Average — CMS composite of the measures below.
A standard survey is most likely before around November 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 The Bradley Gardens during CMS and state inspections, most recent first.
Improper Food Storage and Unsanitary Kitchen Conditions: During a kitchen tour, an undated sandwich, undated and unlabeled breadcrumbs, opened vinegar and soy sauce without open/use-by dates, and opened honey, pasta, flour, and sugar containers with residue were observed. A rust-discolored shelf was also found in the walk-in refrigerator. The DS and RD stated the items should have been labeled and dated and the shelving should be rust free and clean.
Improper Dumpster Waste Disposal: One dumpster lid was observed open and trash was overflowing in the dumpster storage area. The DS stated the lids should have been closed and the trash should not have been overflowing, and the MS stated staff disposing of trash were responsible for keeping the lids closed and the area clean to prevent attracting flies and rodents. Facility policy required kitchen waste and garbage to be properly contained with lids closed.
The CP failed to identify and report irregularities during monthly MRRs for five residents receiving anticoagulants, including rivaroxaban and apixaban. Nursing staff and leadership stated residents on blood thinners required daily bleeding/bruising monitoring, documentation in the MAR, and related care plans, but the records for multiple residents showed the medications were given without documented monitoring for adverse reactions and, in some cases, without a monitoring order. The DON stated the irregularity should have been identified in the MRR.
Failure to monitor residents on anticoagulants for adverse effects. Five residents receiving rivaroxaban or apixaban had MARs showing the meds were given, but there was no documented monitoring for bleeding or bruising. LPNs, an RN, and the DON stated residents on anticoagulation therapy should be monitored daily and that the monitoring should be documented, but the records for these residents did not show that this was done.
Delayed Meal Service Affected Resident Dignity: Two residents seated at the same table were served their lunch trays after the other residents at their tables had already begun eating, leaving one resident waiting about five minutes and the other about eight minutes while watching others eat. The DSD stated one delay was due to a room change, and the RD stated residents seated together were expected to receive meals at the same time as a group to support dignity and avoid residents feeling left out.
A resident with paranoid schizophrenia received Risperdal 3 mg BID, but the facility did not adequately document or tailor monitoring of the resident’s target behaviors. The MAR showed the medication was administered as ordered, while the behavior monitoring record listed episodes of paranoid ideation without describing the behaviors observed, and staff gave inconsistent explanations of what those behaviors were. Facility policy required specific target behaviors, expected outcomes, and monitoring for efficacy when psychotropic meds are used.
Failure to Initiate Care Plans for Anticoagulant Therapy: Two residents receiving rivaroxaban had the medication administered as ordered, but their records showed no documented anticoagulation care plan for months after therapy began. Interviews with nursing staff and the DON confirmed that a care plan should have been initiated when the new anticoagulant was started, and the facility policy required a comprehensive person-centered care plan within 7 days of the MDS and no more than 21 days after admission.
Delayed Hospice Medication Order Implementation: A resident with COPD and Alzheimer’s disease on hospice had a Prednisone order from the hospice NP that was not administered until four days later. The hospice RN said she faxed the order and called the pharmacy but did not verify receipt with facility staff, while the DON and an LPN stated they were unaware of the order until the medication was delivered and then initiated.
Medication Administration Errors: An LPN was observed preparing medications for a resident and gave docusate at 100 mg instead of the ordered 200 mg, and lactulose at 30 mL instead of the ordered 15 mL. The DON stated the triple-check process was not followed, and the facility policy required verifying the MAR, confirming the dose, and measuring liquids accurately.
Expired opened MDV of PPD were found in the medication refrigerator with open-date labels showing they had been in use beyond the discard period. An LVN acknowledged the vials were expired and should have been discarded, and the DON stated licensed nurses were expected to check refrigerated medications for expiration. The manufacturer’s instructions and the facility’s medication storage policy both required opened multi-dose vials to be discarded within the specified timeframe.
Excessive Number of Residents in Shared Bedrooms: Surveyors observed two resident rooms with five beds each, and each room was occupied by five residents. The DON stated there were no resident complaints about having five residents in the room and no quality of life issues.
An incident occurred in which a resident with cognitive impairment physically struck another resident with an intellectual disability in the TV room. Although staff immediately separated the residents and assessed the situation, the administrator did not notify the state survey agency of the abuse allegation within the required two-hour window, instead reporting it after six hours, in violation of regulatory requirements.
Two cognitively impaired residents were transferred to another skilled nursing facility without adequate justification or documentation. Despite severe cognitive impairments, the facility proceeded with the transfers based on care plan conferences discussing operational changes. The residents were unable to understand or recall the reasons for their transfers, indicating a failure to meet transfer or discharge requirements.
The facility failed to provide timely written notice of transfer or discharge to two cognitively impaired residents without legal representatives, and the LTC Ombudsman. The Social Service Director indicated notices were not given unless requested, contrary to the facility's policy requiring a 30-day advance notice. This deficiency potentially violated residents' rights and hindered the Ombudsman's ability to advocate for them.
Two residents with severe cognitive impairments were transferred between skilled nursing facilities without proper orientation or involvement of legal representatives. Despite their inability to make decisions, facility staff proceeded with the transfers based on perceived understanding during care conferences. Interviews later revealed the residents were confused and unaware of the transfer reasons, indicating a failure to adhere to facility policies requiring proper notification and orientation.
The facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen, including the absence of an air gap in the prep sink, improper concentration of Quat sanitizer, dust in several areas, chipped paint on refrigerator shelves, grime buildup on equipment, trash and food debris in multiple areas, food residues in containers, broken tiles, improper thawing of ground meat, a cook without a hair restraint, a dirty trash can touching clean surfaces, rust on equipment, and open food items in the freezer.
The facility failed to submit staffing information based on payroll data to the CMS database for the first fiscal quarter. The Payroll Manager outsourced the PBJ reporting to a third party, which encountered difficulties. The PM did not take action to resolve the issue, resulting in the report not being submitted by the deadline.
The facility failed to ensure dietary staff could safely and effectively carry out food and nutrition services, leading to potential foodborne illness and nutritional deficiencies for residents. Staff did not recognize correct sanitizer concentrations, improperly cleaned surfaces, did not follow menus, and served inappropriate food consistencies.
The facility failed to follow menu and portion sizes, leading to incorrect servings of pureed chicken, spinach, and potato wedges. Additionally, biscuits and gravy were not served as required. These deficiencies had the potential to impact the nutritional needs of 30 out of 31 residents.
The facility failed to follow recipes for preparing pureed foods, resulting in diluted and watery meals for seven residents. This inconsistency in food preparation had the potential to compromise the residents' nutritional status.
The facility failed to provide the appropriate liquid texture for two residents on nectar thick liquids, serving them improperly thickened milk and jello, which could lead to aspiration. Observations and interviews confirmed the inconsistency with physician orders and facility policy.
The facility failed to ensure that a resident or their representative was informed and provided with written information regarding the formulation of an advance directive upon admission. The resident's records indicated no assistance was offered in formulating an advance directive, contrary to the facility's policy.
The facility failed to ensure a resident received appropriate care when a dietitian's recommendation for a diet upgrade was not communicated to the physician. Despite the family's request and the dietitian's referral to the hospice MD, the resident remained on the current diet due to a communication breakdown among the staff.
The facility failed to ensure accurate accountability of controlled medications for two residents. Discrepancies were found in the Controlled Drugs Record (CDR) and Medication Administration Records (MAR), resulting in unaccounted hydrocodone-acetaminophen and Percocet tablets. The Director of Nursing confirmed the discrepancies and emphasized the importance of accurate documentation to prevent overdoses and track medication usage.
A resident receiving Seroquel was not monitored for blood abnormalities such as high cholesterol and high blood sugar, as required by the medication's prescribing information. The Consultant Pharmacist failed to recommend necessary lab work during monthly medication regimen reviews, and the Director of Nursing confirmed no documentation of required monitoring was found.
A resident was administered Seroquel without the required monitoring for blood abnormalities such as high cholesterol and high blood sugar. Despite guidelines and policies indicating the need for such monitoring, no lab tests were ordered, potentially leading to adverse effects and unidentified risks.
The facility failed to employ a full-time director of food and nutrition services, resulting in a lack of qualified supervision for 30 residents. Interviews and payroll records confirmed the Dietary Supervisor had transitioned to on-call status and worked minimal hours, while the Registered Dietitian visited once a week.
A facility failed to implement its infection prevention program when an LVN did not disinfect a BP cuff machine before and after use on two residents. The DON confirmed that the expectation was to clean and disinfect equipment before and after each use, as per facility policy and CDC guidelines.
The facility failed to ensure that two resident bedrooms did not accommodate more than four residents per room, as required by regulations. During a survey, it was observed that two rooms had five beds each, with one room occupied by four residents and the other by five residents. Despite the non-compliance, no adverse effects on the residents' quality of life were observed, and the DON confirmed no complaints or issues were reported by the residents regarding the room occupancy.
Improper Food Storage and Unsanitary Kitchen Conditions
Penalty
Summary
Food items in the kitchen were observed stored and maintained without proper labeling, dating, or sanitary conditions during a kitchen tour with the Dietary Supervisor. An undated sandwich was found inside the refrigerator, along with an undated and unlabeled bag of breadcrumbs. A gallon container of balsamic vinegar and a gallon container of soy sauce were open without an open date or use-by date, and the soy sauce bottle had residue on the outside. Two bottles of honey also lacked an open or use-by date and had sticky residue on the outside. A bag of pasta was opened and taped shut without a label or open date, and a flour container and sugar container had excess residue on the outside and lid, respectively. The walk-in refrigerator also contained a green shelf with brown discoloration resembling rust. During interview, the Dietary Supervisor stated the sandwich and breadcrumbs should have been labeled and dated, opened vinegar and soy sauce should have been dated, honey bottles should be clean and free from residue, pasta should be stored in a container once opened, and flour and sugar containers should be clean and free from residue. The Registered Dietitian later stated the storage shelves in the walk-in refrigerator should be rust free because they are difficult to clean, and that all food needs labels and dates and shelves need to be clean to prevent cross contamination and bacterial growth.
Improper Dumpster Waste Disposal
Penalty
Summary
The facility failed to ensure proper disposal of garbage when one dumpster in the outside dumpster storage area was observed with its lid not closed and trash overflowing. During the observation, the Dietary Supervisor stated the dumpster lids were open and should have been closed, and the trash should not have been overflowing to prevent pest infestations. The Maintenance Supervisor later stated that staff disposing of trash were responsible for keeping the dumpster lids closed and the surrounding area clean, and that the dumpster lids should always be closed and the area free from trash to prevent attracting flies and rodents. The facility policy titled Sanitization stated that kitchen waste should be kept in clean, leakproof, nonabsorbent, tightly closed containers and that garbage and refuse should be properly contained in dumpsters or compactors with lids or otherwise covered.
Pharmacist Failed to Identify Missing Bleeding Monitoring for Residents on Anticoagulants
Penalty
Summary
The facility failed to ensure the Consultant Pharmacist identified and reported irregularities during the monthly medication regimen review for five sampled residents who were receiving anticoagulant therapy. The report states that Residents 5 and 6 were receiving rivaroxaban, and Residents 10, 11, and 30 were receiving apixaban. Facility staff described that residents on blood thinners should have been monitored daily for adverse effects such as bleeding or bruising, that this monitoring should have been documented in the MAR, and that a care plan should have been developed. Staff also stated that residents on anticoagulation therapy needed a provider order for bleeding monitoring. For Resident 6, the record showed rivaroxaban was ordered for DVT prevention and that an order dated March 31, 2025 required monitoring, documenting, and reporting adverse reactions of anticoagulant therapy every shift, with notification of the physician for identified side effects. The MARs from December 14, 2024 through March 30, 2025 showed the medication was administered, but there was no documented evidence of monitoring for adverse reactions. For Resident 30, the record showed apixaban was ordered for DVT treatment and prevention, including an order dated February 28, 2025 for monitoring, documenting, and reporting adverse reactions every shift. The MARs from November 23, 2024 through February 27, 2025 showed apixaban administration, but no documented evidence of monitoring for adverse reactions. For Resident 10, apixaban was ordered on July 16, 2025 for acute embolism and thrombosis of unspecified deep veins of the left lower extremity. There was no physician order for monitoring adverse reactions of anticoagulant therapy between July 16, 2025 and August 20, 2025, and the MARs showed no documentation of bleeding monitoring. During interview and record review, LVN 1 confirmed there were no monitoring orders and no documentation of monitoring for bleeding during apixaban use. For Resident 5, the record showed rivaroxaban had been administered since January 8, 2025, with a later order on May 20, 2025 for acute embolism and thrombosis of unspecified deep veins of the left lower extremity; there was no order for adverse reaction monitoring and no documentation of monitoring in the MARs. For Resident 11, apixaban had been administered since May 2, 2025, but there was no order for adverse reaction monitoring and no documentation of monitoring in the MARs. The DON stated the CP should have identified and reported the irregularity in the monthly MRR for these residents, and the facility policy described MRR as a monthly review intended to identify medication-related problems and irregularities, including inadequate monitoring.
Failure to Monitor Residents on Anticoagulants for Adverse Effects
Penalty
Summary
The facility failed to ensure that five sampled residents receiving anticoagulant therapy were monitored for signs and symptoms of adverse effects related to blood thinning medications. Residents 5 and 6 were receiving rivaroxaban, and Residents 10, 11, and 30 were receiving apixaban. For each of these residents, the record review showed that the medications were administered, but there was no documented evidence that nursing staff monitored for adverse reactions of anticoagulant therapy such as bleeding or bruising. Resident 6 had diagnoses including chronic embolism and thrombosis of unspecified deep veins of the left lower extremity and was ordered rivaroxaban for DVT prevention. Resident 30 had a history of DVT and was ordered apixaban for DVT treatment and prevention. Resident 10 had acute embolism and thrombosis of unspecified deep veins of the left lower extremity and was ordered apixaban. Resident 5 had acute embolism and thrombosis of unspecified deep veins of the left lower extremity and was ordered rivaroxaban. Resident 11 had acute embolism and thrombosis of unspecified deep veins of the right lower extremity and was ordered apixaban. In each case, the MARs showed administration of the anticoagulant, but the records did not show documented monitoring for adverse reactions during the periods reviewed. During interviews, LVN 1, LVN 3, RN 1, and the DON described that residents on anticoagulation therapy should be monitored daily for bleeding or bruising, that this monitoring should be documented in the MAR or progress notes, and that a care plan should be initiated for anticoagulation therapy. For Resident 10 and Resident 11, LVN 1 confirmed there were no physician orders for adverse reaction monitoring and no documentation of bleeding monitoring. The facility policy titled Anticoagulation - Clinical Protocol also stated staff and the physician would monitor for possible complications in individuals being anticoagulated and assess for signs or symptoms related to adverse drug reactions.
Delayed Meal Service Affected Resident Dignity
Penalty
Summary
The facility failed to ensure dignity was provided for two residents when their lunch trays were not delivered to their tables at the same time as the other residents seated with them. On August 18, 2025, Resident 5 was observed in the dining room seated with another resident who had already been served and had begun eating, while Resident 5 waited about five minutes for his meal and was observed looking over his right shoulder until it arrived. During an interview shortly afterward, Resident 5 stated that this had happened before and that he had to wait for his meal while other residents at his table were already eating. Later that same day, Resident 38 was observed seated with two other residents who were served and began eating while Resident 38 waited about eight minutes for his lunch tray. The other two residents were nearly finished with their meals before Resident 38 received his tray. The Director of Staff Development stated the delay was due to a room change, and later stated that meal trays should be served one table at a time so residents are not waiting and watching others eat in order to respect residents’ rights. The Registered Dietitian stated residents seated together were expected to receive their meals at the same time as a group, and that serving meals separately could make residents feel left out and affect their sense of dignity.
Inadequate Monitoring of Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure one resident receiving psychotropic medication was free from unnecessary psychotropic use when risperidone was administered without adequate monitoring. The resident was admitted with a diagnosis of paranoid schizophrenia and had an order for Risperdal 3 mg by mouth twice daily, along with monitoring for episodes of paranoid schizophrenia evidenced by paranoid ideations. The care plan identified the resident as admitted with antipsychotic medication related to paranoid schizophrenia and at risk for adverse drug reaction, with an approach to monitor and record occurrence of target behavior symptoms. The resident’s MAR showed risperidone was given as ordered from June 19 through August 21, 2025. The monitoring record showed no episodes during June 19 to 30, six morning-shift episodes and four evening-shift episodes in July, and 17 morning-shift episodes in August, with no evening or night-shift episodes during that period. However, the eMAR medication administration note and health status note did not document any description of the resident’s paranoid ideations on the dates they were observed. During interviews, staff gave differing descriptions of the resident’s paranoid ideations, including asking for medications, missing smoke breaks, and asking for Tylenol. An LVN stated there was no specific monitoring of the resident’s paranoid ideations and that it should be indicated so the behavior being monitored would be clear. The BHND stated behavior monitoring was broad and general and that specific behaviors were not tailored, while the DON stated behavior monitoring should be resident specific and important to evaluate effectiveness of the medication and identify changes of condition or new behaviors. The facility policy required specific target behaviors, expected outcomes, and monitoring for efficacy when psychotropic medications are prescribed for behavioral symptoms.
Failure to Initiate Care Plans for Anticoagulant Therapy
Penalty
Summary
The facility failed to ensure a comprehensive, person-centered care plan was initiated for two residents who were receiving anticoagulant therapy with rivaroxaban. Resident 6 was admitted and later readmitted with diagnoses of chronic embolism and thrombosis of unspecified deep veins of the left lower extremity, and had a physician order on December 13, 2024 for rivaroxaban 20 mg by mouth in the evening for DVT prevention. The resident’s MARs from December 14, 2024 through April 7, 2025 showed the medication was administered as prescribed, but the care plan reports for that period showed no documented care plan for anticoagulation therapy use and management after the medication was ordered and given. A care plan entry for anticoagulant therapy was not documented until April 8, 2025, about 3.5 months after therapy began. Resident 5 was admitted and later readmitted with a diagnosis of acute embolism and thrombosis of unspecified deep veins of the left lower extremity, and had a physician order on May 20, 2025 for rivaroxaban 20 mg by mouth daily for that condition. The record also showed the resident had been administered rivaroxaban since January 8, 2025, and the MARs from January 8, 2025 through May 29, 2025 showed the medication was given as ordered. However, the care plan reports for that same period showed no documented care plan for anticoagulation therapy use and management after rivaroxaban was ordered and administered. A care plan entry for anticoagulant therapy was not documented until May 30, 2025, about 5 months after therapy began.
Delayed Hospice Medication Order Communication and Implementation
Penalty
Summary
The facility failed to ensure timely communication and implementation of a hospice physician’s medication order for a resident with COPD and Alzheimer’s disease who was admitted to hospice services. The resident’s hospice physician ordered Prednisone 20 mg, 2 tablets daily for five days on August 8, 2025, but the e-MAR showed the medication was first administered on August 12, 2025, four days after the order was written. During interviews and record review, LVN 2 stated she was not aware of the Prednisone order and said the standard practice was for a medication ordered on August 8, 2025, to be available the same day or the following day and administered as soon as it became available. The DON stated she was not aware of the order and that any change in condition or new medication order was expected to be communicated to her by the hospice physician or hospice nurse. The hospice RN stated the nurse practitioner evaluated the resident and issued the order, that she sent it to the facility by e-fax and called the facility pharmacy, and that she should have verified the order was received by facility staff. LVN 3 stated she saw the delivered Prednisone on the medication cart on August 12, 2025 and contacted hospice and the physician, who then authorized initiation of the medication.
Medication Administration Errors
Penalty
Summary
A medication error rate of 6.9% was identified when two medication errors occurred out of 29 opportunities during medication administration for one resident. During observation, LVN 1 prepared six medications for the resident, including docusate 100 mg soft gel capsules and lactulose oral solution. Review of the resident’s medical record showed physician’s orders for lactulose oral solution 20 GM/30 mL, 15 mL by mouth one time a day for constipation, and docusate oral capsule 100 mg, 200 mg by mouth two times a day for supplement, hold for loose stool. During a concurrent interview and record review, LVN 1 stated the resident had an order for docusate 200 mg by mouth but she gave only one 100 mg soft gel capsule instead of two. LVN 1 also stated the resident had an order for lactulose 15 mL but she administered 30 mL. The DON stated LVN 1 should have completed the triple check process by comparing the physician’s order on the computer screen with the bubble pack and checking the resident’s name and expiration date. The facility’s policy for administering oral medications required checking the label and MAR, confirming the medication dose, re-checking the proper dose, and measuring liquid medications accurately.
Expired PPD Vials Left in Refrigerator
Penalty
Summary
The facility failed to ensure proper medication storage and labeling when two opened refrigerated multi-dose vials (MDV) of Tuberculin Purified Protein Derivative (PPD) were left in active stock after their discard date. During a concurrent observation and interview in the medication room, two opened refrigerated MDV of PPD 5 TU per 0.1 ml were found with an open date label showing they had been opened on July 12, 2025. The LVN stated the vials were good for 30 days when opened and acknowledged that both vials had expired on August 11, 2025, seven days earlier, and that expired medications should have been discarded. During a later interview, the DON stated she expected licensed nurses to check all medications in the refrigerator for expired medications. The manufacturer’s instructions for the PPD vial stated that a vial of PPD that has been entered and in use for 30 days should be discarded. The facility policy and procedure on Medication Labeling and Storage stated that multi-dose vials that have been opened or accessed are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial.
Excessive Number of Residents in Shared Bedrooms
Penalty
Summary
The facility failed to ensure that two resident bedrooms did not accommodate more than four residents per room. During the survey from August 18 to August 21, 2025, rooms [ROOM NUMBERS] were observed to each have five beds, with one room occupied by five residents and the other room also occupied by five residents. On August 21, 2025, the DON was interviewed and stated that there had been no resident complaints about having five residents in the room and that there were no quality of life issues.
Failure to Timely Report Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure that an allegation of abuse involving two residents was reported to the state survey agency within the required two-hour timeframe. On the evening of March 6, 2025, a male resident with diagnoses including schizophrenia, COPD, depression, and anxiety disorder, who lacked decision-making capacity, became physically aggressive in the TV room. He struck a female peer, who had cerebral edema, secondary malignant neoplasm of the brain, schizophrenia, COPD, and an intellectual disability, on the hand/arm after perceiving her actions as threatening. Staff present immediately separated the residents and assessed the female resident, finding no injury or complaints of pain. Both the CNA and LVN on duty confirmed the incident and stated that the DON and administrator were notified right away, in accordance with facility policy to report such allegations within two hours. Despite internal notifications, the administrator did not notify the state survey agency until six hours after the incident, exceeding the regulatory requirement. The facility's policy, revised in July 2017, mandates prompt reporting of abuse allegations to local, state, and federal agencies as defined by current regulations. The delay in external reporting constituted a failure to comply with timely reporting requirements for suspected abuse, as identified through observation, interviews, and record review.
Improper Transfer of Cognitively Impaired Residents
Penalty
Summary
The facility failed to meet the transfer or discharge requirements for two residents, both of whom were cognitively impaired, when they were transferred to another skilled nursing facility. Resident 1, who had severe cognitive impairment with a BIMS score of 3, was transferred following a care plan conference where the facility's operational changes were discussed. Despite the resident's severe cognitive impairment, the Social Services Director and Director of Nursing believed the resident understood the changes and proceeded with the discharge process. However, there was no documentation in the progress notes or social services notes explaining what was communicated to the resident about the facility changes that led to the transfer. Resident 2, diagnosed with Alzheimer's disease and a history of stroke, also had severe cognitive impairment with a BIMS score of 4. During a care plan conference, the resident reportedly expressed a desire to transfer to a facility where smoking is prohibited. Similar to Resident 1, there was no prior documentation indicating that Resident 2 requested a transfer before the care conference. The Social Services Director and Director of Nursing proceeded with the discharge, believing the resident understood the changes. However, upon interview at the new facility, Resident 2 was confused and unaware of the reason for the transfer. The facility's policy on transfers and discharges requires that such actions be necessary for the resident's welfare and that the resident's needs cannot be met at the current facility. It also mandates proper documentation and notification. In both cases, the transfers were documented as resident-initiated, but the lack of clear documentation and the residents' cognitive impairments suggest that the transfers may not have been appropriately justified or communicated.
Failure to Provide Timely Transfer/Discharge Notice
Penalty
Summary
The facility failed to provide a written notice of transfer or discharge to two residents who were cognitively impaired and had no legal representatives. The deficiency involved not providing timely written notice to the residents and the Office of the Long Term Care Ombudsman. Resident 1, diagnosed with cognitive communication deficit and dementia, was involved in a care plan conference where a transfer was discussed, but there was no documentation of a notice being provided. Similarly, Resident 2, diagnosed with Alzheimer's disease, was informed about a transfer, but the notice of proposed transfer/discharge was crossed out, and there was no indication that a notice was provided to the resident or the Ombudsman. The Social Service Director stated that the notice would not be given unless requested by the resident, and the Ombudsman would receive the notice on or after the day of discharge. The facility's policy requires a 30-day advance written notice to the resident and the Ombudsman for facility-initiated transfers or discharges. The lack of timely notification potentially violated the residents' rights and did not allow the Ombudsman to advocate for the residents, ensuring the transfer or discharge was necessary.
Failure to Ensure Safe Transfer for Cognitively Impaired Residents
Penalty
Summary
The facility failed to ensure that two residents with cognitive impairments were provided with proper orientation in a form they could understand for a safe and orderly transfer from one skilled nursing facility (SNF A) to another (SNF B). Both residents lacked the capacity to make decisions and had no listed legal representatives. The facility's discharge and transfer list indicated that these residents were transferred without family representative involvement, despite being deemed incapable of making decisions. Resident 1 was admitted with diagnoses including cognitive communication deficit, unspecified dementia, unspecified psychosis, and bipolar disorder. The resident's BIMS score indicated severe cognitive impairment. Despite this, the facility's social service notes claimed the resident agreed to explore a transfer, but there was no documentation explaining the discharge plan to the resident. Interviews with facility staff revealed confidence in the resident's understanding, yet the resident was unable to provide information about the transfer when interviewed at SNF B. Resident 2, diagnosed with Alzheimer's disease and a history of transient ischemic attack, also had a BIMS score indicating severe cognitive impairment. The facility's records suggested the resident expressed a desire to transfer, but there was no prior documentation of such a request. Interviews with staff indicated they believed the resident understood the changes, but the resident was confused and unaware of the transfer's reason when interviewed at SNF B. The facility's policies required resident or representative notification and orientation for transfers, which was not adequately documented in these cases.
Sanitary Deficiencies in Kitchen
Penalty
Summary
The facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen. The deficiencies included the absence of an air gap in the prep sink, improper concentration of Quat sanitizer, and the presence of dust in several areas of the kitchen. Additionally, the reach-in refrigerator had chipped paint on its shelves, and several pieces of equipment had grime buildup. Trash and food debris were found in multiple areas, and containers used to store clean scoops, utensils, and lids had food residues. Broken tiles were observed under the reach-in refrigerator and utility area, and ground meat was not fully submerged during the thawing process. A cook with facial hair did not wear a hair restraint, and a dirty trash can was found touching clean surfaces. Rust was found on several pieces of equipment, and several food items were open and exposed to the air in the reach-in freezer. On March 26, 2024, during an observation and interview with Cook 1, it was noted that the prep sink did not have an air gap. The Dietary Supervisor confirmed this and stated she was unaware of the requirement. The Quat sanitizer used to sanitize food preparation surfaces did not meet the required concentration levels on multiple occasions, as confirmed by various staff members, including the Dietary Supervisor and Registered Dietitian. Dust was observed in several areas of the kitchen, including the wall next to the entrance door, underneath the prep table, and on shelves next to the oven. The reach-in refrigerator had chipped paint on four out of seven shelves, and several pieces of equipment, including the microwave and oven, had grime buildup. Trash and food debris were found on the floor under the oven and reach-in refrigerator. Containers used to store clean scoops, utensils, and lids had food residues. Broken tiles were observed under the reach-in refrigerator and utility area. During the thawing process, ground meat was not fully submerged in running water. A cook with facial hair did not wear a hair restraint, and a dirty trash can was found touching clean surfaces. Rust was found on the drying rack, silver shelves, and inside the ice cream freezer. Several food items in the reach-in freezer were open and exposed to the air, potentially causing freezer burn and affecting the quality of the food.
Failure to Submit Staffing Information to CMS
Penalty
Summary
The facility failed to electronically submit staffing information based on payroll data to the CMS database for the first fiscal quarter of the year. During a review of the CMS PBJ Staffing Data Report CASPER for FY Quarter 1 (October 1-December 31), it was indicated that the facility did not submit the required data. In an interview, the Business Office Manager (BOM) stated that the Payroll Manager (PM) was responsible for submitting the report to CMS. The PM revealed that the PBJ reporting had been outsourced to a third party, which encountered difficulties in submitting the report on February 9, 2024. The PM did not take any action to resolve the issue and relied on the third-party company. Consequently, the PBJ report was not submitted by the deadline of February 14, 2024.
Deficiencies in Dietary Staff Practices
Penalty
Summary
The facility failed to ensure that dietary staff were able to carry out the functions of food and nutrition services safely and effectively. Food service workers did not recognize that the Quat sanitizer concentration was not at the right concentration, with multiple staff members incorrectly stating that the sanitizer was at the right concentration when it was not. This failure had the potential to cause foodborne illness for 30 out of 31 sampled residents who received foods from the kitchen. Additionally, Diet Aide 1 and Cook 2 were unable to properly clean working surfaces, using incorrect cleaning methods that did not follow the facility's policy and procedure for cleaning and sanitizing food contact surfaces. This also had the potential to cause foodborne illness for the residents. Cook 2 did not follow the menu for serving lunch on March 27, 2024, which included serving incorrect portions and not following recipes. This failure had the potential for 30 out of 31 residents receiving food prepared in the kitchen to not meet their nutritional needs, which may lead to nutritional-related health complications. Furthermore, Diet Aide 2 served Jello to residents who required nectar thick consistency, which posed a risk of aspiration for two of the sampled residents. The Registered Dietitian confirmed that residents on nectar thick consistency should not receive Jello because it turns into a thin liquid when it melts in the mouth. Cook 2 also did not know the right concentration of chlorine for the dish machine, incorrectly stating that the test strip should read between 100-200 ppm when the dish machine required 50 ppm available chlorine. This failure had the potential to cause foodborne illness for 30 out of 31 sampled residents who received foods from the kitchen. The facility's job descriptions for dietary staff indicated that they should follow menus, recipes, and maintain high standards of sanitation, which were not adhered to in these instances.
Failure to Follow Menu and Portion Sizes
Penalty
Summary
The facility failed to ensure that menus were followed and resident nutritional needs were met. Specifically, correct portion sizes were not adhered to during meal service. On March 27, 2024, the cook used incorrect scoops for serving pureed chicken and spinach, and served three potato wedges instead of four to residents on a regular diet. This was observed during an interview and meal plating service, and confirmed by the Dietary Supervisor and Registered Dietitian, who emphasized the importance of following menu portion sizes to meet residents' nutritional needs and avoid over or under-serving food portions. The facility's policy and procedure documents also outlined the necessity of adhering to specified portion sizes to ensure residents receive the appropriate nutrients and avoid unnecessary weight gain or nutrient deficiencies. The facility's Resident Diet List indicated that several residents were on pureed and regular diets, highlighting the importance of accurate portion control for these individuals. Additionally, the cook failed to serve biscuits and gravy as required by the menu. During the same meal service observation, it was noted that biscuits were not available on the trayline, and gravy was not served to residents on a pureed diet. The Dietary Supervisor acknowledged that the cook, who was assigned to prepare the noon meal instead of his usual evening meal, still needed to follow the menu and serve all listed food items. The Registered Dietitian reiterated that cooks should adhere to the menu to ensure residents receive the appropriate diet. The facility's policy and procedure documents supported the requirement to prepare foods according to the menu, including serving all specified items. The deficiencies observed in portion control and menu adherence had the potential to impact the nutritional needs of 30 out of 31 residents receiving food prepared in the kitchen, potentially leading to nutritional-related health complications.
Failure to Follow Pureed Food Recipes
Penalty
Summary
The facility failed to ensure the recipe for preparing pureed foods was followed for seven residents receiving pureed diets. During an observation, Cook 2 was seen adding unmeasured hot water to chicken and spinach while preparing pureed meals, resulting in a watery consistency. The Dietary Service Supervisor confirmed that plain water should not be used as it dilutes the nutritive value and flavor of the food. The Registered Dietitian also stated that chicken broth should have been used instead of water for pureeing chicken. The facility's diet list and recipes indicated that pureed foods should have a smooth, pudding-like consistency, which was not achieved in these instances. The residents affected by this deficiency had various diet orders, including regular-puree, fortified-puree, and nectar thick liquids. The facility's documentation specified that pureed foods should be smooth, moist, and able to hold their shape, which was not the case for the pureed chicken and spinach prepared by Cook 2. This failure had the potential to compromise the nutritional status of the residents, as the diluted and watery pureed foods could lead to decreased oral intake and weight loss.
Failure to Provide Appropriate Liquid Texture
Penalty
Summary
The facility failed to ensure that two residents received the appropriate liquid texture as prescribed by their physicians. Resident 6, who was on a fortified pureed diet with nectar thick liquids, was observed being fed jello and milk that was not properly thickened. The Dietary Service Supervisor confirmed that the milk had chunks of thickener at the bottom, indicating it was not mixed well, and stated that residents on nectar thickened liquids should not receive jello. Similarly, Resident 24, who was also on a fortified pureed diet with nectar thickened liquids, was observed with milk and jello on her meal tray. The Infection Preventionist noted that the milk did not appear to be of nectar thick consistency, and the Registered Dietitian confirmed that jello should not be given to residents on nectar thickened liquids as it turns into a thin liquid when melted in the mouth. The facility's policy on thickened liquids was reviewed and indicated that all liquids should be thickened according to the physician's order and mixed well to achieve the appropriate consistency. The International Dysphagia Diet Standardization Initiative framework also supports that gelatin should only be provided on a regular thin liquid diet. The failure to adhere to these guidelines and physician orders had the potential to place the residents at risk for aspiration.
Failure to Provide Advance Directive Information
Penalty
Summary
The facility failed to ensure that Resident 38 or their representative was informed and provided with written information regarding the formulation of an advance directive upon admission. A review of Resident 38's Physician Orders for Life Sustaining Treatment (POLST) dated January 31, 2024, indicated that the resident did not provide information regarding an advance directive. Additionally, the document titled 'Residents Receipt of Self-Determination Act Information' dated February 1, 2024, showed that the resident responded 'No' when asked whether an advance directive was executed, and there was no documentation showing that the facility offered assistance in formulating one. During interviews with the Social Service Director and the Business Office Manager, it was confirmed that the admitting nurse did not ask Resident 38 about the advance directive, and the facility did not assist in formulating one. The facility's policy on advance directives, dated December 2016, requires that the Social Service Director or designee inquire about the existence of any written advance directives prior to or upon admission and offer assistance if none exist. This policy was not followed, leading to the deficiency noted in the report.
Failure to Communicate Dietary Recommendations
Penalty
Summary
The facility failed to ensure that Resident 24 received appropriate care and treatment to maintain their highest practicable physical well-being. Despite a dietitian's recommendation for a diet upgrade from puree to mechanical soft, this recommendation was not communicated to the physician by the licensed nurses. Resident 24, who was admitted with diagnoses including cerebral infarction and dementia, had a severe cognitive impairment as indicated by a BIMS score of 3. The resident's family had requested a diet upgrade in June 2023, and the dietitian had made a referral to the hospice MD. However, the hospice physician was not made aware of the family's request or the dietitian's recommendation, resulting in the resident remaining on the current diet. Interviews with the Dietary Supervisor, Registered Dietitian, and Director of Nursing revealed that the communication breakdown occurred because the nursing staff did not inform the hospice team about the dietary recommendations. The Director of Nursing stated that she was unaware of the dietary preferences upgrade request and acknowledged that the physician should have been informed. The facility's policy on resident examination and assessment emphasizes the importance of coordinating care with the hospice provider and ensuring that all care needs are communicated and documented. However, this policy was not followed in the case of Resident 24, leading to a failure in providing the necessary dietary upgrade.
Controlled Medication Accountability Issues
Penalty
Summary
The facility failed to ensure accurate accountability of controlled medications for two out of three residents during a survey. For Resident 27, discrepancies were found in the Controlled Drugs Record (CDR) and Medication Administration Records (MAR). Specifically, the CDR indicated that hydrocodone-acetaminophen tablets were removed on certain dates, but there was no corresponding documentation on the MAR to show that the medication was administered. Additionally, there was an instance where the MAR indicated that a tablet was administered, but there was no record of its removal from the CDR. These discrepancies were confirmed by the Director of Nursing (DON), who acknowledged that three tablets were unaccounted for and that proper documentation should have been maintained in both the CDR and MAR. For Resident 23, a similar issue was identified. The CDR showed that a Percocet tablet was removed, but there was no documentation on the MAR to indicate that the medication was administered. This discrepancy was also confirmed by the DON, who acknowledged that one Percocet tablet was unaccounted for. The DON emphasized the importance of accurate documentation to prevent potential overdoses and to track medication usage to avoid diversion. The facility's policies and procedures for controlled substances and medication administration were reviewed. The policies required that each dose administered be properly recorded in the resident's medical record, including the name of the resident, the medication, the time of administration, and the nurse's signature. The failure to adhere to these policies resulted in unaccounted controlled medications, highlighting a significant deficiency in the facility's medication management practices.
Failure to Monitor Resident on Seroquel for Metabolic Abnormalities
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist (CP) identified and reported irregularities during the monthly medication regimen review (MRR) for a resident who was administered Seroquel without manufacturer-specified monitoring. The resident, who had been receiving Seroquel since June 2021, was not monitored for blood abnormalities such as high cholesterol and high blood sugar, as required by the medication's prescribing information. This oversight persisted even after the resident was taken off hospice care in November 2022, and no baseline labs were ordered or recommended by the CP during the monthly MRRs from January 2023 to February 2024. During a review of the resident's medical records, it was found that there were no orders for the necessary lab work to monitor for metabolic abnormalities associated with Seroquel use. The Director of Nursing (DON) confirmed that no documentation was found indicating that the required labs were ordered or monitored. The CP acknowledged that the resident should have been monitored for lipids and hyperglycemia but failed to make any recommendations for such monitoring in the monthly MRRs. The facility's policies and procedures, as well as the prescribing information for Seroquel, clearly indicate the need for monitoring for metabolic changes, including hyperglycemia and dyslipidemia. Despite these guidelines, the CP did not document any irregularities or recommend the necessary lab work during the monthly reviews. This failure to adhere to established protocols and guidelines resulted in the resident not receiving the appropriate monitoring for potential adverse effects of the medication.
Failure to Monitor Psychotropic Medication Side Effects
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medications when the resident was administered Seroquel without manufacturer-specified monitoring. The resident, who had been receiving Seroquel since June 2021, was not monitored for blood abnormalities such as high cholesterol and high blood sugar, as required by the medication's prescribing information. This lack of monitoring persisted even after the resident was taken off hospice care in November 2022, and no baseline labs were ordered by the physician or recommended by the pharmacist. During interviews, the Director of Nursing (DON) confirmed that there were no orders for the necessary lab tests in the resident's medical record. The Consultant Pharmacist also acknowledged that the resident should have been monitored for metabolic abnormalities. The facility's policy and procedure for antipsychotic medication use, as well as the prescribing information for Seroquel, both indicated the need for monitoring these side effects. Despite these guidelines, the required monitoring was not conducted, potentially leading to adverse effects and unidentified risks for the resident.
Lack of Full-Time Dietary Supervisor
Penalty
Summary
The facility failed to employ a full-time director of food and nutrition services, which resulted in a lack of qualified supervision over food and nutrition services for 30 residents. The deficiency was identified through interviews and record reviews. Cook 1 confirmed that there had been no Dietary Supervisor (DSS) for about a month. The DSS, who had transitioned to an on-call status since February 28, 2024, confirmed her limited availability. The Administrator acknowledged the absence of a full-time DSS. The Registered Dietitian (RD) stated she visited the facility once a week and worked 24 hours per month. Payroll records indicated the DSS worked minimal hours in March 2024, further confirming the lack of full-time supervision.
Failure to Disinfect BP Cuff Machine
Penalty
Summary
The facility failed to implement its infection prevention and control program when a Licensed Vocational Nurse (LVN) did not disinfect the automatic blood pressure (BP) cuff machine before and after use on residents. During a medication pass observation, the LVN was seen using the BP cuff machine on two residents without disinfecting it before and after each use. The LVN acknowledged the failure to disinfect the equipment and stated that it was important for infection control. The Director of Nursing (DON) confirmed that the expectation was for nursing staff to clean and disinfect any equipment before and after use on each resident. The facility's policy and procedure, as well as CDC guidelines, require that non-critical resident-care items like blood pressure cuffs be disinfected after each use. The failure to follow these guidelines had the potential to expose vulnerable residents to cross-contamination and infections.
Overcrowding in Resident Rooms
Penalty
Summary
The facility failed to ensure that two resident bedrooms did not accommodate more than four residents per room, as required by regulations. During a survey conducted from March 26 to March 29, 2024, it was observed that two rooms had five beds each, with one room occupied by four residents and the other by five residents. Despite the non-compliance, no adverse effects on the residents' quality of life were observed during the survey. The Director of Nursing confirmed that there were no complaints or quality of life issues reported by the residents regarding the room occupancy.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 342 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near San Jacinto
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hemet Valley Healthcare Center | 2.2 mi | ★★★★★ | 18 | 0 |
| Devonshire Care Center | 2.3 mi | ★★★★★ | 4 | 0 |
| San Jacinto Valley Post Acute | 2.3 mi | ★★★★★ | 14 | 0 |
| The Village Healthcare Center | 2.8 mi | ★★★★★ | 1 | 0 |
| Ramona Rehabilitation And Post Acute Care Center | 3.3 mi | ★★★★★ | 15 | 1 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.