Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Hills Post Acute during CMS and state inspections, most recent first.
Oxygen Tubing Not Labeled, Dated, or Stored Properly: Three residents receiving continuous O2 at 2 L/min were observed with nasal cannula tubing that was unlabeled and undated; two residents also lacked an oxygen storage bag. An LVN confirmed the findings and stated the tubing should be labeled with the date and changed every 7 days per facility policy. One resident had dementia and no capacity to make medical decisions, another had no capacity, and the third had capacity and an order for continuous O2 for SOB.
A facility failed to keep dialysis communication records complete and accurate for three residents receiving hemodialysis. Records for residents with a Permacath incorrectly documented bruit and thrill, while records for a resident with an AV fistula were missing required access-site checks, vital signs, lung sounds, and physician notification for absent bruit/thrill. Fluid restriction tracking was also inaccurate, with 24-hour totals not matching documented intake and one MAR entry showing dietary fluids after the resident had already been transferred to an acute care hospital.
Unlabeled nasal sprays and inhaler mouthpieces were found on two med carts, with staff confirming they belonged to specific residents but lacked resident-specific identification. In addition, ammonium lactate cream was left in a resident's bedside drawer and Neosporin ointment was left on another resident's overbed table without documentation for self-administration or bedside storage. Staff acknowledged the unlabeled and unsecured medications.
The facility failed to follow a pureed starch recipe and multiple renal diet menu items, including serving substituted foods without informing residents. A resident on a renal diet was also served a different lunch entrée than listed on the menu, and another resident who refused breakfast and lunch was not offered food substitutions. Staff and the RD verified the menu and recipe deviations, and the resident involved stated he was not informed of the change and did not receive the food he expected.
Kitchen Food Safety and Storage Deficiencies: Surveyors found that the dry storage room had no temperature monitoring log or system, kitchen equipment including a can opener and mixer had visible soil and residue, and a container of ham in Walk-In Refrigerator 1 was past its use-by date and lacked a label/date. The DSS confirmed each finding, and facility policies required proper temperature monitoring, sanitation, and food labeling.
The facility failed to follow its infection surveillance and IPCP policies. Surveillance was limited to residents prescribed antimicrobials, and residents with signs or symptoms of infection who were not on antimicrobials were not evaluated using McGeer’s criteria or included in the log. Staff also left a cell phone on the clean laundry sorting table, stored a resident’s gown on a soiled trash can lid, placed a call light on a resident’s bed without disinfecting it, performed GT feeding care without the required gown under enhanced barrier precautions, stored a resident’s soda on the floor, and delivered meal trays without hand hygiene.
Delayed response to a resident’s call light was observed when the light remained on for several minutes while multiple staff passed by the room without answering it. The resident, who had moderately impaired cognition and needed assistance with ADLs and transfers, stated staff take a long time to respond and that they turn off the light but do not come back. Facility policy required call lights to be answered within a reasonable time, but the light was not turned off until another staff member entered the room and responded.
Call Lights Not Within Residents’ Reach: Two residents with severe cognitive impairment were observed with call light buttons placed out of reach. One resident also had upper extremity impairment, and staff confirmed the call lights were positioned where the residents could not access them.
Unsafe and Disrepair Conditions in Resident Rooms: The facility failed to maintain a safe, clean, and homelike environment for two sampled residents and one nonsampled resident. One resident’s room had a hanging ceiling panel, a cord connected to a power strip, chipped and peeled paint, and black streak marks on the wall; another resident’s room had chipped wall trimmings and peeling paint; and a third resident’s room had scratched and chipped walls and bathroom door. An LVN verified the room conditions, and residents stated their rooms needed painting.
A resident was transferred to an acute care hospital for further evaluation due to altered mental status and facial drooping, with a physician order for transfer and a bed hold if admitted. The Notice of Proposed Transfer/Discharge form was not completed, and the medical record did not show that the Ombudsman was notified of the transfer as required by facility policy.
A resident’s PASRR Level 1 screening was inaccurate because it showed no mental illness diagnosis and no psychotropic meds, even though the resident had unspecified psychosis, lacked capacity for medical decisions, and had an order for Seroquel for psychosis with combative behavior. The MDS Assistant verified the screening should have reflected a serious mental illness and that a resident review should have been completed.
Incomplete Person-Centered Care Plans: The facility failed to develop and implement person-centered care plans for several residents with identified needs. A resident with a NAS diet had frequent chip intake that was not addressed in the nutrition care plan; another resident receiving HD had fluid restrictions, AV fistula monitoring, and dialysis treatments that were not included in the care plan; a resident using a LAL mattress had no related care plan; and a resident with dementia had no dementia-specific care plan with measurable goals or interventions.
A facility failed to revise the comprehensive care plans for two residents to reflect current care needs and interventions after MDS assessments. One resident had moderate cognitive impairment with a BIMS score of 9, and the other was cognitively intact with a BIMS score of 15. During record review and interviews, an LVN and an RN verified the care plans were not updated, and the DON confirmed the plans had not been revised.
Failure to Address Significant Weight Loss: A resident with moderate cognitive impairment had an unplanned 16-lb weight loss over 28 days while on a soft and bite sized diet with thin liquids. The record did not show a change of condition, physician or RP notification, RD assessment, or a revised care plan, and staff observations noted the resident was eating very little and preferred only milk, bread, cheese, and soup.
A resident with a GT and severely impaired cognitive skills did not receive the ordered enteral feeding as prescribed. Staff observed the Glucerna 1.2 bag still full and running, and an LVN showed that 1850 ml had been fed even though the order was for 1200 ml; the LVN stated the resident did not get the total amount ordered. The DON verified the findings.
A resident receiving IV cefepime had an IV bag and tubing that were not properly labeled with the required date, time, and nurse initials, and the resident’s care plan did not address the IV antibiotic therapy or monitoring for side effects. The DON and an LVN verified the findings, and the resident had severe cognitive impairment with a BIMS score of 2.
An LVN administered a resident’s calcium supplement with vitamin D at a lower vitamin D dose than ordered, and the DON confirmed the medication did not match the prescriber’s order. In addition, the Controlled Substances Log for two residents’ liquid morphine sulfate bottles was missing RX Numbers in the blue book used for shift-to-shift reconciliation.
A resident with dementia was prescribed trazodone and escitalopram for depression, but the Pharmacy Consultant recommended considering a single antidepressant or documenting the clinical rationale for dual therapy if continued. The physician signed to continue both meds, yet the record, including the H&P and progress notes, did not document the clinical justification for the dual antidepressant regimen, and an LVN confirmed the rationale was absent.
A resident with dementia was ordered amiodarone 200 mg daily with instructions to hold the dose if HR was below 60 bpm, but the MAR showed the medication was given without documentation of HR monitoring. An LVN verified the missing HR documentation and stated it should have been monitored and recorded per the MD order; the Administrator and DON were informed and acknowledged the finding.
Food Not Palatable or Appealing: Three residents expressed dissatisfaction with the taste of meals, stating the food did not taste good, was bland, or tasted very old. During a test tray evaluation with the DSS, RD 2, and surveyors, the potatoes served were verified to be bland, and the Administrator, DON, Clinical Resource Nurse, and Dietary Resource acknowledged the findings.
Two residents received lunch trays that did not match their documented food preferences. One resident who disliked all vegetables was served green beans and red peppers, and another resident who disliked apple juice was served apple juice. The RD and DSS verified the tray line findings, and the facility's policy stated diet evaluations include resident likes and dislikes.
Unlabeled outside food was found in resident refrigerators, including ice cream, dairy, Ensure, and soda items that lacked the resident name, location, and/or date required by facility policy. Staff gave inconsistent accounts of who educated families and visitors on safe food handling, and multiple staff denied providing instruction on key practices such as temperature control, cross contamination prevention, and hand hygiene.
A hospice resident’s communication forms lacked the resident name and ID number, and the hospice visit calendar was pre-initialed for future visits before care occurred. Another resident had a wanderguard in place, but the chart did not contain an elopement re-evaluation or other documentation showing exit-seeking behavior or the reason for the device. The DON, RN, and hospice staff verified the missing and pre-signed documentation during record review.
A resident receiving hospice care for end-stage Parkinson's disease had missing hospice documentation in the chart. The record did not contain chaplain and CHHA visit notes, the next month's hospice visitation calendar was absent, and the schedule did not show a skilled nurse visit for one week; the CHHA sign-in form also lacked documentation of the care provided, and a chaplain visit was not documented in the hospice log.
Late Transmission of Discharge MDS Assessments: The facility failed to timely complete and transmit Discharge MDS assessments for three residents. Review of closed records showed one assessment was still in progress and two were not documented as completed and submitted, and CMS submission data confirmed all three were accepted weeks past the required transmission deadline. The MDS Assistant verified the findings, and the Administrator, DON, and Clinical Resource Nurse were informed.
Multiple residents with IV access did not receive required weekly dressing changes, and staff failed to consistently measure and document arm circumference and external catheter length during dressing changes. Physician's orders and care plans for IV maintenance were missing or delayed for several residents, and some IV sites were not properly labeled upon insertion. These deficiencies were confirmed through observation, record review, and staff interviews, and were acknowledged by facility staff.
Surveyors found that the kitchen hood was not cleaned as required, kitchen utensils were in poor repair and not properly sanitized, and cutting boards were heavily marred and difficult to clean. Additionally, a chest freezer lacked a thermometer for temperature monitoring, and milk beverages were served above the recommended temperature. These deficiencies were acknowledged by the RD and Assistant DSS during observations and interviews.
Several residents reported ongoing issues with excessive noise from slamming doors and staff speaking loudly during shift changes, which disrupted their rest. Observations confirmed that doors made loud noises and that staff gatherings contributed to the problem. Additionally, a resident's room was found to have a wall in disrepair, with scratches and chipped paint, which had not been repaired despite the resident spending significant time in the room.
Two residents did not have their care plans updated to reflect current physician orders and changes in condition. One resident's care plan listed an incorrect fluid amount compared to the physician's order, and another resident's care plan was not revised when the behavioral manifestation for antipsychotic medication use changed. These omissions were confirmed by facility staff during record reviews and interviews.
A resident who was fully dependent on staff for ADLs was repeatedly observed with long, sharp fingernails and self-inflicted facial scratches. Staff interviews confirmed that nail care was not provided as required by the care plan, which specifically called for keeping nails short to prevent skin injury. The facility's policy for individualized ADL assistance was not followed, resulting in unmet personal hygiene needs and compromised skin integrity.
A resident with end-stage renal disease and a physician-ordered fluid restriction was not provided the prescribed 360 ml of fluids with each meal, instead only receiving 240 ml. The dietary department's practice did not match the physician's order, and there was no documentation of refusal or physician notification about the discrepancy, as confirmed by the resident and the RD.
Three residents received respiratory care that did not meet facility policy, including one who received oxygen therapy without a physician's order and had unsanitary equipment, and two others whose oxygen tubing and related supplies were not properly labeled or stored. Staff confirmed the lack of labeling and improper storage, and acknowledged these practices did not follow infection control protocols.
Two residents did not receive appropriate dialysis care: one was given antihypertensive medication on dialysis days against physician orders, and another's AV shunt site was not properly monitored or reported to the physician when negative findings were documented. Nursing staff and the DON confirmed that required notifications and assessments were not consistently performed.
The facility did not consistently obtain required nurse signatures on controlled substance logs for two medication carts, resulting in incomplete accountability for narcotic medications. Additionally, a nurse failed to properly administer prescribed eye drops to a resident with cognitive impairment and glaucoma, not following protocol to ensure medication absorption.
Surveyors found that a vial of Lidocaine was removed from an IV emergency kit without documentation in the Emergency Kit Usage Log, and expired Santyl ointments were present on a treatment cart. The IP, DON, and an LVN confirmed these deficiencies, noting that required documentation and removal of expired medications did not occur.
A resident who required a sippy cup for self-feeding, as documented in medical records and physician orders, was not provided with the adaptive equipment during meals. The resident used regular cups instead, and both a CNA and an LVN confirmed that the sippy cup should have been supplied but was not.
Surveyors identified that three residents had incomplete or inaccurate medical records, including missing documentation of medication administration, required monitoring, and an incomplete POLST form. One resident's weekly fluid intake was incorrectly documented as daily totals, and staff confirmed these errors during interviews and record reviews.
Surveyors observed multiple infection control lapses, including a resident's urinal placed next to drinks on a bedside table, an LVN failing to perform hand hygiene or change gloves during GT medication administration, and a nurse not using required PPE while providing GT care to a resident on Enhanced Barrier Precautions for a respiratory MDRO. These actions were confirmed by staff and posed a risk for contamination and infection transmission.
A resident with a recent pneumonia diagnosis was observed receiving continuous oxygen therapy without a physician's order or a comprehensive care plan in place. Both an LVN and the DON confirmed that the care plan for oxygen use had not been initiated after the resident's readmission.
A resident with documented dislikes for certain foods was repeatedly served those items despite clear notations on her care plan and diet card. The resident expressed frustration and did not eat her meal, and a CNA confirmed the tray should not have included the disliked foods.
A resident with dysphagia and other medical conditions was given regular peanut butter sandwiches instead of a prescribed pureed diet, leading to a choking incident and subsequent death. The healthcare assistant was unaware of the dietary restrictions, and the facility staff confirmed the inconsistency with the diet orders.
A long-term care facility failed to safeguard controlled medications for nine residents, resulting in the diversion of significant quantities of tramadol, hydrocodone-acetaminophen, and Oxycontin. The facility's medication logs were falsified to show that medications were transferred to the DON, but signatures were forged, and the medications were missing. The facility's narcotic count process did not detect the diversion, as the logs falsely indicated the medications were in the DON's possession.
A resident experienced an unwitnessed fall resulting in a head injury, but the facility failed to document the necessary post-fall assessment details as per their policy. Despite the resident's report of significant pain and visible injury, the medical records lacked comprehensive documentation of the skin and wound condition. The DON confirmed the absence of required documentation.
The facility failed to ensure complete and accurate medical records for three residents. A resident's MAR lacked documentation of blood sugar levels and medication administration on specific dates. Another resident's MAR was missing similar documentation, and a third resident's MAR lacked nurse initials for medication administration. The DON confirmed these findings, highlighting the expectation for immediate documentation post-medication administration.
The facility failed to properly manage and document controlled substances, resulting in missing oxycodone medications for a resident. The investigation revealed inconsistencies in the Medication Administration Record (MAR) and Controlled Drug record, as well as missing signatures on shift count sheets for multiple medication carts. These lapses were acknowledged by the DON and nursing staff.
Oxygen Tubing Not Labeled, Dated, or Stored Properly
Penalty
Summary
The facility failed to ensure safe and appropriate respiratory care for three residents receiving continuous oxygen therapy. Facility policy required oxygen cannulas or masks and tubing to be changed at least every 7 days, with tubing kept off the floor and labeled and dated bags provided for cannulas and masks when not in use. During observation and concurrent interviews, Resident 31 was seen in the dining room on oxygen at 2 liters per minute with nasal cannula tubing that was unlabeled and undated. The LVN confirmed the tubing was unlabeled and undated and stated oxygen tubing needs to be changed every seven days to prevent infection. Resident 31’s record showed a physician’s order for continuous oxygen at 2 liters per minute and that the resident had no capacity to make medical decisions. Resident 7 was observed on portable oxygen at 2 liters per minute with nasal cannula tubing that was undated, unlabeled, and without an oxygen storage bag. The LVN verified the tubing was not labeled or dated and that no storage bag was present, and stated the cannula should be labeled with the date and changed every seven days. Resident 175 was also observed on portable oxygen at 2 liters per minute with nasal cannula tubing that was undated, unlabeled, and without a storage bag. The LVN confirmed those findings and stated the cannula should be labeled with the date and changed every seven days. Resident 7’s record showed dementia with no capacity to make medical decisions, and Resident 175’s record showed capacity to make medical decisions and a physician’s order for continuous oxygen at 2 liters per minute for shortness of breath.
Incomplete and inaccurate dialysis communication and fluid monitoring
Penalty
Summary
The facility failed to ensure dialysis care and services were accurately documented for three residents who received hemodialysis and had ordered access-site and fluid-restriction monitoring. The facility policy required assessment of dialysis access patency, redness, swelling, bleeding, and communication with the dialysis facility, with documentation of pre- and post-dialysis care in the clinical record. Surveyors reviewed dialysis communication records, physician orders, MARs, and interviewed residents and staff, and found multiple incomplete or inaccurate entries across the sampled residents' records. For one resident with a right upper chest Permacath and hemodialysis three times weekly, the dialysis communication forms contained inaccurate entries showing bruit and thrill were present on multiple dates, even though staff later stated bruit and thrill would not be assessed for a Permacath. Some post-dialysis entries also failed to document required access-site assessment for infection, bleeding, dressing status, vital signs, shortness of breath, and pain. The resident stated he received hemodialysis and was on fluid restriction, and the MDS Assistant and DON acknowledged the documentation problems. For a second resident with a left AV fistula and ordered fluid restriction, the dialysis communication records were incomplete on several treatment dates, including missing respirations, lung sounds, vital signs, access-site bleeding, infection checks, and bruit/thrill documentation. The MAR also showed documented absence of bruit and thrill on two shifts, but the record did not show the physician was notified as ordered. In addition, the resident's fluid intake documentation was inaccurate on multiple days, where the recorded 24-hour total did not match the sum of the dietary and nursing fluids actually documented. Staff confirmed the records were incomplete and the fluid totals were not calculated accurately. For a third resident with a right upper chest Permacath and hemodialysis schedule, the dialysis communication record also showed inaccurate documentation of bruit and thrill as present on multiple dates, despite staff stating that bruit and thrill would not be assessed for a Permacath. The MAR further documented dietary fluid intake after the resident had already been transferred from the dialysis center to an acute care hospital and had not returned to the facility, making the entry inaccurate. The Administrator, DON, Clinical Resource Nurse, and Dietary Resource acknowledged the findings.
Unlabeled Medications and Unsecured Bedside Storage
Penalty
Summary
Drugs and biologicals were not stored and labeled in accordance with facility policy and accepted professional principles on two medication carts. On Medication Cart A, Resident 192 had one opened carton of azelastine nasal solution and one opened carton of ipratropium nasal solution, and both bottles were observed without resident-specific labeling. LVN 6 verified the unlabeled nasal spray bottles belonged to Resident 192 and stated the containers were supposed to be labeled in case they fell out of the opened cartons. On Medication Cart B, Resident 158 had an opened carton of budesonide-formoterol inhaler, Resident 117 had an opened carton of Tudorza Pressair inhaler, and Resident 67 had an opened carton of azelastine nasal solution. The mouthpieces for Resident 158's inhaler and Resident 117's inhaler, along with Resident 67's nasal spray bottle, were observed without resident-specific information. RN 2 verified the unlabeled inhaler mouthpieces and nasal spray bottle and stated they were to be labeled with the resident's information to ensure administration to the right resident. Drugs were also left unattended at the bedside for two residents. Resident 164, who had severely impaired cognitive skills for daily decision making, was observed with two medication cups of ammonium lactate cream in an open bedside table drawer, and the medical record did not show an order for self-administration or bedside storage. Resident 132 was observed with Neosporin ointment on the overbed table and stated the nurse gave it to her to keep; the record did not show an order for Neosporin use, self-administration assessment, or care plan. Staff confirmed both residents had medication at the bedside without the required documentation.
Failure to Follow Puree and Renal Diet Menus and Offer Meal Substitutions
Penalty
Summary
The facility failed to follow its IDDSI Level 4 pureed starch recipe for residents receiving pureed diets. During observation of pureed potatoes, a cook placed 25 servings of potatoes into a blender and added two cups of warm milk before blending. The facility’s recipe stated the potatoes were to be pureed on low speed to a paste consistency before any liquid was added, with warm milk added gradually afterward. The cook verified that the recipe was not followed. The facility also failed to follow the renal diet menu for residents on renal diets. The posted spring menu showed renal diet residents were to receive brown rice with margarine, a wheat roll, and pineapple and mandarin orange mix, but during tray line observation two residents on renal diets did not receive those items. The RD stated the brown rice was available but was not cooked in time and macaroni pasta was substituted without informing residents. The DSS stated the fruit mold was not prepared as listed on the menu, and both the RD and DSS verified that residents on renal diets were not informed of the menu changes. In addition, the facility failed to serve roast beef with salt-free gravy as listed on the menu for renal diets and instead served a beef patty to a resident on a renal diet. Although invoices showed roast beef had been received, staff stated it was not thawed in time for lunch. A resident stated he was not informed of the change and did not eat the beef patty because he was expecting roast beef. The facility also failed to offer food substitutions to a resident who refused breakfast and lunch; the resident had no capacity to make medical decisions, stated he was not offered anything else, and CNA staff confirmed substitutions were not offered. The DSD stated staff were expected to offer meals three times and provide substitutions, but no documentation showed this occurred.
Kitchen Food Safety and Storage Deficiencies
Penalty
Summary
Food safety and sanitary requirements were not met in the kitchen during observations and document review. The facility’s policies stated that correct temperatures were to be used for storage and handling of foods, and that thermometers should be used to check temperatures of refrigerators, freezers, and food storerooms. However, during an observation in the dry storage room, the facility had no temperature monitoring log or system for that area, and the DSS confirmed that the temperature should be checked to ensure food was stored at appropriate temperature levels. Kitchen equipment was also observed in an unclean condition. A can opener had brown discoloration, silver shavings, and dirt particles, and a mixer had dried food particles. The DSS confirmed these findings and stated kitchen equipment should be cleaned and sanitized to prevent contamination of foods prepared in the kitchen. In addition, inside Walk-In Refrigerator 1, one container of ham showed a use by date of 4/28/26, and the ham packaging had no label or date. The DSS verified the finding and stated food items should be labeled so kitchen staff are aware of when food should be served.
Infection Control and Surveillance Failures
Penalty
Summary
The facility failed to implement its Infection Prevention and Control Program in accordance with its own policies. The Infection Surveillance Outcome and Reporting policy stated that the facility would maintain ongoing surveillance to identify possible communicable diseases or infections, and that the charge nurse would record all residents displaying symptoms of infection on the Infection Surveillance log. However, review of the monthly Infection Surveillance Logs from April 2025 through February 2026 showed that the facility only tracked residents who were prescribed antimicrobial medications. The Infection Preventionist stated that when a resident exhibited signs and/or symptoms of infection but was not prescribed an antimicrobial medication, the facility did not initiate the Infection Surveillance V-2 form and did not include those residents in the surveillance program. The Infection Preventionist was also unable to state how many residents had infections that met McGeer’s criteria without antimicrobial medications during that period. The facility also failed to keep clean laundry areas and resident care items free from contamination. In the laundry room, the counter designated for clean laundry sorting had a staff member’s cell phone on it next to clean linens, despite the facility policy stating clean linens are to be kept protected from dust and other contaminants prior to use. In Resident 26’s room, a folded gown was observed stored on the lid of the soiled trash can before morning care had been provided. Resident 26 stated staff routinely placed gowns, linens, and towels used for care on the trash can before care. CNA 8 confirmed that linens not being used should be placed on the bedside table or in the dirty linen hamper and stated the gown should not have been stored on the trash can lid. Additional infection control failures were observed during resident care and routine activities. Resident 12’s call light was found on the ground, and CNA 8 picked it up and placed it on the resident’s bed without disinfecting it first. For Resident 107, who had severe cognitive impairment and had a physician’s order for enhanced barrier precautions due to a feeding tube, LVN 7 performed GT feeding care while wearing gloves but without a gown, and she stated she should have used the gown. Resident 105 had a case of soda stored on the floor in the room. During meal tray delivery, CNA 3 and CNA 4 were observed handling resident care and meal trays without performing hand hygiene as required, and both CNAs acknowledged that hand hygiene was not performed before and after tray delivery.
Delayed Response to Resident Call Light
Penalty
Summary
The facility failed to ensure staff provided care and promoted dignity and respect for one resident when the resident’s call light was not answered in a timely manner. Facility policy stated the call light is used as a means of communication with nursing staff and should be answered within a reasonable time. During observation, Room C’s call light was activated at 0914 hours and multiple staff were seen passing by the room and walking through the hallway without responding. The call light remained on while Housekeeping 1 entered the room at 0918 hours, and staff including COTA 1 were observed going to Nurses Station A and passing the room without answering the light. The call light was not turned off until 0923 hours when AIT 1 entered the room and responded to it. Resident 77 stated that staff take a long time to respond, that they come and turn off the light but do not come back, and that he needs help with cleaning himself up, sometimes has trouble with the TV, and sometimes walks to the nurses’ station to ask for coffee. The resident had a BIMS score of 12, indicating moderately impaired cognition. His care plan directed staff to encourage use of the call light for assistance and noted he required one-person assistance for transfers and was at risk for falls and injuries. The Administrator and DON were informed that Resident 77’s call light was not answered in a timely manner and acknowledged the findings.
Call Lights Not Within Residents’ Reach
Penalty
Summary
The facility failed to provide a reasonable accommodation for two residents by not ensuring their call lights were within reach. The facility policy titled Call Light/Bell stated to leave the resident comfortable and place the call device within the resident's reach before leaving the room. Resident 54 had a BIMS score of 2, indicating severe cognitive impairment, and had one-sided upper extremity impairment. During observation, Resident 54 was seated in a wheelchair on the left side of the bed, while the call light button was on the right side of the wheelchair and not within reach. A CNA later confirmed that Resident 54 had right upper extremity mobility impairment and that the call light was too far away to reach. Resident 147 had a BIMS score of 6, indicating severe cognitive impairment. During observation, the resident's call light button was hanging on the left side of the headboard behind the resident, and the resident stated he could not locate it. A CNA later stated that Resident 147 would call for help by pressing the call light button and verified that the button was hanging on the headboard and could not be reached by the resident. The DON, Clinical Resource, and Administrator were informed of the findings.
Unsafe and Disrepair Conditions in Resident Rooms
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for Residents 26, 48, and 117. Resident 26, who was admitted and later readmitted to the facility, was observed in Room D with a white thin panel hanging from the ceiling to the right of the bed, a cord connected between the panel and an electrical power strip, chipped and peeled paint on the ceiling, and the wall behind the head of bed showing black vertical streak marks with chipped paint on the wall and wall trimming. During interview and observation, LVN 6 verified the condition of the room and stated the ceiling needed to be painted and that she did not know what the black streak marks were. Resident 26 stated that after looking at the ceiling, a visitor asked whether the facility was falling apart. Resident 48 was observed in Room E with the wall behind the head of bed in disrepair, including chipped wall trimmings and chipped and peeling paint on the wall, and LVN 6 verified those findings. Resident 117 was observed in Room B sitting in a wheelchair, with the wall and bathroom door adjacent to the bed showing scratches and chipped paint. Resident 117 stated the entire room needed to be painted. The DON stated the facility was in the process of repairing residents' rooms in need of repairs, and the Administrator, DON, and Nurse Consultant were informed and acknowledged the findings.
Failure to Notify Ombudsman of Resident Transfer
Penalty
Summary
The facility failed to provide a copy of the transfer/discharge notification to the Office of the State Long-Term Care Ombudsman for Resident 7 when the resident was transferred to an acute care hospital. The facility’s policy titled Criteria for Transfer and Discharge, revised April 2025, stated that a copy of the notice shall be sent to the State Long-Term Care Ombudsman, including when an immediate transfer or discharge is required by the resident’s urgent need. Resident 7 was admitted to the facility and later transferred to the acute care hospital for further evaluation due to altered mental status and facial drooping. The physician’s order dated 2/24/26 included transfer to the hospital and a bed hold for seven days if admitted. Review of the resident’s Notice of Proposed Transfer/Discharge form showed the resident’s name and other information were not filled out, and the medical record did not show documented evidence that the Ombudsman was notified of the transfer. The MRD reviewed the form and verified it was not completed and that the notice was not sent to the Ombudsman.
Inaccurate PASRR Level 1 Screening for Resident with Psychosis
Penalty
Summary
The facility failed to ensure the PASRR Level 1 screening was accurate for one of four sampled residents reviewed for PASRR, identified as Resident 94. The resident had a diagnosis of unspecified psychosis not due to a substance or known physiological condition, and the H&P stated the resident had no capacity to make medical decisions. However, the PASRR Level 1 screening dated 12/17/25 indicated the resident had no diagnosis of mental illness and no prescribed psychotropic medications, and it was marked negative with no Level 2 evaluation required because the resident did not have a serious mental illness. Medical record review also showed an order dated 12/24/25 for Seroquel 25 mg by mouth twice a day for psychosis manifested by combative behavior. During a concurrent review with the MDS Assistant, the assistant verified the Level 1 PASRR screening was inaccurate and stated a resident review should have been completed because the resident had a serious mental illness diagnosis and was prescribed a psychotropic medication. The DON, Clinical Resource, and Administrator were later informed of and acknowledged the findings.
Incomplete Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for four sampled residents with identified care needs. The report states that the interdisciplinary team did not create care plans with measurable objectives and timeframes for Resident 1’s noncompliance with a prescribed dietary regimen, Resident 12’s hemodialysis treatments, fluid restrictions, hemodialysis access monitoring, and nutrition status, Resident 13’s use of a low air loss mattress, and Resident 94’s dementia-related care needs. The facility’s own policy required comprehensive resident-centered care plans to address medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment. Resident 1 was observed with unopened and open bags of chips in the room, and staff reported the resident frequently had chips and soda brought in by a friend and was fed chips when requested. The resident had an order for a no added salt regular diet, level 7 texture, and thin liquids, but the nutrition care plan only addressed honoring dietary choices and monitoring for decreased appetite. Staff and the RD acknowledged that the resident’s consistent chip consumption was not addressed in the nutrition care plan despite the NAS diet. Resident 12 stated he received hemodialysis three times weekly and was on fluid restrictions, and the record showed orders for AV fistula monitoring every shift, dialysis treatments on Tuesdays, Thursdays, and Saturdays, and a 1500 ml daily fluid restriction split between nursing and dietary. However, the care plan did not address hemodialysis, access site monitoring, nutrition, or fluid restriction. Resident 13 had an order for a low air loss mattress with monitoring of proper function and setting every shift, but the MDS Assistant verified there was no care plan addressing its use. Resident 94 had a diagnosis of dementia and no capacity to make medical decisions, yet the care plan report showed no dementia-related care plan, and family expressed concerns about communication breakdown among staff regarding how to care for the resident.
Care Plans Not Updated After Assessments
Penalty
Summary
The facility failed to ensure that the comprehensive care plans for two residents were revised to reflect their current care needs and interventions. Review of the facility policy showed that the interdisciplinary team was responsible for developing a comprehensive person-centered care plan for each resident and reviewing or revising it after each assessment. For Resident 53, who had been admitted and later readmitted to the facility and had a 5-day PPS MDS assessment showing a BIMS score of 9, the care plan report did not show that the plan of care had been reviewed or updated. During an interview and concurrent record review, LVN 2 verified that the resident's care plan was not revised or updated by the target date. For Resident 98, who had been admitted and later readmitted to the facility and had an annual MDS assessment showing a BIMS score of 15, the care plan report also did not show that the plan of care had been reviewed or updated. During an interview and concurrent record review, RN 1 verified that the resident's care plan was not revised or updated by the target date. The DON later confirmed that care plans are the guide for providing resident care and need to be updated and revised if interventions are effective or not, and the Administrator and DON acknowledged the findings.
Failure to Address Significant Weight Loss
Penalty
Summary
The facility failed to ensure that the RD and IDT analyzed and implemented interventions when Resident 53 experienced unplanned significant weight loss, and failed to notify the physician and the resident and/or representative of the change in condition. Resident 53, who had moderate cognitive impairment with a BIMS score of 9, was on a regular soft and bite sized diet with thin liquids and had a nutrition goal to maintain weight between 189 and 199 lbs. The resident’s weight decreased from 199 lbs on 4/4/26 to 183 lbs on 5/2/26, a loss of 16 lbs or 8.04% in 28 days. The record showed progressive weight loss over several weekly weights, including 195 lbs, 192 lbs, 188 lbs, and then 183 lbs. The medical record did not show documentation of a change in condition when the resident reached the significant weight loss threshold, and it did not show that the physician or resident/responsible party was informed. The record also failed to show that a care plan was initiated to address the resident’s weight loss. During observation, Resident 53 was seen in bed with a breakfast tray and stated she did not want to eat breakfast and only wanted milk. On another observation, the resident was holding milk and only wanted to eat bread, while CNA 10 stated the resident did not like the facility food and only wanted bread with cheese and soup. RD 2 stated she was only made aware of the weight loss on 5/5/26 and said she was still in training, while LVN 2 and the DON both stated that a change of condition, physician and responsible party notification, RD assessment, and care plan intervention should have occurred for the weight loss.
GT Feeding Not Delivered as Ordered
Penalty
Summary
The facility failed to provide the necessary GT care and services for one of three sampled residents reviewed for enteral feeding care, Resident 164. Resident 164 was admitted and later readmitted to the facility, and the annual MDS showed severely impaired cognitive skills for daily decision making. A physician’s order dated 4/29/26 directed Glucerna 1.2 to be administered at 60 ml per hour for 20 hours or until the volume limit was completed, to provide 1200 ml/1440 kcal via GT, with feeding to restart at 1600 hours. During observation on 5/3/26, Resident 164 was seen in bed with a GT feeding hanging and connected to a feeding pump. The feeding formula bag was full and labeled as Glucerna 1.2, dated as administered from 5/3/26 at 0630 hours at 60 ml per hour for 20 hours. The bag was still full and running when observed. When asked to show the total amount of feeding given, LVN 1 showed 1850 ml had been fed, although the order was for 1200 ml. LVN 1 stated this was incorrect and that Resident 164 did not get the total amount of the GT feeding. The DON later verified these findings, and the Administrator and DON were informed and acknowledged them.
IV Therapy Labeling and Care Planning Deficiencies
Penalty
Summary
The facility failed to provide the necessary care and services to maintain IV access for one resident receiving IV therapy. During observation, the resident was seen in bed awake with a peripheral IV line to the right hand area. The IV bag was dated 5/2/26, but there was no time or nurse initials on the bag. The IV tubing also had no label, no date, no time of change, and no nurse initials. The DON verified that when a licensed nurse hangs an IV medication, the bag and tubing are required to be labeled with the date, time, and initials. The facility also failed to develop a care plan for the resident’s IV antibiotic therapy. The resident had a physician’s order for cefepime 1 gram IV daily for urinary tract infection until 5/7/26 and had a BIMS score of 2, indicating severe cognitive impairment. Review of the care plan did not show a problem related to the cefepime IV antibiotic, and the medical record did not show documentation that side effects of the antibiotic were monitored. An LVN stated that a care plan should have been developed when the cefepime was ordered to monitor for side effects, and the LVN verified the findings.
Medication Administration Error and Incomplete Controlled Substance Log Entries
Penalty
Summary
Medication administration for one resident was not carried out in accordance with the prescriber’s order. The resident had an order for calcium carbonate 600 mg combined with cholecalciferol (vitamin D3) 10 mcg by mouth twice daily, but during a medication pass observation, an LVN prepared and administered a tablet containing calcium 600 mg with cholecalciferol 5 mcg instead. During a later interview and record review, the LVN confirmed the resident received the 5 mcg product rather than the ordered 10 mcg dose, and the DON stated the medication nurse was expected to verify the medication before administration. Controlled substance reconciliation was also incomplete for two residents whose liquid morphine sulfate bottles were stored in Medication Cart B. During inspection of the cart and review of the Controlled Substances Log, the RX Number was missing for both bottles, one for each resident, on the log pages used for reconciliation. The DON confirmed the missing RX Numbers and stated the incoming and outgoing medication nurses use the blue book for controlled substance reconciliation, and that the RX Number is used to identify the medication.
Lack of Clinical Rationale for Dual Antidepressant Therapy
Penalty
Summary
The facility failed to ensure that the Pharmacy Consultant’s recommendation was acted upon for one resident reviewed for unnecessary medications. The resident was prescribed trazodone 50 mg at bedtime for depression and escitalopram 10 mg daily for depression. A Pharmacy Consultant note to the attending physician/prescriber stated that the resident was currently receiving both antidepressants and recommended considering management of the resident’s depression with a single antidepressant if clinically appropriate, or documenting the clinical rationale if dual therapy was continued. The physician responded to continue the dual antidepressant therapy, but the form did not include documentation of the clinical rationale for that decision. Review of the resident’s medical record, including the care plan, H&P, and physician progress notes, did not show documentation supporting the continued use of trazodone and escitalopram together. The resident had impaired cognitive function/dementia related to dementia. During interview and concurrent record review, an LVN confirmed that the record did not contain the rationale for continued dual antidepressant therapy and stated that the rationale was not there. The Administrator and DON were informed of the continued use of trazodone and escitalopram without a clinical rationale and acknowledged the findings.
Failure to Monitor Heart Rate With Ordered Amiodarone
Penalty
Summary
Resident 7 was cited for unnecessary drugs because the facility did not ensure the resident’s heart rate was monitored for the ordered use of amiodarone. The resident was admitted to the facility and had an H&P dated 3/4/26 showing no capacity to understand and make decisions due to dementia. A physician order dated 3/3/26 directed staff to give amiodarone HCL 200 mg by mouth daily for hypertension, give with food, and hold the medication if the heart rate was less than 60 beats per minute. Review of Resident 7’s May 2026 MAR showed the amiodarone was administered, but there was no evidence that the heart rate was monitored and documented. During a concurrent interview, LVN 4 verified that no heart rate was documented on the MAR and stated the heart rate should have been monitored and documented per the physician’s order. The Administrator and DON were later informed that the resident’s heart rate was not monitored as ordered, and they acknowledged the findings.
Food Not Palatable or Appealing
Penalty
Summary
Food and drink were not ensured to be palatable and attractive when three residents expressed dissatisfaction with the taste of the food served. During the initial tour, one resident stated the food did not taste good. During dining observations, another resident stated the food was a bit bland, and a third resident stated the food tasted very old. The facility’s Spring Cycle Menus dated 5/4/26 showed the regular lunch menu included tarragon chicken with sauce, oven roasted potatoes, green beans with red peppers, broccoli salad, and tropical fruit mold. During an interview and concurrent test tray evaluation of the regular menu with the DSS, RD 2, and five surveyors present, the potatoes served were verified to be bland. The Administrator, DON, Clinical Resource Nurse, and Dietary Resource were informed of these findings and acknowledged them.
Meals Not Consistent With Documented Food Preferences
Penalty
Summary
The facility failed to ensure that two residents received lunch trays consistent with their documented food preferences. Resident 175 had a meal ticket that documented a dislike for all vegetables, but during tray line observation the resident's lunch tray included green beans and red peppers. The RD verified the finding during the observation. Resident 194 also had a documented dislike for apple juice on the meal ticket, but during tray line observation the resident's lunch tray included one cup of apple juice. The DSS verified the finding. The facility's Diet Type Report showed 153 residents received food from the kitchen, and the facility's Nutrition Status Management policy stated diet evaluations include resident likes and dislikes.
Unlabeled Outside Food in Resident Refrigerators and Inconsistent Staff Education
Penalty
Summary
The facility failed to follow its policy for foods brought by family or visitors and failed to ensure staff were educated on safe food handling of outside food. The facility’s policy required food brought to a resident by family or visitors to be accepted by the resident, inspected before storage, stored and served according to food safety standards, and labeled with the resident name, location, and date. During observation and concurrent interview with the DSS, multiple items in Resident Refrigerator A were found without the required labeling, including a case of Black Cherry Thrifty ice cream, a half and half container, two Ensure bottles, and five diet coke bottles in a brown bag. In Resident Refrigerator B, a case of McConnell’s Fine Ice dated 4/18/26 was observed without a resident name label. The DSS confirmed the items should have been labeled with the resident’s name, date, and room number per facility policy. The facility also did not ensure that staff who received food from residents’ family members and visitors were educated on proper safe food handling of outside food. The DSS stated he instructed families and visitors that food must be as fresh as possible and that it would need to be labeled with the resident’s name, date, and room number, but he did not provide education on safe food handling techniques. LVN 1 stated families and visitors were educated on the resident’s diet but denied providing education on safe food handling, including hold temperatures for meats, cross contamination prevention, and hand hygiene. LVN 8 also denied providing this education. The DSD stated education on preparation and cooking temperatures was provided by the DSS, while the DSS denied providing that education and stated the DSD and/or IP provided it. The Administrator, DON, Clinical Resource Nurse, and Dietary Resource were informed and acknowledged the findings.
Incomplete hospice documentation and missing elopement re-evaluation
Penalty
Summary
The facility failed to ensure medical records were accurate and complete for two residents. For one resident receiving hospice services, the hospice binder contained Hospice Visit Communication forms from 6/1/25 through 5/5/26 that documented the disciplines visiting, significant findings or new orders, and the hospice staff signature and date of visit, but the resident name and ID number section was left blank. The same resident’s Hospice Team Visit Calendar for May 2026 also showed hospice staff initials entered for future visits before the visits occurred. During record review, the Case Manager and Hospice Nurse verified the missing resident identifier and the pre-signed calendar entries, and both stated the resident name and ID number should have been completed and the calendar should not have been signed before care was performed. The resident had a surrogate medical decision maker and limited participation due to cognitive impairment. For another resident, the record showed an elopement evaluation on admission stating there was no history of elopement or wandering and no behaviors such as wanting to go home, packing belongings, or staying near an exit door. The physician later ordered a wanderguard for the resident’s left ankle, but the medical record did not contain an elopement re-evaluation or other documentation showing the resident was at risk for elopement before the wanderguard order. The resident’s care plan listed the wanderguard under special treatments, procedures, and devices, but there was no documentation explaining why it was being used. During interviews, an RN stated that if a resident showed exit-seeking behavior, the facility would initiate a change in condition evaluation and a new elopement evaluation, and that a physician would be notified if the resident was at high risk. An LVN stated the resident had tried to pack belongings and attempted to leave when newly admitted, but was easily reoriented and redirected. The DON stated there should have been an elopement re-evaluation or nurse’s progress note documentation to justify the wanderguard, and acknowledged that no documentation could be found showing wandering or attempts to exit the facility before the device was used.
Missing Hospice Visit Documentation and Calendar Entries
Penalty
Summary
The facility failed to provide the necessary care and services for one of three final sampled residents, Resident 52, who was receiving hospice services for end-stage Parkinson's disease. Resident 52 had a physician's order to admit under Hospice A, and Hospice A's plan of care included skilled nursing visits one to three times per week, hospice aide services, and chaplain services. Review of the resident's hospice records showed the medical record did not contain the Chaplain and Certified Home Health Aide visit notes, and the hospice visitation calendar for May 2026 was not available in the resident's medical record to show the scheduled weekly visits. Survey review also found the hospice visitation calendar for April 2026 did not show the scheduled skilled nurse visit for the week of 4/26/26, and the Hospice Visit Summary Log did not document that the skilled nurse visited during that week. The calendar showed the CHHA was scheduled to visit on 4/9/26, but the CHHA sign-in form did not document the care provided, including personal care, presence of shortness of breath and/or pain, or the resident's last bowel movement. The calendar also showed a chaplain visit scheduled for 4/29/26, but the Hospice Visit Summary Log did not show documentation that the resident was seen by the chaplain.
Late Transmission of Discharge MDS Assessments
Penalty
Summary
The facility failed to complete and transmit Discharge MDS assessments within the required time for three of three nonsampled residents reviewed for resident assessments: Residents 19, 24, and 101. Review of the closed medical records showed Resident 24 was admitted and later discharged on 12/4/25, but the Discharge MDS assessment was in progress and had not been submitted at the time of review. Resident 19 was admitted and discharged on 1/17/26, and the record did not show that a Discharge MDS assessment had been completed and submitted. Resident 101 was admitted and discharged on 1/21/26, and the record also did not show that a Discharge MDS assessment had been completed and submitted. On 5/4/26, the MDS Assistant reviewed the closed records for Residents 19, 24, and 101 and verified the findings. A CMS Submission Report dated 5/5/26 showed that Resident 24's Discharge MDS was accepted more than 17 weeks past the required transmission date, Resident 19's Discharge MDS was accepted more than 11 weeks past the required transmission date, and Resident 101's Discharge MDS was accepted more than 10 weeks past the required transmission date. On 5/6/26, the Administrator, DON, and Clinical Resource Nurse were informed of and acknowledged these findings.
Failure to Ensure Safe and Appropriate IV Care and Documentation
Penalty
Summary
The facility failed to provide necessary care and services for the safe and appropriate administration and maintenance of IV fluids and access devices for multiple residents. For several residents with PICC lines or midline catheters, the facility did not ensure that dressing changes were completed weekly as required, nor did they consistently measure and document arm circumference and external catheter length during dressing changes. In some cases, such as with one resident, the care plan for IV use was not developed in a timely manner, and documentation was bypassed by staff entering 'N/A' instead of actual measurements. Additionally, the facility did not always obtain physician's orders for the care and maintenance of IV lines, nor did they develop care plans for residents with IV access. For example, one resident received IV hydration therapy without a corresponding physician's order for maintenance, and there was no documentation of site assessment or a care plan addressing the IV site. Another resident had a peripheral IV site that was not labeled with the date, time, or initials upon insertion, and there was no physician's order or care plan for the maintenance of the IV site as required by facility policy. Observations and interviews confirmed that these lapses in care and documentation were acknowledged by facility staff, including the MDS Coordinator, RNs, and the DON. The failures included not following facility policies for IV site labeling, not performing or documenting required assessments and measurements, and not initiating or updating care plans in a timely manner. These deficiencies were identified through direct observation, medical record review, and staff interviews, and had the potential to delay the identification of catheter-related complications for the affected residents.
Multiple Food Safety and Sanitation Failures in Kitchen Operations
Penalty
Summary
Surveyors identified multiple failures in the facility's kitchen related to food safety and sanitation. During an initial kitchen tour, the hood over the stove was found to have black, dirt residue, contrary to the facility's policy requiring biweekly cleaning and USDA Food Code standards. The kitchen staff acknowledged that the hood was only cleaned monthly, and both the Registered Dietitian (RD) and Assistant Dietary Services Supervisor (DSS) recognized this as an infection control and fire hazard issue. Additionally, several kitchen utensils, including slotted scoops, spatulas, and serving spoons, were observed to have partially melted handles, discoloration, and were in poor repair, which the RD and Assistant DSS confirmed should have been replaced according to policy and food code requirements. Further observations revealed that multiple utensils and kitchenware, such as knives, scoops, and serving spoons, were dirty, with dry, crusted residue, cloudy film, and watermarks present. The RD and Assistant DSS acknowledged these items had not been properly washed, violating both facility policy and food code standards for cleanliness. Cutting boards in the kitchen were also found to be heavily marred, fuzzy, and with deep grooves, making them difficult to clean and sanitize. The RD stated the boards had been changed the previous month, but the Assistant DSS agreed they should have been replaced due to infection control concerns. Additional deficiencies included the absence of a thermometer in the chest freezer used for ice cream storage, despite facility policy requiring two thermometers per freezer and food code guidance on proper temperature monitoring. During meal service, milk beverages were found to be above the recommended temperature, with one instance measuring 43 degrees Fahrenheit and another at 49.1 degrees Fahrenheit, exceeding the facility's policy and food code requirements for cold food holding. These findings were verified by the RD and DSS during observation and interview.
Failure to Maintain Comfortable Sound Levels and Room Condition
Penalty
Summary
The facility failed to maintain a comfortable and homelike environment for several residents, as evidenced by excessive noise levels and physical disrepair in a resident's room. Multiple residents expressed concerns about loud noises caused by staff slamming kitchen and dining room doors, as well as staff speaking loudly in the hallways, particularly during shift changes at night. These concerns were consistently reported during resident council meetings and individual interviews, with residents stating that the noise disrupted their rest and that the issue persisted despite being brought to the facility's attention. Observations confirmed that the dining room door made a loud noise when closed, and both the Administrator and Maintenance Director acknowledged the problem during on-site checks. Residents reported that the noise was especially problematic during the 2300 hours shift change, when staff would gather and socialize in the hallway, further increasing the noise level. Some residents also noted that they had not been offered alternative room placements in response to their complaints about the noise. Additionally, one resident's room was found to be in disrepair, with scratches and chipped paint on the wall adjacent to the bed. The resident indicated that while some repairs had been made to other parts of the room, the damaged wall near the bed, where the resident spent significant time, had not yet been addressed. The Administrator confirmed the condition of the room and acknowledged the outstanding repairs.
Failure to Revise Care Plans Following Physician Orders and Changes in Condition
Penalty
Summary
The facility failed to ensure that comprehensive care plans were revised in accordance with physician orders and changes in resident conditions for two residents. For one resident, the care plan indicated that 240 ml of fluid should be provided with each meal, while the physician's order specified 360 ml per meal as part of a fluid restriction protocol. This discrepancy was confirmed during a review with the Registered Dietitian, who acknowledged that the care plan did not reflect the current physician's order. For another resident, the care plan addressing psychotropic medication use was not updated when there was a change in the manifestation of the resident's behavior. The physician's order was revised to monitor episodes of psychosis manifested by seeing objects that were not there, but the care plan continued to reference only persecutory delusions. Both the MDS Coordinator and the DON confirmed that the care plan was not revised to reflect the updated behavioral symptoms as required.
Failure to Provide Adequate Nail Care Resulting in Self-Inflicted Injuries
Penalty
Summary
A deficiency was identified when a resident who was dependent on staff for activities of daily living (ADL), including personal hygiene and grooming, did not receive adequate nail care. The resident was observed multiple times with long and sharp fingernails, which resulted in self-inflicted scratches on the face. Staff interviews confirmed that the resident required total assistance with ADLs and could not perform personal hygiene independently. The care plan for the resident specifically included an intervention to keep fingernails short due to a history of self-inflicted skin impairment, but this intervention was not consistently implemented. Observations and interviews with CNAs and an LVN revealed that the resident's fingernails had not been trimmed as required, and staff could not recall the last time nail care was provided. The resident was repeatedly seen scratching his face, and staff acknowledged that the long fingernails contributed to the skin injuries. The facility's policy required staff to provide ADL assistance according to individualized care plans, but this was not followed for the resident in question, resulting in unmet personal hygiene needs and skin integrity issues.
Failure to Provide Prescribed Fluid Amounts with Meals
Penalty
Summary
A deficiency occurred when a resident with end-stage renal disease and a physician-ordered fluid restriction of 2000 ml per 24 hours did not receive the prescribed amount of fluids with meals. The physician's order specified that the dietary department should provide 360 ml of fluids with each meal (breakfast, lunch, and dinner), totaling 1080 ml per day from dietary sources. However, the resident was only provided with 240 ml of fluid (a carton of Nepro) at each meal, which was consistent with a lower fluid restriction than ordered. There was no documentation indicating that the resident refused the additional fluids or that the physician was notified about the discrepancy. The issue was identified through observation, interviews, and medical record review. The resident confirmed only receiving 240 ml of fluid with each meal and expressed a preference for a variety of fluids, including water, juice, and hot chocolate. The registered dietitian (RD) verified that the dietary department was not following the physician's order and that the resident had not received the ordered amount of fluids since at least a specific date. The RD also confirmed that the kitchen's diet order did not match the physician's order, and there was no documentation of any refusal or physician notification regarding the missed fluids.
Failure to Provide Safe and Sanitary Respiratory Care
Penalty
Summary
The facility failed to provide safe and sanitary respiratory care for three residents who required oxygen therapy. One resident received oxygen therapy without a physician's order, and the oxygen tubing and nasal cannula for this resident were found lying on the floor, not maintained in a sanitary manner. The resident had a recent history of pneumonia and was readmitted from an acute care hospital, but there was no current physician order for oxygen therapy, as confirmed by both observation and staff review of the medical record. Another resident was observed using oxygen tubing that was not labeled with the date it was first used or changed, and the tubing was not stored in a sanitary manner, being left on the bed and not placed in a plastic bag as required by facility policy. Staff interviews confirmed that the tubing should have been labeled and stored properly to prevent contamination, and that the tubing was being changed every 72 hours, although the infection preventionist later stated the change interval was weekly. The tubing was replaced after the deficiency was identified. A third resident's oxygen tubing and humidifier bottle were also not labeled with the date they were last changed, contrary to facility policy. Staff verified that labeling was necessary to ensure timely changes and prevent infection. The Director of Nursing confirmed the importance of dating these items for infection control. These findings were based on direct observation, staff interviews, and review of facility policies and medical records.
Failure to Provide Appropriate Dialysis Care and Monitoring
Penalty
Summary
The facility failed to provide necessary care and services for two residents requiring dialysis. For one resident, who was scheduled for dialysis three times per week, physician orders specified that antihypertensive medications should be withheld on dialysis days. Despite these orders, the medication Benazepril hydrochloride was administered on several dialysis days, as confirmed by both the Medication Administration Record (MAR) and the Director of Nursing (DON). This occurred even after the physician's orders were updated to clarify when the medication should be held. For another resident with an arteriovenous (AV) shunt in the left upper arm, the facility did not consistently assess and monitor the dialysis access site as required. The facility's policy and physician orders required that the AV shunt be checked for bruit and thrill every shift, and that the site be monitored for redness, bleeding, skin breakdown, and edema. Documentation in the MAR showed multiple instances where the AV shunt was assessed as negative for thrill and bruit, and positive for signs of redness, bleeding, skin breakdown, or edema. However, there was no evidence that the physician was notified of these findings, despite facility policy and physician orders requiring immediate notification for such changes. Interviews with nursing staff confirmed that the absence of bruit and thrill, as well as the presence of redness, bleeding, skin breakdown, or edema, should have prompted physician notification. The DON and other staff acknowledged that these findings represented a change in condition and that the physician should have been informed, but this did not occur according to the documentation reviewed.
Failure to Account for Controlled Medications and Improper Eye Drop Administration
Penalty
Summary
The facility failed to ensure proper accounting and safeguarding of controlled medications by not consistently obtaining signatures from incoming and outgoing licensed nurses on the Controlled Substance Logs for two medication carts. Multiple instances were identified where nurses' signatures were missing for various shifts, as verified by facility staff and the Director of Nursing. The facility's policy requires a physical inventory and documentation of controlled medications at each shift change, but this procedure was not consistently followed, creating gaps in medication accountability. Additionally, the facility did not ensure proper administration of an eye drop medication for a resident with moderate cognitive impairment and a diagnosis of mild open-angle glaucoma. During a medication administration observation, the nurse did not compress the resident's tear duct or ensure the resident's eyes remained closed for the required time after instilling the eye drops, as outlined in facility policy. The nurse left the room before confirming the medication was properly absorbed, and the resident was observed opening and wiping his eyes shortly after administration.
Failure to Document Emergency Kit Medication Use and Remove Expired Medications
Penalty
Summary
The facility failed to ensure proper documentation and storage of medications as required by its own policies and professional standards. During an inspection of the medication room's IV emergency kit, it was observed that a vial of Lidocaine was missing from the kit, and there was no documentation in the Emergency Kit Usage Log regarding its removal, the resident it was administered to, or the date it was taken. The Infection Preventionist (IP) and Director of Nursing (DON) confirmed that the nurse who removed the medication did not document the usage as required by facility policy. Additionally, expired Santyl collagenase ointments were found on Treatment Cart 2 during an inspection. The ointments had expiration dates that had already passed, and the presence of these expired medications was verified by an LVN, who acknowledged that expired medications or medical supplies should be disposed of. The DON was informed of these findings and acknowledged the presence of expired medications on the treatment cart.
Failure to Provide Required Adaptive Eating Equipment
Penalty
Summary
The facility failed to provide special eating equipment, specifically a sippy cup, to a resident who required it to maintain independence in self-feeding. Medical records, including a nutrition evaluation and physician order, indicated the resident should have a sippy cup for meals. The resident's diet card also specified the need for adaptive equipment at all meals. During a mealtime observation, the resident was seen using regular cups for both milk and juice, and a CNA confirmed that the sippy cup was not provided as required. The CNA stated that the kitchen should have supplied the sippy cup, and an LVN verified that the resident should have received it, confirming the deficiency.
Incomplete and Inaccurate Medical Record Documentation for Multiple Residents
Penalty
Summary
The facility failed to maintain complete and accurate medical records for three residents, as evidenced by missing or incomplete documentation in medication administration records (MAR), physician orders, and required forms. For one resident, the MAR did not show administration of prescribed medications such as Protonix and Humalog insulin, nor did it document completion of a tuberculin test or required monitoring activities, including hours of sleep, non-pharmacological interventions, side effects of hypnotics, signs and symptoms of bleeding related to anticoagulant use, and pain level assessments for specific shifts. The LVN confirmed that these omissions meant the care or monitoring was not performed or not documented as required. Another resident's Physician Orders for Life-Sustaining Treatment (POLST) form was found to be incomplete, lacking the physician's name, telephone number, license number, signature, and date for a period of six months. Both the Social Services Designee and the DON acknowledged that the POLST should have been fully completed according to requirements. Additionally, the facility did not accurately calculate and document weekly fluid intake totals for a third resident who was on a physician-ordered fluid restriction and required weekly evaluation of intake and output. The documentation reflected daily, rather than weekly, fluid intake amounts, which was verified as inaccurate by the DON. These documentation failures were confirmed through interviews and concurrent record reviews with facility staff.
Infection Control Lapses in Resident Care and GT Procedures
Penalty
Summary
The facility failed to implement appropriate infection prevention and control practices as evidenced by multiple observed deficiencies. In one instance, a resident's urinal containing approximately 200 ml of urine was placed on a bedside table next to a water pitcher and two cups of juice, creating a potential for contamination of the drinks. The MDS Coordinator confirmed the placement and acknowledged the risk of contamination. Additionally, staff did not adhere to hand hygiene protocols during gastrostomy tube (GT) care. An LVN was observed administering medication via GT without performing hand hygiene or changing gloves after touching the privacy curtain, despite facility policy requiring handwashing before handling GTs. Furthermore, a nurse failed to follow Enhanced Barrier Precautions (EBP) for a resident with a respiratory MDRO and an indwelling medical device, as she did not don a gown and mask while providing GT care, even though signage and care plans indicated EBP was required. These lapses were verified by staff during interviews.
Failure to Develop Care Plan for Oxygen Therapy
Penalty
Summary
A deficiency was identified when the facility failed to develop a comprehensive care plan for a resident who was receiving oxygen therapy. The resident, who had been diagnosed with pneumonia and was recently readmitted from an acute care hospital, was observed lying in bed with an oxygen concentrator set to deliver continuous oxygen at 2 liters per minute. The oxygen tubing and nasal cannula were attached, and the resident had been receiving this therapy since readmission. During interviews and medical record reviews with both an LVN and the DON, it was confirmed that there was no physician's order for the oxygen therapy and no care plan had been initiated to address the resident's use of oxygen. The DON acknowledged that a care plan should have been started at the time the resident began receiving oxygen therapy after readmission, but this was not done.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to honor a resident's documented food preferences, resulting in the resident being served items she had specifically identified as dislikes. The resident's care plan and nutrition evaluation clearly listed several foods she did not want, including bacon, pork, mushrooms, spinach, olives, cabbage, and shredded carrots. Despite these documented preferences, the resident was observed being served cabbage and carrots for lunch, which were noted as dislikes on her diet card. During interviews and observations, the resident expressed frustration about receiving unwanted food items, and a CNA confirmed that the lunch tray should not have included cabbage and chopped carrots. The resident did not eat her lunch and requested an alternative meal, further verifying that her preferences were not being honored as required by her care plan and dietary documentation.
Failure to Provide Appropriate Dietary Texture Leads to Resident's Choking Incident
Penalty
Summary
The facility failed to provide a resident with the appropriate dietary texture as ordered by the physician, which put the resident at risk for choking. The resident, who had diagnoses including dysphagia, acute respiratory failure, epilepsy, and autism, was on a fortified, pureed diet with nectar thick liquids. Despite this, the resident was given regular peanut butter and jelly sandwiches, which were not consistent with the prescribed pureed diet. The facility's documents clearly indicated that peanut butter sandwiches were not allowed for residents on a pureed diet. The incident occurred when a healthcare assistant (HA) provided the resident with regular texture sandwiches, unaware of the resident's dietary restrictions. The HA stated that the resident frequently requested and consumed these sandwiches, and there was no communication regarding the resident's specific diet orders. The resident experienced a choking episode, followed by seizure-like activity, and was found unresponsive with food in their mouth. Despite efforts to perform the Heimlich maneuver and initiate CPR, the resident expired. Interviews with facility staff, including the Administrator and Director of Nursing (DON), confirmed the inconsistency with the resident's diet orders.
Controlled Medication Diversion in LTC Facility
Penalty
Summary
The facility failed to provide necessary pharmacy services to safeguard controlled medications for nine of 11 sampled residents. This deficiency was identified through interviews, medical record reviews, and facility document reviews. The missing medications included significant quantities of tramadol, hydrocodone-acetaminophen, and Oxycontin, which were not accounted for in the medication cart's locked narcotic drawer. The facility's policies and procedures required controlled substances to be handled, stored, and documented according to federal and state laws, but these protocols were not followed, leading to the diversion of medications. The investigation revealed that the controlled medication logs for the affected residents showed discrepancies. For instance, the logs indicated that medications were transferred to the Director of Nursing (DON) for destruction, but the signatures on these logs were forged. The missing medications were from residents who either had large amounts of controlled medications on hand, took pain medication infrequently, or were transferred out of the facility. The facility's narcotic count, conducted at each shift change, failed to detect the diversion because the logs falsely indicated that the medications were in the possession of the DON. Interviews with the DON and Administrator confirmed that the controlled medications were supposed to be transferred to the DON's locked cabinets when discontinued or when residents were transferred. However, the perpetrator forged the signatures of the DON and a witnessing nurse on the controlled medication logs, making it appear as though the medications were properly transferred. This failure in the facility's medication management system resulted in the unaccounted loss of controlled substances, highlighting a significant breach in the facility's responsibility to safeguard medications.
Failure to Document Post-Fall Assessment
Penalty
Summary
The facility failed to ensure that a resident received the necessary care and services to maintain their highest practicable well-being following an unwitnessed fall. The resident, who had the capacity to understand and make decisions, experienced a fall resulting in a head injury. Despite the facility's policy requiring a physical assessment and documentation in the Nursing Progress Notes after a fall, there was a lack of detailed documentation regarding the resident's skin condition and the description of the hematoma on the right frontal temporal region. The resident reported a pain level of 8 out of 10 and had a visible bump with a scab on the head. Although the resident was transferred to an acute care hospital and later returned to the facility, the medical records lacked comprehensive documentation of the skin and wound condition. The Director of Nursing confirmed the absence of necessary documentation, acknowledging that the staff should have documented the description of the hematoma as per the facility's policy.
Incomplete Medical Record Documentation for Residents
Penalty
Summary
The facility failed to ensure the completeness and accuracy of medical records for three of eight sampled residents. For Resident 2, the licensed nurse did not document blood sugar levels, levothyroxine administration, and the amount of regular insulin administered in the Medication Administration Record (MAR) on two specific dates. This lack of documentation was confirmed during an interview with the Director of Nursing (DON), who stated that the expectation was for nurses to document medication administration immediately after it occurred. Similarly, for Resident 3, the MAR lacked documentation of blood sugar levels, the amount of insulin administered, and the nurse's initials on the same two dates. The DON verified these findings during a review and interview, reiterating the expectation for immediate documentation post-medication administration. For Resident 8, the MAR was missing the nurse's initials for medication administration on two separate dates. The medications involved were for the treatment of Parkinson's disease. The DON confirmed these omissions during a review and interview, acknowledging the expectation for timely documentation. These documentation failures had the potential to impact the residents' care needs due to incomplete and inaccurate medical information.
Failure to Properly Manage and Document Controlled Substances
Penalty
Summary
The facility failed to provide the necessary pharmacy services for a resident, specifically in the management and documentation of controlled substances. The facility did not ensure that the resident's oxycodone medications were stored properly, resulting in missing medications. Additionally, the facility did not ensure that the Controlled Drug record and the Medication Administration Record (MAR) documentation for the resident's oxycodone matched. This discrepancy was confirmed through interviews with the Director of Nursing (DON), Registered Nurse (RN), and Licensed Vocational Nurses (LVNs), who acknowledged the missing medications and documentation inconsistencies. The facility's policies and procedures (P&P) required that controlled substances be received, stored, and documented by licensed personnel. However, the investigation revealed that the resident's oxycodone medications were not properly stored or accounted for. RN 1 admitted to receiving the medications but failed to inform anyone or properly store them, leading to the medications being unaccounted for. Further review showed that the MARs did not reflect the administration of the medications on specific dates, despite being signed out in the Controlled Drug record. Additionally, the facility failed to conduct proper inventory checks of all narcotics during shift changes. The investigation found multiple instances of missing signatures on the shift count sheets for Medication Carts 1, 2, 3, and 5, indicating that the required physical inventory of controlled substances was not consistently performed. This lapse in procedure was verified by the DON and Clinical Resource nurse, who acknowledged the missing documentation and the potential for medication diversion due to these failures.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 3,749 citations issued within 25 miles in the last 12 months — including the 7 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 Santa Ana
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Advanced Rehab Center Of Tustin | 1.2 mi | ★★★★★ | 49 | 0 |
| French Park Care Center | 1.3 mi | ★★★★★ | 51 | 0 |
| Healthbridge Children's Hospital - Orange D/p Snf | 1.3 mi | ★★★★★ | 18 | 0 |
| Town & Country | 1.3 mi | ★★★★★ | 27 | 0 |
| Orange Healthcare & Wellness Centre, Llc | 1.6 mi | ★★★★★ | 27 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.