limited assistance with dressing and hygiene, and was independent with eating. The pain assessment identified fractures as a painful diagnosis, an acceptable pain level of 3 out of 10, and a plan to address pain with medications as prescribed and by calling the MD. The care plan identified the resident as at risk for altered comfort after ORIF and directed staff to provide pain medications as ordered. The physician ordered hydrocodone-acetaminophen 5-325 mg, 1 tablet by mouth every 4 hours as needed for pain management for pain levels of 4 to 6 out of 10. Review of the MAR showed the medication was administered for pain levels of 8 out of 10 on two occasions and for pain levels of 7 out of 10 on two occasions. During interview, RN 2 stated the medication should not have been given for those higher pain levels and that nursing staff should have informed the doctor to obtain an appropriate order. RN 1 and the DON stated pain medication should be given as ordered and according to the resident's pain level, and the facility policy stated medications are to be administered in accordance with prescribed orders and that the pain medication regimen is implemented as ordered.
Dialysis Access Site Not Assessed or Documented
Penalty
Summary
Failure to provide safe, appropriate dialysis care/services occurred for a resident with ESRD, dependence on renal dialysis, and type 2 DM. The resident was readmitted to the facility with an order for pre-dialysis monitoring of vital signs, access site, and other patient condition every shift. The resident’s care plan identified the dialysis access site as a left upper arm AV shunt and directed staff to check the access site before and after dialysis and communicate with the HD center regarding pre- and post-dialysis status. Review of the Nurses Dialysis Communication Records from 3/1/2026 through 3/26/2026 showed entries on several dialysis days identifying the access site as the left upper arm, but the records did not reflect an assessment of the access site and/or dressing. During interview, the RN supervisor stated licensed nursing staff should have assessed and documented whether there was redness, swelling, drainage, or whether the dressing was intact or present. The DON stated facility protocol required licensed nursing staff to assess residents receiving dialysis and document the access site before and after dialysis on the communication record so dialysis center staff would know the resident’s condition. The facility policy stated residents with ESRD would be cared for according to recognized standards of care and that the resident’s status prior to dialysis would be communicated by completing the dialysis communication form.
Failure to Verify Resident Identity Before Medication Administration
Penalty
Summary
The facility failed to verify the identity of one sampled resident before administering medications, as required by its policy. During a medication administration observation, an LVN was observed giving medications to the resident without checking the resident’s arm band first. When interviewed, the LVN stated she did not check the arm band and acknowledged that she should have verified the resident’s identity before medication administration. Resident 20’s record showed diagnoses of HTN, DM, and acute kidney failure. The resident’s MDS indicated intact cognitive skills for daily decision making and partial/moderate assistance with several activities of daily living, including toileting hygiene, bathing, dressing, footwear, and personal hygiene. The facility’s policy on administering medications stated that the person giving medications must verify the resident’s identity before administration, including by checking the identification band.
Inaccurate MAR Documentation for Oxygen Therapy
Penalty
Summary
The facility failed to ensure the Medication Administration Record (MAR) was accurate for Resident 85, whose record showed diagnoses including dementia, Parkinson’s disease, and hypertensive heart disease, and who had severely impaired cognitive skills for daily decision making. The resident’s order summary included oxygen 2 liters per minute via nasal cannula as needed to maintain oxygen saturation at 92% and to call the MD if there was no improvement, with the order beginning on 11/1/2025. During record review, the resident’s weights and vitals summary showed oxygen saturation was obtained while the resident was receiving oxygen via nasal cannula on 11 days in 3/2026, including 3/2, 3/3, 3/6 through 3/10, 3/12 through 3/14, and 3/22. However, the MAR for 3/1/2026 through 3/25/2026 did not document any administration of oxygen on those dates. LVN 1 stated the oxygen use should have been documented in the MAR because it was given, and RN 2 stated the MAR should have shown when oxygen was administered on those dates and that the MAR was not accurate or complete because the oxygen was not documented.
Residents' Rights Not Posted as Required
Penalty
Summary
The facility failed to ensure the Residents' Rights information was posted in a prominent and accessible location within the facility, as required by its policy. During a concurrent observation and interview, the Social Services Director stated that a copy of the Residents' Rights was not posted or displayed in any prominent area of the facility and that the facility does not post the Resident's Rights, providing copies only upon request at admission. During a later interview, the Administrator confirmed that the Residents' Rights were not currently posted in the facility and stated that the facility policy required the Residents' Rights to be posted. Review of the facility's Policy and Procedure titled Resident Rights, dated 2/2021, showed that copies of the residents' rights are posted throughout the facility.
Lack of Documentation for HVAC Preventive Maintenance by Outside Contractor
Penalty
Summary
The deficiency involves the facility’s failure to maintain documented evidence that its Heating, Ventilation, and Air Conditioning (HVAC) system was being serviced and maintained by an outside HVAC contractor to ensure it was safe and in good working condition. Review of the undated floor plan showed 54 resident rooms across two floors, and a census report showed 95 residents in the facility with a bed capacity of 99. During interviews and record review, the Maintenance Supervisor was unable to provide any logs, records, or reports of semi-annual HVAC maintenance visits by the outside company since he had been employed in the role. He acknowledged that he did not have a log or record of maintenance visits and that he should have been tracking HVAC maintenance by outside companies to monitor compliance and ensure the system remained safe and functional. Further interviews with the Administrator confirmed that the facility did not have copies of HVAC maintenance visit records on hand to verify that the system was being checked and maintained to keep temperatures within normal ranges. The Administrator stated that documentation of maintenance services from outside companies should be available to ensure the HVAC system was being checked, safe, and working properly, and noted that a request for past service records had only been sent on the day of the survey. Review of the facility’s “Maintenance Service” policy and procedure, dated 2001, indicated that the maintenance director (maintenance supervisor) is responsible for maintaining records and reports of work order requests and maintenance schedules, and that these records are to be maintained in the maintenance director’s office. Despite this policy, the required HVAC maintenance documentation was not available during the survey.
Inappropriate Purchase of Resident’s Prescribed Glucose Monitoring Device for Staff Training
Penalty
Summary
The deficiency involves the facility’s failure to maintain ethical standards of practice and resident rights by engaging in a business transaction with a resident for a prescribed medical device. Resident 1, who had type 2 DM, hypertensive heart disease with heart failure, and difficulty walking, was cognitively intact for daily decision-making and largely independent in ADLs. Resident 1 had an order allowing nursing staff to monitor blood sugar levels using a Brand 1 continuous glucose monitoring device. On 10/13/2025, an untitled facility document, signed by the DON, Resident 1, and LVN 1, indicated that Resident 1 had three Brand 1 devices and that the facility would purchase one device from the resident for $110 for education and training purposes. A petty cash receipt confirmed that the facility paid Resident 1 $110 for the Brand 1 device. During interviews, the DON stated that Resident 1 had offered to sell the Brand 1 device to the facility for training, and she agreed to purchase it with facility funds, later using the purchased device in a staff training session on how to apply the Brand 1 sensor. LVN 1 confirmed witnessing the cash payment to the resident. Resident 1 reported consenting to the sale and signing an agreement with the DON and LVN 1, and stated that at the time he did not know it was a violation. The Business Office Manager stated that paying a resident for a prescribed device was not usual practice, that such items should be obtained through a vendor, and that there was no policy allowing payment to residents for their prescribed devices because it could create an inappropriate business relationship. The Administrator acknowledged the facility purchased the device from the resident for training and to help the resident financially. The facility’s existing policies on Assistive Devices and Equipment and Resident Rights addressed supervision of assistive devices and the requirement to treat residents with kindness, respect, and dignity, but there was no policy regarding purchasing devices from residents.
Failure to Provide Timely Psychiatric Consult Following Acute Behavioral Change
Penalty
Summary
The facility failed to provide a timely psychiatrist or psychologist consult for a resident who experienced an acute behavioral change, as ordered by the physician and outlined in the care plan and facility policy. The resident, who had diagnoses including diabetes mellitus, hypertensive heart disease with heart failure, and difficulty walking, was admitted with intact cognitive skills and independence in daily activities. On the date of the behavioral change, the resident exhibited verbal aggression and refused a blood glucose fingerstick, prompting a physician's order for a psychiatric consult and an update to the care plan to include this intervention. Despite the order and care plan intervention, the psychiatric consult was not provided for 25 days. Interviews with nursing staff revealed that the facility's protocol required nursing to notify the psychiatrist of such consults the same day, with the expectation that the psychiatrist or physician assistant would evaluate the resident the following day. However, the psychiatrist was not informed of the consult order until he was at the facility for routine rounds nearly a month later. Nursing staff acknowledged that they did not follow up or endorse the consult order on subsequent shifts, and there was no documentation of the consult being offered, completed, refused, or of any physician notification during this period. A review of the resident's medical chart confirmed the absence of documentation regarding the psychiatric consult, refusals, or follow-up actions. Facility policy required thorough evaluation of new or changing behavioral symptoms by the interdisciplinary team to identify underlying causes, including psychiatric or psychological stressors. The lack of timely notification and follow-up by nursing staff resulted in the resident not receiving the ordered psychiatric evaluation as required by the physician's order, care plan, and facility policy.
Failure to Ensure Nursing Competency With CGM Device Use
Penalty
Summary
The facility failed to ensure licensed nursing staff were competent with the knowledge and use of a continuous Brand 1 glucose monitoring system for one sampled resident. The resident was admitted and readmitted with diagnoses including type 2 diabetes mellitus with unspecified complications, unspecified systolic heart failure, and presence of a cardiac pacemaker. The physician order dated 12/26/2024 directed the resident to apply the CGM and change it every 10 days. The resident’s quarterly MDS dated 10/31/2025 indicated no cognitive impairment and showed the resident was independent with eating, oral hygiene, toileting hygiene, dressing, footwear, and personal hygiene, with partial assistance needed for showering and bathing. The facility’s Education/Training Attendance Roster dated 10/15/2025 showed the DON began in-service training for licensed nurses on how to apply the CGM device, but there was no training for programming the CGM device to the receiver or smartphone. During interview and record review, the DON stated she did not provide training to licensed nurses on the Brand 1 glucose monitoring system because the resident was capable of applying and monitoring the device himself and she did not think training was important since it was a personal device. The DON also stated she could not provide documented evidence of return demonstration check-offs or sign-in sheets showing licensed nurses had undergone the training. The resident stated staff nurses refused to replace the CGM device after it was dislodged on 11/15/2025 at about 6:10 AM. The resident also stated the facility did not provide training to licensed nurses about how to apply and manage the CGM device until around 10/15/2025, and there was no training on setting up the CGM application to retrieve blood sugar data on the facility’s smartphone system. The resident stated most licensed nurses told him they were not properly trained in putting on and managing the CGM device, and that only one LVN was confident enough to apply it, though that LVN could not use the CGM application to manage the device. The DON stated the first facility training on applying CGM devices began on 10/15/2025, that the training was provided through an online video from Website 1, and that she should have requested in-person professional training from the CGM company representative or the facility pharmacy, but this was not done.
Care Plan Lacked Specificity for Two-Person ADL Assistance
Penalty
Summary
The facility failed to ensure that a resident's care plan was individualized and accurately reflected the resident's need for two-person assistance with activities of daily living (ADLs). The resident, who had diagnoses including quadriplegia and multiple sclerosis, was assessed as being dependent on staff for all ADLs such as eating, oral care, toileting, personal hygiene, showering, dressing, and footwear. The Minimum Data Set (MDS) confirmed the resident's dependency and need for two or more helpers for these activities. Interviews with facility staff, including the Director of Staff Development and a Licensed Vocational Nurse, confirmed that the resident was always assigned two CNAs for mobility and transfers to ensure safety. Despite these assessments and staff practices, the resident's care plan did not specify the requirement for two-person assistance with ADLs. The care plan only generally stated that staff should assist with mobility and ADLs daily, lacking the necessary detail to guide all staff, especially those unfamiliar with the resident. Both the LVN and the Director of Nursing acknowledged during interviews that the care plan should have been more specific and resident-centered, explicitly stating the need for two-person assistance to maintain a safe environment.
Failure to Promote Resident Dignity During Meals
Penalty
Summary
The facility failed to promote dignity and respect for three residents by labeling them as 'feeders' during dining observations. Resident 10, who has severe cognitive impairment and requires assistance with eating, was referred to as a 'feeder' by a CNA, which was against the facility's policy. The Director of Nursing confirmed that staff should not use such labels as it affects the residents' dignity. Resident 244, who has moderately impaired cognitive skills and requires setup or clean-up assistance for eating, was addressed by a CNA using a generic term rather than their name. This practice was acknowledged by the CNA as inappropriate, as residents should be addressed by their first or last names to maintain their dignity. Similarly, Resident 58, who has severe cognitive impairment and requires substantial assistance, was repeatedly called 'Mama' by an LVN during meals. Both the LVN and the DON recognized that residents should be addressed by their names to ensure they are treated with respect. The facility's policy on dignity emphasizes that residents should be treated with respect and addressed by their names, not by labels or generic terms.
Temperature Regulation and Personal Belongings Management Deficiencies
Penalty
Summary
The facility failed to maintain a comfortable and safe environment for several residents, as evidenced by issues with room temperature regulation and the handling of personal belongings. Resident 187 was found in a room with a temperature of 66°F, which is below the facility's policy range of 71-81°F. This was confirmed by the Maintenance Supervisor using a laser temperature thermometer. The resident expressed discomfort due to the cold temperature, and the Director of Nursing acknowledged that such conditions could lead to hypothermia. Residents 18 and 54 were found in a room with a temperature of 86°F, exceeding the facility's acceptable range. The Maintenance Assistant confirmed the excessive heat, and Registered Nurse 1 emphasized the importance of maintaining comfortable temperatures to prevent harm such as dehydration and hyperthermia, especially for residents unable to communicate their discomfort. The facility's policy on maintaining a homelike environment was not adhered to, as routine checks of ambient air temperatures were not required, although the Maintenance Assistant and Supervisor claimed to check temperatures daily. Additionally, the facility failed to address the issue of missing personal belongings for Resident 69. The resident reported missing sweatpants to the Laundry Staff, who did not report the issue as required by the facility's Theft and Loss Program policy. The Social Service Assistant confirmed the missing item on the inventory list, and the Administrator stated that he was not notified of the missing items, which should have triggered an immediate search. This oversight in handling personal belongings could negatively impact the resident's emotional well-being.
Failure to Provide Adequate Respiratory Care
Penalty
Summary
The facility failed to provide necessary respiratory care services for three residents, leading to deficiencies in their care. Resident 15, who was moderately impaired cognitively and dependent on assistance for daily activities, was observed without a nasal cannula in her nostrils, despite physician orders for continuous oxygen therapy. This oversight was confirmed by both a registered nurse and the Director of Nursing, who acknowledged that the nasal cannula should have been properly placed to ensure the resident received the prescribed oxygen. Resident 71, diagnosed with pneumonia and hemiplegia, was found to have their oxygen set at seven liters per minute, contrary to the physician's orders. The Director of Nursing confirmed that the oxygen administration did not follow the prescribed orders, and a registered nurse acknowledged the discrepancy. The facility's policy and procedure for oxygen administration, which includes reviewing physician orders, was not adhered to in this case. Resident 73, who was on oxygen therapy and had moderate cognitive impairment, had their oxygen tubing unchanged for 37 days, despite the facility's policy of weekly changes. The tubing was also not stored in a plastic bag to protect it from dust, as required. Both a certified nursing assistant and a licensed vocational nurse noted the outdated tubing, and the Director of Nursing confirmed the need for weekly changes and proper storage. This failure to follow protocol could lead to respiratory infections due to potential inhalation of particles from the tubing.
Deficiencies in Food Handling and Hygiene Practices
Penalty
Summary
The facility failed to adhere to proper food handling practices as observed during a survey. Food items in the preparation area, refrigerators, and freezers were not labeled with the item name and date opened, which is against the facility's policy. This included unlabeled large food containers, bags of noodles, hotdogs, ice cream cups, condiments, and burger buns. The Dietary Supervisor acknowledged these lapses, noting that unlabeled items should be discarded to prevent potential foodborne illnesses among residents. Additionally, the facility did not maintain cleanliness in the kitchen and food preparation areas. Observations revealed food debris on preparation surfaces, dirty equipment, and improper storage of items such as a dirty peanut butter container and opened water bottles. Trash bins were placed too close to clean serving trays, increasing the risk of contamination. The facility's ice machine cleaning logs were incomplete, lacking weekly cleaning records as required by the facility's policy. The dietary staff also failed to perform proper hand hygiene and glove changes during food preparation and tray assembly. Staff members were observed not washing hands between tasks and using the same gloves for different activities, which could lead to contamination. The facility's policies on food storage, preparation, and equipment cleaning were not followed, as evidenced by the lack of proper labeling, cleaning, and hand hygiene practices.
Failure to Obtain Informed Consent for Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that a resident or their representative was informed in advance about the treatment risks, benefits, options, and alternatives for the use of antipsychotic medication. This deficiency was identified for one resident who was prescribed Seroquel, an antipsychotic medication, to manage psychosis symptoms. The resident's medical records did not contain an informed consent form, which should have been obtained from the resident or their representative prior to administering the medication. The absence of informed consent was confirmed through interviews with facility staff, including a Licensed Vocational Nurse, a Medical Records Designee, and a Registered Nurse, all of whom acknowledged that the informed consent process was not followed as per the facility's policy. The resident in question was admitted with diagnoses including dementia, psychotic disturbance, and mood disturbance, and was noted to be severely impaired in cognitive skills for daily decision-making. Despite these conditions, the facility did not secure informed consent from the resident's representative before administering the antipsychotic medication. The facility's policy, revised in July 2022, mandates that residents and their representatives be informed of treatment recommendations, risks, benefits, and potential adverse consequences of antipsychotic medications, and that they have the right to refuse such medications. The failure to obtain informed consent potentially affected the resident's right to direct their own medical treatment.
Inaccurate MDS Discharge Status for a Resident
Penalty
Summary
The facility failed to ensure an accurate assessment of the Minimum Data Set (MDS) for one of the sampled residents, identified as Resident 84. The deficiency occurred when the MDS Coordinator documented and transmitted the resident's discharge status incorrectly. Despite multiple records, including the Physician's Orders, Notice of Transfer/Discharge form, Post Discharge Plan of Care, and Physician's Discharge Summary, all indicating that Resident 84 was discharged to home with home health services, the MDS discharge status was inaccurately recorded as a discharge to a short-term general hospital. This error was acknowledged by the MDS Coordinator during an interview, where she admitted to confusing the discharge status with the admission status. The facility's policy and procedure on resident assessments, revised in March 2022, assigns the responsibility of accurate resident assessments to the resident assessment coordinator. This includes assessments for admission, quarterly, annual, significant changes in status, significant corrections to prior comprehensive assessments, and discharge assessments. The inaccurate MDS discharge status impacts the facility's quality of care reporting to the Centers for Medicare & Medicaid Services (CMS), as noted by the MDS Coordinator. The report does not mention any corrective actions taken following the identification of this deficiency.
Failure to Implement Baseline Care Plan for Antipsychotic Medication
Penalty
Summary
The facility failed to complete and implement a baseline care plan within 48 hours of admission for a resident diagnosed with dementia, psychotic disturbance, and mood disturbance. The resident was admitted on November 15, 2024, and had a physician's order for Seroquel, an antipsychotic medication, to be administered twice daily for psychosis. However, a review of the resident's medical record revealed that there was no baseline care plan for the antipsychotic medication use as indicated in the physician's order. Interviews with Licensed Vocational Nurses (LVN) 4 and 3 confirmed that the baseline care plan should have been initiated upon the resident's admission and signed by the admitting Registered Nurse (RN). LVN 3 stated that the baseline care plan should be completed within 14 to 30 days from admission and kept in the resident's chart. The absence of this care plan had the potential to affect the resident's quality of care by not promoting continuity of care and communication among the nursing home staff.
Failure to Provide Communication Boards for Residents with Language Barriers
Penalty
Summary
The facility failed to ensure that two residents, Resident 15 and Resident 73, were provided and were using a communication board, which is essential for residents with communication barriers to express their needs. Resident 15, who was moderately impaired cognitively and dependent on staff for daily activities, was observed speaking in a non-English language and complaining about pain. The staff present did not understand the resident, and the communication board, which was supposed to be used as per the care plan, was found hidden and not in use. This oversight was acknowledged by LVN 3, who confirmed that the communication board should have been used to facilitate communication. Similarly, Resident 73, who had a language barrier and was dependent on staff for daily activities, was observed trying to communicate with CNA 2, who did not understand the resident's language. The communication board, which was supposed to be easily accessible as per the facility's policy, was not found in the room. The Director of Nursing confirmed that it was the facility's policy to provide communication boards to residents with language barriers to ensure they receive the necessary care. The facility's policy emphasized the importance of effective communication with limited English proficient persons to ensure they benefit from the services offered.
Failure to Maintain Resident's Personal Hygiene
Penalty
Summary
The facility failed to provide adequate care and services to maintain good grooming and personal hygiene for a resident, identified as Resident 44. The resident was admitted with Parkinson's disease, hypertensive heart disease, and muscle weakness, and required partial/moderate assistance with activities of daily living, including personal hygiene. The resident's care plan indicated a need for assistance with self-care due to limited mobility and aimed to ensure the resident was clean, well-groomed, and neatly dressed daily. However, during an observation, the resident was found with long, untrimmed, and dirty fingernails, which had not been trimmed for a month, contrary to the resident's expectation of weekly trimming. Interviews with facility staff, including a CNA and an RN, confirmed the resident's fingernails were long and dirty, and it was the CNA's responsibility to trim and maintain the residents' nails to prevent skin injury and infection. The Director of Nursing also stated that nail care was part of the grooming duties performed on bath days. The facility's policy on fingernail care, revised in February 2018, emphasized the importance of keeping nails trimmed and clean to prevent infections. The failure to adhere to this policy and provide necessary nail care had the potential to negatively impact the resident's self-esteem and posed a risk for skin breakdown and infection.
Incorrect LAL Mattress Settings for Resident with Pressure Ulcer
Penalty
Summary
The facility failed to ensure that the low air loss (LAL) mattress was set correctly for a resident, in accordance with the facility's Pressure Injury policy and procedure. The resident, who was at high risk for skin breakdown with a Braden Scale score of 10, had a stage 4 pressure ulcer on the left buttock. The resident was dependent on staff for various activities of daily living and had moderately impaired cognitive skills. The physician's order specified the use of an LAL mattress for wound management, but the settings were not adjusted according to the resident's weight, as required by the facility's guidelines and the manufacturer's instructions. During observations, it was noted that the LAL mattress was set incorrectly on two separate occasions. On the first occasion, the mattress was set at 180 mmHg, which was not appropriate for the resident's weight of 124 pounds. On the second occasion, the mattress was set at 140 mmHg, while it should have been set at 130 mmHg according to the resident's weight. Licensed Vocational Nurses confirmed that the incorrect settings would not be effective for the resident's wound management. The facility's policy and the manufacturer's manual both indicated that the mattress settings should be adjusted based on the resident's weight to optimize comfort and reduce the incidence of pressure ulcers.
Improper Foley Catheter Bag Positioning
Penalty
Summary
The facility failed to maintain proper positioning of a foley catheter bag for a resident, identified as Resident 15, which is a critical aspect of catheter care. The resident, who was moderately impaired cognitively and dependent on assistance for daily activities, had an indwelling catheter due to urinary retention. During an observation, it was noted that a Certified Nursing Assistant (CNA) moved the resident's catheter bag from below the level of the bladder to above it, placing it on top of blankets at the foot of the bed. This improper positioning was observed again when the CNA held the catheter bag above the bladder level while untangling it, causing urine to flow back towards the resident. Interviews with the Licensed Vocational Nurse (LVN) and the Infection Preventionist Nurse (IPN) confirmed that the catheter bag should always be kept below the bladder level to prevent urine backflow, which could lead to a urinary tract infection (UTI). The facility's policy on urinary catheter care, revised in August 2022, also stipulated that the drainage bag must be positioned lower than the bladder at all times. The failure to adhere to this policy and the improper handling of the catheter bag posed a potential risk for the resident to develop a UTI.
Delayed Administration of Metformin for Diabetic Resident
Penalty
Summary
The facility failed to administer Metformin hydrochloride to a resident with diabetes mellitus type 2 within one hour of the prescribed time, as per the physician's order. The resident, who was admitted with multiple diagnoses including diabetes mellitus, cerebral infarction, dysphagia, and hemiplegia, required assistance with various activities of daily living. The physician's order specified that Metformin should be administered with meals, but it was given late by a Licensed Vocational Nurse (LVN), who admitted to forgetting the timing requirement. This oversight was observed during a medication administration process, where the LVN acknowledged the error and its potential impact on the resident's blood sugar levels. The facility's policy and procedure for administering medications, reviewed in October 2024, mandates that medications be given within one hour of the prescribed time and in accordance with specific instructions such as with meals. A Registered Nurse (RN) confirmed the importance of timely medication administration, particularly for diabetes medications, to prevent adverse effects like hypoglycemia or hyperglycemia. The Medication Administration Audit Report corroborated the delay, showing that Metformin was scheduled for 7:15 AM but was administered at 9:22 AM, highlighting a deviation from the prescribed protocol.
Failure to Conduct Required Laboratory Tests for a Resident
Penalty
Summary
The facility failed to ensure that laboratory orders were completed for a resident, identified as Resident 14, who was admitted with diagnoses of hypertensive heart disease and hyperlipidemia. Upon admission, the resident was prescribed pravastatin sodium to manage cholesterol levels and prevent cardiovascular events. However, a Consultant Pharmacist's recommendation for a lipid and liver panel test, necessary for monitoring the effects of the medication, was not executed. This recommendation was made on December 24, 2024, but the required tests were not ordered or performed as confirmed by a review of the physician's orders and an interview with a registered nurse. The deficiency was identified during a review of the resident's records and an interview with Registered Nurse 1, who confirmed that the lipid and liver panel tests were not carried out. The nurse explained that RN supervisors are responsible for verifying and entering physician orders into the electronic medical records, which should then trigger laboratory services. However, in this case, the necessary tests were not ordered, leading to a failure in providing timely laboratory services to meet the resident's needs.
Failure to Accommodate Resident's Dietary Preferences
Penalty
Summary
The facility failed to provide food that accommodated a resident's preferences, specifically for a resident with dysphagia and dementia. The resident was on a low sodium, low fat, and low cholesterol diet with pureed food and thin liquids, as per physician orders. However, the resident's responsible party (RP) reported that the pureed food was too thick, causing the resident to gag and making it difficult for her to eat. Despite informing the Dietary Supervisor (DS) about this issue months prior, no follow-up action was taken to address the concern. Observations confirmed that the pureed diet provided was indeed thick, which was not in line with the resident's dietary needs. The facility's policy on food quality and palatability, which requires food to be palatable and attractive, was not adhered to in this case. The lack of action from the DS after being informed of the issue contributed to the deficiency, potentially affecting the resident's meal intake and overall health.
Delayed Meal Service for Two Residents
Penalty
Summary
The facility failed to ensure timely meal service for two residents, resulting in meals being served later than the scheduled time. Resident 287, who was admitted with diagnoses including colon cancer and required assistance with daily activities, was observed without a lunch tray at 12:09 PM and expressed hunger at 12:30 PM. The lunch tray was only delivered at 12:45 PM. Similarly, Resident 38, who had diagnoses including cellulitis and type 2 diabetes, was observed waiting for a lunch tray at 12:23 PM and expressed hunger at 12:42 PM. The lunch tray was delivered at 12:47 PM, after the scheduled lunch time of 12 noon. The Dietary Supervisor acknowledged the delay in meal delivery, stating it was unacceptable as it could negatively affect residents' well-being. The facility's policy indicated that meals should be served within designated time frames unless there is an emergency or resident request. However, the delay was attributed to the CNA being busy with other residents, which was not an emergency situation. This deficiency in meal service timing had the potential to impact the psychosocial well-being of the residents involved.
Incomplete Documentation of Orthostatic Blood Pressure
Penalty
Summary
The facility failed to ensure complete documentation of orthostatic blood pressure measurements for a resident, specifically missing the lying position measurement. This deficiency was identified for one of the sampled residents, who was admitted with diagnoses including dementia, psychotic disturbance, and mood disturbance. The resident was prescribed Seroquel, an antipsychotic medication, with a physician's order to monitor blood pressure in both sitting and lying positions every Sunday. However, the Medication Administration Record (MAR) showed several instances where the lying position blood pressure was not documented. Interviews with nursing staff revealed that the facility's process requires nurses to follow physician orders and document blood pressure readings. If unable to do so, they must note the reason in the progress notes. Despite this protocol, the resident's orthostatic blood pressure was not consistently recorded, potentially increasing the risk of falls due to hypotension or dizziness. The facility's policy on antipsychotic medication use emphasizes the importance of monitoring and reporting adverse effects, which was not adhered to in this case.
Infection Control Breach During Peri-Care
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices were followed by staff during the provision of peri-care to a resident. Specifically, a Certified Nursing Assistant (CNA) did not change gloves or perform hand hygiene after providing peri-care to a resident who was dependent on staff for personal hygiene and had an indwelling catheter. The CNA was observed using the same gloves to touch the resident's clean bed pad and bed sheets, which is against the facility's policy and procedure for hand hygiene. The resident involved was moderately impaired in cognitive skills and required assistance with various activities of daily living, including personal hygiene. The facility's policy, revised in 2019, mandates hand hygiene after contact with bodily fluids and before moving from a contaminated to a clean body site. The Infection Preventionist Nurse confirmed that the CNA should have removed gloves, performed hand hygiene, and donned new gloves to prevent the spread of infection, as the use of gloves does not replace the need for hand hygiene.
Water Leak in Kitchen Ceiling
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment by not addressing a water leak in the kitchen ceiling from January 26 to January 27, 2025. During an initial observation on January 27, 2025, a moderate amount of water was found on the floor near the dishwashing area, with a wet/dry vacuum actively suctioning water and rolled bed sheets placed around the puddle. The Dietary Supervisor confirmed the presence of the water leak, which was traced back to a hole in the metal duct for ventilation between the roof and ceiling, as explained by the Maintenance Supervisor. The duct had collected rainwater, leading to the leak. Interviews revealed that the water leak was reported by kitchen staff on the night of January 26, 2025, but there was uncertainty about whether maintenance staff had conducted rounds on January 24, 2025. The Maintenance Assistant was informed of the leak on the morning of January 27, 2025, and confirmed the presence of leaking water. Concerns were raised about potential food contamination due to the leak, which could result in the kitchen being unusable and no food being available for residents. The facility's maintenance policy, revised in December 2009, states that the maintenance department is responsible for keeping the building in good repair and free from hazards, which was not adhered to in this instance.
Inaccurate Documentation and Unauthorized Medication Administration
Penalty
Summary
The facility failed to maintain accurate documentation in the medical records for one of the sampled residents by allowing a Certified Nursing Assistant (CNA) to administer a topical cream, while a Licensed Vocational Nurse (LVN) documented the administration in the Treatment Administration Record (TAR). This practice was observed during a review of the resident's TAR for November 2024, where it was noted that the treatment nurse was recorded as having applied the hydrophilic wound dressing to the resident's buttocks, despite the CNA being observed performing this task. The facility's policy and procedure require that only licensed nurses administer and document medications, which was not adhered to in this instance. The resident involved had a medical history of quadriplegia and multiple sclerosis, requiring assistance with various activities of daily living. The resident's physician orders specified the application of hydrophilic wound dressing to the buttocks every shift for skin maintenance. However, during an interview, the treatment nurse admitted that CNAs had been applying the cream, and licensed nurses were signing off on the TAR. This discrepancy between the facility's policy and the actual practice was confirmed by the Director of Nursing, who stated that only licensed nurses should complete and sign entries in the TAR.
Improper Disposal of Resident's Medication
Penalty
Summary
The facility failed to adhere to its policy for the proper disposal of medication, resulting in the inappropriate disposal of medication for one resident. The resident, who was admitted with diagnoses of hypertensive heart disease with heart failure and atherosclerotic heart disease, was prescribed carvedilol to manage these conditions. Despite the medication being actively used, 182 tablets of carvedilol were disposed of by a Licensed Vocational Nurse (LVN) and a Registered Nurse (RN) after the resident requested the disposal. This action was contrary to the facility's policy, which stipulates that medications should only be disposed of if they are unused or expired. Interviews with the nursing staff involved revealed that they signed the Medication Disposition Record/Pass Log and disposed of the medication based on the resident's request. However, the Director of Nursing (DON) confirmed that the facility's policy was not followed, as the medication was neither unused nor expired. The DON acknowledged the lack of a process for handling medications brought in by residents and the need for better coordination with the pharmacy to prevent overstocking and wastage of medications like carvedilol.
Failure to Provide Bed Hold Notice During Resident Transfer
Penalty
Summary
The facility failed to provide a written notice of bed hold policy to a resident during their transfer to a General Acute Care Hospital (GACH). The resident, who was cognitively intact and capable of making their own decisions, was transferred to the hospital following a psychiatric emergency evaluation. Despite the facility's policy requiring that residents or their representatives be given written information about bed hold policies at the time of transfer, this was not done for the resident in question. The facility's administrator admitted that the bed hold notice was not provided because they did not expect the resident to return after the psychiatric emergency transfer. The resident had a history of depression and agitation, and had refused psychotropic medications. The facility's policy, revised in October 2022, mandates that written notice regarding bed hold policies be provided to residents or their representatives at the time of transfer, or within 24 hours if the transfer was an emergency. However, this procedure was not followed, and no bed hold order was placed for the resident when they were transferred to the hospital. This oversight violated the resident's right to make informed decisions and receive information about their rights to have the bed held for their return.
Deficiencies in Medication Management and Documentation
Penalty
Summary
The facility failed to have a process in place for handling medications brought in by residents or their families, specifically in the case of a resident with type 2 diabetes mellitus. The resident's family brought in Ozempic, an injectable medication, which was stored at the bedside and administered by the facility's nursing staff. However, the facility's policy did not include procedures for managing such medications, and there was no log or inventory kept of the medications brought in by the resident from September 2023 to August 2024. The Director of Nursing (DON) confirmed that the procedures followed did not match the facility's policy. Additionally, the facility failed to document the injection site for one of the Ozempic injections administered to the resident in August 2024. The medication administration record for that month lacked documentation of the injection site for the dose given on August 14, 2024. The Registered Nurse (RN) confirmed that the Licensed Vocational Nurse (LVN) who administered the dose did not document the site, and there was no indication of the last injection site used in the nurse's notes. The facility also failed to properly store and discard expired and discontinued medications. During an inspection, expired medications and medications belonging to discharged residents were found in a medication refrigerator in the infection preventionist's office. The facility's policy required such medications to be removed from the current supply and disposed of in a timely manner. Furthermore, the temperature monitoring of the medication refrigerator was not documented for 30 out of 62 days in July and August 2024, which could affect the efficacy of the stored medications.
Failure to Inventory Resident's Medications
Penalty
Summary
The facility failed to log or take inventory of a resident's personal and current medications, which had the potential for misappropriation of resident properties. The resident, who was admitted with diagnoses including type 2 diabetes mellitus, heart failure, muscle wasting, and legal blindness, reported a theft of his medication, Ozempic, which is used to manage diabetes. The resident stated that a dose of Ozempic was unaccounted for after he requested it in the dining room. He noted that there should have been one opened box with one dose left and two new unopened boxes in his personal medication refrigerator, but the opened box was missing. Interviews with the facility's administrator and director of nursing revealed that the resident had been personally picking up his medications from an outside pharmacy and dropping them off with the LVN on duty since the previous year. However, the facility did not maintain a log or inventory of these medications from September 2023 to August 2024. The facility's policy on personal property, dated December 2008, required that residents' personal belongings be inventoried and documented, which was not adhered to in this case.
RN Lacks Competency in Insulin Administration
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was competent and skilled in administering medication via injection, specifically insulin, to a resident. The RN, who had a phobia of needles and had not administered an injection in a long time, instructed the resident to self-administer their insulin. This occurred despite the resident being legally blind and having a diagnosis of diabetes mellitus. The resident was capable of understanding and making decisions, as indicated in their medical records, but the RN's actions were not in accordance with the facility's policy and procedure for medication administration. The Director of Nursing (DON) and the Director of Staff Development (DSD) acknowledged that the facility lacked a formal process for assessing and documenting the competency of nursing staff in administering injections. The facility's policy required that only licensed individuals administer medications, and staff must demonstrate specific competencies. However, the DSD confirmed that the training for newly hired RNs and LVNs was primarily orientation and class discussion, without return demonstrations to verify competency. This lack of competency assessment contributed to the RN's inability to properly administer the insulin injection.
Resident Self-Administers Insulin Without Authorization
Penalty
Summary
The facility failed to adhere to its policy regarding medication administration, resulting in a deficiency related to a resident self-administering insulin without proper authorization. Resident 1, who has diabetes mellitus and legal blindness, was instructed by a registered nurse to self-administer his Humalog insulin injection. This occurred despite the absence of a physician's order or a self-administration form authorizing the resident to manage his own medication. The facility's policy, revised in April 2019, clearly states that only licensed or permitted individuals are allowed to prepare, administer, and document medication administration. Interviews with the staff revealed that on the morning of the incident, both a registered nurse and a licensed vocational nurse were involved in preparing the insulin pen for Resident 1, who then administered the injection himself. The Director of Nursing confirmed that there was no order in place for the resident to self-administer medications, highlighting a breach in protocol. The resident's Minimum Data Set indicated that he was independent in cognitive skills for daily decision-making, yet the facility's policy was not followed, leading to the potential for improper medication administration.
Failure to Provide Timely Access to Medical Records
Penalty
Summary
The facility failed to provide a resident or the resident's legal representative with a copy of the resident's medical records upon request and within the stipulated time frame of two working days, as per the facility's policy. The resident, who had been diagnosed with conditions including urinary tract infection, chronic obstructive pulmonary disease, pneumonia, and unspecified asthma, was deemed incapable of making decisions. The request for the resident's medical records was made by the resident's legal representative and was received by the facility via electronic mail. Despite the facility's policy requiring records to be released within 72 hours, excluding weekends and holidays, the records were not provided in a timely manner. Interviews with facility staff, including the Director of Nursing and Medical Record staff, revealed that the request was forwarded to the facility's lawyers, as it was made by the resident's lawyers. However, there was no confirmation that the records were actually sent. The Medical Record staff later confirmed that the resident's lawyers had not received the requested records, which were needed for the resident's follow-up medical care. The facility's policy on the release of information clearly states that residents have the right to access their records within the specified time frame, but this was not adhered to, resulting in a violation of the resident's rights.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 7,259 citations issued within 25 miles in the last 12 months — including the 37 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Alhambra
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Royal Gardens Healthcare | 0.6 mi | ★★★★★ | 35 | 0 |
| Alhambra Hospital Med Ctr Dp/snf | 0.9 mi | ★★★★★ | 0 | 0 |
| Atherton Baptist Home | 1 mi | ★★★★★ | 10 | 0 |
| Heritage Manor | 1.3 mi | ★★★★★ | 33 | 0 |
| Monterey Park Conv Hosp | 1.4 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.