Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
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 Terrace Post Acute during CMS and state inspections, most recent first.
A resident with chronic pain and multiple comorbidities had several concurrent physician orders for acetaminophen-containing medications, including routine acetaminophen and PRN acetaminophen and hydrocodone-acetaminophen, all with instructions not to exceed 3 g of acetaminophen per day from all sources. MARs showed the resident routinely received 3,000 mg of acetaminophen daily from scheduled doses and also received additional hydrocodone-acetaminophen on multiple days, resulting in total daily acetaminophen doses above 3,000 mg. Despite this, the consultant pharmacist’s monthly MRRs documented that no recommendations were needed, and the pharmacist later stated she assumed nursing would withhold routine acetaminophen when PRN acetaminophen products were given, contrary to the facility’s policy requiring identification and reporting of medication-related irregularities.
Two residents did not receive PRN medications as ordered by their physicians. One resident with quadriplegia and intact cognition had a PRN order for Ketorolac Tromethamine eye drops for itchy eyes, but when the resident requested the drops, nursing staff reported they were not available because they had not been reordered after expiration and had to be obtained from the pharmacy. Another resident with spinal stenosis, DM, spinal fusion, and chronic low back pain had a PRN order for acetaminophen 325 mg, two tablets, for mild pain rated 1–4/10, yet an RN supervisor administered this dose when the resident reported pain at 6/10, contrary to the physician’s order and facility policies requiring medications to be given as prescribed.
The facility failed to protect resident privacy when an entertainer hired for an activity recorded and posted images and video of multiple cognitively intact residents participating in the event to her personal social media accounts without obtaining explicit written consent from the residents or their representatives. Several residents with significant medical conditions, including type 2 DM with complications, chronic kidney disease, and acute kidney failure, were identifiable in the posted material. The Administrator confirmed that the entertainer did not notify the facility or seek consent before recording or posting, and that this conduct violated the facility’s written policy on videotaping, photographing, and imaging of residents, which requires explicit written consent prior to obtaining or releasing resident images except in limited circumstances.
A resident with influenza A was on ordered droplet and contact isolation with posted precaution signage and a care plan directing staff education on PPE use. A CNA twice entered the resident’s room, handled the resident’s water pitcher, and exited without performing hand hygiene or donning required PPE (gown, gloves, face shield), stating she believed PPE was only needed for direct care and that the resident had a urinary infection. The IP confirmed the resident’s influenza A diagnosis, the need for droplet and contact precautions, and that staff were required to perform hand hygiene and wear appropriate PPE upon room entry per facility policy.
A facility failed to follow pain management orders and care plans for three residents. Two cognitively intact residents had orders for PRN pain meds and care plans directing staff to try and document nonpharmacological interventions first, but their MARs showed repeated pain medication administration with no documentation that interventions such as repositioning, heat, relaxation, or other measures were attempted. A third resident with a history of femur fracture received scheduled and PRN Norco, but the MAR contained no documentation of monitoring for opioid side effects such as respiratory depression or constipation, despite the care plan requiring it.
A resident with DM2 did not receive a scheduled Mounjaro dose because the medication was not available in the cart or facility, and another resident’s PRN hydrocodone-acetaminophen was documented late on the MAR, creating an inaccurate record that prevented timely pain medication administration. In addition, three eKITs containing controlled substances were found without shift-by-shift reconciliation documentation, despite facility policy requiring immediate documentation after administration and controlled medication counts at each shift change.
Medication Error Rate Exceeded Allowed Threshold: Survey observation, interview, and record review found 3 medication errors out of 28 opportunities, for a 10.71% error rate. One resident did not receive ordered ascorbic acid during med pass, and another resident did not receive ordered Mounjaro and received metformin outside the ordered breakfast time. The LVNs and DON acknowledged the missed and late doses were medication errors under the facility’s 60-minute med administration window.
Opened respiratory meds were found without open dates, discontinued and discharged-resident meds remained in carts and a refrigerator, an expired stock med was still on hand, and eye drops were stored with oral meds in several cart bins. Staff and the DON acknowledged that multi-dose inhalation products needed opening dates, expired or discontinued meds should be removed from use, and oral and external meds should be stored separately.
Failure to Serve Menu-Listed Condiments With Hamburger Meal: Multiple residents with intact cognition and ordered regular or modified diets did not receive ketchup, mayonnaise, or mustard with a hamburger meal even though the menu and diet tickets listed those condiments. Residents reported missing condiments, a CNA confirmed trays lacked ketchup and mustard, and the DDM and DON stated the condiments were supposed to be served as listed.
Incomplete insulin and blood glucose documentation: Two residents with DM2 had inaccurate MAR entries related to insulin care. One resident's insulin injections were documented with the site listed as "NA" multiple times despite an order to rotate injection sites, and another resident's blood sugar results were repeatedly charted as "NA" for numerous scheduled checks. The DON stated that both the injection site and BG results should be documented to support continuity of care and diabetic management.
A resident with COPD, DM, a GT, and severely impaired cognition was receiving Eliquis with orders to monitor every shift for bleeding and hypoglycemia and notify the MD if symptoms were present. The MAR showed a positive finding for both bleeding and hypoglycemia symptoms on one shift, but the progress notes and SBAR/COC did not document the symptoms or any physician notification, and the DON confirmed the lack of notification.
A resident with COPD, DM, GT infection, and severe cognitive impairment had a care plan that was not updated to match the current enteral feeding order; the plan still listed an older formula and rate. In a separate issue, an MDSN stated that quarterly IDT care conferences were not held for another resident during two quarters, and the resident and representative were not involved in the care planning process as required by facility policy.
A resident with CHF, A-fib, and HTN received orders for digoxin, diltiazem, and metoprolol via PEG, but the EMAR lacked apical pulse and HR documentation sections and did not show physician-ordered HR parameters for the medications. RN and DON stated the orders should have been clarified/read back and that giving these meds without checking HR first was a medication error.
Missing Oxygen Orders and Unlabeled Oxygen Equipment: Two residents were found receiving oxygen without physician orders in place. One resident with COPD, respiratory failure, and CHF was observed on oxygen at 4 LPM, and staff confirmed no oxygen order was documented. Another resident with AFib, atherosclerotic heart disease, and weakness had an oxygen concentrator with an unlabeled nasal cannula and dated sterile water, while staff stated oxygen tubing and set-ups should be changed weekly and labeled with the date.
Delayed CNA Competency Validation: The facility failed to ensure one CNA had annual competency validation completed on time. The DSD reviewed the CNA’s competency assessment and found it was completed well after the annual due date based on the hire date. The facility policy required competency evaluations upon hire and annually, and the DON stated annual skills validation is needed to ensure CNAs can perform their duties and receive further training if needed.
A resident who was newly admitted and had muscle weakness and a history of falling did not receive breakfast on time because the Diet Requisition Form was not forwarded to the kitchen before the morning meal. The resident was observed in bed waiting for breakfast while her roommate had already received a tray, and the RD later stated the form had not been sent the night before or before breakfast that morning. The ADON stated the form should be completed and sent on admission so the resident does not miss a meal.
Improper Disposal of Soiled Gloves and Masks Near Dumpster Area: Multiple used gloves and masks were observed on the floor around the dumpster bins during separate observations with the HKD and IPN. Both staff members acknowledged the area should be kept clean, and facility policies stated the grounds should be sanitary and free of litter and that the environment should prevent transmission of infection.
A smoker aide served ice to a resident without performing hand hygiene, despite hand sanitizer being available nearby, and later acknowledged forgetting to use it. In a separate event, a housekeeper cleaned the room of a resident on EBP without wearing an isolation gown, even though the resident’s care plan and EBP signage required gloves and gowns for environmental cleaning.
Failure to Provide Bedside Fluids: A resident with dysphagia, GERD, and high dehydration risk did not have a water pitcher at bedside during observation. The care plan directed staff to encourage fluids of her choice and ensure access to liquids whenever possible, and staff stated she should have had a bedside pitcher to help prevent dehydration. The facility policy also called for CNAs to provide and encourage bedside, snack, and meal fluids on a daily and routine basis.
A resident who was fully dependent on staff and receiving morphine sulfate for severe pain was given the medication after its expiration date. The MAR confirmed administration of the expired medication on several occasions. Both an LVN and the DON acknowledged the error, noting that facility policy requires checking expiration dates before administration and removal of expired medications.
A physician assistant did not include a mental status assessment in a resident's comprehensive H&P following admission, despite the resident having moderately impaired cognition and multiple complex diagnoses. The omission was confirmed by the DON during record review, and facility policy requires such assessments to be completed and documented.
A nurse failed to document the administration and refusal of scheduled medications for a resident with quadriplegia and anxiety, leaving the MAR blank for an evening shift. The resident, who was cognitively intact but dependent on staff, only accepted simethicone and refused other medications. The nurse was distracted by an emergency and did not record the outcomes as required by facility policy.
A resident with chronic pain and severe cognitive impairment reported a headache to a CNA, who failed to promptly notify an LVN, resulting in delayed pain assessment and relief. Additionally, required quarterly pain risk assessments were not completed for the resident, contrary to facility policy.
A resident with a history of colon disease and dementia was prescribed Golytely Oral Solution for colonoscopy preparation. The resident refused the medication multiple times, but the refusals were not documented and the physician was not notified, contrary to facility policy. As a result, the colonoscopy had to be rescheduled due to incomplete preparation.
A resident with multiple health conditions and moderately impaired cognition did not receive necessary ADL care, including facial grooming and fingernail trimming, despite being dependent on staff for these tasks. Interviews with staff confirmed the oversight, which was contrary to the facility's policy requiring CNAs to provide daily grooming and hygiene services.
A facility failed to ensure staff wore appropriate PPE in an isolation room of a resident with RSV. A CNA entered the room without a face shield, which was not available in the isolation cart, despite the facility's policy requiring full PPE for droplet precautions. The Infection Preventionist confirmed the necessity of full PPE to prevent infection spread.
A facility failed to label an IV antibiotic bag for a resident with the required date, time, and nurse's initials, as per policy. The resident, with conditions including quadriplegia and hypertension, had an order for cefepime hydrochloride. The DON confirmed the labeling omission, which could lead to medication errors.
A resident with multiple health conditions did not receive a physician-ordered Hemoglobin A1c test due to a lapse in the facility's process for handling lab requisitions. The DON confirmed the oversight, which was contrary to the facility's policy requiring complete and accurate physician orders.
A resident admitted with serious health conditions did not have their admission assessment form completed, as required by the facility's standards. The RNS responsible for the admission forgot to fill out the Nursing Documentation Evaluation form, which is crucial for developing a care plan. The DON confirmed the oversight, highlighting a lapse in following the facility's documentation policy.
A resident with multiple health conditions had their medication administration not properly documented on the MAR during two evening shifts. The resident sometimes refused medications, and a nurse confirmed a refusal but did not document it. The DON acknowledged the oversight, which violated the facility's policy requiring documentation of medication refusals.
The facility failed to develop and implement person-centered care plans for four residents, leading to deficiencies in addressing their specific needs. A resident with anxiety and depression lacked care plans for prescribed medications, while another with psychosis had no care plan for antipsychotic use. A resident with a language barrier and another with vision decline also lacked appropriate care plans, potentially delaying necessary care.
A facility failed to monitor a resident for side effects and behavioral episodes while on quetiapine, an antipsychotic medication. Despite physician orders requiring monitoring every shift, there was no documentation of such monitoring. Interviews with staff confirmed the oversight, and the facility's policy mandated observation and reporting of medication effectiveness and side effects.
A resident with severe cognitive impairment was administered lisinopril despite a physician's order to hold the medication if systolic blood pressure was below 110 mm Hg. The medication was given when the resident's blood pressure was 98/65 mm Hg, as confirmed by an LVN and the DON, violating the facility's medication administration policy.
The facility failed to ensure proper food handling and storage practices, as bins of zucchini and cantaloupe in the refrigerator and open bags of pasta and tostadas in dry storage were found without labels indicating receipt or opening dates. This lack of labeling, confirmed by staff, could risk foodborne illness for 114 residents. The Dietary Supervisor emphasized the importance of labeling to track food storage duration, aligning with the facility's policy on safe food handling.
A LTC facility failed to ensure proper infection control practices, including hand hygiene by an LVN during eye care, provision of PPE disposal bins for residents on Enhanced Barrier Precautions, and timely changing of nasal cannula oxygen tubing. These deficiencies were observed during a survey and involved residents with severe cognitive impairment and other medical conditions.
A facility failed to keep a resident's Advance Directive in the medical record, despite multiple submissions by the resident's son. The resident, with intact cognition and requiring moderate assistance, had signed an Advance Directive Acknowledgement Form twice. Interviews with staff confirmed the document's absence, highlighting the importance of having it on file to respect the resident's healthcare wishes. The facility's policy requires maintaining a copy of the Advance Directive in the medical record.
The facility failed to include two residents in their IDT care plan meetings, violating their right to participate in developing a resident-centered care plan. One resident was not involved in discussions about weight issues, despite having intact cognitive skills and requiring moderate assistance. Another resident was excluded from meetings about skin alterations, despite having intact cognitive skills and being dependent on staff for daily activities. The facility's policy required resident inclusion, but this was not followed.
A resident with severe cognitive impairment and multiple diagnoses did not have their respiration rate checked before receiving Gabapentin, contrary to physician orders. An LVN administered the medication without verifying the respiration rate, which was required to be above 12. The DON confirmed that this oversight could lead to complications and emphasized adherence to the facility's medication administration policy.
A resident received fingersticks seven times a day instead of the usual four due to a failure to clarify orders after a G-tube removal. The oversight resulted in excessive testing for 158 days, causing potential pain. Staff interviews revealed unawareness of the duplicate order, and the resident's Nurse Practitioner confirmed the need for order adjustment.
The facility failed to implement fall prevention measures for two residents at high risk for falls. One resident's bed was not kept in a low position as ordered, and another resident was not provided with a tab alarm and floor mats. These deficiencies were confirmed by staff observations and interviews, highlighting a lack of adherence to physician's orders and facility policy.
A resident with respiratory conditions did not receive proper respiratory care as the nebulizer tubing was not labeled with the date it was last changed. Despite the facility's policy requiring weekly changes and labeling, this oversight was confirmed by both the Infection Preventionist and the DON, potentially risking the resident's health.
A resident verbally threatened another resident, saying "I will kill you," during an altercation on the patio. The incident was witnessed by staff, who intervened to separate the residents. The resident who made the threat had a history of anger outbursts and was under a care plan for monitoring verbally abusive behaviors, though some staff were unaware of this requirement.
A facility failed to maintain an infection control program by not labeling a urinal bottle with a resident's name and room number, as observed by the DON. The resident, admitted with conditions like atherosclerotic heart disease and hypertension, required assistance for daily activities. This oversight contradicted the facility's infection control policies, risking cross-contamination.
A resident did not receive a Lidoderm Patch for pain management on time due to the facility's failure to reorder the medication before the last dose was used. The resident, with a history of back pain, was left without the prescribed medication, as observed during a survey. The facility's policy requires medications to be reordered five days in advance, but this was not adhered to, resulting in a delay.
A facility failed to promptly inform a physician of a resident's lab results, which included abnormal findings from a urinalysis and culture indicating E. coli. The resident, who had serious health conditions, had a STAT order for these tests. Despite receiving the results on separate days, there was no documentation of physician notification until a day after the final results were received, delaying necessary interventions.
A facility failed to ensure accurate documentation of medication administration for a resident, leading to discrepancies between the MAR and CDR for tramadol and Ativan. Interviews with the DSD and DON confirmed that the facility's policy requires documentation on both records to ensure compliance with controlled substances regulations.
The facility failed to ensure call lights were within reach for two residents, potentially delaying assistance. One resident with dysphagia and muscle weakness was found yelling for help with the call light on the floor. Another resident with hypertension and difficulty walking was calling out with the call light behind the headboard. Staff confirmed the importance of call light accessibility for safety and assistance.
A resident with quadriplegia and mild risk for pressure ulcers was not repositioned as required during the night shift. CNAs did not reposition the resident unless instructed by the resident, who needs a two-person assist, and failed to offer or explain the importance of repositioning. This was against facility policy, which mandates proactive repositioning and education to prevent pressure injuries.
A facility failed to conduct timely pain assessments for a resident with quadriplegia and knee pain, as required by its policy. The resident experienced new knee pain, but the last documented assessment was nearly a year prior, and no quarterly assessments were completed. A nurse confirmed that assessments should occur upon admission, quarterly, and with new pain, but this was not done, potentially affecting the resident's comfort.
A resident with multiple diagnoses, including Parkinsonism and bipolar disorder, left the facility without supervision due to an inaccurate elopement risk assessment. The RN Supervisor failed to document the resident's history of elopement, contrary to facility policy, which requires accurate assessments upon admission and re-admission.
Failure to Identify Excessive Acetaminophen Dosing During Medication Regimen Review
Penalty
Summary
The deficiency involves the facility’s failure to ensure an accurate monthly Medication Regimen Review (MRR) by the consultant pharmacist for one resident, resulting in multiple active orders for acetaminophen-containing medications that were not identified or reported as a medication irregularity. The resident was admitted with diagnoses including spinal stenosis, diabetes mellitus, spinal fusion, low back pain, muscle weakness, and difficulty walking, and had intact cognition and partial independence in activities of daily living. The facility’s policy required the consultant pharmacist to review the medical record to prevent, identify, report, and resolve medication-related problems and irregularities. Record review showed that the resident had several concurrent physician orders for acetaminophen. One order directed acetaminophen 325 mg, two tablets by mouth every six hours as needed for mild pain, with instructions not to exceed 3 g of acetaminophen in 24 hours from all sources. A second order directed acetaminophen 500 mg, two tablets by mouth every eight hours routinely for pain, also with a maximum of 3 g per 24 hours from all sources. A third order directed hydrocodone-acetaminophen 5 mg-325 mg, one tablet by mouth every four hours as needed for moderate pain, again with instructions not to exceed 3 g of acetaminophen per day. MAR reviews for January through April showed the resident routinely received acetaminophen 500 mg, two tablets three times daily (totaling 3,000 mg per day), and also received hydrocodone-acetaminophen on multiple days across these months, resulting in total daily acetaminophen doses that exceeded 3,000 mg per day. Despite these concurrent orders and documented administrations, the MRRs dated in late January, mid-February, and late March each indicated that the consultant pharmacist reviewed the medications and found no recommendations were needed. In interview, the consultant pharmacist stated she believed nursing staff would withhold the routine acetaminophen dose when a PRN acetaminophen-containing medication was given, based on the “not to exceed 3 g per day” instruction, and the DON stated that during the MRR process the pharmacist should have identified and notified the facility that the resident was at risk of exceeding 3 g of acetaminophen per day due to multiple pain management orders.
Failure to Provide and Administer PRN Medications as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services as ordered, specifically PRN medications, for two residents. For the first resident, who was admitted with quadriplegia, hypotension, and an anxiety disorder, the physician’s order dated on an unspecified date directed Ketorolac Tromethamine 0.4% eye drops, one drop in both eyes every eight hours as needed for itchy eyes. The resident’s H&P documented that the resident had capacity to understand and make decisions, and the MDS showed intact cognition and dependence on staff for ADLs. The resident reported requesting the Ketorolac Tromethamine earlier in the month and being told by nursing staff that the eye drops were not available and would need to be ordered from the pharmacy. During interview, RN 1 confirmed that the resident had a PRN order for Ketorolac Tromethamine for itchy eyes and that when the resident requested the medication, it was not available and had to be ordered from the pharmacy. RN 1 further stated that Ketorolac Tromethamine expires 28 days after opening and that nursing staff should have reordered the medication prior to expiration to ensure it was available when needed. The DON stated that PRN medications should be available for residents as ordered by the physician and acknowledged that staff should have ordered a replacement Ketorolac eye drop when the previous one expired so it would be available for the resident. For the second resident, admitted with diagnoses including spinal stenosis, DM, spinal fusion, low back pain, muscle weakness, and difficulty walking, the physician order specified acetaminophen 325 mg, two tablets by mouth every six hours as needed for mild pain rated 1–4/10, with a maximum of 3 g in 24 hours from all sources. The MDS indicated intact cognition and varying levels of independence and supervision for ADLs. Review of the MAR showed that on a specified date, RNS 1 administered acetaminophen 325 mg, two tablets, for a reported pain level of 6/10. In interview, RNS 1 confirmed administering the medication and acknowledged that the order limited use to mild pain of 1–4/10, and that the medication should not have been given for a pain level greater than 4. The DON stated that RNS 1 should have followed the physician’s order and not administered acetaminophen 325 mg, two tablets, for a pain level of 6/10. Facility policies on administering medications and pain management required medications to be administered safely, timely, and in accordance with prescriber orders and professional standards of practice.
Failure to Obtain Consent Before Posting Resident Images on Social Media
Penalty
Summary
The deficiency involves the facility’s failure to protect residents’ personal privacy when an entertainer hired by the facility recorded and posted images and video of residents participating in a facility activity to her social media accounts without obtaining explicit written consent. The entertainer performed at the facility on 12/31/2025 and took video and pictures of approximately 20 residents during the entertainment event. These images were later posted on multiple social media accounts, and the facility became aware of this through an email notification. Three sampled residents were specifically identified as being included among those filmed: Resident 1, Resident 3, and Resident 4. Resident 1 was admitted with type 2 DM with diabetic peripheral angiopathy with gangrene and diabetic neuropathy, had intact cognition per the MDS dated 2/13/2026, and required moderate assistance from staff with toileting hygiene, bathing, dressing, personal hygiene, and mobility. Resident 3 had a history of type 2 DM with unspecified diabetic retinopathy without macular edema, pneumonia, and type 2 DM with hypoglycemia without coma, also had intact cognition, and required moderate assistance with similar ADLs. Resident 4 was admitted with chronic kidney disease, hyperlipidemia, and acute kidney failure, had intact cognition, and required supervision or touching assistance with toileting hygiene, bathing, dressing, personal hygiene, and mobility. During interviews and record review, the Administrator confirmed that the entertainer took and posted the images and recordings without informing the facility and without obtaining written consents from the residents or their representatives. The Administrator acknowledged that the facility’s policy titled “Videotaping, Photographing, and Other Imaging of Residents,” last reviewed on 1/21/2026, requires that residents be protected from invasion of privacy and that staff may not take or release images or recordings of any residents without explicit written consent. The policy further specifies that written consent must be obtained from the resident or representative prior to obtaining images or recordings for any purposes other than specified exceptions. The Administrator stated that the facility failed to protect residents’ privacy, and that this could result in unauthorized exposure of residents’ confidential information.
Failure to Follow Droplet and Contact Precautions for Resident With Influenza A
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control policy for a resident on droplet and contact precautions. The resident was admitted with influenza A and had physician orders for contact and droplet isolation every shift. The resident’s care plan included an intervention to provide instructions and education to family, visitors, and staff regarding contact precautions and proper use of PPE when in direct contact with the resident and materials used by the resident. Droplet and contact precaution signage was posted outside the resident’s room. Surveyors observed a CNA enter the resident’s room on two occasions without donning the required PPE and without performing hand hygiene. On the first occasion, the CNA entered the room without gown, gloves, or face shield, removed the resident’s water pitcher, and exited the room without hand hygiene. On the second occasion, the CNA again entered the room without performing hand hygiene or donning gown, gloves, or face shield, placed a water pitcher on the bedside table, and left without hand hygiene. In an interview, the CNA stated she believed she only needed to wear a gown and gloves when providing direct care and thought the resident was on isolation for a urinary infection. The Infection Preventionist confirmed the resident was on droplet and contact precautions for influenza A and stated that all staff entering the room should perform hand hygiene and wear a face shield, disposable gown, and gloves, consistent with the facility’s written isolation policy.
Pain interventions and opioid monitoring were not documented
Penalty
Summary
The facility failed to provide pain management consistent with professional standards of practice and the residents’ person-centered care plans for three sampled residents. For Residents 6 and 109, the care plans and physician orders included nonpharmacological pain interventions such as heat, repositioning, relaxation breathing, food/fluid, massage, exercise, immobilization, and other documented interventions, with instructions to document whether they were effective or ineffective. Both residents had diagnoses and assessments showing ongoing pain needs, and both were cognitively intact and able to make decisions. For Resident 6, the record showed orders for hydrocodone-acetaminophen as needed for moderate and severe pain, and the MAR documented multiple administrations in January 2026. The MAR did not indicate any nonpharmacological interventions were attempted at any time in January 2026. For Resident 109, the record showed orders for Tylenol, Tylenol Extra Strength, and oxycodone as needed for pain, and the MAR documented repeated administrations of oxycodone and other pain medications throughout January 2026. The MAR also did not indicate any nonpharmacological interventions were attempted at any time in January 2026. For Resident 11, the record showed a history of left femur fracture, severe cognitive impairment, and orders for Norco twice daily for pain management and Norco as needed for breakthrough pain. The care plan directed staff to administer analgesia as ordered and monitor and document side effects of pain medication. However, review of the 12/2025 and 1/2026 MARs showed no documentation that the resident was monitored for side effects of Norco during the reviewed period. RN 2 confirmed there was no documentation of monitoring for side effects, and the DON stated the care plan should be followed and that monitoring for adverse effects such as respiratory depression and constipation should be documented in the MAR.
Medication administration and controlled substance accountability failures
Penalty
Summary
The facility failed to provide pharmaceutical services to meet resident needs in three separate events involving medication administration and controlled substance accountability. One resident with DM2 was prescribed Mounjaro 0.5 ml subcutaneously once a day every Monday, but the dose scheduled for the morning medication pass was not administered because the medication was not available in the medication cart or in the facility. During interview, the nurse stated the dose was missed because the medication was not available and that the pharmacy would need to be contacted for delivery. The resident’s MAR showed no documentation that the dose was given at the scheduled time. A second resident, admitted with diagnoses including aftercare following knee joint replacement surgery and with intact cognition, was prescribed hydrocodone-acetaminophen 10-325 mg orally every 4 hours as needed for severe pain. During the medication pass, the resident reported pain at a level of 7 and stated the last dose had been given sometime after midnight. The MAR/eMAR showed the medication documented at 7:22 a.m., while the controlled drug record showed 19 tablets remaining after a dose recorded at 1 a.m. The nurse acknowledged that the MAR was not documented immediately after administration and that the later entry created inaccurate records and prevented another nurse from administering the medication when requested. In a medication room refrigerator, three medication eKITs containing controlled substances were observed without an accountability log showing reconciliation at every shift change for January 2026. Facility policy required a physical inventory of all controlled medications, including emergency supply, at each shift change by two licensed nurses and documentation on the controlled medication accountability record. The DON and nursing staff stated the eKITs had not been reconciled at every shift, and the report noted that the facility policy also required controlled medications to be documented immediately after administration and medications to be available for administration within the ordered time window.
Medication Error Rate Exceeded Allowed Threshold
Penalty
Summary
The facility failed to keep its medication error rate below 5 percent. Survey observation, interview, and record review identified 3 medication errors out of 28 opportunities, resulting in a 10.71% medication error rate and affecting two residents during medication administration observations. The errors involved one resident not receiving ascorbic acid as ordered and another resident not receiving Mounjaro as ordered and receiving metformin at a time different from the physician’s order. During an observation of medication administration, an LVN administered multiple oral medications to one resident but did not administer the ordered Mounjaro 0.5 ml SQ injection. The LVN stated the medication was not available in the medication cart or facility and that the dose was not given at the scheduled time. The LVN also administered metformin 1000 mg later than the physician-ordered breakfast time and acknowledged that this was outside the facility’s 60-minute medication administration window and was considered a medication error. During another medication pass observation, an LVN administered several ordered medications to a second resident but did not prepare or administer the ordered ascorbic acid tablet. The LVN stated that failing to give the medication was a medication error and that the resident did not receive the prescribed supplement during the morning medication administration. Record review confirmed the residents’ diagnoses and the physician orders for ascorbic acid, Mounjaro, and metformin, and the DON stated that the medications should be administered within the facility’s 60-minute window and according to physician orders.
Medication Storage and Labeling Deficiencies
Penalty
Summary
Medication storage and labeling practices were deficient in multiple medication carts and a medication room. During observation, an opened Spiriva inhaler for one resident was found at room temperature without a date showing when it was first opened. An opened budesonide inhalation foil envelope for another resident was also found without a date indicating when the envelope was opened, and the remaining unused vials were still stored with active medications. Facility staff stated these multi-dose respiratory medications should have been labeled when opened and that the budesonide supply had been discontinued months earlier. Several discontinued or discharged-resident medications were still present in medication storage areas. An open and used albuterol inhaler for one resident remained in a medication cart after that resident had been discharged. A budesonide inhalation medication for another resident had been discontinued but was still stored in the cart without being marked for discontinuation or separated from active medications. In the medication room, an expired acetaminophen suppository stock box remained with other facility stock medications, and a daptomycin IV bag for a resident who had already been discharged remained in the refrigerator and was not marked for discontinuation or separated from active medications. Eye drops were also stored together with oral medications in multiple medication carts. Brimonidine eye drops were stored in the same bin as nitroglycerin oral tablets and oral capsules, and other eye drop solutions were stored with oral tablets and lozenges in separate cart bins. Facility leadership and nursing staff stated that oral and external medications should be stored separately, that discontinued medications should be removed from use, and that expired medications should be removed from stock. Facility policy and manufacturer guidance reviewed during the survey required multi-dose containers to be dated when opened, discontinued or expired medications to be removed and separated, and oral medications to be kept separate from externally used medications.
Failure to Serve Menu-Listed Condiments With Hamburger Meal
Penalty
Summary
The facility failed to follow the dietary menu by not providing condiments with a hamburger meal for six residents who were prescribed regular diets or diet variations that included condiments on the menu. The weekly menu for the Sunday evening meal listed hamburger with tater tots, lettuce, tomato, pickle, banana mandarin oranges, milk, and ketchup, mayonnaise, and mustard. The facility’s policy stated menus would be served as written unless a substitution was provided for preference, unavailability, or a special meal. Resident 32 was admitted with COPD, was cognitively intact, and required setup or clean-up assistance with eating. Resident 43 was admitted with DM, was cognitively intact, and required setup or clean-up assistance with eating. Resident 56 was admitted with hemiplegia following a stroke, was cognitively intact, and required setup or clean-up assistance with eating. Resident 58 was admitted with COPD, was cognitively intact, and was independent with eating. Resident 64 was admitted with hypertension, was cognitively intact, and was independent with eating. Resident 67 was admitted with COPD, was cognitively intact, and needed supervision with eating. Their physician orders reflected regular diets or related diet orders, and their care plans directed staff to provide and serve the diet as ordered. During resident council and subsequent interviews, multiple residents stated they did not receive condiments with their hamburgers. Resident 67 stated she received only a small hamburger with no condiments. Resident 56 and Resident 32 stated a CNA told them the kitchen did not have any condiments. The Dietary District Manager stated ketchup, mayonnaise, and mustard were to be served with the hamburger and that residents would expect condiments if listed on the menu. A CNA stated the trays had burgers and tater tots but no mustard or ketchup, and she was told the kitchen was out of mustard. The DON stated residents should receive condiments if listed on the dietary menu because they help improve the taste of food and residents expect them when listed on the dietary ticket.
Incomplete insulin and blood glucose documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents receiving insulin therapy. For one resident admitted with muscle weakness, COPD, and type 2 diabetes mellitus, the record showed an order for insulin lispro before meals and at bedtime with instructions to rotate the injection site. A review of the MAR showed that insulin doses were documented, but the injection site was recorded as "NA" on multiple administrations, including 1/3/2026, 1/5/2026, 1/9/2026, and 1/10/2026. The ADON stated the injection site should have been documented and that documenting "NA" could confuse nurses and interfere with site rotation. For the second resident, who was admitted and later readmitted with muscle weakness, hypertension, and type 2 diabetes mellitus and had fluctuating capacity to understand and make decisions, the record showed an order for insulin aspart before meals and at bedtime with instructions to rotate the injection site. A review of the MAR for 12/2025 showed that blood sugar test results were documented as "NA" on multiple dates and times, including 12/4/2025, 12/9/2025 through 12/13/2025, 12/17/2025 through 12/19/2025, and 12/23/2025 through 12/27/2025 at both 4:30 p.m. and 9:00 p.m. The ADON stated that blood sugar results should be documented even when within the normal range and that consistent documentation is part of diabetic management so the provider has a clear picture of the resident's status and can decide whether to discontinue, modify, or adjust insulin. Facility policies titled Insulin Administration Purpose, Charting and Documentation, and Obtaining a Fingerstick Glucose Level required rotation of insulin injection sites and documentation of blood glucose results in the medical record.
Failure to Notify Physician of Bleeding and Hypoglycemia Symptoms
Penalty
Summary
The facility failed to notify the physician of a resident's change in condition for one of one sampled resident, Resident 4, when the resident had signs and symptoms of bleeding and hypoglycemia. Resident 4 was admitted with diagnoses including COPD, DM, and GT infection, and the MDS indicated the resident had severely impaired cognition for daily decision-making and was dependent on staff for ADLs. The resident also had a GT and was receiving Eliquis 2.5 mg via GT twice daily, with orders to monitor every shift for signs and symptoms of bleeding and hypoglycemia and to notify the physician if present. During review of the MAR, progress notes, and SBAR/COC with the DON, the MAR showed a (+) yes for signs and symptoms of bleeding and hypoglycemia on the 11:00 p.m. to 7:00 a.m. shift. However, the progress notes and SBAR/COC did not document that Resident 4 had symptoms of bleeding or hypoglycemia, and they did not show that the physician was notified of the change in condition. The DON stated that licensed nurses must follow physician orders and notify the physician of any signs and symptoms of bleeding or hypoglycemia in order to provide proper care to Resident 4.
Care Plan Not Updated for Tube Feeding and IDT Conference Not Held With Resident Participation
Penalty
Summary
The facility failed to update one resident’s comprehensive care plan to reflect the most recent physician’s order for enteral feeding. Resident 4 was admitted with diagnoses including COPD, DM, and GT infection, and the MDS showed severely impaired cognition for daily decision-making, dependence on staff for ADLs, and the presence of a GT. The order summary showed an order dated 1/9/2026 for Glucerna 1.2 calories at 55 cc to provide 1100 ml per day via pump with 100 ml water flush every four hours. During a concurrent interview and record review with the DON, Resident 4’s enteral feeding care plan, created on 9/6/2023, was reviewed and found to still list an order for Isosource 1.5 at 50 ml per hour for 20 hours. The DON stated the care plan was not updated to reflect the resident’s current enteral feeding order. The facility policy stated that comprehensive person-centered care plans are revised as information about residents and their conditions change. The facility also failed to ensure the resident or the resident’s representative participated in the IDT care plan meeting for Resident 7. Resident 7 was admitted with diagnoses including muscle weakness and dementia, and the MDS showed moderately impaired cognitive skills for daily decision-making and total dependence on staff for ADLs. The MDSN reviewed the resident’s IDT care conferences and stated the facility did not conduct the IDT care conference for two quarters, in 5/2025 and 11/2025, even though the conference is conducted quarterly with the required quarterly MDS assessment. The MDSN stated the resident and representative are required to be involved in care planning so their input and concerns can be addressed, and facility policy stated the resident and representative are encouraged to participate in development and revisions to the care plan.
Failure to Clarify Cardiac Medication Orders and Monitor Pulse Parameters
Penalty
Summary
Licensed nurses failed to ensure Resident 93’s medication orders were clarified and properly monitored before administration of digoxin, diltiazem, and metoprolol. Resident 93 was admitted with CHF, A-fib, and HTN, and the H&P indicated the resident did not have the capacity to understand and make decisions. The MDS indicated the resident rarely understood others, rarely was able to make herself understood, and was completely dependent on staff for activities such as toileting, dressing, and putting on/taking off footwear. The order summary included digoxin 125 mcg via PEG daily for A-fib, diltiazem 60 mg tablet 0.5 tablet via PEG four times daily for HTN with a hold parameter for SBP <110, and metoprolol 25 mg tablet 0.5 tablet via PEG every 12 hours for HTN with a hold parameter for SBP <110. The EMAR from 12/24/2025 to 1/14/2026 did not include a supplemental section to record apical pulse for digoxin or heart rate for diltiazem and metoprolol. RN 1 stated these medications were missing heart rate parameters and the supplemental documentation needed to record apical pulse and heart rate, and stated telephone orders must be read back or clarified with the physician. The DON stated licensed staff must clarify with the physician and read back telephone orders to ensure accuracy, and that giving digoxin, diltiazem, and metoprolol without checking heart rate first is a medication error.
Missing Oxygen Orders and Unlabeled Oxygen Equipment
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was deficient for two sampled residents. Resident 13, who had diagnoses including COPD, respiratory failure, and CHF, was observed receiving oxygen at 4 LPM via nasal cannula and stated, "I use oxygen at all times." Review of the resident's care plan noted oxygen therapy related to ineffective gas exchange, but RN 2 stated there was no physician order for oxygen therapy in the medical record. The DON also stated that a physician order for oxygen therapy should have been obtained and documented before oxygen was administered. Resident 42, who had diagnoses including atrial fibrillation, atherosclerotic heart disease, and generalized muscle weakness, was observed with an oxygen concentrator, an unlabeled nasal cannula, and oxygen sterile water dated 12/31/2025. The resident stated she used oxygen at night and when feeling anxious. The IPN stated oxygen equipment should be changed and dated every seven days, and RT 1 stated residents should not receive oxygen without a physician's order and that oxygen set-ups are changed weekly and labeled with the date. The DON stated Resident 42's physician orders did not indicate an order for oxygen therapy.
Delayed CNA Competency Validation
Penalty
Summary
The facility failed to ensure that one of three Certified Nursing Assistants, CNA 7, possessed the competencies necessary to perform job duties because the CNA competency assessment was not completed within the facility’s annual timeframe. During interview and record review, the Director of Staff Development reviewed CNA 7’s competency assessment and found that CNA 7 was hired on 4/03/2024, but the competency assessment was completed on 8/09/2025. The Director of Staff Development stated that CNA skills validation should be completed every 12 months and that CNA 7’s assessment should have been done by 4/03/2025. The facility’s policy titled, Competency of Nursing Staff, indicated that facility and resident-specific competency evaluations are conducted upon hire, annually, and as deemed necessary based on the facility assessment. The Director of Nurses also stated that skills competencies for licensed nursing staff and CNAs should be completed annually to ensure staff are able to perform their duties and receive further training if necessary.
Delayed Breakfast Due to Late Diet Requisition Form
Penalty
Summary
The facility failed to ensure that a resident’s Diet Requisition Form was completed and forwarded to the kitchen in a timely manner for a newly admitted resident who had diagnoses including muscle weakness and a history of falling. The resident’s history and physical stated that she had the capacity to understand and make decisions. During observation on 1/12/2026 at 9:15 a.m., the resident was in bed without a breakfast tray and stated she was waiting for breakfast, was a bit hungry, and wondered why her tray had not been delivered when her roommate’s tray had arrived about two hours earlier. During a later observation at 10:26 a.m., the Registered Dietitian was seen leaving the resident’s room with the breakfast tray and stated that the Diet Requisition Form had not been forwarded to the kitchen the night before or before breakfast that morning. The form provided by the RD showed a kitchen receipt date of 1/12/26 at 9:20 a.m. The ADON reviewed the form and stated that upon admission the Diet Requisition Form should be completed and forwarded to the kitchen so the resident does not miss any meal. The facility’s meal schedule listed breakfast from 7:30 a.m. to 8:30 a.m., lunch from 11:45 a.m. to 12:45 a.m., and dinner from 5:30 p.m. to 6:30 p.m.
Improper Disposal of Soiled Gloves and Masks Near Dumpster Area
Penalty
Summary
The facility failed to dispose garbage and refuse properly by not ensuring there were no soiled gloves and masks on the floor area and surroundings of the dumpster bins. During a concurrent observation and interview on 1/13/2026 at 10:34 a.m. with the HKD, multiple used gloves and masks were observed on the floor in the surrounding area of the dumpster bins, and the HKD stated that the surrounding area of the dumpster should be clean due to infection control. During a second concurrent observation and interview on 1/15/2026 at 12:27 p.m. with the IPN, the same multiple used gloves and masks were again observed on the floor in the surrounding area of the dumpster bins, and the IPN stated that the facility should maintain cleanliness without any trash on the floor due to high risk of infection. Facility policies reviewed included Infection Prevention and Control, which stated the facility will maintain a safe, sanitary, and comfortable environment and prevent and manage transmission of diseases and infections, and Grounds, which stated facility grounds shall be maintained in a safe and attractive manner and housekeeping shall be responsible for keeping the grounds free of litter.
Hand Hygiene and PPE Not Followed During Resident Care and Room Cleaning
Penalty
Summary
The facility failed to maintain infection control measures when Smoker Aid 1 did not perform hand hygiene before scooping ice and serving it to a resident in the smoking patio area. During the observation, the aide assisted residents with their seats and cigarettes, opened the dining room door, used the ice scoop to remove ice from the ice chest, and then served ice to the resident without washing or sanitizing hands before or after the contact. A bottle of hand sanitizer was observed nearby, and the aide later stated that hand sanitizer was available and is normally used, but was forgotten at that time. The resident who received the ice had been admitted to the facility with diagnoses including difficulty walking and acute respiratory failure. The resident’s MDS indicated the resident could make himself understood and understood others, but required supervision from facility staff for tasks such as showering, lower body dressing, and putting on or taking off footwear. The nursing supervisor stated that staff were expected to perform hand hygiene before and after any contact with residents to prevent the spread of infection, and that failure to do so can lead to spread of infection among residents. The facility also failed to ensure Housekeeper 2 wore an isolation gown while cleaning the room of a resident on enhanced barrier precautions. The resident had diagnoses including ESRD and CHF, had severely impaired cognition for daily decision-making, and was dependent on staff for ADLs. The resident had an order for EBP, and the care plan required gloves and gowns when cleaning environmental surfaces. During the observation, the housekeeper cleaned the room without wearing an isolation gown, and stated she was supposed to wear both gloves and an isolation gown when cleaning an EBP room. The housekeeping director and infection preventionist both stated that gowns and gloves were required for cleaning an EBP room, and the facility’s signage indicated staff must wear gloves and gowns when cleaning the environment.
Failure to Provide Bedside Fluids
Penalty
Summary
The facility failed to offer sufficient fluid intake to maintain proper hydration and health for one sampled resident. Resident 20 was admitted with diagnoses including peptic ulcer, dysphagia, and gastro-esophageal reflux disease, and the H&P indicated she did not have the capacity to understand and make decisions. Her MDS showed she sometimes understood others and sometimes made herself understood, and that she required assistance from facility staff for ADLs. Her care plan identified her as high risk for dehydration and directed staff to encourage fluids of her choice and ensure access to liquids whenever possible. During an observation in Resident 20’s room, she was lying in bed asleep and did not have a water pitcher at her bedside. CNA 3 stated Resident 20 did not have a water pitcher at bedside but should have one to help prevent dehydration, and stated dietary staff change the water pitchers daily around 11:00 a.m. RN 1 stated proper hydration is extremely important for all residents and that staff encourage hydration by providing individual water pitchers at the resident’s bedside in accordance with the prescribed diet. The resident’s physician order specified a regular diet with soft and bite sized texture and thin liquids, and the facility policy stated that nurses’ aides are to provide and encourage intake of bedside, snack, and meal fluids on a daily and routine basis.
Expired Morphine Administered to Resident
Penalty
Summary
A resident with quadriplegia and hypotension, who was cognitively intact and fully dependent on staff for daily care, was administered morphine sulfate oral solution after the medication had expired. The medication order specified morphine sulfate 10 mg/5 mL to be given by mouth every eight hours as needed for severe leg/knee pain. Review of the Medication Administration Record (MAR) confirmed that the expired morphine sulfate was administered on multiple occasions after its expiration date. During interviews and record reviews, it was acknowledged by both a Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) that the medication had expired prior to its administration. The DON confirmed that nurses are required to check expiration dates before administering medications and that expired medications should be removed and reordered, not given to residents. Facility policy also required checking expiration dates prior to administration, but this procedure was not followed in this instance.
Incomplete H&P: Omission of Mental Status Assessment
Penalty
Summary
A physician assistant failed to complete a comprehensive History and Physical (H&P) examination for a resident by omitting an assessment of the resident's mental status. The resident was admitted with multiple diagnoses, including a nondisplaced intertrochanteric fracture of the left femur, respiratory failure, and metabolic encephalopathy. The Minimum Data Set (MDS) assessment indicated that the resident had moderately impaired cognition and required varying levels of staff assistance for daily activities. However, the H&P completed shortly after admission did not document any evaluation of the resident's mental status. During a review of the resident's records, the Director of Nursing confirmed that the H&P was incomplete and acknowledged that a mental status assessment should have been included. The facility's policy requires a comprehensive physical examination, including mental status, to be documented within a specified timeframe after admission. The lack of a documented mental status assessment resulted in an incomplete evaluation of the resident's overall condition.
Failure to Document Medication Administration and Refusals on MAR
Penalty
Summary
A deficiency occurred when a licensed nurse failed to accurately document the administration and refusal of medications for a resident with quadriplegia, muscle wasting, and anxiety disorder. The resident, who had intact cognition and was dependent on staff for most activities of daily living, had several scheduled medications due during an evening shift. The Medication Administration Record (MAR) for that shift was left blank, with no indication of whether the medications were administered or refused. Interviews revealed that the resident often experienced confusion regarding which nurse would administer evening medications and frequently refused most of them, only accepting simethicone on the shift in question. The nurse assigned to the resident offered the medications, documented that only simethicone was taken, and reported being distracted by an emergency, which led to forgetting to document the administration and refusals on the MAR. Facility policy required immediate documentation of medication administration or refusal, which was not followed in this instance.
Failure to Timely Communicate and Assess Resident Pain
Penalty
Summary
A deficiency occurred when a certified nurse assistant (CNA) failed to report a resident's complaint of a headache to a licensed nurse in a timely manner. The resident, who had a history of chronic pain syndrome, unclear speech, and severely impaired cognition, reported a headache to the CNA during morning care. The CNA did not inform the licensed vocational nurse (LVN) of the resident's complaint, as required by facility policy, because she became occupied with another resident and forgot to communicate the information. As a result, the LVN was unaware of the resident's pain until later in the day, which delayed assessment and potential pain relief for the resident. The resident's medical records indicated a history of chronic pain and significant cognitive impairment, requiring assistance with daily activities. Observations throughout the day showed the resident remained in bed with the call light within reach. Interviews with staff confirmed that the CNA did not report the headache to the LVN, and both the LVN and the Director of Nursing (DON) acknowledged that timely communication of pain complaints is necessary for proper assessment and intervention. Additionally, the facility failed to complete required quarterly pain risk assessments for the resident, as outlined in their pain management policy. The last documented pain risk assessment was several months overdue, and the DON confirmed that assessments should have been completed quarterly. The absence of these assessments meant the resident's pain status was not thoroughly evaluated as required by facility procedures.
Failure to Document Medication Refusals and Notify Physician
Penalty
Summary
The facility failed to follow its policy and procedure for administering medications for one resident by not documenting multiple refusals of a prescribed medication and not notifying the resident's physician of these refusals. The resident, who had a history of chronic ulcerative recto sigmoiditis, malignant neoplasm of the sigmoid colon, and vascular dementia, was scheduled for a colonoscopy and had a physician's order to receive Golytely Oral Solution as preparation. The medication was to be administered in specific amounts at set intervals until the entire dose was consumed. On the day prior to the scheduled colonoscopy, the resident only consumed part of the prescribed Golytely solution and refused further doses a total of seven times. The licensed nurse on duty did not document each refusal in the medical record and did not inform the resident's physician about the refusals, as required by facility policy. Instead, the nurse reported the refusals to the Registered Nurse Supervisor, assuming that further action would be taken, but no documentation or physician notification occurred. As a result of the incomplete administration of the medication, the resident was not adequately prepared for the colonoscopy, and the procedure had to be rescheduled. The facility's policy required that all medication refusals be documented and that the physician be notified when a medication is refused, but these steps were not followed in this instance.
Failure to Provide Necessary ADL Care
Penalty
Summary
The facility failed to ensure that a resident received necessary services to maintain personal hygiene, resulting in the resident having long facial hair and overgrown fingernails. The resident, who was admitted with diagnoses including pneumonia, type 2 diabetes, sepsis, urinary tract infection, and hypertension, had moderately impaired cognition and required moderate assistance for oral hygiene and was dependent on staff for toileting hygiene and showering. Despite documentation in the ADL log indicating daily personal hygiene care, interviews revealed that the resident did not receive facial grooming or fingernail trimming during their stay. Interviews with facility staff, including the Director of Staff Development and the Director of Nursing, confirmed that CNAs are responsible for providing daily ADL care, including grooming and trimming of fingernails. However, a CNA assigned to the resident admitted to not providing these services. The facility's policy and procedure on ADLs, revised in January 2025, stated that residents unable to perform ADLs independently should receive necessary services to maintain personal hygiene, with the consent of the resident and in accordance with the care plan. The deficiency was identified through interviews and record reviews, highlighting a failure in the facility's adherence to its own policies and procedures.
Inadequate PPE Use in Isolation Room
Penalty
Summary
The facility failed to implement its infection control policy by not ensuring that staff wore appropriate personal protective equipment (PPE) while in an isolation room of a resident who tested positive for respiratory syncytial virus (RSV). The resident, admitted with diagnoses including shortness of breath and RSV, was placed under contact and droplet isolation precautions. However, during an observation, a Certified Nursing Assistant (CNA) entered the resident's room wearing a mask, gloves, and gown but without a face shield, which is required under the facility's infection control policy for droplet precautions. The CNA acknowledged the omission, stating that a face shield should have been worn but was not available in the isolation cart outside the resident's room. The Infection Preventionist confirmed that full PPE, including a face shield, is necessary to prevent the spread of infection in droplet isolation rooms. A review of the facility's infection prevention and control policy indicated that staff should adhere to specific PPE requirements to maintain a safe environment and prevent disease transmission. The lack of a face shield in the isolation cart led to the CNA's non-compliance with the policy, contributing to the deficiency.
Failure to Label IV Medication Bag
Penalty
Summary
The facility failed to properly label and date an intravenous (IV) antibiotic medication bag for a resident, which is a deviation from the facility's policy. The resident, who was admitted with conditions including quadriplegia, hypertension, and muscle wasting, had a physician's order for cefepime hydrochloride to be administered intravenously twice daily. During an observation, it was noted that the IV bag next to the resident's bed lacked the required date, time, and signature of the nursing staff who administered the medication. The Director of Nursing confirmed that the IV bag should have been labeled with the nurse's initials, date, and time of administration, as per the facility's policy. The facility's policy, titled "Continuous Infusion of Medications and Solutions," mandates that registered nurses and IV-certified licensed vocational nurses label medication containers with the date, time, and nurse's initials. This oversight had the potential to lead to medication administration errors.
Failure to Complete Physician-Ordered Lab Test
Penalty
Summary
The facility failed to ensure that a resident received laboratory services as ordered by their physician. The resident, who was readmitted to the facility with diagnoses including multiple sclerosis, type 2 diabetes, and bipolar disorder, had a physician order for a Hemoglobin A1c test dated November 15, 2024. Despite the order, the test was not completed. The resident confirmed in an interview that the test had not been drawn, and the Director of Nursing (DON) acknowledged the oversight during a review of the resident's records. The facility's policy and procedure for physician orders, approved on January 16, 2025, requires that all orders be complete and accurate, with the medical records department responsible for verification. The DON explained that the usual process involves nursing staff placing the order and completing a laboratory requisition form for the laboratory technician. However, the DON was unsure why the test was not completed, indicating a lapse in following the established procedure for handling physician orders and laboratory requisitions.
Incomplete Admission Assessment for Resident
Penalty
Summary
The facility failed to maintain medical records in accordance with accepted professional standards for a resident by not completing the admission assessment form, titled Nursing Documentation Evaluation, upon the resident's admission. The resident was admitted with serious health conditions including sepsis, COPD, parkinsonism, and morbid obesity. The Minimum Data Set indicated the resident had moderately impaired cognition and required assistance with daily activities. Despite these needs, the initial assessment form was left blank, which could have impacted the care provided. Interviews with the Registered Nurse Supervisor (RNS) and the Director of Nursing (DON) revealed that the RNS, who was responsible for the admission, forgot to complete the necessary documentation. The DON confirmed that the correct process was not followed, as the Nursing Documentation Evaluation form should have been completed to assist in creating a detailed plan of care. The facility's policy on nursing documentation emphasizes the importance of clear, concise, and accurate documentation to communicate the resident's status and ensure comprehensive care.
Failure to Document Medication Refusal
Penalty
Summary
The facility failed to ensure accurate documentation of medication administration for a resident, leading to a deficiency in pharmaceutical services. Specifically, the Medication Administration Record (MAR) for a resident with quadriplegia, hypertension, anxiety, and muscle spasms was left blank on two consecutive days during the evening shift. This lack of documentation did not indicate whether the resident received or refused their scheduled medications, which included Baclofen, Diclofenac sodium gel, Docusate sodium, Fluorometholone suspension, Hiprex, Methocarbamol, and Pepcid. Interviews with the resident and nursing staff revealed that the resident sometimes refused medications, and a registered nurse confirmed that the resident had refused medications during her shift but failed to document this refusal on the MAR. The Director of Nursing acknowledged the resident's history of medication refusal and confirmed that the nursing staff should have documented the refusals on the MAR as per the facility's policy. The facility's policy requires that any refusal or withholding of medication be documented accordingly, which was not adhered to in this instance.
Failure to Develop and Implement Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement person-centered care plans for four residents, leading to deficiencies in addressing their specific needs. Resident 51, who was admitted with anxiety disorder and depression, had orders for lorazepam and venlafaxine but lacked corresponding care plans. Despite having moderately impaired cognition and requiring maximal assistance for daily activities, the absence of care plans for these psychotropic medications meant that staff were not guided on how to monitor and assist the resident effectively. Resident 86, admitted with hemiplegia and unspecified psychosis, was prescribed quetiapine for auditory hallucinations. However, there was no care plan in place to address the use of this antipsychotic medication. The resident's inability to make medical decisions and dependence on staff for most activities of daily living further underscored the need for a comprehensive care plan to ensure consistent and appropriate care. Resident 96 faced a language barrier, as their primary language was Hungarian, and they had limited English proficiency. Despite this, there was no care plan to address the language barrier, which hindered effective communication and care delivery. Similarly, Resident 88, who had a decline in vision due to cataracts, did not have a care plan to address their visual impairment, despite requiring assistance with various activities of daily living. The lack of care plans for these residents' specific needs had the potential to delay necessary care and services.
Failure to Monitor Antipsychotic Medication Side Effects
Penalty
Summary
The facility failed to monitor a resident, identified as Resident 86, for side effects and behavioral episodes associated with the use of quetiapine, an antipsychotic medication. Resident 86 was admitted with diagnoses including hemiplegia and had moderately impaired cognition, being dependent on staff for most activities of daily living. The physician's orders required the administration of quetiapine for unspecified psychosis and mandated monitoring for side effects and behavioral episodes every shift. However, during a review of the Medication Administration Record, it was found that there was no documentation indicating that the licensed nurses were monitoring for these side effects and behavioral episodes. Interviews with the Licensed Vocational Nurse and the Director of Nursing confirmed the lack of documentation and monitoring. The Director of Nursing emphasized the importance of monitoring to determine if dosage adjustments were necessary and to report adverse side effects to the physician. The facility's policy on antipsychotic medication use required staff to observe, document, and report the effectiveness of interventions and any side effects to the attending physician. The failure to monitor and document these aspects had the potential to result in the resident receiving unnecessary medication and experiencing adverse side effects.
Failure to Follow Medication Hold Parameters
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors by not adhering to the physician's hold parameters for administering lisinopril, a medication used to treat high blood pressure. The resident, who was severely impaired in cognition and required supervision for daily activities, had a physician's order to hold lisinopril if the systolic blood pressure was less than 110 mm Hg. However, on a specific date, the medication was administered despite the resident's blood pressure being recorded at 98/65 mm Hg, which was below the threshold set by the physician. During interviews and record reviews, it was confirmed by both a Licensed Vocational Nurse (LVN) and the Director of Nurses (DON) that the medication was given when it should have been held. The LVN could not recall the specific events of that day but acknowledged the importance of following the physician's parameters to prevent further lowering of the blood pressure. The facility's policy on medication administration, which requires adherence to physician orders, was not followed in this instance, leading to the deficiency.
Improper Food Handling and Storage Practices
Penalty
Summary
The facility failed to ensure proper food handling and storage practices, as observed during a survey. In the walk-in refrigerator, a bin full of zucchini and a bin full of cantaloupe were found without labels indicating the date they were received. This was confirmed by a staff member who acknowledged that the bins should have been labeled with the date of receipt. Additionally, in the dry storage room, an open bag of dry pasta and an open bag of tostadas were found without labels indicating when they were opened. The Maintenance Supervisor verified the absence of labels on these items. During an interview, the Dietary Supervisor stated that all food should be labeled with the date they were received and opened to ensure that staff are aware of how long the items have been stored. The facility's policy, last reviewed and revised in September 2024, requires that food be received and stored in compliance with safe food handling practices, including labeling and dating. The lack of proper labeling had the potential to place 114 out of 116 residents at risk for foodborne illness due to the possibility of food expiring or spoiling if not used within a certain timeframe.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices were followed by a Licensed Vocational Nurse (LVN) during the administration of eye care for a resident. The LVN did not remove gloves or perform hand hygiene between cleaning the resident's eyes and opening a new package of supplies, nor between administering eye drops to both eyes. This oversight was observed during a medication administration session, where the LVN cleaned the resident's eyelids and administered eye drops without changing gloves or sanitizing hands, contrary to the facility's policy. The resident involved had severe cognitive impairment and was dependent on assistance for daily activities. Additionally, the facility did not provide a trash bin for disposing of Personal Protective Equipment (PPE) in the room of two residents on Enhanced Barrier Precautions (EBP). The Infection Preventionist confirmed that the absence of a trash bin for used PPE in the residents' room could lead to the spread of infection, as staff were required to discard PPE inside the room to prevent contamination. The facility's policy mandates the placement of a trash bin inside the room for proper disposal of PPE. Furthermore, the facility failed to change a resident's nasal cannula oxygen tubing weekly as per the facility's policy. The tubing was observed to be dated two weeks prior, and the Registered Nurse confirmed that the tubing should have been changed weekly. The Infection Preventionist emphasized the importance of changing the tubing to prevent bacterial growth and potential respiratory infections. The facility's policy requires weekly changes of nasal cannula and oxygen tubing to maintain hygiene and prevent infection.
Failure to Maintain Resident's Advance Directive in Medical Record
Penalty
Summary
The facility failed to maintain a copy of a resident's Advance Directive in the medical record, which is a legal document indicating the resident's preferences on end-of-life treatment decisions. This deficiency was identified for one resident out of 29 sampled. The resident, who had intact cognition and required moderate assistance for activities of daily living, had been admitted and readmitted to the facility with multiple diagnoses, including Parkinsonism, COPD, bipolar disorder, schizophrenia, dementia, and breast cancer. Despite the resident having signed an Advance Directive Acknowledgement Form on two occasions, the document was not found in the medical record during reviews conducted on different dates. Interviews with facility staff, including the Social Services Director and the Director of Nursing, revealed that the resident's son had sent the Advance Directive to the facility multiple times, yet it was still missing from the medical record. The staff acknowledged the importance of having the Advance Directive on file to ensure the resident's healthcare wishes are respected, especially in emergencies. The facility's policy on Advance Directives, which was last reviewed and revised, mandates that a copy of the Advance Directive be maintained as part of the resident's medical record.
Failure to Include Residents in Care Plan Meetings
Penalty
Summary
The facility failed to ensure that two residents, Resident 69 and Resident 12, were invited and participated in their Interdisciplinary Team (IDT) care plan meetings. This deficiency violated the residents' right to be included in developing a resident-centered care plan. For Resident 69, the IDT care conference was held to discuss the resident's weight issues, but the resident was not included in the meeting. The resident had intact cognitive skills and required moderate assistance for daily activities, indicating that they could have contributed to the care planning process. The Licensed Vocational Nurse (LVN) acknowledged that the resident should have been included to provide input on food preferences compatible with dietary orders and restrictions. Similarly, Resident 12 was not included in IDT meetings regarding skin alterations and other concerns. The resident had intact cognitive skills and was dependent on staff for certain daily activities. The Registered Nurse (RN) noted that the resident's input was necessary for developing a resident-centered care plan, especially concerning treatment goals for a stage four pressure ulcer. The RN acknowledged that the resident's cooperation was crucial for the success of the care plan, particularly regarding the resident's preference for prolonged sitting in a wheelchair. The facility's policy indicated that the IDT should include the resident to the extent practicable, but this was not adhered to in these cases.
Failure to Check Respiration Rate Before Gabapentin Administration
Penalty
Summary
The facility failed to meet professional standards of care for a resident by not checking the resident's respiration rate before administering Gabapentin, as ordered by the physician. The resident, who was initially admitted on 9/5/2021 and readmitted on 3/24/2023, had diagnoses including cerebrovascular disease, epileptic seizures, and major depressive disorder. The resident's Minimum Data Set (MDS) indicated severely impaired cognition and dependence on assistance for daily activities. The physician's order required Gabapentin to be administered twice daily, with a specific instruction to hold the medication if the respiration rate was less than 12. During a medication administration observation, an LVN was seen administering Gabapentin to the resident without checking the respiration rate. The LVN later acknowledged missing this step. The Director of Nursing confirmed that failing to follow a physician's order could lead to complications, such as respiratory depression, and emphasized that the facility's policy requires LVNs to check vital signs as ordered. The facility's medication administration policy, last reviewed on 9/23/2024, mandates that medications be administered according to prescribed orders, including verifying specific information for each resident prior to administration.
Failure to Clarify Fingerstick Orders Leads to Excessive Testing
Penalty
Summary
The facility failed to clarify fingerstick orders with the physician for a resident, resulting in the resident receiving fingersticks seven times a day instead of the usual four times. This discrepancy was not identified or corrected, leading to the potential for increased pain from excessive fingersticks. The resident, who was severely impaired in cognition and required supervision for daily activities, had been receiving these excessive fingersticks for 158 days. The issue arose from a duplicate order that was not caught after the resident's G-tube was removed. The resident's physician's orders included fingerstick blood glucose checks every six hours, which was appropriate when the resident had a G-tube. However, after the G-tube was removed and the resident began eating by mouth, the order should have been adjusted to only require fingersticks before meals and at bedtime. This oversight was confirmed during interviews with the facility's staff, including the Director of Nurses and a Licensed Vocational Nurse, who were unaware of the duplicate order. The resident's Nurse Practitioner was also unaware of the excessive fingersticks and confirmed that the order should have been adjusted. The facility's policy and procedures indicated that the physician and staff should evaluate the effectiveness and effects of medications, but this process failed to identify the duplicate order. The resident had complained about the frequency of fingersticks, but the staff continued to follow the outdated order, leading to the deficiency.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure that a resident's bed was in the low position as per physician's orders, which was necessary to prevent falls and potential injuries. Resident 32, who was admitted with diagnoses including type 2 diabetes, a history of falling, and dementia, was observed with their bed in a high position. This was confirmed by LVN 4, who acknowledged that the bed should be lower to prevent serious injury in the event of a fall. The facility's policy on fall management indicated that residents at risk should receive appropriate interventions, which were not followed in this case. Additionally, the facility did not provide a resident at high risk for falls with a tab alarm and floor mats as ordered by the physician. Resident 51, who had a history of severe injuries from falls, was observed without the necessary safety devices in place. CNA 1 and CNA 2 confirmed the absence of a tab alarm on the resident's wheelchair and bed, as well as the lack of floor mats. The Director of Nursing acknowledged that these devices should have been provided to minimize the risk of further falls and injuries. The facility's failure to adhere to physician's orders and its own fall management policy placed the residents at increased risk of sustaining falls with injuries. The lack of appropriate interventions for residents identified as high fall risks demonstrates a significant oversight in ensuring resident safety and compliance with established care plans.
Failure to Label Nebulizer Tubing
Penalty
Summary
The facility failed to provide appropriate respiratory care to a resident, identified as Resident 84, by not labeling the nebulizer tubing with the date it was last changed. This oversight was discovered during an observation and interview with a Licensed Vocational Nurse (LVN 6) in the resident's room. The resident, who had been admitted with acute respiratory failure, chronic obstructive pulmonary disease, and encephalopathy, required nebulizer treatments as per a physician's order. The order specified the use of Ipratropium-Albuterol Solution to be inhaled twice daily for shortness of breath. However, the nebulizer tubing was not labeled with the date of its last change, which is a critical step in preventing respiratory infections. Interviews with the Infection Preventionist (IP) and the Director of Nursing (DON) confirmed that the facility's policy required nebulizer tubing to be changed and labeled every seven days. Both the IP and DON acknowledged that the failure to adhere to this policy could lead to respiratory infections. The facility's policy and procedure document, last reviewed in September 2024, also stipulated that nasal cannula and tubing should be changed weekly. This deficiency in following the established protocol for respiratory care had the potential to compromise the resident's health by increasing the risk of infection.
Verbal Abuse Incident Between Residents
Penalty
Summary
The facility failed to protect a resident from verbal abuse when one resident screamed a death threat at another resident. On the specified date, Resident 88 yelled "I will kill you" at Resident 89 during an altercation on the patio. This incident was witnessed by multiple staff members, including a Registered Nurse and a Licensed Vocational Nurse, who intervened to separate the residents. The facility's policy prohibits abuse and requires adequate supervision when there is a risk of resident-to-resident altercation. Resident 89, who was subjected to the verbal abuse, had been admitted to the facility with diagnoses including quadriplegia and chronic pain syndrome. The resident's cognitive skills were intact, and they required assistance with various activities of daily living. The altercation was documented in the resident's Change in Condition Evaluation form and discussed in an Interdisciplinary Care Conference. Resident 88, who made the threatening statement, had a history of anger outbursts and was known to have verbally abusive behaviors. The resident's care plan included interventions for monitoring and documenting such behaviors, but some staff members were unaware of this monitoring requirement. The facility's administrator acknowledged that the incident should not have occurred according to the abuse policy and regulations.
Failure to Label Urinal Bottle Leads to Infection Control Deficiency
Penalty
Summary
The facility failed to implement and maintain an infection control program for one of the six sampled residents by not labeling a urinal bottle with the resident's name and room number. This oversight was identified during an observation and interview with the Director of Nursing, who confirmed that the urinal bottle was hanging on the right upper side rail of the resident's bed without a label. The Director of Nursing acknowledged that the staff should have labeled the urinal bottle to prevent potential cross-contamination and infection spread among residents. The resident involved was admitted to the facility with diagnoses including atherosclerotic heart disease, anemia, and hypertension. The resident was cognitively intact and required moderate to maximal assistance for various activities of daily living. The facility's policies on standard precautions and infection prevention and control emphasize the importance of handling resident care equipment in a manner that prevents contamination and the transfer of microorganisms. However, the failure to label the urinal bottle was a deviation from these policies, posing a risk of cross-contamination.
Failure to Timely Reorder and Administer Medication
Penalty
Summary
The facility failed to reorder, refill, and administer a Lidoderm Patch for a resident in a timely manner, as observed during a survey. The resident, who was admitted with diagnoses including hypertension, epilepsy, depression, periodontitis, and muscle wasting, had a physician's order for the Lidoderm Patch to be applied in the morning for pain management. However, during a medication administration observation, it was found that the patch was not available, and the nurse had to order it from the pharmacy, indicating a delay in medication delivery. Interviews with the resident and the Director of Nursing (DON) revealed that the charge nurses are responsible for reordering medications before the last dose is used, ideally when five doses remain, to prevent any disruption in medication administration. The facility's policy supports this practice, stating that medications should be reordered five days in advance. Despite these protocols, the Lidoderm Patch was not reordered in time, resulting in the resident not receiving the medication as prescribed, which could have led to increased pain and discomfort.
Failure to Timely Communicate Lab Results to Physician
Penalty
Summary
The facility failed to ensure timely communication of laboratory results to the physician for a resident who was readmitted with serious health conditions, including paroxysmal atrial fibrillation, cardiomyopathy, and sepsis due to E. coli. The resident had an order for a STAT urinalysis and culture and sensitivity test on 9/18/2024. The urinalysis results, indicating a large presence of leukoesterase, were received on 9/19/2024, and the culture results showing E. coli were received on 9/21/2024. However, there was no documented evidence that the physician was informed of these results until 9/22/2024, which delayed potential interventions. The Director of Nursing (DON) confirmed during an interview and record review that the facility's policy required licensed nurses to inform the physician of lab results and document the communication. The DON acknowledged that the staff failed to notify the physician promptly upon receiving the abnormal lab results on 9/19/2024 and 9/21/2024. The facility's policy emphasized the importance of timely communication with the attending physician based on the seriousness of any abnormalities and the resident's current condition, which was not adhered to in this case.
Medication Documentation Discrepancies
Penalty
Summary
The facility failed to ensure that the Medication Administration Record (MAR) coincided with the Controlled Drug Record (CDR) and that entries were accurately documented according to facility policy for one of the sampled residents. This deficiency was identified during a review of Resident 1's records, who was admitted with diagnoses including quadriplegia, polyneuropathy, anxiety, and knee pain. The review revealed discrepancies in the documentation of tramadol and Ativan, both controlled substances prescribed to Resident 1. Specifically, tramadol was documented on the CDR but not on the MAR, and Ativan was inconsistently documented between the CDR and MAR. Interviews with the Director of Staff Development (DSD) and the Director of Nursing (DON) confirmed that the facility's policy requires licensed nurses to document medication administration on both the MAR and CDR to ensure accurate narcotic medication counts and compliance with controlled substances regulations. The DON acknowledged the discrepancies and emphasized the importance of following the facility's policy and procedure on medication administration. The facility's policies on administering medication and controlled substances were reviewed, highlighting the requirement for accurate documentation to prevent medication errors and potential drug diversion.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that call lights were within reach for two residents, leading to potential delays in meeting their needs. Resident 2, admitted with diagnoses including dysphagia, muscle weakness, and difficulty walking, was observed in bed yelling in Spanish because the call light was on the floor and out of reach. A CNA confirmed that the resident was calling for assistance to use the restroom. The Infection Preventionist stated that call lights should always be within reach for safety, and residents should not have to yell for help. Similarly, Resident 3, readmitted with conditions such as hypertension, abnormal posture, and difficulty walking, was found calling out in Spanish with the call light coiled and hanging behind the headboard, out of reach. A CNA retrieved the call light and placed it within reach, acknowledging the importance of accessibility for safety and assistance. The Director of Nursing reiterated that call lights should always be accessible. The facility's policy on answering call lights emphasized ensuring timely responses and accessibility of call lights to residents in bed.
Failure to Reposition Resident at Risk for Pressure Ulcers
Penalty
Summary
The facility failed to ensure that a resident at risk of developing a pressure ulcer was repositioned as required. The resident, who was admitted with diagnoses including quadriplegia and polyneuropathy, was assessed with a Braden Scale score indicating mild risk for pressure ulcers. The care plan for the resident included an order to reposition every two hours or as determined by a turning/repositioning plan. However, during interviews, it was revealed that the resident was not repositioned during the 11 p.m. to 7 a.m. shift on multiple occasions. Certified Nursing Assistants (CNAs) assigned to the resident during these shifts stated that they did not reposition the resident unless instructed by the resident, who requires a two-person assist. The CNAs admitted to only performing actions requested by the resident and did not offer or explain the importance of repositioning to the resident. This practice was contrary to the facility's policy, which requires staff to offer and explain the importance of turning and repositioning to prevent pressure injuries. Interviews with the Director of Staff Development and the Director of Nursing confirmed that staff should not wait for residents to request repositioning. Instead, they should proactively offer and educate residents on the importance of repositioning. The facility's policy also mandates documentation of repositioning activities and requires notifying a supervisor if a resident refuses care. The failure to adhere to these protocols placed the resident at risk of developing pressure ulcers.
Failure to Conduct Timely Pain Assessments
Penalty
Summary
The facility failed to adhere to its policy on pain management by not completing a pain risk assessment quarterly and for a new onset of pain for a resident. The resident, who was admitted with diagnoses including quadriplegia, polyneuropathy, and knee pain, was observed with inflammation and complained of pain in the left knee. Despite these conditions, the last documented pain assessment was conducted nearly a year prior, and no quarterly assessments were completed as required. During an interview, a registered nurse confirmed that pain assessments should be conducted upon admission, quarterly, and whenever there is a new onset of pain. However, the facility did not perform a pain risk assessment for the resident's new pain complaint, which occurred on a specific date. The facility's policy mandates that pain assessments be conducted at these intervals to ensure proper pain management and care planning, but this was not followed, potentially impacting the resident's comfort level.
Failure to Accurately Assess Elopement Risk
Penalty
Summary
The facility failed to accurately assess a resident for elopement risk, which led to the resident leaving the premises without staff supervision. The resident, who had been admitted with diagnoses including Parkinsonism, dysphagia, difficulty in walking, bipolar disorder, and hypertension, was noted to have intact cognition and required varying levels of assistance for daily activities. On the date of the incident, the resident left the facility without a pass, indicating a lapse in monitoring and assessment. Upon re-admission, the Registered Nurse Supervisor completed an Elopement Evaluation Form but inaccurately marked that the resident had no history of elopement, despite the recent incident. The Director of Nursing confirmed the inaccuracy in the assessment, which should have noted the resident's history of elopement. The facility's policy requires accurate assessments for elopement risk upon admission, re-admission, and with any change in condition, but this was not adhered to in this case.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
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 4,222 citations issued within 25 miles in the last 12 months — including the 26 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.
Illustrative
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 Van Nuys
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| California Healthcare And Rehabilitation Center | 1 mi | ★★★★★ | 43 | 0 |
| Berkley Post-acute | 1.1 mi | ★★★★★ | 8 | 0 |
| The Meadows Post Acute | 1.2 mi | ★★★★★ | 23 | 1 |
| The Care Center On Hazeltine, Llc | 1.9 mi | ★★★★★ | 12 | 0 |
| Lake Balboa Care Center | 1.9 mi | ★★★★★ | 17 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.