Below average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Gardens Healthcare Center during CMS and state inspections, most recent first.
A resident with hemiplegia, impaired cognition, impaired vision, and a history of falls was observed using a low air loss mattress with bilateral bolsters and bed/pad alarms. The record contained orders for a low air loss mattress and alarms, but no physician order, informed consent, restraint assessment, or care plan for the bolsters, and no restraint assessment for the alarms. Staff and the QAN confirmed the missing documentation, and the DON stated the alarm use should have had an assessment for safe use.
Failure to develop and implement care plans for a resident with a CGM, a resident receiving Augmentin for UTI, and a resident receiving Cephalexin and using grab bars. Staff observed the CGM in place and discussed routine sensor changes, but the care plan did not include the sensor change intervention. The QAN and DON confirmed there were no care plans for the antibiotic therapies or the grab bars, despite orders, assessments, and resident-specific needs.
Incorrect Low Air Loss Mattress Settings for Residents at Risk for Pressure Injury. A facility failed to set LALM devices according to resident weight for three residents with pressure injury risk or existing wounds. One resident with DTI and severe cognitive impairment had a mattress set at 220 lbs despite weighing 91 lbs; another resident with a heel DTI and sacrococcyx skin damage weighed 155 lbs but the mattress remained set at 220 lbs; and a third resident with severe cognitive impairment and a post-op spine condition weighed 164 lbs but the pump was set at 260 lbs. Staff and the DON acknowledged the settings were incorrect and not consistent with the manufacturer’s weight-based guidance.
Improper Bed Rail Assessment and Use: The facility used grab bars as bed rails for multiple residents without completing the required pre-installation assessment process. Residents with diagnoses including muscle weakness, dementia, hemiplegia/hemiparesis, altered mental status, and fall history were observed with bilateral grab bars in place even when the BSA was incomplete, not recommended, or assessed for the wrong rail type. The QAN and DON stated grab bars are bed rails and that the required process was not followed.
Missing competency documentation and DON knowledge deficits: The facility could not provide complete annual skills competency records for the DON, RN 2, or an LVN, and the DON’s own checklist was later produced unsigned. During survey interviews, the DON also showed limited understanding of several nursing practices, including pressure-relief mattress settings, psychotropic consent, insulin site rotation, fall-prevention measures, restraint concerns, meal assistance positioning, and CGM care planning.
Failure to Rotate Insulin Injection Sites: Two residents with DM2 received Humalog KwikPen insulin injections at repeated SQ sites instead of having sites rotated as ordered. The LARs showed multiple injections in the same arm or abdominal areas, and the QAN and DON both acknowledged the staff did not follow the MD order, facility policy, or manufacturer instructions for site rotation.
A resident on a liberal renal diet and another resident receiving hot food were affected when dietary staff failed to follow the standardized recipe for mini egg rolls and served them at room temperature instead of at or above 140 degrees F. The resident with ESRD, DM, and CKD reported repeated dissatisfaction with the food and said she was not given a therapeutic diet menu to choose from; staff served her a regular-menu alternative rather than the liberal renal options listed for lunch, and the CDM confirmed the resident did not receive a separate therapeutic menu.
Food items throughout the kitchen were found without required received dates, open dates, or use-by dates, including seasonings, breads, refrigerated foods, produce, and dry goods. The CMD stated all food products must be labeled with these dates and acknowledged the facility policy on labeling and dating foods was not followed. Some items were also observed with outdated labels, unreadable writing, or visible spoilage such as mold.
Failure to Monitor Antibiotic Use and Include Stop Date for Antifungal Order: The facility did not document shift-by-shift monitoring for adverse effects for two residents receiving ATBs, including amoxicillin-clavulanate and cephalexin, despite the QAN and DON stating such monitoring was required. The facility also had a resident on terbinafine without a stop date, even though the order and policy required complete anti-infective orders with duration and stop date information.
A resident with lumbar spinal stenosis, generalized weakness, and hand tremors needed help eating and was on a soft & bite-sized CCHO, NAS diet. During lunch assistance, a CNA stood over the resident while feeding him, despite acknowledging staff are supposed to sit down for the resident’s comfort. The QAN stated this was a dignity and safety issue and did not meet residents’ rights.
Call Light Not Within Reach of a Resident: A resident with a G-tube, severe cognitive impairment, dysphagia, hemiplegia/hemiparesis, and dependence for multiple ADLs was observed in bed with the call light wrapped around the tube feeding pump pole and out of reach. A CNA moved it near the resident’s hand and stated it should be within reach so the resident could call for help; the DON stated all staff are responsible for keeping call lights within reach, and facility policy required call light accessibility while the resident was in bed.
Failure to Protect Resident Confidentiality: An RN left a resident’s eMAR open and unattended on a med cart in the hallway while caring for the resident, with the screen visible out of view and near visitors and housekeeping staff. In a separate incident, a DA discarded resident meal tickets containing names, room numbers, diet orders, allergies, and food preferences into regular trash during dish washing, instead of disposing of them as confidential records.
Incomplete informed consent for psychotropic medications: Five residents had antidepressant orders tied to depression, withdrawn behavior, sadness, or sleep issues, but the psychotherapeutic drug consent forms did not include the reason for use or the benefits. The QAN and DON stated licensed staff should verify that the consents were complete, and the facility policy required psychotropic drugs to be used only when medically necessary with informed consent verified by the LPN.
A resident with enterocolitis, COPD, and acute respiratory failure was transferred to an acute care hospital for hypotension, but the facility did not complete the bed hold notification form to show the transfer/discharge or document that the resident or representative was given the written 7-day bed hold policy. The QAN and DON acknowledged the form was incomplete, the spouse could not be reached, and the record did not show an order for the transfer or bed hold.
Floor Mat Obstructed by Side Table: A resident with altered mental status, reduced mobility, muscle weakness, and severe cognitive impairment had bilateral floor mats in the room, but a side table was placed on the center of one mat. RN and QAN stated objects should not be on the mat because it defeats the purpose of the soft-landing surface and can make the table unstable; the DON also stated the table should not be on the mat. The resident was identified as at risk for falls, and the care plan included keeping the room free from clutter.
A resident with dehydration, thrombocytosis, viral pneumonia, and severe cognitive impairment had a midline IV access for continuous therapy, but the dressing was observed loose and dated beyond the weekly change interval. RNs stated the dressing should have been changed weekly and PRN if loose, but it was not changed because the bio patch supply had run out. The QAN and DON confirmed the dressing was overdue and that facility policy required weekly transparent dressing changes and antimicrobial disc changes every 7 days and PRN.
A resident with atrial fibrillation, GERD, hemiplegia/hemiparesis, and moderate cognitive impairment had an order for Apixaban 5 mg via G-tube BID, and the care plan identified risk for bruising and bleeding related to anticoagulation therapy. However, the OSR, MAR, and progress notes did not show monitoring for adverse effects, and the QAN and DON stated the facility did not follow its anticoagulant protocol or the Eliquis HPI.
A resident on a soft and bite-sized diet received hard carrots on the lunch tray and in the soup, and the carrots did not pass the IDDSI level 6 fork pressure test. The resident said he could not eat the carrots and requested another tray. The CNA confirmed the carrots were not soft or mashable, while the CDM and RD stated soft and bite-sized foods must be soft enough to mash and that food failing the fork pressure test is not acceptable for that diet.
A resident’s MAR showed Flonase as administered even though the nasal spray was not available at the time, and the RN documented the medication before it had been delivered. In addition, a controlled substance shift audit for one medication cart had multiple missing oncoming and outgoing charge nurse signatures, and RN staff stated the signatures confirm the count was completed.
Missing COVID-19 Vaccination Documentation for Staff: The facility failed to maintain required COVID-19 vaccination records for an CNA, including documentation that the vaccine was offered, information on obtaining it, or verification of vaccination, exemption, or refusal. The IP stated the facility offers COVID-19 vaccine to residents and staff, but the CNA’s file only contained the influenza consent form and no COVID-19 consent or declination documentation. The DON stated COVID-19 vaccination was offered during flu season and, if missed, staff could obtain it through their healthcare provider.
Improperly Fitted Specialty Mattress Created Bed Gap: A resident with severe cognitive impairment and extensive assistance needs was observed on a low air loss mattress that did not fit the bed frame well, leaving an approximately six-inch gap between the grab bar and the mattress. The QAN and MS both stated the mismatch created an entrapment risk, and the mattress supplier confirmed the mattress was 36 inches wide while the bed frame had width extensions from the original mattress. The resident reported difficulty getting up from the bed and discomfort while sleeping.
A facility failed to honor residents’ rights to choose their AP for five residents. Two residents had records showing Physician 1 as their AP, but the facility assigned the MD instead, and both residents/family said they were not allowed to keep Physician 1. Three other residents, each documented as having capacity to make decisions, said they were never asked if they wanted to keep their own AP and were simply assigned the facility MD. The AD stated it was standard practice to assign the MD unless an outside physician would follow the resident, while the DON acknowledged residents should be given the option to choose their AP.
A resident with multiple health conditions did not receive their prescribed morning medications, which were left unattended on a meal tray in the hallway. Nursing staff signed the MAR indicating the medications were administered, despite not observing the resident take them. Facility policy required staff to witness medication ingestion and accurately document administration, which was not followed in this instance.
A resident with an indwelling catheter did not receive or have documented catheter care as ordered by the physician on several shifts, and two residents identified as candidates for bowel and bladder retraining did not have such programs initiated due to staff oversight of assessment forms. These deficiencies were confirmed through record review and staff interviews.
The facility did not post actual daily nurse staffing information, including the number of staff and hours worked, in a visible and prominent location as required. Instead, only projected staffing was displayed, and actual staffing data for previous days was not made accessible to residents or visitors, contrary to facility policy.
Two residents with Permacath catheters had their pre- and post-dialysis assessments inaccurately documented by nursing staff, who repeatedly recorded the presence of thrill and bruit—findings not possible with this type of access. Both a registered nurse and the DON confirmed the inaccuracy, and facility policy required precise documentation of dialysis care in the medical record.
A resident with an indwelling urinary catheter, cognitive impairment, and a need for staff assistance was observed to have their urinary catheter bag uncovered, contrary to facility policy and physician orders. Both an RN and the DON confirmed that catheter bags should be covered to maintain dignity, but this was not done for the resident.
A resident with dementia, depression, and a history of falls was found in bed with the call light on the floor and out of reach, despite a care plan requiring it to be accessible. Staff confirmed the call light was not within reach, and facility policy mandates that call lights be accessible to residents at all times.
A resident with intact cognition and multiple medical conditions had an advance directive on file, but facility staff failed to keep a current copy in the active clinical record. Both the SSD and DON confirmed the document was missing from the chart, despite facility policy requiring its presence for staff guidance.
A resident with multiple diagnoses and an indwelling catheter was admitted, but the baseline care plan developed within 48 hours did not address catheter care as required. Staff interviews and record reviews confirmed the omission, despite physician orders for catheter care and facility policy mandating comprehensive baseline care plans for all care areas.
A resident with diabetes, hypertension, and COPD was using a continuous glucose monitoring (CGM) system as ordered by a physician, but staff did not develop or implement a comprehensive, person-centered care plan to address the use and monitoring of the CGM sensor. Interviews with the MDSC and DON confirmed that no care plan with goals or interventions was created, despite facility policy requiring such plans for all residents.
A resident with type 2 diabetes did not receive proper monitoring or support for their continuous glucose monitoring (CGM) system, as staff failed to ensure the availability of sensor patches and did not apply or monitor the device as ordered. The resident independently applied the CGM sensors without staff assessment or documentation, and the admission assessment and care plan were incomplete and did not address the use of the CGM system.
An LVN left a bottle of vitamin C unattended and accessible on top of a medication cart while administering medications to a resident with diabetes, hypertension, and COPD. The bottle was not secured in the cart, making it easily accessible to other residents in the hallway, contrary to facility policy requiring medications to be stored securely and attended by authorized staff.
A resident with multiple medical conditions and cognitive impairment did not receive weekly weight monitoring as ordered by a physician. After an initial weight was recorded, staff failed to document the required weekly weight, missing one week before the next weight entry. Facility leadership confirmed the omission and acknowledged it was not in line with policy or physician orders.
A resident admitted after spinal fusion surgery retained a peripheral IV catheter without a physician order or ongoing need. Nursing staff did not assess or remove the IV upon admission, and facility records lacked documentation or indication for its use, contrary to facility policy requiring physician orders for IV therapy.
A resident with an order for continuous oxygen via nasal cannula was found with their oxygen tubing on the floor and the cannula not attached, contrary to physician orders and facility policy. An LVN confirmed the tubing was contaminated, and the DON acknowledged staff are required to follow oxygen administration orders.
Surveyors found that medications were disposed of in a manner that left them retrievable and that three medications were not properly documented with witness signatures on the Medication Disposition Record/Pass Log. Both a nurse and the DON confirmed that facility policy requiring non-retrievable disposal and dual nurse verification was not followed.
A resident with multiple medical conditions, who was dependent on staff for most ADLs but cognitively intact, had a baked custard left at the bedside for longer than four hours after lunch. Facility staff and dietary policy confirmed that leftover food should be removed within four hours, but this was not done, resulting in improper food handling and sanitation practices.
A resident with dementia and impaired cognition was made to sign her own consent forms for citalopram, influenza, and COVID-19 vaccines, despite lacking the capacity to make medical decisions. The facility failed to involve the Responsible Party (RP) as required by policy, placing the resident at risk. Staff interviews confirmed the oversight and acknowledged the need for RP involvement.
A resident with dementia and high fall risk was not reassessed for elopement risk after triggering exit alarms and wandering. The resident exited the facility without assistance, resulting in a fall and injuries. The facility failed to implement necessary safety measures, contributing to the incident.
A resident's medical records were incomplete due to the facility's failure to document physician orders for surgical wound treatment and urinary catheter drainage bag changes before performing these procedures. The resident, admitted with a spinal fusion, muscle weakness, and hypertension, had an indwelling catheter and a surgical wound. Despite these conditions, treatments were administered without documented orders, leading to inaccuracies in the clinical record. The facility's policies required immediate documentation of verbal orders, but delays were noted, potentially resulting in missed orders.
Two residents in the facility had incomplete care plans, leading to deficiencies in their care. One resident's care plan lacked specified frequency for neuro checks after an unwitnessed fall, while another resident's care plan did not include details about their urinary catheter care. These omissions were confirmed by staff and did not align with the facility's policy on comprehensive care plans.
A resident with an indwelling urinary catheter was not provided proper care as the catheter was not secured to the thigh, contrary to the care plan and facility policy. This oversight was observed during a survey, with the DON acknowledging the risk of dislodgement and infection due to improper securing.
A resident on enhanced barrier precautions was at risk due to a breach in infection control procedures by an RN. The RN failed to change gloves after touching unclean surfaces while performing wound treatment and changing a urinary catheter drainage bag. The facility's infection prevention policies were not adhered to, as confirmed by the DON.
The facility failed to implement comprehensive care plans for residents using psychotropic and anticoagulant medications, side rails, and urinary catheters. This lack of care plans led to unmonitored medication side effects, increased risk of falls, and potential health complications. The ADON and MDSC acknowledged these deficiencies, which were contrary to the facility's policies requiring person-centered care plans.
The facility failed to rotate injection sites for insulin administration for three residents, leading to potential adverse effects. Despite guidelines from insulin manufacturers, repeated injections were given in the same areas, risking complications such as lipodystrophy and poor medication absorption. The ADON confirmed the lack of site rotation for insulin and heparin injections.
The facility failed to properly document and reconcile controlled medications, with missing entries on audit forms for Medication Cart 2. Additionally, a resident did not receive their prescribed cholecalciferol oral liquid due to its unavailability in the medication cart. The facility's policy required timely reordering of medications, which was not followed, leading to a lapse in medication management.
The facility failed to ensure that the drug regimen for two residents was free from unnecessary medications. One resident's order for apixaban lacked a specific medical condition, while another resident receiving heparin was not monitored for adverse effects. These omissions were identified by the MDS Coordinator and the ADON, who confirmed that the facility's policy requiring specific clinical conditions for medication orders and monitoring for adverse effects was not followed.
The facility failed to manage and monitor psychotropic medication regimens for several residents, leading to deficiencies in their care. One resident received lorazepam without a 14-day limit or specific behavior monitoring, while another was given buspirone without documented behavior monitoring. Additionally, residents on quetiapine and citalopram lacked appropriate physician's orders for monitoring target behaviors and adverse effects, risking unnecessary medication use and adverse effects.
The facility failed to rotate injection sites for insulin and heparin in three residents, leading to potential adverse effects. The ADON confirmed repeated injections in the same areas, contrary to guidelines and facility policy.
Unassessed Mattress Bolsters and Alarm Use
Penalty
Summary
The facility failed to ensure a resident was free from physical restraints when a low air loss mattress with bilateral bolsters was in use without a physician’s order, informed consent, restraint assessment, or a care plan addressing that device. The resident was admitted with diagnoses including hemiplegia, hemiparesis following cerebral infarction, muscle weakness, and a history of falling. The H&P stated the resident did not have the capacity to understand and make decisions, and the MDS indicated severely impaired cognitive skills, impaired vision, dependence for mobility and ADLs, and a history of falls. The resident’s record showed orders for sensor pad alarms on the bed and wheelchair and a pressure redistribution low air loss mattress, but no order for a low air loss mattress with bilateral bolsters. The care plan addressed fall risk and included use of bed and wheelchair alarms, but it did not include the bilateral bolster on the mattress. During observation, the resident was seen in bed on a low air loss mattress with elevated sides, with a bed/pad alarm in place, and staff were preparing the resident for transfer to a wheelchair. RN 2 stated he did not know the purpose of the elevated sides of the mattress. The LALM representatives stated the mattresses delivered to the facility had bilateral bolsters that could be inflated. The QAN stated she could not find a physician’s order, informed consent, restraint assessment, or care plan for the low air loss mattress with bilateral bolsters, and could not find a restraint assessment for the pad alarms. The DON stated the use of the bed/pad alarm should have an assessment for safe use. The facility’s policies stated restraints require a pre-restraint assessment, physician order, consent, and care plan, and that alarms require identification of risks and assessment before use.
Failure to Develop and Implement Care Plans for CGM, Antibiotics, and Grab Bars
Penalty
Summary
The facility failed to develop and implement person-centered care plans for three residents. Resident 1 was admitted with diagnoses including aftercare following digestive system surgery, gastrostomy tube presence, pneumonitis due to inhalation of food and vomit, bacterial pneumonia, hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, dysphagia, cognitive communication deficit, and type 2 diabetes mellitus. The MDS indicated severe cognitive impairment and that the resident never or rarely made decisions, and the resident was dependent for feeding, dressing, toileting, showering, and transferring to a wheelchair. During observation, Resident 1 had a continuous glucose monitoring (CGM) sensor attached to the right upper arm above the elbow. The caregiver stated the sensor needle was changed by nurses when the resident's wife brought replacement supplies. RN 1 reviewed the physician's orders for monitoring skin breakdown at the CGM site and monitoring CGM placement every shift, and stated the sensor needle should be changed every 30 days or so depending on the brand. RN 1 also stated the family usually brought supplies to change the needle as needed or per family request. The care plan titled, At risk for Skin breakdown secondary to presence of CGM on the skin, included monitoring CGM placement every shift and observing for pain, swelling, redness, and drainage, but RN 1 stated there was no intervention or care plan to change the sensor needle and no nurses' notes about needle change. Resident 2 was admitted and later readmitted with diagnoses including UTI and fracture of the neck of the left femur. The H&P indicated the resident had the capacity to understand and make decisions, and the MDS indicated the resident could make self understood and understand others, had moderate cognitive impairment, and was on a high-risk drug class antibiotic. The order summary showed Amoxicillin-Pot Clavulanate 875-125 mg, one tablet by mouth twice a day for UTI for 10 days from the EKIT. During review, the QAN stated there was no care plan on the use of Amoxicillin-Pot Clavulanate, and the DON stated licensed staff should have developed and created a care plan for the antibiotic as part of standard antibiotic monitoring. Resident 26 was admitted with diagnoses including UTI, sepsis, and muscle weakness. The H&P indicated the resident could make needs known but could not make medical decisions, and the MDS indicated severe cognitive impairment, need for substantial to set up assistance with mobility and ADLs, and use of a high-risk drug class antibiotic. The order summary showed Cephalexin 500 mg by mouth twice a day for UTI for 10 days and bilateral grab bars up as an aid to bed mobility, turning and repositioning, and transfers every shift. The BSA indicated the resident had grab/transfer assist bars or rails, the FRE indicated the resident was at risk for falls, and observation confirmed bilateral grab bars on the bed. The QAN stated there were no care plans for the Cephalexin or the grab bars, and the DON stated licensed staff should have developed and created care plans for the antibiotic and grab bars.
Incorrect Low Air Loss Mattress Settings for Residents at Risk for Pressure Injury
Penalty
Summary
The facility failed to ensure that residents with pressure ulcers or at risk for pressure injury received pressure redistribution mattress settings consistent with their documented weights and the manufacturer’s guidance. Surveyors observed that the low air loss mattress (LALM) settings for three sampled residents were not aligned with the residents’ weights, despite orders and care plans indicating use of a pressure redistribution mattress for wound management or prevention. Resident 54 was admitted with severe protein-calorie malnutrition and pressure-induced deep tissue damage to the left heel and sacral region. The resident’s records showed severe cognitive impairment, dependence for mobility and ADLs, and a latest weight of 91 lbs. The care plan included a low air loss mattress for wound management, yet during observation the mattress was set at 220 and in alternating mode. The RN stated the setting was based on weight, but also acknowledged the resident weighed 91 lbs. The QAN and DON later stated the mattress was not set according to the resident’s weight and that the setting was incorrect. Resident 4 was admitted with spinal stenosis, dorsalgia, and generalized muscle weakness, and the records showed the resident had capacity to make decisions and required substantial to maximal assistance with bed mobility. The resident had orders for a low air loss mattress for prevention and later for wound management, and the care plan included the mattress for skin integrity. Although the resident weighed 155 lbs., the mattress was repeatedly observed set at 220 lbs. Staff stated the resident was on the mattress because of a left heel DTI and sacrococcyx skin damage, but the DON confirmed that for a resident weighing 155 lbs. the mattress should have been set at 150 lbs. The manufacturer’s guidance in the record indicated the pressure range was selected by the patient’s weight. Resident 53 was admitted after lumbar spine fusion surgery and had severe cognitive impairment and maximal assistance needs for several activities. The resident weighed 164 lbs. and had an order for a low air loss mattress for preventative measures. During observation, the resident reported the mattress was sinking, was difficult to get up from, and that she had to scoot to the edge of the bed. The QAN observed the mattress was inflated with soft and firm sections, noted the pump setting was 260 lbs., and stated the setting was wrong and should have been set for 170 lbs. The QAN also stated the mattress setting should be based on the resident’s weight and that not following the weight settings could cause pain and pressure injury to the resident’s skin.
Improper Bed Rail Assessment and Use
Penalty
Summary
The facility failed to ensure that bed rails or grab bars were properly assessed before installation for four sampled residents. The report states that the facility used the terms grab bars and bed rails interchangeably, and that the residents had orders for bilateral grab bars as aids to bed mobility, turning and repositioning, and transfers. The facility’s own policy required an interdisciplinary assessment, physician consultation, informed consent, entrapment assessment, and care plan inclusion before bed rail use. For Resident 54, the record showed diagnoses including muscle weakness, dementia, and hemiplegia/hemiparesis. The resident’s H&P stated the resident did not have capacity to understand and make decisions, and the MDS showed severe cognitive impairment and dependence for mobility and ADLs. Although the BSA dated 7/4/2026 stated that bed rails were not recommended by the IDT and physician, the resident was observed with bilateral grab bars in place. The QAN stated the grab bars were bed rails and that staff still applied them despite the BSA. For Resident 25, the record showed diagnoses including hemiplegia/hemiparesis and muscle weakness, and the H&P stated the resident could make needs known but could not make medical decisions. The BSA was incomplete and had no recommendation for bed rail use, while the resident was observed with bilateral upper grab bars on the bed. For Resident 26, the record showed reduced mobility, muscle weakness, and altered mental status, with the H&P stating the resident could make needs known but could not make medical decisions. The BSA stated grab bars were not recommended by the IDT and physician, yet the resident was observed sleeping in bed with bilateral grab bars in place and later again with bilateral upper grab bars on. For Resident 42, the record showed muscle weakness, history of falling, and hemiplegia/hemiparesis. The H&P stated the resident had capacity to understand and make decisions, and the MDS showed moderate cognitive impairment and a recent fall. The physician’s order was for bilateral grab bars, but the BSA assessed for 1/2 rails instead. The resident was observed in bed with bilateral grab bars on, and the QAN stated the assessment was for the incorrect bed rail type. The DON and QAN both stated that grab bars are an example of a bed rail and that the proper assessment process was not followed.
Missing Competency Documentation and DON Knowledge Deficits
Penalty
Summary
The facility failed to ensure that nursing staff had documented annual competency evidence and failed to demonstrate that the DON had the appropriate competencies to oversee nursing practice. During interview, the DON stated the facility’s RN Clinical Consultant was responsible for verifying his annual skills competency checklist, but he did not know where the document was kept after the consultant left the facility. The DON later stated he could not provide documented evidence of his own annual skills competency check. An unsigned annual skills checklist dated 3/19/2026 was later provided to the State Survey Agency after the survey had ended; the form identified the DON and the evaluator, but the evaluator’s signature line contained only a printed name and no signature. The DON also could not provide documented evidence of annual skills competencies for RN 2 and LVN 1 beyond medication administration. During the employee file review, the DON stated that the only annual skills assessments he could produce for those staff addressed medication administration, and he was unable to locate additional competency documentation in the skills checklist binder. He stated he would need to search multiple binders in the DSD’s office and elsewhere in the facility to try to find the requested assessments. During the survey, the DON was also unable to demonstrate appropriate competency and understanding of several nursing practices reviewed by surveyors. He stated that a low air loss mattress not set according to the resident’s weight had no effect on skin integrity, said there was no issue with psychotropic medication consents signed by nurses without a reason for use, refused to discuss whether failure to rotate insulin injection sites could be a medication error, and did not recognize concerns related to placing a side table on a floor mat for a resident at high risk for falls. He also stated that a low air loss mattress with bolster, tab/pad alarm, and bedrail did not constitute a restraint and did not require a physician’s order, informed consent, restraint assessment, or care plan. In addition, he stated that staff standing over residents while assisting with meals was not an issue, and he could not answer questions about CGM sensor replacement, care planning, or infection risk beyond stating that staff could monitor skin changes.
Failure to Rotate Insulin Injection Sites
Penalty
Summary
The facility failed to ensure that two residents were free from significant medication errors when insulin was administered without rotating subcutaneous injection sites as ordered. For Resident 2, the record showed a diagnosis of type 2 diabetes mellitus, an order for Humalog KwikPen insulin lispro with instructions to rotate sites, and a location of administration record showing repeated injections in the same areas, including the left lower quadrant of the abdomen on multiple occasions and the left upper arm on multiple occasions. The resident’s care plan included administration of prescribed insulin as ordered. For Resident 30, the record also showed a diagnosis of type 2 diabetes mellitus, an order for Humalog KwikPen insulin lispro with instructions to rotate sites, and a location of administration record showing repeated injections in the same areas, including the right arm on two occasions, the left arm on two occasions, and the left upper quadrant of the abdomen on two occasions. The resident’s care plan likewise included administration of prescribed insulin as ordered. Both residents had high-risk hypoglycemic medication listed in their assessments. During interviews, the Quality Assurance Nurse stated that rotating insulin sites meant not repeating the same site and that the staff did not follow the physician’s order, the facility policy and procedure, or the manufacturer’s specifications for Humalog. The DON stated that licensed staff should have followed the physician’s order to rotate insulin administration sites and acknowledged that the failure to do so was not followed for both residents. The facility policy on insulin administration stated that injection sites should be rotated, preferably within the same general area, and the medication error policy defined medication error as administration not in accordance with physician orders, manufacturer specifications, or accepted professional standards.
Failure to Follow Recipe Temperatures and Provide Therapeutic Diet Menu Choices
Penalty
Summary
The facility failed to follow a standardized recipe for mini egg rolls by serving them at room temperature instead of at or above 140 degrees F. The facility’s recipe for the egg rolls required hot food to be held and served at or above 140 degrees F, and the facility’s policy on standardized recipes stated that standardized recipes shall be developed and used in food preparation. During lunch tray line observation, dietary staff measured the egg rolls at room temperature while other hot items were being checked and served at appropriate temperatures. The Certified Dietary Manager later confirmed that the egg rolls were not served at the required temperature and that the recipe and policy were not followed. The facility also failed to provide a therapeutic diet menu and appropriate food choices for a resident on a liberal renal diet. The resident had multiple diagnoses including ESRD, dependence on renal dialysis, diabetes mellitus with chronic kidney disease, and cognitive communication deficit, and the record showed a diet order for a regular texture, consistent carbohydrate, liberal renal, thin liquids diet with fluid restriction. The resident stated that the food at the facility was awful and that she repeatedly filled out the menu and told staff what foods she liked and did not like, but continued to be told what foods she could not have. During lunch observation, the resident was initially served an Italian sausage hoagie with peppers and onions while other residents received chicken with pasta. Staff explained that the chicken pasta contained cheese and was not appropriate for the resident’s diet, and the CDM offered an alternative meal after the resident questioned why she could not have the same food as others. The record review and staff interviews showed that the resident was not provided a separate therapeutic diet menu to choose from, and staff acknowledged that the resident received the regular menu alternative rather than the liberal renal diet alternatives listed for that meal.
Food items were left without required dating and labeling
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety during a kitchen tour on 7/13/2026. Surveyors observed numerous food items in the seasoning area, deli area, walk-in refrigerator, and dry pantry that were missing required labeling information such as received dates, open dates, and use-by dates. Items observed included multiple seasonings, breads and buns, chopped garlic in oil, mayonnaise, produce items, and dry goods, with several containers and packages lacking one or more required dates and some items showing outdated or unreadable labels. In the walk-in refrigerator, surveyors observed food items including chopped garlic in oil, key lime juice, mayonnaise, celery, chopped salad, lettuce, tomato, parsley, arugula, green onions, green bell peppers, cucumber with mold, carrots, heads of lettuce, cantaloupes, and honey dew. In the deli and dry pantry areas, surveyors found multiple bread products, English muffins, bagels, hot dog buns, buttermilk pancake mix, and opened powdered mashed potatoes that were missing required dating information. Some items had use-by dates but no open dates or received dates, while others had open dates without use-by dates or received dates. During a concurrent interview and record review on 7/16/2026, the CMD stated that all food products in the kitchen must have a received date, open date, and use-by date, and that food cannot be used after the use-by date because it is unsafe. The CMD stated the failure to label food items with the required dates had the potential for residents to experience food poisoning and acknowledged that the facility policy titled, Labeling and Dating of Foods, was not followed. The reviewed policy stated that all food items in the storeroom, refrigerator, and freezer need to be labeled and dated, including received dates for delivered food and open dates and use-by dates for newly opened items.
Failure to Monitor Antibiotic Use and Include Stop Date for Antifungal Order
Penalty
Summary
The facility failed to implement its antibiotic stewardship program for two residents by not monitoring ordered antibiotics for adverse effects. For one resident, the record showed an order for Amoxicillin-Pot Clavulanate 875-125 mg, and the QAN stated the licensed staff should have monitored for adverse effects every shift to ensure the antibiotic was appropriate and to prevent antibiotic resistance. The QAN also stated the facility failed to follow its Antibiotic Stewardship Program and Antibiotic Stewardship- Orders for Antibiotic policy because shift assessments were missed. The DON stated the resident’s antibiotic use should have been monitored and documented every shift, and that there should have been no missed documentation. For another resident, the record showed an order for Cephalexin 500 mg, one capsule by mouth twice a day for UTI for 10 days. During concurrent interview and record review, the QAN stated there was no monitoring for adverse effects documented in the progress notes. The QAN stated the licensed staff should have monitored for adverse effects every shift and that the facility failed to follow its antibiotic stewardship policy by missing shift assessments. The DON similarly stated the resident’s Cephalexin use should have been monitored for adverse effects and documented every shift. The facility also failed to ensure a stop date was included for a prescribed antifungal medication for a third resident. The resident’s order summary showed Terbinafine HCl 250 mg, one tablet by mouth daily for toe fungus, with a start date but no stop date. The QAN stated terbinafine is an antifungal medication and should have a stop date, and that the nurse should have notified the MD about the missing stop date. The DON stated the IP nurse and the DON or designee were responsible for checking the order, and that there should be a stop date for the antifungal medication. The facility policy stated antibiotic and anti-infective orders should include duration of treatment and a start and stop date or number of days of therapy.
Dignity Violation During Meal Assistance
Penalty
Summary
The facility failed to provide care in a manner that maintained Resident 4’s dignity and respect during mealtime when CNA 3 assisted the resident with lunch while standing over him. Resident 4 was admitted with lumbar spinal stenosis with neurogenic claudication, dorsalgia, and generalized muscle weakness. The resident’s H&P indicated he had the capacity to understand and make decisions, and the MDS indicated he had clear speech, adequate hearing, lower extremity impairment on both sides, and needed supervision or touching assistance with eating. The resident also received a mechanically altered diet and a therapeutic diet, and his care plan directed staff to provide verbal, visual, and physical cues as indicated and to provide the diet as ordered. During the dining observation, Resident 4 stated he had carrots and rice and needed help to eat, and he reported having hand tremors since leaving the hospital. CNA 3 stated she would assist him with lunch and then assisted him while standing over him. When interviewed, CNA 3 stated she could not find a chair but acknowledged she was not supposed to stand over the resident when assisting with feeding and that staff are supposed to sit down for the resident’s comfort. The QAN stated that standing over residents while assisting them to eat is a dignity and safety issue and does not meet residents’ rights. The facility’s Resident Rights policy stated residents have the right to a dignified existence and to be treated with respect, kindness, and dignity, and the in-room meal assistance policy instructed staff to assist the resident as necessary while encouraging self-feeding as much as possible.
Call Light Not Kept Within Resident’s Reach
Penalty
Summary
The facility failed to ensure that a resident’s call light was within reach. The resident was admitted after surgery on the digestive system and had a gastrostomy tube, pneumonitis due to inhalation of food and vomit, bacterial pneumonia, hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, dysphagia, cognitive communication deficit, and type 2 DM. The resident’s MDS indicated severely impaired cognitive function, that the resident never or rarely made decisions, and that the resident was dependent on assistance with feeding, dressing, toileting, showering, and transferring to a wheelchair. The care plan for high risk for falls and injury included having needed items within reach, including the call light. During observation, the resident was in bed sleeping and the call light was not within reach; it was wrapped around the tube feeding pump pole on the side of the bed. During a concurrent observation and interview, a CNA removed the call light from the pole and placed it near the resident’s left hand, stating it was not within reach and should be near the resident’s hand or in the resident’s hand so the resident could call for help in an emergency. The DON stated all staff are responsible for ensuring call lights are within residents’ reach, and the facility policy stated staff should facilitate call light placement within reach and secure it as needed.
Failure to Protect Resident Confidentiality
Penalty
Summary
The facility failed to keep a resident’s personal and medical records confidential when RN 1 left Resident 36’s electronic health record open and unattended on a medication cart in the hallway. Resident 36 had been admitted with diagnoses including sepsis, UTI, and COPD. During observation, the laptop screen was open and displaying the resident’s eMAR while RN 1 was inside the dining room checking the resident’s blood pressure, and the cart was out of RN 1’s view with visitors in the nursing station and housekeeping staff passing by. RN 1 stated he had left the screen open, acknowledged he was not supposed to do that, and said he forgot to lock it while caring for the resident. The DON stated the laptop should not be left unattended and should be closed to protect resident health information. The facility also failed to protect resident confidentiality when DA 3 disposed of meal tickets in a regular trash bin during kitchen dish washing. During observation, DA 3 emptied food scraps and leftovers, including resident meal tickets, into the regular trash. The CDM stated the meal tickets contain resident information such as diet order, allergies, food likes and dislikes, name, and room number, and said they should not have been thrown into regular trash. The CDM later reviewed the facility policy on confidentiality and stated the meal tickets should have been placed in a separate container for shredding, and that disposing of them in regular trash had the potential to break resident privacy.
Incomplete informed consent for psychotropic medications
Penalty
Summary
The facility failed to ensure the resident drug regimen was free from unnecessary psychotropic medications for five sampled residents by not ensuring the informed consent forms included the reason for use of the psychotropic medication and the benefits. The deficiency involved Residents 54, 2, 25, 26, and 42, all of whom had orders for antidepressant medications and documentation showing psychotropic drug use related to depression, anxiety, withdrawn behavior, sadness, or inability to sleep. Resident 54 was admitted and later readmitted with diagnoses including Alzheimer’s disease, dementia, and depression. The H&P stated the resident did not have the capacity to understand and make decisions, while the MDS showed severe cognitive impairment and use of antipsychotic and antidepressant drug classes. The order summary included escitalopram for depression manifested by loss of interest in daily activities, but the psychotherapeutic drug informed consent did not indicate the reason for use or the benefits. Resident 2 had a diagnosis of major depressive disorder, capacity to understand and make decisions, and an MDS showing moderately impaired cognition and antidepressant use. The order summary showed escitalopram for depression manifested by being isolative and withdrawn, but the informed consent also lacked the reason for use and benefits. Resident 25 was admitted with depression, and the H&P stated the resident could make needs known but could not make medical decisions. The MDS showed moderate cognitive impairment and antidepressant use. The order summary included trazodone for depression manifested by inability to sleep, including a routine dose and a PRN dose if the routine dose was ineffective, but the informed consent did not include the reason for use or benefits. Resident 26 had diagnoses including anxiety disorder, depression, and dementia, with the H&P stating the resident could make needs known but could not make medical decisions and the MDS showing severe cognitive impairment. The order summary showed escitalopram for depression manifested by verbalizing sadness, and the informed consent again did not indicate the reason for use or benefits. Resident 42 was admitted with depression, had capacity to understand and make decisions, and the MDS showed moderate cognitive impairment and antidepressant use. The order summary showed duloxetine for depression manifested by isolative and withdrawn behavior, but the informed consent did not indicate the reason for use or benefits. The DON stated licensed staff should check whether informed consents were completed and complete or flag incomplete forms so the physicians could complete them, and the facility’s policies required psychotropic medications to be used only when medically necessary and informed consent to be verified and documented.
Failure to Provide Written Bed Hold Notification During Hospital Transfer
Penalty
Summary
The facility failed to provide written information to the resident or representative regarding the seven-day bed hold notification when the resident was transferred to an acute care hospital. Resident 48 was admitted with diagnoses including enterocolitis, COPD, and acute respiratory failure. The resident’s H&P indicated the resident had capacity to understand and make decisions, while the MDS indicated the resident could make self-understood and understand others and had moderate cognitive impairment. Resident 48 was transferred to General Acute Care Hospital 1 for hypotension. The Notice of Transfer and Discharge documented that the resident was transferred and that the facility was unable to contact the spouse. The Bed Hold Notification Form was not updated to reflect the transfer/discharge status or identify the person who received the written bed hold policy. The Order Summary Report did not indicate an order for transfer to acute care hospital and a 7-day bed hold. During interview, the QAN stated there was no order to transfer the resident to GACH 1 and no 7-day bed hold in the electronic record, and that the nurse should have obtained orders from the attending physician. The QAN also stated the bed hold notification form was only signed on admission and was not completed during transfer to show the destination or who received the written bed hold agreement. The DON stated the form should be used to offer residents the option to hold their bed when they go to the hospital, and acknowledged the form was incomplete and did not reflect the transfer/discharge. Facility policy required residents or resident representatives to be informed in writing of the bed-hold and return policy prior to transfers and therapeutic leaves, and required notice of transfer and the facility’s bed hold policy to be provided for emergency transfers.
Floor Mat Obstructed by Side Table
Penalty
Summary
The facility failed to ensure the resident environment was free of accident hazards for Resident 26 by allowing a side table to be placed on top of the resident’s floor mat. Resident 26 was admitted on 6/19/2026 with diagnoses including altered mental status, reduced mobility, and muscle weakness. The resident’s H&P dated 6/22/2026 indicated the resident could make needs known but could not make medical decisions. The MDS dated 6/21/2026 indicated severe cognitive impairment and that the resident required substantial to set-up assistance with mobility and ADLs. The Fall Risk Evaluation dated 6/19/2026 identified the resident as at risk for falls, and the care plan included keeping the room and common areas free from clutter. During a concurrent observation and interview on 7/13/2026, RN 2 observed bilateral floor mats in the resident’s room with a side table on the center of the right floor mat. RN 2 stated there should be no objects on top of the floor mat because they can fall on the resident and cause injury, and that placing items on the mat makes the side table unstable and can cause it to fall on the resident. During later interview and record review, the QAN stated the floor mat serves as a safe soft-landing surface and that equipment or furniture on top of it defeats its purpose and can cause injuries such as fractures. The DON stated the side table should not be on top of the floor mat. The facility’s policy stated the environment should be as free from accident hazards as possible, and the manufacturer’s information stated heavy materials should not be left on the mat for an extended time.
Loose Midline Catheter Dressing Not Changed Per Policy
Penalty
Summary
The facility failed to ensure safe, appropriate administration of IV fluids for a resident when the resident’s midline catheter dressing was not changed in accordance with facility policy and procedure. Resident 54 was admitted with diagnoses including dehydration, thrombocytosis, and viral pneumonia, and the history and physical indicated the resident did not have the capacity to understand and make decisions. The MDS noted severe cognitive impairment and that the resident had a midline IV access for continuous therapy, with an order to observe the midline site every shift for signs and symptoms of infiltration, extravasation, redness, swelling, and pain. On observation, the resident’s midline catheter dressing was loose and dated 7/3/2026 when it was seen on 7/13/2026. RN 1 stated the dressing was loose and dated 7/3/2026, and RN 4 stated it should have been changed on 7/10/2026 because the dressing must be changed weekly or every seven days. RN 4 stated the dressing needed to be changed weekly to prevent infection and said it had not been changed because the bio patch supply had run out. The QAN and DON both stated the dressing should have been changed weekly and PRN if loose, and the DON stated the dressing was compromised because it was loose. The facility’s PICC Dressing Change policy stated transparent dressings are to be changed at least weekly and if the integrity of the dressing has been compromised, and the antimicrobial disc is to be changed every 7 days and PRN.
Failure to Monitor Apixaban for Adverse Effects
Penalty
Summary
The facility failed to ensure that one resident's drug regimen was free from unnecessary drugs by not monitoring for adverse effects related to Apixaban use. Resident 25 was admitted with diagnoses including paroxysmal atrial fibrillation, GERD, and hemiplegia/hemiparesis. The resident's H&P stated the resident could make needs known but could not make medical decisions, and the MDS noted moderate cognitive impairment. The OSR showed an order for Apixaban 5 mg via G-tube twice daily for atrial fibrillation, and the care plan identified the resident as at risk for bruising and bleeding related to anticoagulation therapy with interventions to observe and report signs and symptoms such as bruising, bleeding gums, coffee ground emesis, tarry stool, and hematuria. A record review found no documentation in the OSR, MAR, or progress notes showing monitoring for adverse effects of Apixaban. During interview and record review, the QAN stated there was an order for Apixaban but no order to monitor for adverse effects, and stated the facility's Anticoagulant- Clinical Protocol and the HPI for Eliquis were not followed. The DON stated the resident's use of Apixaban should have been monitored for adverse effects and that it was important because the medication can cause bleeding.
Hard carrots served on soft and bite-sized diet
Penalty
Summary
The facility failed to prepare food in a form designed to meet individual needs for one resident on a soft and bite-sized diet. During lunch service, the resident received hard carrots on the meal plate and in the soup, and the carrots did not pass the IDDSI level 6 fork pressure test. The resident stated he could not eat the carrots and requested another tray because he could not eat them. The resident was admitted with diagnoses including lumbar spinal stenosis with neurogenic claudication, dorsalgia, and generalized muscle weakness. The resident’s assessment showed clear speech, adequate hearing, the ability to understand others and make self understood, lower extremity impairment on both sides, and a need for supervision or touching assistance with eating. The physician ordered a consistent carbohydrate, no added salt, soft and bite-sized diet with thin liquids, and the care plan directed staff to provide verbal, visual, and physical cues as indicated and to provide the diet as ordered. During observation, the CNA assisting the resident stated the carrots were not soft and could not be mashed with a fork. The CNA also stated the carrots on the plate and in the soup were hard and could not be cut or broken apart with the side of a fork. The CDM stated soft and bite-sized foods are soft and can be mashed, and the RD stated that when food cannot be mashed by a fork it is not acceptable to be served to residents on that diet. The facility’s recipe for carrot coins directed staff to steam or boil carrots until soft and to use the fork pressure test to confirm IDDSI level 6 texture.
Incomplete Medication Documentation and Missing Controlled Substance Count Signatures
Penalty
Summary
The facility failed to ensure Resident 18’s medication record was complete and accurately documented when Flonase nasal spray was documented as given even though it was not available at the time of administration. Resident 18 was admitted with diagnoses including hypertensive heart disease, hyperlipidemia, and generalized muscle weakness. Her H&P indicated she had the capacity to understand and make decisions, and the MDS indicated she could make herself understood and understand others. The MAR for July 2026 showed Flonase sensimist nasal suspension 27.5 mcg/spray, one spray in both nostrils twice daily for allergies, with a start date of 7/13/2026 at 5 p.m., and the MAR showed it was administered on 7/14/2026 at 5 p.m. During observation on 7/15/2026, Resident 18 told RN 2 that she had a stuffy nose and that her doctor had ordered a nasal spray three days earlier but she had not received it yet. RN 2 stated he did not have the Flonase nasal spray, would contact the doctor, and would ask front desk staff to call the pharmacy to expedite delivery. RN 2 then administered the resident’s medications without having the Flonase available. In a concurrent interview and record review, RN 2 stated the MAR showed Flonase as given the prior day even though the medication was not present and had not yet been delivered. The facility’s receipt later showed Flonase was purchased at a retail pharmacy, and the pharmacy manifest showed it was delivered to the facility later that day. The DON stated that the medication nurse documents after medication administration and that for Resident 18, LVN 1 marked the medication as given when it was scheduled but made a late entry after it was identified. The facility also failed to ensure controlled substance counts were completed and documented on multiple shifts on Medication Cart 1. During review of the Controlled Substance/MAR Change of Shift Audit - Skilled Nursing form for the period from 6/25/2026 to 7/15/2026, RN 1 identified missing signatures for the oncoming or outgoing charge nurse on several shifts, including 6/27/2026 3 p.m., 7/7/2026 3 p.m., 7/8/2026 11 p.m., 7/10/2026 11 p.m., 7/11/2026 7 a.m., 7/12/2026 3 p.m., and 7/12/2026 11 p.m. RN 1 stated the audit form is completed each shift by the oncoming and outgoing charge nurse to confirm the count, and stated that if the nurses are not signing, it would be likely that the count was not done. The DON stated the controlled count audit form is signed by both nurses before leaving their shift, that the count and any discrepancies are documented, and that the signature and count fields are not optional.
Missing COVID-19 Vaccination Documentation for Staff
Penalty
Summary
The facility failed to implement its COVID-19 vaccination policy by not maintaining documentation for Certified Nursing Assistant (CNA) 10 related to the offer of COVID-19 vaccination, information on obtaining the vaccine, or verification of vaccination, exemption, or refusal. During review of CNA 10’s onboarding documents dated 1/13/2026, the records showed that policies and documents were acknowledged and signed, but the COVID-19 vaccine consent form was not present in the file. During interviews and record review with the Infection Preventionist (IP), the IP stated the facility offers the COVID-19 vaccine to residents and staff, but she did not have a declination form for staff and only had the influenza consent form completed for CNA 10. The IP stated she missed CNA 10’s COVID-19 vaccine consent form and did not have it documented. The DON stated COVID-19 vaccination was offered during flu season and that if the offering was missed, it was optional for staff to obtain the vaccine through their healthcare provider. The facility policy required documentation of offering or providing information on obtaining the COVID-19 vaccine and verification of vaccination or documentation of exemption or refusal.
Improperly Fitted Specialty Mattress Created Bed Gap
Penalty
Summary
The facility failed to ensure that a low air loss mattress fit the bed frame size and that there were no gaps between the grab bar and the mattress for one resident. During observation, the mattress was noted to be inflated with soft and firm sections and did not fit the bed frame well, with an approximately six-inch gap between the grab bar and the mattress. The Quality Assurance Nurse stated the mattress did not fit the bed frame and that it was an entrapment risk. The resident involved had been admitted after lumbar spine fusion surgery and had diagnoses including acute pulmonary edema, depression, legal blindness, bipolar disorder, and a right artificial knee joint. The Minimum Data Set indicated severely impaired cognitive function and that the resident required maximal assistance with dressing, toileting, bathing, standing, and transferring. During interviews, the resident stated it was not convenient to get up from the mattress, slept badly, could not be comfortable, and had to scoot to the edge of the bed to get up. The Maintenance Supervisor stated the mattress was smaller than the bed frame because the bed frame had width extensions for the original mattress, and that the width extensions should have been removed before installation so the mattress would fit. The mattress supplier representative stated the model number indicated a 36-inch-wide mattress. The DON stated that a resident could get hurt if there was a gap and that nurses and maintenance personnel should check bed safety. The facility's bed safety policy required inspection of beds and related equipment and review of gaps within the bed system, and the bed frame manual warned that an improperly fitted mattress could result in injury or death.
Residents Not Given Choice of Attending Physician
Penalty
Summary
The facility failed to honor residents’ rights to choose their attending physician for five sampled residents. For Residents 1 and 2, the record showed that Physician 1 had been identified as the primary care provider or attending physician during hospital discharge and transfer documentation, but facility leadership later assigned the facility’s medical director as the attending physician. Resident 1’s history and physical indicated capacity to understand and make decisions, and the resident’s family member stated that Physician 1 had been the resident’s physician for years and that no change had been authorized. Resident 2’s records also showed capacity to understand and make decisions, and the resident stated she did not understand why she was not allowed to keep Physician 1 as her attending physician and that the facility would not allow Physician 1 to see her. For Residents 3, 4, and 5, the admission records, histories and physicals, and interviews showed that each resident had capacity to understand and make decisions, yet none were asked whether they wanted to keep their own attending physician. Resident 3 stated she was not asked and was already assigned the medical director when she arrived. Resident 4 stated she was not asked and was simply informed that whoever was the physician at the facility would be her attending physician. Resident 5 stated he was not asked and was already assigned a physician whom he had never met. Facility leadership and staff stated that the medical director was assigned to residents unless the outside attending physician would follow them in the facility. The admission director stated it was standard practice to assign the facility’s medical director if the resident’s physician was not theirs, and that residents were not asked about a preferred attending physician unless requested. The administrator stated Physician 1 did not have privileges in the facility after 12/2025 and that residents were offered lateral transfer if they wanted to keep Physician 1, while the DON stated residents should be given the option to choose their attending physician as stated in the facility policy. The record also showed that there was no documented evidence that Resident 2 was offered the lateral transfer.
Medications Left Unattended and Incorrectly Documented as Administered
Penalty
Summary
A deficiency occurred when a resident, who was moderately impaired in thought process and dependent on staff for activities of daily living, did not receive their prescribed morning medications as required. The resident had diagnoses including hypertension, osteoarthritis, and pulmonary embolism, and was prescribed medications such as Eliquis, multivitamins, Coenzyme Q10, losartan potassium, and metoprolol. On the day of the incident, a medication cup containing five medications was observed left on top of the resident's breakfast tray, which was parked unattended in the hallway. Both a Licensed Vocational Nurse and a Registered Nurse confirmed the presence of the medication cup and stated that the nurse responsible should have observed the resident taking all medications to ensure proper administration. Despite the medications not being administered, the Medication Administration Record (MAR) was signed by the nurse, indicating that the medications had been given. Interviews with nursing staff and the Director of Nursing confirmed that the MAR should not have been signed unless the medications were actually administered and observed to be ingested by the resident. Facility policy also required staff to observe residents after medication administration to ensure the full dose was taken, and to document any partial ingestion. The failure to follow these procedures resulted in a significant medication error for the resident.
Failure to Provide Catheter Care and Bowel/Bladder Retraining
Penalty
Summary
The facility failed to provide proper care and services for a resident with an indwelling catheter by not administering catheter care as ordered by the physician. The resident, who had diagnoses including urinary retention and a history of urinary tract infection (UTI), required catheter care every shift, including cleansing the area and monitoring for signs of infection. Documentation revealed that on three specific shifts, there was no evidence that licensed nurses provided or documented the required catheter care or monitoring for redness, irritation, swelling, or symptoms of UTI. Both the MDS Coordinator and the Director of Nursing confirmed that the care was not documented and acknowledged that licensed nurses are required to implement physician orders and document the care provided. Additionally, the facility did not implement a bowel and bladder retraining program for two residents who were identified as candidates for such a program upon admission. Both residents had assessments indicating they could comprehend and follow instructions and were suitable for retraining programs. However, after the initial 72-hour assessment period, the staff failed to review the Bowel and Bladder Assessment forms when determining the need for retraining, resulting in neither resident being started on a program. Interviews with the MDS Coordinator and a registered nurse confirmed that the assessments were overlooked, and the required programs were not initiated as per facility policy. The facility's policies and procedures required that catheter care be documented in the resident's medical record, including assessment data and the resident's response to care, and that a toileting program be established within four days of admission for eligible residents. In these cases, the required documentation and program initiation did not occur, as confirmed by staff interviews and record reviews.
Failure to Post Actual Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that daily nurse staffing information, including the actual number of staff and hours worked, was posted in a visible and prominent location as required. During an observation and interview with the Director of Staff Development (DSD), it was found that only projected staffing information for the current day was posted at the nursing station, rather than the actual staffing data for previous days. The DSD confirmed that the actual staffing information for the previous two days was not posted. Further interviews revealed that the Director of Nursing (DON) stated that daily staffing information is placed at the nursing station and that residents, families, and visitors could ask staff about the number of nursing personnel providing direct care. However, review of the facility's policy indicated that actual staffing numbers and hours worked for each shift must be posted within two hours of the beginning of each shift in a prominent location. The facility did not follow this policy, resulting in the required information not being readily accessible to residents and visitors.
Inaccurate Dialysis Assessment Documentation for Residents with Permacath Catheters
Penalty
Summary
The facility failed to ensure accurate completion of pre- and post-dialysis assessments for two residents who were dependent on dialysis and had Permacath catheters in place. Both residents had complex medical histories, including type 2 diabetes, muscle weakness, and end-stage renal disease, and were dependent on staff for activities of daily living. Documentation in their medical records repeatedly indicated that a thrill and bruit were present at the dialysis access site, which is not possible with a Permacath catheter. Record reviews showed that for multiple dates, nursing staff checked off the presence of thrill and bruit on both pre- and post-dialysis assessment forms for these residents. During interviews, a registered nurse and the DON confirmed that this documentation was inaccurate, as Permacaths do not produce a thrill or bruit. The facility's policy required accurate documentation of dialysis care, including the use of the Pre/Post Dialysis form, and maintaining this information in the resident's medical record. The inaccurate charting of assessment findings was acknowledged by both the registered nurse and the DON, who stated that licensed nurses should not have documented the presence of thrill and bruit for residents with Permacaths. This failure to accurately assess and document the residents' dialysis access sites resulted in the maintenance of incorrect medical information in the residents' records.
Failure to Cover Urinary Catheter Bag with Privacy Bag
Penalty
Summary
A resident with a history of urinary retention, urinary tract infection, and falls was admitted to the facility and had an indwelling urinary catheter in place. The resident's Minimum Data Set indicated moderately impaired cognitive skills and a need for substantial to moderate staff assistance with activities of daily living, including toileting and hygiene. Physician orders required staff to check the placement of the indwelling catheter every shift. During an observation, it was noted that the resident's urinary catheter bag was not covered with a privacy (dignity) bag, as required by facility policy. Both a registered nurse and the Director of Nursing confirmed that catheter bags are required to be covered to promote resident dignity, and acknowledged that the resident's catheter bag was not covered at the time of observation. The facility's policy on dignity specifically prohibits practices that compromise resident dignity and directs staff to assist residents in keeping urinary catheter bags covered.
Call Light Not Accessible to Resident with High Fall Risk
Penalty
Summary
A deficiency occurred when staff failed to ensure that the call light was within reach of a resident who had been admitted with diagnoses including dementia, depression, and a history of falls. The resident's care plan specifically required that the call light and personal belongings be placed within her reach to minimize fall risk and ensure her ability to request assistance. During an observation, the resident was found lying in bed with the call light on the floor, unable to locate or reach it. The resident attempted to search for the call light but was unsuccessful. Certified Nursing Assistant 1 confirmed during the observation that the call light was not within the resident's reach and acknowledged that it should always be accessible. The Director of Nursing also stated that call lights are required to be accessible to residents at all times. Review of the facility's policy indicated that call lights must be within easy reach of residents while in bed. The failure to follow these procedures resulted in the resident's inability to call for help when needed.
Failure to Maintain Resident's Advance Directive in Clinical Record
Penalty
Summary
Facility staff failed to maintain a current copy of a resident's advance directive in the active clinical record, despite documentation indicating that the resident had executed such a directive. The resident, who had diagnoses including normal pressure hydrocephalus, type 2 diabetes mellitus, and major depressive disorder, was assessed as having intact cognition and the capacity to make decisions. During record review, it was found that while the Advance Directive Acknowledgement Form indicated the existence of an advance directive, the actual document was not present in the resident's chart. Interviews with the Director of Social Services and the Director of Nursing confirmed that the advance directive should have been kept in the resident's active chart to guide staff in honoring the resident's wishes. The facility's policy also required that a copy of any executed advance directive be maintained in the resident's medical record and be readily retrievable by staff. The absence of the advance directive in the clinical record constituted a failure to ensure the resident's wishes regarding medical treatment were accessible to facility staff.
Failure to Address Indwelling Catheter in Baseline Care Plan
Penalty
Summary
The facility failed to develop a complete baseline care plan within 48 hours of admission for a resident who had an indwelling catheter. Upon review, it was found that the baseline care plan did not address the resident's indwelling catheter, despite the resident having diagnoses including type 2 diabetes mellitus, obstructive uropathy, reflux uropathy, and benign prostatic hyperplasia. The resident required varying levels of assistance for activities of daily living and had a physician's order for catheter care, including cleansing and monitoring for signs of infection every shift. Interviews with facility staff, including the MDS Coordinator and the DON, confirmed that the baseline care plan was incomplete and did not include interventions for the indwelling catheter. The facility's policy required a baseline care plan to be developed within 48 hours of admission, addressing all care areas and necessary nursing interventions. The omission was acknowledged by staff, who stated that the baseline care plan must be thorough to meet the resident's immediate care needs.
Failure to Develop Care Plan for Resident's Continuous Glucose Monitoring System
Penalty
Summary
Facility staff failed to develop and implement a comprehensive, person-centered care plan for a resident who was using a continuous glucose monitoring (CGM) system. The resident, admitted with diagnoses including type 2 diabetes mellitus, hypertension, and COPD, had intact cognitive skills and was prescribed hypoglycemic medication. Physician orders specified the application of a CGM sensor every 14 days for continuous blood sugar monitoring. Despite this, there was no care plan created to address the use, monitoring, or management of the CGM sensor. Interviews with the MDS Coordinator and the Director of Nursing confirmed that licensed nurses did not develop a care plan with goals and interventions for the resident's CGM sensor. Both acknowledged that the absence of such a care plan meant there were no documented strategies to ensure the sensor was applied properly or functioning as intended. Review of facility policy indicated that a comprehensive, person-centered care plan with measurable objectives and timeframes should have been developed and implemented for each resident, but this was not done for the resident in question.
Failure to Monitor and Support Resident's Continuous Glucose Monitoring System
Penalty
Summary
The facility failed to provide necessary care and services for a resident with type 2 diabetes by not monitoring the resident's continuous glucose monitoring (CGM) system and not ensuring that CGM sensor patches were available for application as ordered by the physician. Documentation showed that on multiple occasions, the required CGM sensor patches were not available in the facility, and staff did not apply the sensors as ordered. Instead, the resident independently applied the CGM sensor patches every 14 days without staff assistance, despite not having requested self-administration of medication. Licensed staff did not monitor the placement or functionality of the CGM system, and the Director of Nursing was unaware of the resident's use of the CGM sensor until it was observed during the survey. Additionally, the facility did not complete the resident's Admission/Readmission Screen and Baseline Care Plan form accurately upon admission. The assessment was left incomplete and unsigned, and it did not address the resident's use of a CGM system. The lack of a comprehensive, person-centered care plan meant that there were no documented goals or interventions for monitoring the resident's CGM sensor, as required by facility policy. The MDS Coordinator confirmed that the absence of a complete assessment and care plan could result in a lack of necessary care and services for the resident. Interviews with nursing staff revealed that the physician's order for the CGM sensor was received and processed, but no additional order for monitoring the device was obtained. Staff acknowledged that the resident's ability to self-administer the CGM sensor was not properly assessed, and the facility did not ensure the availability of sensor patches. Facility policies reviewed indicated that all services and changes in resident condition should be documented, and that comprehensive, person-centered care plans should be developed and implemented for each resident.
Unattended Medication Bottle Left Accessible on Medication Cart
Penalty
Summary
A Licensed Vocational Nurse (LVN) was observed preparing morning medications for a resident with diagnoses including type 2 diabetes mellitus, hypertension, and COPD. During the medication pass, the LVN removed a bottle of vitamin C from the medication cart, dispensed a tablet, and left the bottle unsecured on top of the cart before entering the resident's room to administer medications. The bottle of vitamin C was left unattended and easily accessible to other residents in the hallway. The LVN later acknowledged leaving the vitamin C bottle outside the medication cart, stating that medications should not be left unattended and accessible to residents. The Director of Nursing confirmed that the bottle should not have been left on the cart, as it allowed unsupervised access to medications. Facility policies reviewed indicated that medications must be stored securely and only accessible to authorized personnel, with medication carts locked or attended at all times.
Missed Weekly Weight Monitoring for Resident
Penalty
Summary
The facility failed to follow a physician's order to conduct weekly weights for a resident who was admitted with diagnoses including type 2 diabetes, muscle weakness, and metabolic encephalopathy. The resident was dependent on staff for activities of daily living and had cognitive impairments, as documented in the admission records and assessments. The physician's order, dated 4/21/2025, specified that the resident's weight should be monitored weekly for 30 days. However, a review of the weight records showed that after an initial weight was recorded on 4/22/2025, the next weight was not documented until 5/4/2025, with no weight recorded on 4/29/2025 as required by the order. Interviews with facility staff, including the Director of Staff Development and the Director of Nursing, confirmed that the weekly weight was missed and acknowledged that this was not acceptable practice. The facility's policy on weighing and measuring residents, last reviewed on 1/20/2025, emphasizes the importance of regular weight monitoring as an indicator of nutritional status. The failure to obtain and document the weekly weight as ordered resulted in a deficiency related to the monitoring of the resident's nutritional status.
Failure to Assess and Remove Unnecessary IV Catheter
Penalty
Summary
The facility failed to provide care and services that meet professional standards of quality by not assessing the continued need for a peripheral intravenous (IV) catheter for a resident who was admitted after spinal fusion surgery. Upon admission, the resident had an IV in place on the back side of her right lower arm, but there was no physician order or indication for IV fluids or medications. The resident expressed that she did not know why the IV had not been removed and found it annoying, though it was not painful. The admission and skin evaluation records did not document the presence of an IV, and the electronic medical record also lacked any order or indication for its use. Nursing staff, including a registered nurse and the Director of Nursing, confirmed that the IV should have been identified and removed upon admission, as there was no ongoing need for it. The facility's policy required physician orders for initiating IV therapy, specifying details such as dose, frequency, duration, and diagnosis, none of which were present for this resident. The failure to remove the unnecessary IV upon admission constituted a lapse in following professional standards and facility policy.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
A deficiency was identified when a resident who had a physician's order for continuous oxygen at two liters per minute via nasal cannula was observed with their oxygen tubing on the floor and the cannula not attached to their nose. The tubing was found under the resident's body, with one end connected to the oxygen concentrator, and the other end not in use. This observation was confirmed by a Licensed Vocational Nurse, who acknowledged that the tubing was contaminated and not in accordance with professional standards of practice. The resident involved had a history of right femur fracture, aphasia, and urinary tract infection, and was assessed as able to make needs known but unable to make medical decisions. Facility policy required the nasal cannula to be properly placed in the resident's nose and secured, and CDC guidelines indicated that floors can become rapidly contaminated. The Director of Nursing confirmed that staff are required to implement physician orders for oxygen administration and acknowledged the potential for infection if tubing contacts the floor and for desaturation if the cannula is not attached.
Improper Medication Disposal and Incomplete Documentation
Penalty
Summary
The facility failed to ensure proper disposal and documentation of medications in accordance with federal regulations and facility policy. During an observation in the medication room, a pharmaceutical waste bin was found to contain a mixture of unopened and unused medications in their original manufacturer packaging, as well as loose, intact tablets and capsules. The registered nurse present confirmed that medications were disposed of without rendering them non-retrievable, as required by policy, since no liquid was poured over them to prevent retrieval. This left the medications in a form that could be easily accessed and reused. Additionally, a review of the Medication Disposition Record/Pass Log revealed that three disposed medications—Vancomycin oral suspension, Nystatin powder, and Naloxone spray—were not documented with the required verifying signatures of two licensed nurses. Both the registered nurse and the Director of Nursing confirmed that these medications were not logged or witnessed as per policy. The facility's policy requires that all destroyed medications be entered on the disposition form with date, resident's name, medication details, and signatures of witnesses, which was not followed in these instances.
Failure to Remove Leftover Food from Resident Room Within Required Timeframe
Penalty
Summary
The facility failed to ensure proper sanitation and food handling practices when a resident's leftover food was not removed from the bedside after four hours. Specifically, a resident with diagnoses including normal pressure hydrocephalus, type 2 diabetes mellitus, and major depressive disorder, who was cognitively intact but dependent on staff for most activities of daily living, had a baked custard left on the bedside table for an extended period. The resident reported that the custard had been in the room for a couple of days, and staff confirmed it was served during lunch the previous day. Facility policy, as reviewed with the Dietary Supervisor, requires that leftover food not be stored in resident rooms for more than four hours due to the lack of temperature control and the risk of foodborne illness. Observations and interviews with nursing and dietary staff confirmed that the custard was not removed within the required timeframe, and the policy was not followed. The failure to remove the food in a timely manner created a situation where the resident could have consumed contaminated food.
Failure to Obtain Proper Consent for Resident with Impaired Cognition
Penalty
Summary
The facility failed to ensure that the Responsible Party (RP) or Resident Representative (RR) signed consent forms for a resident with a history of dementia and moderately impaired cognition. The resident, who was unable to make medical decisions, was made to sign her own consent forms for the administration of citalopram, an influenza vaccine, and a COVID-19 vaccine. This action was contrary to the facility's policy, which requires a surrogate decision-maker to be identified when a resident lacks the capacity to make informed decisions. The resident's admission record indicated diagnoses including Parkinson's disease, generalized muscle weakness, and a neurocognitive disorder with Lewy bodies. Despite these conditions, the resident signed the consent forms in the presence of a registered nurse, without the involvement of the RP. The facility's policy mandates that informed consent should be obtained from the RP when a resident is determined to lack decision-making capacity, which was not adhered to in this case. Interviews with facility staff, including the Director of Nursing and the Director of Staff Development, revealed that the RP was not notified prior to the administration of the medications and vaccines. The staff acknowledged that the resident did not have the capacity to sign the consent forms and that the RP should have been contacted to provide consent. The facility's failure to follow its own policies and procedures for obtaining informed consent placed the resident at risk for making healthcare decisions without proper understanding or authorization.
Failure to Prevent Resident Elopement and Fall
Penalty
Summary
The facility failed to ensure adequate supervision and safety measures for a resident with a history of dementia, high fall risk, and wandering behavior. The resident, admitted on 12/30/2024, had diagnoses including Parkinson's disease, generalized muscle weakness, and neurocognitive disorder with Lewy bodies. Despite being assessed as high risk for falls, the resident was not reassessed for elopement risk after triggering the exit door alarm twice on 12/31/2024 and exhibiting wandering behavior on 1/1/2025. On 1/2/2025, the resident managed to walk two steps outside the facility's exit door without staff assistance or an assistive device, resulting in a fall. The resident sustained injuries, including a comminuted nasal bone fracture and fractures in the right hand, requiring transfer to a general acute care hospital. The facility's failure to reassess the resident's elopement risk and implement appropriate interventions, such as a wander or elopement alarm, contributed to the incident. Interviews with facility staff revealed that the resident was known to wander and had previously set off the exit door alarm. However, there was no documentation of increased monitoring or reassessment for elopement risk. The facility's policies and procedures for safety and supervision were not adequately followed, as the resident's care plan did not include necessary interventions to prevent elopement and ensure safety.
Incomplete Documentation of Physician Orders
Penalty
Summary
The facility failed to ensure that medical records for a resident were complete and accurately documented, leading to deficiencies in the care provided. Specifically, the facility did not document the physician's order for surgical wound treatment in the resident's clinical record before performing the treatment. Additionally, the order to change the resident's indwelling urinary catheter drainage bag was not documented prior to the change being made. These omissions resulted in inaccurate information in the resident's clinical record. The resident in question was admitted with diagnoses including a fusion of the spine, muscle weakness, and essential hypertension. The resident had an indwelling catheter and a surgical wound, as indicated in the Minimum Data Set. Despite these conditions, the facility staff performed surgical wound treatments and changed the urinary catheter drainage bag without documented physician orders. This lack of documentation was confirmed during interviews and record reviews with nursing staff, who were unable to provide the necessary physician orders for the treatments administered. The facility's policies required that verbal orders be recorded immediately in the resident's chart by the person receiving the order. However, there was a delay in entering the physician's orders into the resident's clinical records, with one order being entered more than seven hours after it was given. This delay in documentation had the potential to result in missed orders, as acknowledged by the Director of Nursing. The facility's failure to adhere to its own policies on documentation and order entry contributed to the deficiencies observed in the resident's care.
Incomplete Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for two residents, leading to deficiencies in their care. For Resident 1, who was admitted with diagnoses including Parkinson's disease, type 2 diabetes mellitus, and essential tremors, the care plan did not specify the frequency of neuro checks following an unwitnessed fall. This omission was identified during a review of the resident's care plan and confirmed by a Licensed Vocational Nurse, who acknowledged that the care plan was incomplete. Resident 2, admitted with conditions such as fusion of the spine, muscle weakness, and essential hypertension, also had an incomplete care plan. The care plan for Resident 2's indwelling urinary catheter did not specify critical details such as the date of the last catheter change, frequency, size, and type of catheter. Additionally, the care plan lacked information on the catheter drainage bag change and surgical wound treatment. This was confirmed during a review with an LVN, who noted the care plan was not specific or individualized. The facility's policy on comprehensive person-centered care plans, dated earlier in the year, mandates that care plans include measurable objectives and timetables to meet residents' needs. However, the care plans for both residents did not adhere to this policy, placing them at risk for not receiving necessary services and assistance, potentially leading to infection and injury.
Failure to Secure Urinary Catheter Leads to Deficiency
Penalty
Summary
The facility failed to provide proper care for a resident with an indwelling urinary catheter, specifically by not securing the catheter tubing to the resident's thigh. This deficiency was identified for one of five sampled residents, who was admitted with diagnoses including spine fusion, muscle weakness, and essential hypertension. The resident's care plan, initiated shortly after admission, indicated a high risk for complications such as urinary tract infections and included interventions to prevent tension on the urinary catheter by securing it with a leg strap. During an observation, the resident was found with the urinary catheter improperly secured, allowing movement through the statlock device on the resident's thigh. A registered nurse, responsible for changing the urinary catheter drainage bag, was unable to secure the catheter properly. The Director of Nursing confirmed that the catheter should have been secured to prevent dislodgement and potential trauma or infection. The facility's policy on urinary catheter care emphasized the importance of securing the catheter to reduce friction and movement at the insertion site.
Infection Control Breach During Resident Care
Penalty
Summary
The facility failed to adhere to infection control procedures during the care of a resident, identified as Resident 2, who was on enhanced barrier precautions due to having an indwelling urinary catheter and a lower back surgical incision. The resident was admitted with diagnoses including fusion of the spine, muscle weakness, and essential hypertension. The care plan for the resident indicated a high risk for developing complications such as urinary tract infections, necessitating strict adherence to enhanced barrier precautions. During an observation, RN 1 was seen performing wound treatment and changing the urinary catheter drainage bag for Resident 2 without changing gloves after touching unclean surfaces. RN 1 did not change gloves after removing the resident's soiled wound dressing and continued to handle the urinary catheter and drainage bag with the same gloves. Additionally, RN 1 placed alcohol pad packets on the resident's bed, which was not a clean working area, and touched the basin under the bed with gloved hands before handling the new drainage bag. Interviews with RN 1 and the Director of Nursing (DON) confirmed that gloves should have been changed after each treatment and after touching soiled surfaces to prevent potential infections. The facility's policies on infection prevention and control, as well as the use of personal protective equipment, were not followed, as evidenced by RN 1's actions during the care of Resident 2.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for several residents, leading to deficiencies in their care. For one resident, there was no care plan for the use of buspirone, a psychotropic medication prescribed for anxiety. The absence of a care plan meant that the resident's behavior and medication effectiveness were not monitored, potentially leading to unnecessary medication administration and increased risk of altered cognition and falls. The Assistant Director of Nursing (ADON) and the Minimum Data Set Coordinator (MDSC) both acknowledged the lack of a care plan and its implications for the resident's health and safety. Another deficiency involved the failure to create care plans for residents using anticoagulant medications. One resident was prescribed apixaban, and another was on rivaroxaban, both without corresponding care plans to monitor for side effects such as bleeding and bruising. The MDSC and ADON highlighted the importance of these care plans in identifying risks and guiding staff in providing appropriate interventions. Without these plans, residents were at risk of health complications due to unmonitored medication side effects. Additionally, the facility did not develop care plans for the use of side rails and urinary catheters for certain residents. Two residents had side rails on their beds without care plans to prevent entrapment, and two others had indwelling urinary catheters without care plans to prevent urinary tract infections. The ADON confirmed the absence of these care plans and emphasized their necessity in ensuring resident safety and proper care. The facility's policies and procedures required comprehensive, person-centered care plans, but these were not followed, resulting in the identified deficiencies.
Failure to Rotate Injection Sites for Insulin Administration
Penalty
Summary
The facility failed to ensure that licensed nurses provided care in accordance with professional standards by not rotating subcutaneous insulin administration sites for three of the five sampled residents. This practice was observed during a review of insulin use, where it was found that repeated injections were administered in the same area, contrary to the guidelines provided by insulin manufacturers. The failure to rotate injection sites can lead to adverse effects such as lipodystrophy, bleeding, and bruising. Resident 34, who was admitted with type 2 diabetes mellitus, received insulin injections without proper site rotation. The resident's care plan indicated the need for insulin administration as ordered, yet the Location of Administration Report showed repeated use of the same injection sites over a period of time. The Assistant Director of Nursing (ADON) confirmed that the administration sites were not rotated, which could lead to poor absorption of insulin and insufficient blood sugar control. Similarly, Resident 11, who was receiving heparin for deep vein thrombosis prophylaxis, also experienced repeated injections at the same sites. The ADON acknowledged the lack of site rotation, which is necessary to prevent complications such as bleeding and irritation. Resident 5, with a history of type 2 diabetes and transient cerebral ischemic attack, also had insulin injections administered without proper site rotation. The ADON confirmed the repeated use of the same sites, which could potentially lead to adverse effects as outlined in the insulin manufacturer's guidelines.
Deficiencies in Medication Management and Documentation
Penalty
Summary
The facility failed to ensure proper documentation and reconciliation of controlled medications, as observed during a review of Medication Cart 2. The Controlled Substance / MAR Change of Shift Audit forms from 5/13/2024 to 6/2/2024 showed multiple missing entries, including signatures from oncoming and outgoing charge nurses and indications of whether the narcotic counts were correct. Licensed Vocational Nurse 2 (LVN 2) confirmed that the facility protocol required both nurses to count narcotics and sign the form at every shift change. The Director of Nursing (DON) stated that the facility policy was not followed, which could lead to medication going missing and delays in care. Additionally, the facility failed to administer medication to a resident, identified as Resident 249, who was admitted with a gastrostomy tube and required cholecalciferol oral liquid for nutritional support. On 6/5/2024, LVN 2 was unable to find the resident's medication in the cart, preventing administration. The Assistant Director of Nursing (ADON) acknowledged that residents would not receive the intended effects of their medications if not administered and emphasized the importance of timely reordering medications. The Operations Manager (OM) noted that the facility did not stock the liquid form of cholecalciferol, only tablets that could not be crushed. The facility's policy on Medication and Treatment Orders, last reviewed on 1/15/2024, required that medications be reordered from the pharmacy at least three days before the last dose to ensure availability. The failure to follow this policy resulted in the resident not receiving their prescribed medication, highlighting a lapse in the facility's medication management system.
Failure to Ensure Drug Regimen Free from Unnecessary Medications
Penalty
Summary
The facility failed to ensure that the drug regimen for two residents was free from unnecessary medications. For Resident 196, the facility did not provide an adequate indication for the use of apixaban, an anticoagulant medication. The resident was admitted with diagnoses including a fracture of the sacrum, hypertension, and atrial fibrillation. However, the physician's order for apixaban only stated it was for a blood thinner, without specifying the medical condition it was intended to treat, such as atrial fibrillation. This omission was identified during a review by the MDS Coordinator and the Assistant Director of Nursing, who acknowledged that the facility's policy requiring a specific clinical condition for medication orders was not followed. For Resident 11, the facility failed to monitor for adverse effects of heparin, another anticoagulant medication. The resident was admitted with conditions including atrial fibrillation, heart failure, and gastritis, and was receiving heparin for deep vein thrombosis prophylaxis. The order for heparin did not include instructions for monitoring adverse effects, such as bleeding and bruising, which are critical for patient safety. The Assistant Director of Nursing confirmed that the order lacked necessary monitoring instructions, which are essential to detect and report any adverse effects to the physician. The facility's failure to provide adequate indications for medication use and to monitor for adverse effects could lead to significant health risks for the residents. The facility's policy and procedures require that medication orders include the clinical condition being treated and that residents are monitored for potential adverse effects, but these protocols were not followed in the cases of Residents 196 and 11.
Deficiencies in Psychotropic Medication Management
Penalty
Summary
The facility failed to manage and monitor the medication regimens of four residents, leading to deficiencies in promoting their highest practicable mental, physical, and psychosocial well-being. For one resident, the facility did not limit the PRN order for lorazepam to a 14-day duration, nor did it identify specific behaviors to monitor, as required by policy. This oversight was acknowledged by the Assistant Director of Nursing (ADON), who confirmed that the physician's order lacked necessary details to prevent unnecessary medication use. Another resident was prescribed buspirone for anxiety without documented monitoring of behavioral manifestations, such as restlessness leading to shortness of breath. The ADON and Director of Nursing (DON) both noted the absence of documentation for monitoring the resident's behavior, which is crucial for evaluating the medication's effectiveness and ensuring the resident's safety. The facility's policy mandates monitoring for efficacy and adverse consequences, which was not adhered to in this case. Additionally, the facility did not ensure appropriate physician's orders for monitoring target behaviors and adverse effects for residents receiving quetiapine and citalopram. One resident was given quetiapine without informed consent or proper documentation of the diagnosis and monitoring requirements. Similarly, another resident was prescribed citalopram without orders to monitor target behaviors and side effects. These lapses in medication management and monitoring placed residents at risk for adverse effects and unnecessary medication use.
Failure to Rotate Injection Sites for Medications
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically in the administration of subcutaneous injections. For Resident 34, the facility did not rotate the injection sites for insulin administration, as evidenced by repeated injections in the same area of the abdomen over a period of time. This practice was confirmed by the Assistant Director of Nursing (ADON) during a review of the Medication Administration Record (MAR), who acknowledged that the sites should have been rotated to prevent adverse effects such as bruising and poor absorption of the medication. Similarly, Resident 5 experienced a lack of rotation in the administration of insulin injections. The MAR indicated that insulin was repeatedly administered in the same areas of the abdomen, which was again confirmed by the ADON. The failure to rotate injection sites was contrary to the manufacturer's guidelines and the facility's policy, which both emphasize the importance of site rotation to prevent complications like lipodystrophy. Resident 11 also suffered from improper medication administration practices, with repeated heparin injections in the same abdominal areas. The ADON confirmed that the sites were not rotated as required, which could lead to issues such as bleeding and irritation. The facility's policy and the manufacturer's guidelines for heparin administration both stress the necessity of rotating injection sites to avoid adverse reactions.
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.
Illustrative
What surveyors actually found near you
We read the 4,348 citations issued within 25 miles in the last 12 months — including the 16 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Northridge
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Magnolia Gardens Convalescent Hospital | 1 mi | ★★★★★ | 34 | 0 |
| Casitas Care Center | 1.2 mi | ★★★★★ | 19 | 0 |
| Rinaldi Convalescent Hospital | 2.3 mi | ★★★★★ | 35 | 0 |
| Granada Hills Convalescent | 2.3 mi | ★★★★★ | 19 | 0 |
| The Rehabilitation Center Of North Hills | 3 mi | ★★★★★ | 26 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for The Gardens Healthcare Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.