Below average — CMS composite of the measures below.
The next survey window likely opens around August 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sunrise Post Acute during CMS and state inspections, most recent first.
Facility assessment was not reviewed and updated annually or as needed. The ADM stated he was responsible for the assessment and acknowledged the last one was completed over a year earlier. Review showed the assessment did not accurately reflect the facility census, cultural needs, staff types, services rendered, or building plant needs, and the facility policy required an annual review and update.
QAPI failed to identify and address a deficient practice involving physician visits, as the NP completed initial visits instead of the primary physician. The ADM stated the QAPI team was unaware of the issue and that the facility had no system to ensure initial resident visits were conducted by the primary physician. The QAPI committee’s recent meeting addressed other topics, but not this deficient practice.
A resident with ESRD, CHF, dementia, and dialysis dependence had physician-ordered intake and output monitoring that was not consistently completed or totaled in 24 hours. LNs documented intake by shift but did not record the daily total as ordered, and output entries were inconsistent, using both cc and urination episodes. The RD’s assessment listed fluid needs of 1750 to 2100 mL/day, but the RN stated the resident’s recorded intake was only about 800 to 920 cc/day, with no evaluation, no specific care plan, and no documentation that the low intake was reported to the physician.
Physician Did Not Complete Initial Face-to-Face Assessments: The facility failed to ensure the attending physician completed the initial face-to-face H&P for five residents. Instead, an NP performed the initial assessments for multiple new admissions and a physician later countersigned the reports. The DON confirmed the physician should have completed these initial evaluations, and the facility policy stated the attending physician is responsible for assessing new admissions in a timely fashion.
A resident had Systane eyedrops, eczema cream, and a pain roll-on at the bedside and stated she self-administered them, but the record showed no physician order or self-administration assessment. The resident had diagnoses including fibromyalgia, osteoarthritis, HTN, and DM, and staff confirmed the medications should not have been at the bedside without authorization.
A resident with a history of prostate CA, HTN, and A-fib was given Seroquel 100 mg BID for psychosis manifested by striking out, even though the PASRR was negative for serious mental illness, the MDS showed no psychosis indicators or behavioral symptoms, and the NP note documented no psych hx. Staff interviews described the resident as alert, cooperative, and pleasant, and the facility policy required documentation of the rationale for behavioral medication use.
A resident with dementia and Plavix-related bleeding risk developed a purplish discoloration on her left elbow that was observed by surveyors, but staff did not report, assess, or refer it to the physician for treatment orders. The CNA documented no skin issues, the eMAR showed routine monitoring without identifying the new discoloration, and both the LVN and TN stated they had not received a report about the finding. The DON confirmed the discoloration should have been identified and referred immediately.
A resident with COPD was observed receiving O2 via NC at 6 LPM even though the physician's order allowed 2 LPM PRN and titration up to 4 LPM. The resident said she needed O2 for SOB, had removed the NC because it made her nose dry, and did not know the ordered rate. An LVN and the DON both confirmed the order was not followed.
Failure to assess pain before obtaining a migraine medication order. An LVN obtained an order for Nurtec ODT for a resident with fibromyalgia and migraines after the resident requested it, but did not first assess pain level, frequency, or vital signs. The LVN stated the resident did not appear to be in pain, and the DON confirmed that licensed nurses are expected to assess pain and use non-pharmacological interventions before contacting the MD for pain medication.
Undated inhalers for two residents with COPD were found stored in the med cart despite routine orders for fluticasone-salmeterol and albuterol, and the DON later stated the remaining puff counts should have been different. An opened blood glucose test strip vial was also found undated in the cart, even though staff stated opened items should be dated and the manufacturer required the vial to be dated when first opened and used within 3 months.
A facility failed to properly label three artificial tears bottles with enough resident-identifying information, as the bottles were only linked to residents by last name on the cartons and one name was misspelled. RN 1 acknowledged the bottles could be mixed up if separated from the cartons, and the DON stated the full resident name should be on both the carton and bottle. The facility also stored keys for discontinued controlled substances in an unlocked drawer in the half-opened DON office, and the DON acknowledged someone could enter the office and access the narcotics.
Two residents did not receive nutrition services as documented. One resident with dementia and other chronic conditions reported receiving cooked vegetables instead of requested raw vegetables, and her tray included peppers she disliked despite a diet order noting no red or green peppers and a care plan to cater to food preferences. Another resident with fibromyalgia, OA, HTN, and DM stated the facility food did not match the menu and requested alternate meals; record review showed no documented annual nutritional assessment had been completed to update her diet needs and preferences.
A prune juice carton that had been opened and was past the 5-day refrigerated limit was observed in the refrigerator and available for use. The DA and DS both stated the juice had been opened on the date shown and should have been discarded, and the facility policy for opened refrigerated juices listed a 5-day limit.
Failure to follow EBP during resident care: two consulting cardiology office employees entered a resident's room, where EBP signage and PPE were available, and performed an ECG/ultrasound while wearing gloves only and no gown. The resident had an indwelling foley catheter and was ordered to receive EBP during high-contact care activities; the IPN stated gown, glove, and mask were required.
A resident with dementia and a history of intolerance to noise was repeatedly moved between rooms without proper assessment or documentation of compatibility, resulting in placement with another resident who frequently vocalized. This led to a violent assault causing severe injuries and death. Staff interviews confirmed that required assessments and documentation were not completed, despite facility policy.
A facility failed to update a care plan for a resident with dementia and a preference for a quiet environment, despite known behavioral risks and multiple room changes. The resident was placed with another resident who exhibited frequent shouting, leading to an altercation in which one resident sustained fatal injuries. Staff interviews confirmed the care plan did not address the need for a quiet room or assess risks during room changes.
The facility did not provide adequate information to authorities regarding an incident of physical abuse between two residents, as the required report lacked essential details such as the nature of the event, time, and those involved. Despite emergency response and notifications, the form sent to the State Agency and Ombudsman only stated an allegation without specifics, contrary to facility policy.
A facility failed to ensure proper initiation and discussion of Advance Directive Acknowledgement, Consent to Treat, POLST, and Bed Hold Notification Policy for a resident with dementia who lacked a legal representative. The necessary documents were incomplete and lacked a valid signature, and the facility did not follow its Bioethics Policy to address the situation, leading to a deficiency.
The facility failed to develop timely discharge plans for two residents, one with dementia and another with a traumatic brain injury. Both residents' Social History Assessments were overdue by 13 days, and the Social Service Director acknowledged the oversight. The facility's policy required these assessments to be completed within 5-7 days, but no later than 14 days after admission.
A resident with COPD and pneumonia was inappropriately transferred to an acute hospital using non-emergency transportation, despite being unstable with fluctuating oxygen levels. The resident, who had a POLST indicating full treatment, was not transported via ambulance, which was necessary given their condition. Upon arrival at the hospital, the resident was in respiratory distress and required immediate medical intervention.
A facility failed to hold a bed for a resident during the 7-day bed hold period, leading to an extended stay at a GACH. The resident, with severe memory impairment, was transferred to the GACH for evaluation, and a bed hold was requested by their representative. However, the facility admitted a new resident into the held bed, leaving no available beds for the resident's return within the 7-day period, contrary to the facility's policy.
A facility failed to secure residents' mail, compromising privacy and confidentiality. An unannounced visit revealed that mailboxes outside the facility gate were unlocked and easily accessible. The DSD and AD confirmed the mailboxes had never been locked, and the DON acknowledged the risk of exposure and theft of residents' personal information. The facility's policy mandates protection of resident confidentiality and privacy.
The facility failed to maintain safe room temperatures for eight residents, with temperatures exceeding the acceptable range of 71 to 81 degrees Fahrenheit. Residents, including those with chronic conditions like asthma and dementia, reported discomfort and difficulty breathing. The issue was linked to broken air conditioning units that had not been replaced, despite recommendations and quotes for repair.
The facility failed to properly assess and monitor the use of psychotropic medications for three residents, leading to potential unnecessary medication administration. One resident was prescribed Aripiprazole without a physician's assessment for its continued use. Another resident was on Ambien for insomnia, but there was no documented evaluation of a recommended frequency reduction. A third resident was prescribed multiple psychotropic medications without documented justification for their continued use. The facility did not adhere to its policy requiring evaluation of psychotropic medication use upon admission.
The facility failed to ensure dietary staff were trained in food cool-down procedures, as a DA and CK could not accurately verbalize the process. The RD clarified the correct procedures, which were not followed, posing a risk of foodborne illness to residents.
The facility failed to maintain a sanitary kitchen environment, as observed with multiple sheet pans having brown-black grime buildup. The Director of Food and Nutrition Services acknowledged the pans were old and needed replacement, posing a risk for cross-contamination and foodborne illness. The Registered Dietitian confirmed the expectation for cleanliness, aligning with the facility's sanitation policy and FDA Food Code requirements.
The facility did not ensure the QAPI committee monitored and re-evaluated high temperature levels in resident rooms due to broken AC units. Despite placing fans and coolers, the effectiveness of these measures was not assessed, leading to unsafe and uncomfortable conditions.
The facility failed to provide education and resources regarding Advance Directives (AD) to three residents, potentially impacting their medical treatment decisions. Despite the facility's policy requiring AD education upon admission, the Social Services Director admitted to not providing this information to the residents or their representatives.
A resident with multiple diagnoses, including dementia and depression, felt uncomfortable filing a grievance due to the attitude of the Social Services Director (SSD). Despite being cognitively intact, the resident expressed this concern during a Resident's Council meeting. The facility's policy guarantees the right to voice grievances without fear, but the resident's discomfort suggests this was not upheld.
A resident with hypertension was administered Carvedilol without food, contrary to medication instructions, by an LVN. The LVN did not verify the resident's food intake, which was undocumented, leading to a deficiency in medication administration as per facility policy.
A facility failed to ensure an LVN was adequately trained in documenting narcotic pain medication administration for two residents. The LVN signed out medications without proper documentation in the eMAR and later created backdated entries. The DON and RN were unaware of the reasons for these actions, and the DSD acknowledged the need for further training. The facility's policy on pain medication documentation was not followed.
A facility failed to document the administration of Hydrocodone-Acetaminophen for a resident with osteoarthritis. A nurse signed out the medication but did not record its administration in the eMAR, contrary to the facility's policy requiring immediate documentation of controlled drugs. This lapse was identified during a review involving a registered nurse.
A resident with multiple sclerosis and anxiety disorder was admitted with dental issues, including missing teeth and cavities. Despite the care plan's directive to coordinate dental care, the facility failed to arrange a dental appointment. Interviews with staff confirmed the oversight, highlighting a lapse in adhering to the facility's policy on providing medically-related social services.
A fly was observed landing on a resident's lunch meal, indicating a failure in the facility's pest control program. The resident, with moderate cognitive impairment and other health issues, was at risk due to this oversight. The facility's policy states an ongoing pest control program, but the incident suggests a lapse in its implementation.
The facility failed to address a doctor's concern regarding ongoing weekly telephone appointments for a resident, resulting in the resident not receiving necessary care. The Social Services staff did not follow up to confirm the scheduled appointment, and the Director of Nursing confirmed that the facility did not follow its policy for medically-related social services.
Facility Assessment Not Reviewed or Updated Annually
Penalty
Summary
The facility failed to ensure its facility assessment was reviewed and updated annually and as needed. During an interview and record review on September 11, 2025, the Administrator stated he was responsible for conducting the facility assessment and said the last assessment was completed on July 24, 2024. He acknowledged the assessment should have been done annually. Review of the facility assessment showed it did not accurately reflect the facility's census, cultural needs, staff types, services being rendered, or building plant needs. The Administrator stated the assessment should accurately reflect the facility census and the cultural needs and services being rendered to the population served. A review of the facility policy and procedure titled Medicare and Medicaid Programs; Reform of Requirements for Long-Term Care Facilities .Rules and Regulations, dated August 18, 2017, indicated the facility must conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during day-to-day operations and emergencies, and must review and update that assessment as necessary and at least annually.
QAPI Failed to Identify Deficient Physician Visit Practice
Penalty
Summary
The facility’s QAPI Program failed to identify and address a deficient practice involving physician visits, specifically the nurse practitioner completing the initial visits instead of the primary physician. During an interview on September 11, 2025, the Administrator and Medical Records staff stated that the QAPI Committee meets quarterly and as needed, and that the last meeting on July 23, 2025, addressed falls, weight variance, elopement, and theft and loss. The Administrator stated the QAPI team was unaware of the deficient practice related to the NP completing the initial visits, and that the facility did not have a system in place to ensure initial resident visits were conducted by the primary physician. Review of the facility’s QAPI policy indicated the committee is responsible for identifying and addressing quality deficiencies, analyzing problems, establishing corrective actions, measuring progress, communicating information to staff and residents, and reporting findings to the Administrator and governing board.
Inaccurate Intake and Output Monitoring for Dialysis Resident
Penalty
Summary
The facility failed to ensure safe, appropriate dialysis-related fluid intake and output monitoring for one resident with ESRD, CHF, dementia, and dependence on renal dialysis. The resident’s history and physical indicated he did not have the capacity to understand and make decisions. Physician orders dated August 22, 2025 directed staff to monitor and record intake and output every shift and to calculate and record total intake and output for the day each evening shift. Another order dated August 26, 2025 directed dialysis treatment three times weekly on Tuesday, Thursday, and Saturday. Record review showed the Licensed Nurses did not consistently monitor, calculate, and record the resident’s total fluid intake and output in 24 hours from August 22 through September 9, 2025. The eMAR reflected intake amounts documented by shift, but the total daily intake was not consistently calculated as ordered. Output documentation was inconsistent, with some entries recorded as measured fluid amounts and others recorded only as the number of urination episodes. The Registered Nurse stated the staff were documenting intake each shift but were not recording the total intake in 24 hours as ordered, and that the output documentation was not accurate because some staff documented cc and others documented episodes. The Registered Dietitian’s nutritional risk assessment dated August 25, 2025 listed estimated fluid needs of 1750 to 2100 mL per day. The RN stated the resident’s recorded daily intake was approximately 800 to 920 cc per day and did not meet those needs, and there was no evaluation of the intake and output monitoring since the order was initiated. The RN also stated there was no care plan developed specific to the intake and output monitoring and no documentation that low daily intake was reported to the physician. The DON stated the low fluid intake should have been reported and the resident monitored for signs and symptoms of dehydration and/or other complications such as fluid overload, and that this was not done.
Physician Did Not Complete Initial Face-to-Face Assessments
Penalty
Summary
The facility failed to ensure a physician conducted the initial face-to-face visit for five sampled residents: Residents 28, 35, 26, 22, and 47. Resident 28 was admitted to the facility and had a History and Physical dated June 25, 2025, documenting that the resident had the capacity to make decisions. The record stated that NP 1 completed the evaluation and treatment encounter, reviewed nursing notes, medication reconciliation, diagnostic testing, and documented the clinical record, while also noting discussion with supervising Physician 1, who agreed with the evaluation, assessment, and plan. During interview, the DON stated NP 1 conducted the initial H&P comprehensive assessment on Resident 28 instead of the primary physician, and MR stated NP 1 usually did the initial H&P on Physician 1's new admit residents. For Residents 35, 26, 22, and 47, the record review showed NP 1 completed the initial H&P assessments, with Physician 1 later countersigning the reports. Resident 35 had a change in physician from Physician 2 to Physician 1 on August 11, 2025, and NP 1 completed the initial H&P assessment that same day. The DON stated NP 1 conducted the initial H&P assessments for Residents 35, 26, 22, and 47, and that Physician 1 should have conducted those assessments. The facility policy titled Attending Physician Responsibilities stated the attending physician is responsible for providing medical services, coordinating healthcare, and assessing new admissions in a timely fashion according to the resident's medical stability.
Unassessed Bedside Medications
Penalty
Summary
The facility failed to ensure a resident’s right to self-administer medications was properly evaluated and authorized when Systane eyedrops, Lmnoop eczema relief cream, and Migrastil pain roll-on were found at the resident’s bedside without resident identifiers or a physician’s order. The resident was observed in bed with the medications on top of the bedside table, and she stated that she self-administered the eyedrops five times daily and used the cream and roll-on as needed. She also stated the facility had never evaluated her for self-administration of medication. The resident’s record showed she was admitted with diagnoses including fibromyalgia, osteoarthritis, hypertension, and diabetes mellitus, and her history and physical indicated she had the capacity to make informed decisions. However, the record did not show a physician’s order for the three medications or an assessment for self-administration. LVN 2 confirmed the medications should not have been at the bedside without an assessment and order, and the DON stated the facility does not allow residents to self-administer medication and that bedside medications should not be present without a physician’s order. The facility policy stated the IDT assesses residents’ cognitive and physical abilities to determine whether self-administration is safe and clinically appropriate, and that residents may self-administer only if the attending physician and IDT determine they can do so safely.
Unnecessary Antipsychotic Use Without Documented Rationale
Penalty
Summary
The facility failed to ensure one resident was free from unnecessary psychotropic medication use when adequate clinical rationale for antipsychotic use was not documented. Resident 6 was admitted with a history of prostate cancer, hypertension, and atrial fibrillation. The resident’s PASRR Level 1 Screening completed by the hospital before admission was negative for serious mental illness, suspected mental illness, and psychotropic medication for serious mental illness. Despite that screening result, the physician ordered Seroquel 100 mg by mouth twice a day for psychosis manifested by striking out, starting June 19, 2025 and ending July 8, 2025. The MAR showed the medication was administered twice daily during that period. The resident’s MDS dated June 25, 2025 indicated no psychosis indicators and no behavioral symptoms directed toward others, verbal behavioral symptoms directed toward others, or other behavioral symptoms not directed toward others. The facility’s own psychotherapeutic review documented that non-pharmacological interventions were usually effective, and the IDT/Pharmacist recommendations noted the Behavior Management Team met with the Psychiatrist to review the resident’s medication regimen and behaviors. A Nurse Practitioner note dated July 8, 2025 stated the resident had no psychiatric history. During interview, a CNA described the resident as alert, cooperative, pleasant, and never seen in a bad mood. The MDS RN stated the diagnosis was psychosis manifested by striking out and that the psychiatrist evaluated the resident after admission. The facility policy required documentation of the rationale for use when medications are prescribed for behavioral symptoms.
Failure to Report and Refer New Skin Discoloration
Penalty
Summary
The facility failed to ensure that a left elbow skin discoloration identified on a resident was reported and referred to the physician in a timely manner for treatment orders. The resident was admitted with dementia and the history and physical indicated she could make needs known but could not make medical decisions. Her physician’s order required monitoring every shift for bleeding, bruising, and skin discoloration related to Plavix use, and the care plan directed staff to monitor for bruising or bleeding and report abnormal findings to the physician. On September 9, 2025, the resident was observed in bed with a purplish skin discoloration on her left elbow; the skin was intact and there was no redness or swelling around the area. In a concurrent interview, the resident stated the discoloration had been present for days and did not hurt, and she believed it may have occurred during repositioning or when her elbow hit the side table. The shower skin sheet for that day indicated the CNA documented no apparent skin issues, and the eMAR showed licensed nurses monitored for bleeding, bruising, and skin discoloration every shift but did not identify a new discoloration during that period. Record review and interviews showed there was no documented evidence that the elbow discoloration was reported, assessed, or referred to the physician for treatment orders. The day shift LVN stated she did not receive a report from the CNA or another nurse about the discoloration. The TN stated she had not received a report that the resident had a skin discoloration on her left elbow and confirmed there was no current treatment order or care plan for it. The DON stated the discoloration should have been identified and referred to the physician immediately, and that staff’s failure to identify, assess, determine the cause, and notify the physician resulted in a delay in treatment.
Failure to Follow Physician's Oxygen Order
Penalty
Summary
The facility failed to provide respiratory care and treatment for one resident reviewed for oxygen administration when the physician's order for oxygen was not followed. On September 8, 2025, the resident was observed in bed with oxygen via nasal cannula at 6 liters per minute. The resident stated she needed oxygen because she was short of breath, that she had to remove the nasal cannula because it was making her nose dry, and that she did not know what rate her oxygen should be on. During the same observation, an LVN confirmed the oxygen was running at 6 liters per minute and verified that the physician's order required oxygen at 2 liters per minute as needed via nasal cannula, with titration up to 4 liters per minute. The LVN stated the order was not followed. The DON later confirmed that the oxygen level should have been between 2 and 4 liters per minute per the physician's order and that the order was not followed. The resident had diagnoses including COPD, and the facility policy required verification of a physician's order for oxygen administration.
Failure to Assess Pain Before Obtaining Migraine Medication Order
Penalty
Summary
Safe, appropriate pain management was not provided for a resident with fibromyalgia and migraines when LVN 1 obtained a medication order for migraine prevention without first conducting a pain assessment. On August 21, 2025, the resident asked for a medication order because she had taken the medication before, and LVN 1 documented that the resident requested migraine medication and that the order for Nurtec ODT 75 mg every 24 hours as needed for migraine prevention was received and carried out. The record did not contain evidence that LVN 1 assessed the resident’s pain level, frequency, or vital signs before contacting the physician. During interview, LVN 1 stated the resident did not appear to be in pain and that she did not conduct a pain assessment before obtaining the order. The DON stated that when a resident complains of pain, licensed nurses are to assess the pain, offer non-pharmacological interventions, and then offer prescribed pain medication if needed, and that obtaining a migraine medication order without a proper assessment was not acceptable standard of practice. The facility’s pain assessment and management policy required staff to identify signs and symptoms of pain, assess intensity, duration, type, and characteristics of pain, and monitor effectiveness of interventions.
Undated inhalers and blood glucose test strips in medication cart
Penalty
Summary
Safe and effective pharmaceutical services were not maintained when inhalers for two residents with COPD were not appropriately administered and an opened blood glucose test strip vial in the medication cart was left undated. Resident 34 had a physician order for fluticasone-salmeterol 250 mcg/50 mcg diskus, one puff twice daily, and the MAR documented the inhaler as administered twice a day. During observation, the opened inhaler was found stored in the medication cart without a date on it, and the carton was labeled 8/27/25 with 51 puffs remaining out of 60. RN 1 acknowledged the undated inhaler, and the DON later stated there should have been approximately 38 puffs remaining when the cart was inspected. Resident 35 had a physician order for albuterol 90 mcg inhaler, two puffs twice daily, and the MAR documented the inhaler as administered twice a day. During observation, the opened albuterol inhaler was also found stored in the medication cart and was undated. The carton was labeled 8/30/25, and the inhaler had 193 puffs remaining out of 200. RN 1 acknowledged the inhaler and the remaining puffs, and the DON later stated there should have been approximately 168 puffs remaining when the cart was inspected. An opened blood glucose test strip vial was also observed in the medication cart without a date. RN 1 and LVN 1 stated the vial contained 24 strips remaining out of 50, and LVN 1 stated it should have been dated as soon as it was opened. The DON stated the expectation was that everything opened would be dated. The manufacturer’s insert stated to write the date on the vial label when first opened and to use the strips within 3 months of opening. The facility policy also directed staff to follow the manufacturer’s guidelines for test strips.
Medication Labeling and Controlled Substance Storage Deficiencies
Penalty
Summary
Three opened cartons of artificial tears eye drops were observed stored in a medication cart, and the medication bottle containers were not labeled with sufficient information to identify the specific resident. The cartons identified the residents by last name only, and one resident’s last name was misspelled on the carton. During the observation, RN 1 acknowledged that the eye drop cartons were only labeled with the residents’ last names and stated that if the unlabeled medication bottles fell outside of the cartons, the eye drops could be exchanged with another resident, which could result in cross contamination. The DON later stated that the resident’s full name should be on both the medication carton and the medication container bottle. The keys to discontinued controlled substances were observed stored in an unlocked drawer in the half-opened DON office. During the observation, three individuals from the facility’s corporate team were present in the DON office without the DON, and the DON stated the narcotic keys were being kept in the unlocked drawer. The DON acknowledged it was possible that someone could enter the half-opened office and use the narcotic key to access the discontinued controlled substances. Facility policy stated that only authorized persons have access to locked medications and that controlled substances remaining in the facility after discontinuation or discharge are to be securely locked in an area with restricted access until destroyed.
Failure to Honor Food Preferences and Complete Annual Nutritional Assessment
Penalty
Summary
Nutrition services were not provided for two residents reviewed. Resident 22, who had diagnoses including dementia, hypertension, and hyperlipidemia and was unable to make informed medical decisions, stated during observation that she had received cooked vegetables again instead of raw vegetables. Her meal ticket showed a preference for raw vegetables, but her lunch tray contained cooked sprouts and a side salad with red chopped bell peppers, which she said she disliked. Her dietary order also documented no red or green peppers, and the care plan noted a focus on catering to food preferences due to risk for malnutrition. Resident 26, who had diagnoses including fibromyalgia, osteoarthritis, hypertension, and diabetes mellitus and was alert and oriented with capacity to make informed decisions, stated the facility food was a "mushy mess" and that she did not receive what was on the menu. She also stated she ordered her own food when she did not like the menu items, and staff observed stored food in her closet. During lunch observation, she stated the roast beef was full of fat and the brussels sprouts were overcooked, and she requested an alternate meal. Record review showed her diet order was a regular consistent controlled carbohydrate diet with thin liquids and extra meat or entree, but there was no documented evidence that an annual nutritional assessment had been conducted to update her nutritional needs and preferences; the Dietary Supervisor stated the last annual nutritional assessment was dated April 17, 2024 and that one should have been completed.
Expired Opened Juice Stored in Refrigerator
Penalty
Summary
The facility failed to ensure that expired food items were not stored in the refrigerator and readily available for use. During an initial kitchen tour on September 8, 2025, a prune juice carton labeled with a use-by date of August 30, 2025 was observed in the refrigerator. In a concurrent interview, the Dietary Aide stated that the August 30, 2025 date was the date the juice carton was opened and that it should have been discarded five days after opening. The Dietary Supervisor also stated that the prune juice had been opened on August 30, 2025 and, once opened, was good for five days. The Dietary Supervisor further stated the prune juice should have been discarded and not stored in the refrigerator past the use-by date. The facility policy, Dry Goods Storage Guidelines (2023), indicated opened refrigerated juices are good for 5 days.
Failure to Follow Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to ensure infection control measures were followed when two employees from a consulting cardiologist's office entered Resident 59's room and provided care without using the required Enhanced Barrier Precautions. Resident 59 was observed in bed, alert, with his upper body half exposed while Cardiac Sonographer 2 sat less than two to three feet from the bed and Cardiac Sonographer 1 stood next to her. Both employees wore gloves but did not wear gowns, and medical equipment was present in the room while they performed an ultrasound on Resident 59. During a later observation and interview, the two employees stated they were performing an ECG on Resident 59 and had only used gloves during the test. Resident 59's room had a sign indicating both he and his roommate were on Enhanced Barrier Precautions, and PPE supplies including gown, mask, and gloves were stored by the door. The Infection Prevention Nurse stated Resident 59 was on EBP because he had a foley catheter and that staff should wear gown, glove, and mask when providing patient care. The nurse also stated the consulting employees should have followed the proper EBP when they entered the room. Resident 59's record showed a physician's order for Enhanced Barrier Precautions during high-contact resident care activities due to an indwelling foley catheter, and the care plan directed staff to use gown and gloves during high-contact resident care activities.
Failure to Assess Room Compatibility Leads to Resident-to-Resident Assault
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident due to inadequate assessment and documentation during multiple room changes. One resident, diagnosed with dementia and anxiety, had a known intolerance to noise but was moved between rooms several times without proper evaluation of his individual needs or compatibility with roommates. Staff did not document the reasons for these room changes or assess the potential for conflict, despite the resident's history of being upset by noise and previous incidents of agitation with other roommates. This lack of assessment and documentation led to the resident being placed in a room with another individual who exhibited frequent moaning, mumbling, and yelling due to severe cognitive impairment and was receiving hospice care. The noise triggered the first resident, resulting in a violent assault. The assaulted resident sustained severe injuries, including lacerations to the head, extensive facial fractures, rib fractures, and a vertebral fracture, and subsequently passed away in the hospital. The incident was unwitnessed, but the aggressor admitted to hitting the roommate due to the noise. Interviews with staff revealed that the process for room changes did not include consistent documentation of assessments or reasons for moves, and staff were aware of the aggressor's intolerance to noise. Facility policies required assessment of compatibility and documentation for room changes, but these procedures were not followed. The failure to assess and document resident needs and preferences during room changes directly contributed to the altercation and resulting harm.
Failure to Revise Care Plan for Resident's Environmental Needs Resulting in Fatal Altercation
Penalty
Summary
The facility failed to review and revise the care plan for a resident with a known preference for a quiet environment, despite documented behavioral risks and multiple room changes. The resident had a history of dementia, severe cognitive impairment, and was a registered sex offender on parole, monitored with an ankle bracelet. The care plan did not address the resident's need for a quiet room, even though staff were aware of his agitation triggered by noise and previous incidents involving other roommates. Another resident, who also had dementia, severe cognitive impairment, and was receiving hospice care, was placed in the same room. This resident exhibited frequent shouting and disruptive behaviors, which were documented in his care plan. Despite these known behaviors, the care plan for the first resident was not updated to reflect the risk posed by being housed with a noisy roommate, nor were interventions implemented to mitigate this risk. As a result, an altercation occurred in which the first resident assaulted the second resident, leading to severe injuries including lacerations, facial fractures, rib fractures, and a vertebra fracture. The injured resident was transferred to a hospital and subsequently expired. Interviews with staff confirmed that the care plan should have been revised to address the resident's preference for a quiet environment and to assess risks during room changes, but this was not done.
Failure to Provide Sufficient Details in Abuse Reporting
Penalty
Summary
The facility failed to provide a report with sufficient information regarding an alleged incident of physical abuse between two residents to the State Agency and the Long Term Care Ombudsman. On the date of the incident, a CNA discovered one resident with blood stains on his face and hands, and the situation was immediately reported to the charge nurse. Emergency services, including 911, police, hospice, physicians, the state health department, the Ombudsman, and the family, were notified, and the injured resident was transferred to the hospital. Documentation indicated that the resident had dementia, impulse disorder, and was receiving hospice care, and did not have the capacity to make decisions. The other resident involved, who also had dementia and a history of being a registered sex offender on parole, was found in the same room, covered with a sheet, and initially refused assessment. Police interviewed this resident, who admitted to hitting the other resident due to noise. The resident was then taken into custody by law enforcement. Both residents had no prior history of aggressive behavior toward each other, and the incident was unwitnessed. A review of the SOC 341 form faxed to the authorities revealed that it lacked pertinent details about the alleged abuse, only stating "allegation" without describing the event, time, or names of those involved. Interviews with facility staff, including an RN and the Administrator, confirmed that the form was incomplete and did not meet the facility's policy requirements for reporting abuse, which specify that detailed information must be included to inform agencies and advocates about the incident.
Failure to Ensure Proper Advance Directive and Consent Procedures
Penalty
Summary
The facility failed to ensure that a resident's Advance Directive Acknowledgement, Consent to Treat, POLST, and Bed Hold Notification Policy were properly initiated and discussed with the resident, family member, or legal representative upon admission. The resident, who was diagnosed with dementia and unable to make medical decisions, did not have an appointed responsible person indicated on their face sheet. The Social Service Director (SSD) acknowledged that the necessary documents were undated, incomplete, and lacked a Resident Representative signature. Additionally, the documents signed by a family member were deemed invalid as the family member was not the legally appointed decision-maker. The SSD admitted that the facility should have contacted Adult Protective Services within the first 24 hours of admission to check the status of the case and locate next of kin, but this was not done due to being overwhelmed with other cases. The Registered Nurse (RN) confirmed awareness of the lack of a legal representative from admission and stated that this issue should have been addressed with the bioethics committee or IDT team, which was not done. The facility's Bioethics Policy indicated the need for addressing situations involving cognitively impaired residents without a surrogate decision-maker, but this protocol was not followed, leading to the deficiency.
Failure to Develop Timely Discharge Plans for Residents
Penalty
Summary
The facility failed to develop a discharge plan for two residents upon their admission, which was necessary to meet their individual discharge planning needs. Resident 1, who was admitted with dementia, did not have a discharge plan documented in the Social History Assessment, which was 13 days overdue. The Social Service Director (SSD) acknowledged the oversight and confirmed that the discharge assessment should have been completed within the first 14 days of admission. Despite a family member's inquiry about the discharge plan shortly after admission, the SSD admitted that the discharge plan had not been completed. Similarly, Resident 2, who was admitted with a traumatic brain injury, also lacked a documented discharge plan. During an interview, Resident 2 expressed readiness to go home but was unaware of any discharge plan. The SSD confirmed that the Social History Assessment for Resident 2 was also 13 days overdue and had not been completed. The facility's policy required these assessments to be completed within 5-7 days, but no later than 14 days after admission, to ensure proper discharge planning.
Inappropriate Medical Transfer of Resident with Respiratory Issues
Penalty
Summary
The facility failed to ensure the appropriate medical transfer for a resident, identified as Resident 3, to an acute hospital emergency department. Resident 3, who was admitted with chronic obstructive pulmonary disease (COPD) and pneumonia, had a Physician's Orders for Life Sustaining Treatment (POLST) indicating a preference for full treatment, including resuscitation. Despite this, the resident was transferred using a non-emergency medical transportation service, which was not equipped to handle potential medical emergencies during transit. Prior to the transfer, Resident 3 had been sent to the emergency room twice due to respiratory issues and was noted to have fluctuating oxygen saturation levels, indicating an unstable health status. The Director of Nursing documented that the resident was still experiencing shortness of breath and had completed a course of antibiotics without improvement. Despite these signs of instability, the resident was transferred using a service that only provided basic CPR training and was not capable of providing emergency medical treatment en route. Interviews with the nursing staff and the non-emergency transportation representatives revealed that the resident was not stable at the time of transfer and should have been transported via ambulance. The transportation driver noted that the resident was difficult to wake and did not respond to verbal cues upon arrival at the hospital. The hospital's emergency provider report indicated that the resident arrived somnolent and in mild to moderate respiratory distress, requiring immediate medical intervention, including the use of BiPAP for breathing support.
Failure to Hold Bed for Resident During 7-Day Bed Hold Period
Penalty
Summary
The facility failed to hold a bed for a resident during the 7-day bed hold period, resulting in a prolonged stay at a General Acute Care Hospital (GACH). The resident, who had a severe memory impairment and a legal representative, was admitted to the facility with a diagnosis of subarachnoid hemorrhage. The resident was transferred to the GACH for further evaluation after experiencing vomiting, with a 7-day bed hold requested and documented by the representative. Despite the resident's representative signing the Bed Hold Notification Policy, the facility did not hold the bed as required. The Admissions Coordinator and Marketing Department were responsible for managing bed holds and new admissions. However, a new resident was admitted to the facility and placed in the bed that was supposed to be held for the resident, leaving no available beds for the resident's return within the 7-day period. The facility's policy required that residents be allowed to return to their previous room within the bed-hold period. The Administrator confirmed that the resident was not able to return to the facility until a day after the 7-day period ended, due to the bed being occupied by a new admission. This oversight resulted in the resident's extended stay at the GACH.
Unsecured Mailbox Compromises Resident Privacy
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of residents' mail, specifically for one resident, when the mailbox was not locked. During an unannounced visit, it was observed that the mailboxes located outside the facility gate were easily accessible and lacked locks. The Director of Staff Development confirmed the accessibility of the mailboxes, and the Activity Director stated that the mailboxes had never been locked. The Director of Nursing acknowledged the potential risk of residents' mail and personal information being exposed and stolen due to the unsecured mailbox. The facility's policy on confidentiality and personal privacy, dated 2001, indicated that resident confidentiality and personal privacy should be protected, and access to personal and medical records should be limited to authorized staff and business associates.
Facility Fails to Maintain Safe Room Temperatures
Penalty
Summary
The facility failed to maintain a comfortable environment for eight residents, as the temperatures in their rooms exceeded the acceptable range of 71 to 81 degrees Fahrenheit. This issue was observed during a survey, where residents reported discomfort due to the heat. For instance, Resident 40, who has bipolar disorder, hypertension, and anxiety, expressed that her room was warm. Similarly, Resident 36, who suffers from chronic obstructive pulmonary disease and dementia, was found in a room with a temperature of 87.4 degrees Fahrenheit, which is above the required range. Resident 28, who has asthma and chronic respiratory failure, was observed in a room with temperatures ranging from 82.4 to 87.7 degrees Fahrenheit. Despite her complaints to the staff, no effective action was taken to address the heat issue. Resident 17, who has dementia and diabetes, also reported difficulty breathing due to the high room temperature, which was recorded at 91 degrees Fahrenheit. The family member of Resident 17 confirmed that the room had been uncomfortably hot since early June. The facility's maintenance supervisor acknowledged that two air conditioning units had been broken since July, affecting the rooms of several residents. Despite receiving recommendations and quotes for replacement, the units had not been fixed, and temporary measures like portable coolers were insufficient. The facility's policy requires room temperatures to be maintained between 71 and 81 degrees Fahrenheit, but this was not achieved, leading to discomfort and potential health risks for the residents.
Removal Plan
- The facility purchased additional five large swamp coolers and 10 free standing air-conditioning (AC) units. The swamp coolers were placed in the hallways and the free-standing AC were placed in the hot and uncomfortable residents' rooms.
- The facility identified the affected residents (Residents 15, 40, 36, 28, 17, 32, 53, and 48) and were assessed and monitored for adverse effects.
- The facility-initiated room temperature checks in the affected resident rooms every two hours and documented in the temperature log.
- The facility staff will provide hydration every two hours.
- The ADM signed a contract to replace the AC units and scheduled to install the AC units.
- The affected residents will be interviewed by the activities staff during morning shift and the Certified Nursing Assistants (CNAs) during afternoon and evening shifts. If the resident's room temperature will not be controlled, the facility will provide room changes and close the affected rooms until the new AC will be installed. If there will be no available beds to accommodate room changes, the facility will utilize emergency transfer to other facilities.
- New window treatment heat reduction film/tint will be placed on the windows and sliding doors of affected rooms.
- The ADM will report average room temperature levels in the affected rooms every quarterly Quality Assurance (QA) meeting.
Failure to Assess and Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure proper assessment and monitoring of psychotropic medication use for three residents, leading to potential unnecessary medication administration. Resident 5, diagnosed with bipolar disorder, was prescribed Aripiprazole, an antipsychotic medication, without documented evidence of a physician's assessment for its continued use. The Director of Nursing (DON) confirmed that the physician did not assess Resident 5 for the appropriateness of continuing Aripiprazole, which is a necessary step to ensure the medication's safety and relevance. Resident 53, who suffers from insomnia, anxiety, and psychosis, was prescribed Ambien for sleeplessness. Despite a recommendation from the Consultant Pharmacist to attempt a frequency reduction of Ambien, there was no documented evidence that the physician or psychiatrist evaluated this suggestion. The DON acknowledged the lack of documentation and rationale for not attempting a frequency reduction, as well as inconsistencies in monitoring Resident 53's sleep patterns. The resident was aware of taking Ambien but was not consulted about a trial reduction in medication frequency. Resident 56, with diagnoses including bipolar disorder and major depressive disorder, was prescribed multiple psychotropic medications upon admission. However, there was no documented assessment or evaluation to justify the continued use of these medications. The DON and Social Service Director admitted that assessments for the continued use of psychotropic medications were not consistently conducted. The facility's policy requires an evaluation of psychotropic medication use upon admission, which was not adhered to in this case.
Deficiency in Dietary Staff Training on Food Cool-Down Procedures
Penalty
Summary
The facility failed to ensure that dietary staff were adequately trained to carry out the functions of food and nutrition services safely and effectively. During interviews, a Dietary Aide (DA) and a Cook (CK) were unable to accurately verbalize the cool-down process for hot food and ambient food temperatures. The DA admitted to not knowing the proper cool-down process for hot food and stated she would put ice on it. For cooling down ambient food temperatures, such as tuna salad, she mentioned placing the tuna on ice after preparation but was unsure of the correct process. Similarly, the CK described a process for cooling ambient food temperatures that did not align with the facility's policy, indicating a lack of understanding of the required procedures. The Registered Dietitian (RD) clarified that the cool-down process for ambient food temperatures requires the food to reach 41 degrees within four hours, and if not achieved, the food should be discarded. The RD also explained the cooling process for hot food, which involves lowering the temperature from 140 degrees to 70 degrees within two hours, and then to 40 degrees within four hours, with a total cool-down time of six hours. The facility's policy and procedure documents confirmed these requirements, emphasizing the importance of following established policies to prevent bacterial growth and ensure food safety. The deficiency in staff knowledge and adherence to these procedures posed a risk of foodborne illness to residents.
Sanitation Deficiency in Kitchen Equipment
Penalty
Summary
The facility failed to maintain a sanitary environment in the kitchen, as observed during a walk-through with the Director of Food and Nutrition Services (DFS). Multiple sheet pans, specifically one half-sheet pan and six full-sheet pans, were found with brown-black grime buildup. The DFS acknowledged that the pans were very old and needed replacement, and confirmed that the discoloration was due to food residue. This condition was recognized as a potential risk for cross-contamination of food, which could lead to foodborne illnesses among residents. Further interviews with the Registered Dietitian (RD) revealed that the expectation was for the kitchen and all equipment to be clean and free of grime buildup. The RD emphasized that the sheet pans should have been clean to prevent cross-contamination and potential foodborne illness. A review of the facility's sanitation policy from 2023 and the FDA Food Code 2022 highlighted the requirement for all equipment, food-contact surfaces, and utensils to be clean to sight and touch, and free from encrusted grease deposits and other soil accumulations.
Failure to Monitor Room Temperature Levels
Penalty
Summary
The facility failed to ensure that the Quality Assessment and Performance Improvement (QAPI) committee effectively monitored and re-evaluated the issue of high temperature levels in resident rooms 22, 23, 24, and 25. This deficiency was identified during a QAPI meeting on July 24, 2024, when it was noted that the central air conditioning units 4 and 5 had broken down on July 9, 2024, leading to temperatures exceeding 81 degrees Fahrenheit in these rooms. Although fans were placed inside the affected rooms and large coolers were positioned in the hallway to mitigate the heat, the facility did not monitor or assess the effectiveness of these measures in maintaining comfortable and safe temperature levels for the residents. The facility's policy on Quality Assurance Performance Improvement, dated February 2020, outlines the process for identifying and correcting quality deficiencies, including monitoring and evaluating the effectiveness of corrective actions. However, the facility did not adhere to this policy, as they failed to re-evaluate and monitor the implemented measures, resulting in unsafe and uncomfortable conditions for the residents.
Failure to Provide Advance Directive Education
Penalty
Summary
The facility failed to provide education and resources regarding Advance Directives (AD) to three residents, which could result in the facility being unable to honor the residents' wishes regarding their medical treatment. Resident 40, who was cognitively intact with a BIMS score of 14, did not have documented evidence of receiving AD education. Resident 46, with severe cognitive impairment and a BIMS score of 6, also lacked documentation of AD education provided to her or her representative. Similarly, Resident 54, with moderately impaired cognition and a BIMS score of 11, did not have documented evidence of receiving AD education. Interviews with the Director of Nursing and the Social Services Director (SSD) revealed that the SSD was responsible for providing AD education upon admission. However, the SSD admitted to not providing the necessary education and information to Residents 40, 46, and 54 or their representatives. The facility's policy, dated December 2016, required that residents be provided with written information about their rights to accept or refuse treatment and to formulate an AD upon admission, which was not adhered to in these cases.
Resident Uncomfortable Voicing Grievance Due to Staff Attitude
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 32, was able to voice a grievance without feeling uncomfortable. Resident 32, who was admitted with diagnoses including bilateral osteoarthritis of the knee, fibromyalgia, dementia, and depression, was found to be cognitively intact with a Brief Interview for Mental Status score of 15. During a Resident's Council meeting, Resident 32 expressed discomfort in filing a grievance with the Social Services Director (SSD), citing the SSD's attitude as a deterrent. The facility's Administrator acknowledged that grievances are managed by the SSD and emphasized the expectation that residents should feel comfortable approaching staff to file grievances. The facility's policy, dated February 2021, guarantees residents the right to voice grievances without fear of discrimination or reprisal. However, the report indicates that this policy was not effectively implemented, as Resident 32 felt unable to file a grievance comfortably, potentially leaving her concerns unaddressed.
Failure to Administer Carvedilol with Food
Penalty
Summary
The facility failed to ensure that the medication Carvedilol was administered as directed for a resident with hypertension. During a medication administration observation, a Licensed Vocational Nurse (LVN) prepared and administered Carvedilol 3.125 mg to a resident without providing food, as required by the medication instructions. The medication label clearly indicated that Carvedilol should be taken with food to prevent potential side effects such as dizziness, nausea, and vomiting. The LVN acknowledged the oversight and noted that the resident's food intake was not documented by the Certified Nursing Assistant (CNA), leaving uncertainty about whether the resident had eaten breakfast. The facility's policy on administering medications emphasizes the importance of administering medications safely and as prescribed, considering factors like enhancing therapeutic effects and preventing medication and food interactions. The failure to adhere to these guidelines resulted in a deficiency in the administration of Carvedilol to the resident.
Inadequate Training in Narcotic Documentation
Penalty
Summary
The facility failed to ensure that a Licensed Vocational Nurse (LVN 1) was adequately trained in the documentation of narcotic pain medication administration for two residents, Resident 6 and Resident 14. This deficiency was identified through observation, interviews, and record reviews. On July 23, 2024, LVN 1 signed out a narcotic pain medication for Resident 14, but there was no documentation in the electronic Medication Administration Record (eMAR) indicating that the medication was administered. Similarly, on July 30, 2024, LVN 1 signed out a narcotic pain medication for Resident 6, but again, there was no documentation in the eMAR of administration. In both cases, LVN 1 had initially documented the administration but later struck out these entries without notifying anyone. The Director of Nursing (DON) and Registered Nurse (RN 1) were unaware of the reasons behind LVN 1's actions, and there was no documented evidence of pain assessments for the residents when the medications were signed out. LVN 1 later created late entries on August 8, 2024, backdating the administration of the medications for both residents. The DON confirmed that LVN 1 should have documented the administration immediately after giving the medications. LVN 1 admitted to being unsure of his documentation due to a lack of knowledge and training. The Director of Staff Development (DSD) acknowledged that LVN 1 needed more competency and skills checks in medication pass and documentation, despite having completed a training skills check during orientation. The facility's policy on administering pain medications requires documentation of pain assessments, medication details, and results, which was not followed in these instances.
Failure to Document Administration of Controlled Medication
Penalty
Summary
The facility failed to ensure proper documentation of the administration of the controlled drug Hydrocodone-Acetaminophen for one resident, identified as Resident 34. This resident was admitted with a diagnosis of osteoarthritis, which typically involves joint pain. A physician's order dated March 12, 2024, prescribed Norco 5-325 mg to be administered every six hours as needed for moderate to severe pain. On July 16, 2024, at 5:20 a.m., a Licensed Vocational Nurse (LVN 2) signed out one tablet of Norco for Resident 34, but there was no documentation in the electronic Medication Administration Record (eMAR) indicating that the medication was administered. During an observation, interview, and record review on August 8, 2024, it was found that the facility's process for administering PRN narcotic pain medication was not followed. According to Registered Nurse (RN 1), the process involves assessing the resident's pain, offering non-pharmacological interventions, checking the physician's order, signing out the medication, administering it, and documenting the administration in the eMAR. However, RN 1 confirmed that there was no documentation by LVN 2 that this process was followed for Resident 34. The facility's policy requires immediate documentation of the administration of controlled drugs, including the date, time, dose, and nurse's signature, which was not adhered to in this instance.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to provide timely dental services for Resident 21, who was admitted with multiple sclerosis and anxiety disorder. Upon admission, Resident 21's care plan noted oral/dental health problems related to cavities or broken teeth, and arrangements for dental care were to be coordinated. However, a review of the Minimum Data Set (MDS) indicated that Resident 21 had obvious or likely cavities or broken teeth, yet no dental appointment had been arranged by the facility. During an observation and interview, Resident 21 confirmed having missing teeth and no dentures, and stated that the facility had not arranged a dental appointment. Interviews with the Social Service Director and a Licensed Vocational Nurse revealed that Resident 21 had not been referred to a dentist, despite the recognition of dental issues. The facility's policy on social services emphasized the provision of medically-related services to maintain residents' well-being, which was not adhered to in this case.
Pest Control Deficiency: Fly on Resident's Meal
Penalty
Summary
The facility failed to maintain a pest-free environment for a resident, identified as Resident 54, when a fly was observed landing on the resident's lunch meal. This incident occurred during a concurrent observation and interview with the Director of Nursing (DON) in the dining room. The DON acknowledged the presence of the fly on the resident's plate, specifically on the gravy, and stated that flies should not be present as they carry diseases that could cause foodborne illness to the residents. Resident 54, who was admitted with diagnoses including hemiplegia, hemiparesis, and cognitive communication deficit, was noted to have moderate cognitive impairment with a Brief Interview for Mental Status score of 11. The facility's policy and procedures on pest control, revised in May 2008, indicate that the facility maintains an ongoing pest control program to ensure the building is free from insects and rodents. However, the presence of the fly on Resident 54's meal suggests a lapse in the implementation of this program.
Failure to Address Doctor's Concern Regarding Resident's Therapy Appointments
Penalty
Summary
The facility failed to address a doctor's concern regarding ongoing weekly telephone appointments for a resident, resulting in the resident not receiving necessary care to achieve his highest level of physical well-being. The resident reported that it had been some time since his last session with his therapist, despite the facility being aware of these appointments. The Social Services (SS) staff acknowledged receiving an email from the resident's therapist expressing concern about the lack of communication but did not follow up to confirm the scheduled appointment with the resident. The Licensed Vocational Nurse (LVN) indicated that the SS was responsible for following up with the doctor and the resident regarding the appointment scheduling. The Director of Nursing (DON) confirmed that the SS was responsible for confirming the scheduled appointments and that the facility did not follow its policy. The facility's policy and procedure for medically-related social services stated that the SS staff should support residents in maintaining their highest practicable level of physical, mental, and psychosocial functioning, including arranging needed counseling services. The failure to follow this policy resulted in the resident missing necessary therapy sessions, impacting his overall well-being.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Banning
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sundance Creek Post Acute | 1.7 mi | ★★★★★ | 15 | 0 |
| Vista Real Post Acute | 2.3 mi | ★★★★★ | 1 | 0 |
| Highland Springs Care Center | 3.6 mi | ★★★★★ | 22 | 0 |
| Oak Glen Post Acute | 4.7 mi | ★★★★★ | 1 | 0 |
| Yucaipa Hills Post Acute | 9.1 mi | ★★★★★ | 9 | 0 |
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