Below average — CMS composite of the measures below.
The next survey window likely opens around January 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 Meadows Post Acute during CMS and state inspections, most recent first.
A cognitively intact resident with COPD, heart failure, and type 2 DM was seated on a patio interacting with other residents when another cognitively intact resident in a wheelchair suddenly stood up and struck the resident in the right eye area with a closed hand, causing a laceration, bruising, and mild pain. Documentation on SBAR and skin assessments described the wound characteristics and discoloration, and interviews with the resident and staff confirmed that the contact was willful and non-consensual. The facility’s abuse policy defined such resident-to-resident contact as abuse and affirmed residents’ right to be free from abuse, neglect, misappropriation, and exploitation.
A cook thawed fish in the prep sink without monitoring water or food temperatures, then delayed cooking while the fish remained in the temp danger zone. The DS stated the facility did not use thawing logs or measure food temps before cooking. Surveyors also observed chipped and peeling refrigerator racks, rust and residue on freezer racks, dented cans stored with non-dented cans, dust in dry storage, and wet trays stacked after dishwashing.
Failure to Protect Confidential Resident Information: Meal tickets containing PHI were observed in the trash in the dishwashing area, and a Dietary Aide was seen discarding them instead of shredding them. The DS stated the tickets included resident names, room numbers, diets, likes and dislikes, and photographs, and that they should have been placed in a box and shredded to protect resident privacy and confidentiality.
Improper Dumpster Closure and Litter Around Waste Area: A dumpster was observed propped open by a box while not in use, and food residue and paper trash were found on the ground around it. The DS stated the dumpster should stay closed when not in use and the area should be kept clean; the box had not been broken down, which caused the lid to remain open.
Infection control failures occurred in dietary operations when two dented cans were stored with non-dented cans, the dumpster was left with a gap in the cover and trash around it, a soiled towel touched the base of a salad plate during plating, and a dietary staff member changed tasks without washing hands. The DS, DON, and IPN stated these practices could contaminate food and spread germs, and facility policies required separation of damaged cans, covered refuse containers, clean dumpster surroundings, separation of soiled and clean items, and hand hygiene when changing tasks.
Failure to Provide Assistance With Mobility and Getting Out of Bed: Three residents with significant care needs were repeatedly observed remaining in bed while staff did not offer or provide assistance to get them up. One resident with encephalopathy and reduced mobility, one resident with acute embolism and muscle weakness, and one resident with severe cognitive impairment were all documented as dependent or needing substantial help with ADLs, yet CNAs stated they did not take them out of bed because they believed the residents did not like it, only got up on shower days, or could not tolerate a wheelchair. The ADON stated residents should be offered to get out of bed as part of ADLs.
Failure to Invite Residents to Group Activities: Two residents were not invited to group activities. One resident with encephalopathy, depression, reduced mobility, and moderately impaired cognition stated he had not participated because no one invited him, and the AD found no documentation that he was offered activities. Another resident with acute embolism/thrombosis, muscle weakness, and dependence for some ADLs stated he was not offered group activities and wished he were asked more often. The AD confirmed both residents should have been invited.
A resident with diabetes had an ordered admission Hgb A1c that was not obtained, and fingerstick blood sugars were documented only with check marks on the MAR without numerical results. The ADON, DON, and RNs confirmed the blood sugars were checked but not properly recorded, leaving no documented A1c or glucose values to support evaluation of the resident’s diabetes management.
Kitchen staff were not routinely trained or evaluated for competency in safe thawing and temperature monitoring. A cook thawed fish under running water in a prep sink without documenting temperatures, then delayed cooking while the fish remained at unsafe temperatures. The DS and RD stated the facility lacked thawing logs, staff had not been trained on sink thawing, and cook competency records were incomplete or not scored.
Food was not served at proper temperatures during lunch trayline service. A DS observed cold items such as sweet corn salad, tartar sauce, milk, and dessert above required cold temps, while puree fish, creamed spinach, and rice were below the facility's hot holding range. The DS stated some items had been plated too early or in a way that allowed temperatures to change before service, contrary to facility P&P and standardized recipes.
A facility failed to prepare IDDSI Level 4 puree foods in a form designed to meet individual needs when pureed rice did not pass the spoon tilt test and pureed salad appeared watery during a test tray observation. The DS stated the rice was too sticky and the salad did not hold its shape, and the facility’s diet manual and recipes required puree foods to be smooth, free of lumps, hold shape, and pass IDDSI testing.
A resident with dementia and severely impaired cognition was documented as lacking capacity to make healthcare decisions, yet the facility had the resident place a thumb-mark on an Advance Directive Acknowledgment form and decline assistance with formulating an AD. RN stated the resident could not understand the form and that the responsible party or representative should have been given the AD materials and informed of the resident's right to execute an advance directive, consistent with the facility policy requiring admission staff or designee to provide this information.
Failure to Follow Up on Required PASARR Level II Evaluation: A resident with dementia, schizoaffective disorder, bipolar disorder, and depression had a PASARR I screen indicating a Level II mental health evaluation was required, but the facility had no documented follow-up. The MDS Nurse stated the required PASARR II evaluation was missed and that no contact was made with a PASARR representative regarding the evaluation.
A resident with paraplegia, hemiplegia/hemiparesis, and tobacco use had a smoking care plan that remained general despite ongoing non-compliance with smoking safety. The record showed he used a cigarette holder, refused to surrender smoking materials, had other residents light his cigarettes in the past, and required supervision while smoking, but the plan did not specify receptionist monitoring, activity staff oversight, limits on lighter access, or staff roles for preventing burn injury. The AD, ADON, and DON all acknowledged the care plan lacked these individualized smoking safety interventions.
A resident with HTN and cataracts had an optometry recommendation for ophthalmology evaluation and a scheduled cataract appointment, but after transfer to a GACH and readmission, the consult was not clarified or kept active. Staff could not locate an active ophthalmology order, and the RN who completed readmission stated she reviewed prior discontinued orders but did not confirm with the physician whether the consult should continue, despite the facility’s readmission policy requiring reconciliation of pending appointments and orders.
Failure to post actual daily nursing staffing information. Surveyors observed that the framed DHPPD postings in nurse's station 1 showed projected hours and incorrect dates instead of the actual hours worked by RN, LPN/LVN, and CNA staff. The DSD and AP/PR confirmed the postings were projected and that actual hours were calculated the next business day, not on the day worked, despite the facility policy requiring daily posting of staffing information in a prominent location.
Buprenorphine was not administered sublingually as ordered for a resident with opioid use disorder. An LVN gave the tablets with water and the resident swallowed them instead of placing them under the tongue to dissolve, and the LVN acknowledged it was a medication error. An RN stated sublingual meds must be given by the ordered route, and the facility policy required the right method of administration.
Failure to Provide Ordered Nutritional Supplement: A resident with metabolic encephalopathy, dysphagia, and severely impaired cognition had a physician order for Magic Cup twice daily, but an observed lunch tray did not include the ordered supplement even though it appeared on the meal ticket as a standing order. CNA staff confirmed the omission, and the RD stated the supplement was intended to provide extra calories and protein and was to be placed on the tray by dietary staff, with nursing responsible for checking tray accuracy.
A resident with osteoarthritis and immunodeficiency reported unclean shower rooms, including mold odor and visible black discoloration in a shower booth. Facility staff confirmed the presence of black spots in multiple areas of the shower, and the janitor responsible for cleaning lacked a set schedule or checklist for deep cleaning. Facility policy required regular cleaning and a homelike environment, but these standards were not met.
A resident with impaired cognition and multiple chronic conditions attended an IDT care conference without the responsible party being notified or invited, despite facility policy and regulatory requirements. Interviews and record reviews confirmed the lack of notification and documentation, resulting in the responsible party not being able to participate in care planning and treatment decisions.
A resident with rheumatoid arthritis and other chronic conditions did not receive a scheduled Remicade IV infusion after an RN failed to promptly communicate an outpatient clinic's notification to the DON. The RN only notified the physician and assumed the resident would receive the infusion after discharge, resulting in a delay of treatment and not meeting the facility's policy for timely care.
A resident with multiple respiratory diagnoses was not provided with continuous oxygen therapy as ordered by the physician. During an observation, the resident was found without oxygen or related supplies, and both an LVN and the DON confirmed that the resident should have been receiving continuous oxygen at the prescribed rate.
A LTC facility failed to administer a prescribed medication for itchiness to a resident with prurigo nodularis, missing doses on two occasions. Additionally, the facility did not obtain physician orders before administering the COVID-19 vaccine to two residents with severe cognitive impairments, using an outside pharmacy without securing necessary documentation. These actions violated the facility's medication administration policy.
A facility failed to provide coordinated hospice services to a resident admitted to hospice care. There was no documented evidence of hospice staff presence, and the facility lacked a designated coordinator to manage hospice care. The resident, with severe cognitive impairment and multiple diagnoses, did not receive well-coordinated hospice services due to these deficiencies.
The facility failed to implement its infection control program by not ensuring a resident's oxygen tubing was labeled and off the floor, and by transporting clean laundry uncovered. The oxygen tubing for a resident with respiratory issues was found touching the floor and undated, contrary to facility policy. Additionally, laundry staff transported clean clothes uncovered, risking contamination, which was against the facility's guidelines.
A facility failed to complete a resident's Quarterly MDS assessment on time, as required by CMS guidelines. The resident, with neuropathy and difficulty walking, was admitted in 2021 and readmitted in 2022. The assessment, due 14 days after the ARD, was completed late, contrary to the facility's policy.
The facility failed to document non-pharmacological interventions before administering PRN opioid pain medication to two residents. Despite care plans outlining non-pharmacological strategies, hydrocodone-acetaminophen was frequently given without prior attempts at these interventions. Interviews confirmed the lack of documentation, contrary to the facility's policy emphasizing non-pharmacological approaches to pain management.
The facility failed to maintain safe food storage and preparation practices, as observed during a survey. Unlabeled wheat bread and English muffins were found in the kitchen, and a resident's food from home lacked a label and received date in the resident's refrigerator. The Dietary Manager and a Registered Nurse confirmed the importance of labeling to prevent foodborne illnesses, as per the facility's policies.
A facility failed to conduct a required quarterly rehabilitation screen for a resident with severe cognitive and physical impairments, as confirmed by the DOR. The resident, admitted with vascular dementia and cerebral palsy, was supposed to have a rehab screen quarterly, but no screen was conducted in August 2024. This oversight was against the facility's policy, which mandates timely and complete documentation in the EMR.
A facility failed to establish a policy for the POLST form, resulting in an incomplete form for a resident with decision-making incapacity. The resident's POLST form lacked the necessary signature from the resident or their legal decision maker, as confirmed by a registered nurse. The administrator acknowledged the absence of a specific policy, which could lead to confusion and delays in care.
The facility failed to document COVID-19 vaccine eligibility screening for two residents before administering the vaccine. Both residents had severely impaired cognition and required assistance with daily activities. The Infection Preventionist did not complete the eligibility screening section on the consent forms, contrary to the facility's policy.
A facility failed to implement proper infection control when an LVN did not wear an isolation gown and face shield before entering a resident's room under novel respiratory precautions for suspected COVID-19. Despite signage indicating the need for full PPE, the LVN entered with only an N-95 mask and gloves, potentially risking the spread of infection. The DON confirmed the requirement to follow posted precautions, as outlined in the facility's infection control plan.
A resident's call light was found out of reach, potentially delaying care. The resident, who required maximum assistance, was unable to call for help. Staff confirmed the call light's improper placement and acknowledged the oversight.
Failure to Prevent Resident-to-Resident Physical Abuse on Patio
Penalty
Summary
The facility failed to protect a resident from physical abuse when one cognitively intact resident struck another in the face while on the facility patio. Resident 3, who had COPD, heart failure, and type 2 diabetes and was assessed as cognitively intact with the capacity to make decisions, was seated on a patio chair interacting with other residents, including Resident 4. At approximately 10:55 a.m., while Resident 3 was conversing with the group, Resident 4, who was seated in a wheelchair in front of Resident 3, suddenly stood up and used a closed fist/hand to hit Resident 3 in the right upper eye area without warning. Resident 3’s assessments indicated that cognition was intact and that the resident required supervision or touching assistance for most ADLs. Following the incident, documentation on an SBAR form and a skin assessment described a linear cut above the right eye, initially measured at 0.5 cm in length by 0.1 cm in width and depth, with small bleeding and reddish discoloration. Subsequent observation by the ADON noted purplish discoloration around the right eye and a laceration approximately 1.0 cm in length by 0.1 cm in width and depth, covered with steri-strips. Resident 3 reported aching pain in the right eye area, rating it 2 out of 10, and expressed being shocked that the incident occurred. Resident 4’s records showed that this resident was also cognitively intact, had decision-making capacity, and required setup or clean-up assistance for most ADLs. On the date of the incident, Resident 4 was on the patio interacting with other residents, including Resident 3, in the presence of an activity staff member (ACS 1). The SBAR for Resident 4 and ACS 1’s interview indicated that Resident 4 suddenly stood up, raised a hand toward Resident 3, and, despite ACS 1’s attempt to intervene, struck Resident 3 in the right eye area. In a subsequent report to the state agency, Resident 4 stated that he felt his hand make contact with Resident 3’s face. The facility’s abuse policy stated that residents have the right to be free from abuse and that willful non-consensual contact between residents is considered abuse and is never to be deemed unavoidable.
Unsafe Fish Thawing and Kitchen Sanitation Deficiencies
Penalty
Summary
The facility failed to implement its Food Preparation and Service policy and failed to ensure safe and sanitary food storage and food preparation practices in the kitchen. During observation, a cook was seen thawing fish in the meat preparation sink under slow running water, and the fish was not in sealed plastic. The dietary supervisor stated the facility’s process was to place fish in the refrigerator, then thaw it in the sink, bread it, and cook it, but staff did not check or record the water temperature and did not monitor the fish temperature during thawing. The cook stated he removed the fish from the freezer around 6:00 a.m., thawed it in the sink, and did not take the fish temperature when it was removed from the sink. The fish remained out of the freezer for an extended period and was later observed in the oven with temperatures of 63.9 F to 69.6 F on randomly selected pieces. The cook stated he did not cook the fish immediately after thawing because he was waiting for another food item to finish cooking and needed to wait until later to cook it. The dietary supervisor stated the facility did not have records or time and temperature logs for monitoring thawing of foods and that staff were not measuring food temperatures prior to cooking. The registered dietitian stated the facility’s thawing process involved either refrigerator thawing or thawing under running water, but also stated that time and temperature monitoring was necessary and that the fish was not appropriate to cook because the extended thawing and preparation time compromised its safety. Additional kitchen observations showed sanitation and storage deficiencies. One rack in the walk-in refrigerator had chips and peeling paint, and one rack in the walk-in freezer had rust and food or ice cream residue. In dry storage, dented cans were stored with non-dented cans, and dust was observed on floor corners, storage racks, and a container lid. During dishwashing, clean trays were observed stacked while still wet after being washed in the dish machine. The dietary supervisor acknowledged these conditions during the observations and stated that the racks, storage areas, cans, and trays should be maintained in a clean and sanitary condition.
Failure to Protect Confidential Resident Information
Penalty
Summary
The facility failed to ensure confidential personal information was protected when meal tickets containing protected health information were not shredded before being discarded in the waste container. During an observation of the dishwashing area, meal tickets were seen in the trash. During a concurrent observation and interview, a Dietary Aide threw the meal tickets into the trash, and the Dietary Supervisor stated the trash bag would later be taken to the dumpsters upstairs after dishwashing. The Dietary Supervisor stated the meal tickets should have been placed in an empty box and shredded to protect resident privacy and dignity because they contained resident names, room numbers, diets, likes and dislikes, and photographs. The supervisor also stated that throwing the meal tickets in the trash could allow someone to access resident information and that the facility had the responsibility to protect residents' confidential information. Review of the facility policy titled Confidentiality of Information and Personal Privacy stated the facility would safeguard resident confidentiality and personal privacy and limit access to resident personal and medical records to authorized staff and business associates.
Improper Dumpster Closure and Litter Around Waste Area
Penalty
Summary
The facility failed to dispose of garbage and refuse properly when one dumpster was observed not fully closed and propped open by a box while not actively in use. During a concurrent observation and interview with the Dietary Supervisor, the dumpster area was also found to have food residue and paper trash on the ground surrounding the dumpster, including cheese and noodle smudges and plastic trash. The Dietary Supervisor stated the dumpster should remain closed when not in use and the surrounding area should be kept clean to prevent attracting flies and other pests. The supervisor also stated the trash was not full, but a box that had not been broken down caused the dumpster lid to be propped open. Facility policy required outside dumpsters to be kept closed and free of surrounding litter, and the Food Code required outside receptacles to have tight-fitting lids or doors and to be kept covered.
Infection Control Failures in Dietary Operations
Penalty
Summary
The facility failed to maintain its infection prevention and control program in the dietary area by allowing two dented cans to be stored with non-dented cans. During interview, the Dietary Supervisor stated the dented cans were mixed with usable stock and explained that dented cans could expose residents to botulism. The facility’s policy on dented cans stated that dented and rusty cans are to be separated from remaining stock and placed in a labeled area for return to the purveyor, and the Food Code noted that dented cans may present a serious potential hazard. The facility also failed to keep the dumpster area sanitary and properly covered. During observation, the dumpster cover had a gap and there were piles of trash, paper, plastic, and a wooden pallet in the surrounding area. The Dietary Supervisor, DON, and Infection Preventionist all stated the dumpster needed to be kept closed and the surrounding area clean and free of debris because trash can attract pests and insects and contribute to the spread of germs. The facility’s policies required garbage and refuse containers to have tight-fitting lids or covers and outside dumpsters to be kept closed and free of surrounding litter. In addition, during salad preparation, a soiled towel was observed touching the base of the salad plate while the salad was being plated. The Dietary Supervisor stated the towel should have been placed in the sanitizer bucket because it could contaminate food and cause foodborne illness. The DON and Infection Preventionist stated dirty and clean items should be separated to prevent cross-contamination. The facility also failed to ensure hand hygiene when changing tasks during food preparation when a dietary staff member chopped vegetables, touched the walk-in refrigerator handle, retrieved carrots, and returned to food preparation without washing hands. The Dietary Supervisor, DON, and Infection Preventionist stated handwashing was required when changing tasks to prevent cross-contamination, and the facility’s hand hygiene and infection control policies required handwashing before and after tasks and when handling soiled items.
Failure to Provide Assistance With Mobility and Getting Out of Bed
Penalty
Summary
The facility failed to ensure that residents were provided with necessary assistance with activities of daily living, specifically mobility and getting out of bed, for three sampled residents. The deficiency was identified through observation, interview, and record review and involved Resident 50, Resident 54, and Resident 9, all of whom were repeatedly observed in bed with call lights within reach during multiple observations. Resident 50 was admitted with diagnoses including encephalopathy, reduced mobility, depression, and unspecified osteoarthritis. The MDS indicated clear speech, the ability to make self understood and understand others, moderately impaired cognition, and dependence on staff for oral hygiene, toileting hygiene, dressing, personal hygiene, and mobility. During observations on multiple days, Resident 50 was seen in bed watching television or eating meals. When interviewed, Resident 50 stated that no one had offered to get the resident out of bed and that the resident would like to get out of bed and get fresh air if offered. A CNA stated that Resident 50 was not taken out of bed because the resident did not like to get out of bed and that no offer was made because the CNA believed the resident would decline. Resident 54 was admitted with diagnoses including acute embolism and thrombosis of the left lower extremity, muscle weakness, and atelectasis. The H&P indicated the resident had capacity to understand and make medical decisions. The MDS showed substantial/maximal assistance with eating and dependence for oral hygiene and toileting. The resident was observed in bed on multiple occasions. During interview, Resident 54 stated that staff did not usually offer to get the resident out of bed, that the resident required assistance to get out of bed, and that the resident would like to go to the patio every now and then but staff did not offer. The CNA stated the resident was not taken out of bed because the resident only gets out of bed on shower days and that no offer was made because the CNA knew the resident did not like to get out of bed. Resident 9 was admitted with diagnoses including encephalopathy, irritable bowel syndrome, unspecified dementia, and depression. The MDS indicated severely impaired cognition, supervision or touching assistance with eating, substantial/maximal assistance with oral hygiene and personal hygiene, and dependence for toileting. The resident was observed in bed with the call light within reach on multiple occasions across several days. The CNA assigned to the resident stated that the resident was not assisted out of bed on two consecutive days because the resident could not tolerate being in a wheelchair, but the CNA did not know where that information came from. The CNA also stated the resident said it hurt and to put the resident back to bed, did not notify licensed nurses, and did not offer the resident to get out of bed on either day. The ADON stated that all residents should be offered to get out of bed as part of ADLs and that charge nurses are responsible for ensuring residents are up out of bed.
Failure to Invite Residents to Group Activities
Penalty
Summary
The facility failed to ensure two residents were invited to attend group activities. Resident 50 was admitted with diagnoses including encephalopathy, reduced mobility, depression, and unspecified osteoarthritis. His MDS dated 11/10/2025 indicated he had clear speech, could make himself understood, could understand others, and had moderately impaired cognition. He was dependent on staff for oral hygiene, toileting hygiene, dressing, personal hygiene, and mobility. Resident 50 was observed in his room in bed watching TV on 2/9/2026 and again on 2/10/2026. On 2/11/2026, he was observed in bed having lunch and stated that he had not participated in group activities because no one had invited him, but that he would attend if invited. The AD reviewed Resident 50's activity notes from 11/2025 through 2/11/2026 and stated there was no documented evidence that he was invited or offered group activities. The AD also stated Resident 50 should have been invited to group activities. Resident 54 was admitted with diagnoses including acute embolism and thrombosis of unspecified deep veins of the left lower extremity, muscle weakness, and atelectasis. His H&P dated 12/10/2025 indicated he had the capacity to understand and make medical decisions. His MDS indicated he required substantial/maximal assistance with eating and was dependent on staff for oral hygiene and toileting. He was observed in bed watching TV on 2/10/2026 at 10:35 a.m. and 12:35 p.m., and on 2/11/2026 he was observed in bed having lunch. He stated that he did not get offered to go to group activities and that it would be nice to be asked every now and then. The AD stated that all residents are offered group activities every morning and throughout the day, but also stated that Resident 54 should have been invited to group activities.
Missing Diabetes Monitoring Documentation and Admission A1c
Penalty
Summary
The facility failed to ensure ongoing monitoring and evaluation of a resident with diabetes mellitus. Resident 82 was admitted with a diagnosis of diabetes mellitus, and the physician ordered a Hgb A1c on admission along with a diabetic protocol for fingerstick blood sugar monitoring and physician notification for blood sugars less than 70 mg/dL or greater than 250 mg/dL. The resident’s MDS indicated moderately impaired cognitive skills for daily decision making and supervision needed with eating. During review of the January 2026 MAR, licensed nurses documented that fingerstick blood sugars were taken from 1/17/2026 through 1/23/2026, but the MAR contained only check marks and no numerical blood glucose values. In a concurrent interview, the ADON stated the check marks indicated the fingersticks were performed, but the results were not documented in the MAR. RN 1 confirmed she checked blood sugars on several dates but did not verify that the values were recorded in the system, and RN 2 also confirmed she took a blood sugar value but did not know why it was not documented. The ADON and DON both confirmed there was no A1c drawn after admission and no recorded fingerstick numerical values for the resident. The DON stated the values were important in case of an abnormal result, and the ADON stated the missing A1c and blood sugar values were important to determine how the resident’s diabetes was being managed. The facility policy required documentation to be objective, complete, and accurate, and the diabetes protocol stated the physician would order appropriate lab tests such as periodic finger sticks or A1c and adjust treatment based on the results.
Unsafe Food Thawing and Incomplete Staff Competency Oversight
Penalty
Summary
The facility failed to ensure kitchen staff were routinely trained and evaluated for competency in safe food thawing and temperature monitoring. During a kitchen observation, a pan of fish was seen thawing under slow running water in the meat preparation sink while not sealed in plastic. A follow-up observation showed a cook removing the fish from the sink and transferring it to a colander. The dietary supervisor stated the facility’s thawing process was to place fish in the refrigerator first, then thaw it in the sink, bread it, and cook it, but also stated staff thaw fish under running water without monitoring or recording the water temperature. During interviews, the cook stated he thawed the fish in a pan under cold flowing water, did not take the fish temperature, and removed it from the freezer around 6 a.m. before discontinuing thawing around 9:00 a.m. He also stated he did not obtain or document the temperature when the fish was removed from the sink. When the fish was later observed in the oven, five randomly selected pieces were measured at 64.9 F, 64.9 F, 63.9 F, 65.1 F, and 69.6 F. The dietary supervisor stated the fish could not be served because the temperature exceeded 45 F and that the fish had not been monitored during thawing. The dietary supervisor and registered dietitian stated the facility did not have records or a time and temperature log for thawing foods, and the current process was to obtain only the final cooking temperature and recheck food before trayline service. The registered dietitian stated thawing under running water required continuous flow, immediate cooking, and time and temperature monitoring, but staff did not log thawing because of a two-hour time limit. Review of the facility’s thawing policy showed food submerged under running potable water at 70 F or lower could not remain in the danger zone for more than 4 hours and must be used immediately. Review of in-service records showed limited documentation for thawing education, and the dietary supervisor stated he had not provided in-service training on thawing in the sink. Competency records for the cooks were incomplete or not scored, including one cook’s competency test that showed a score of zero without documented review of incorrect answers.
Food Served at Improper Temperatures During Lunch Service
Penalty
Summary
Food and drink were not maintained at palatable, attractive, and safe temperatures during lunch service. During observation of trayline meal assembly, staff placed milk, salad, and dessert on trays, and later the Dietary Supervisor (DS) completed a test tray process for the regular diet and the puree diet. The regular diet test tray showed sweet corn salad at 50 F and tartar sauce at 92 F. The puree diet test tray showed puree corn salad at 58 F, milk at 48 F, puree fruit Bavarian cream at 44 F, puree fish at 125 F, puree creamed spinach at 128 F, and puree rice at 107 F. The DS stated the puree fish and rice dropped temperatures and the salad had been plated in an insulated cup. The DS also stated the staff should have plated the salad closer to service or in batches rather than ahead of time so it would remain cold. The DS stated hot foods should be served hot and cold foods should be served cold to prevent bacterial growth and encourage residents to eat, helping prevent weight loss. Facility policies and standardized recipes required food to be prepared and served to conserve nutritive value, flavor, and appearance, and specified trayline temperatures of 160 F to 180 F for hot items and 41 F or less for cold items.
Puree Diet Foods Failed IDDSI Level 4 Texture Standards
Penalty
Summary
The facility failed to prepare puree foods in a form designed to meet individual needs when pureed Cajun country rice did not pass the spoon tilt test and pureed sweet corn salad appeared watery during a concurrent test tray observation with the Dietary Supervisor. The observed puree diet tray for IDDSI Level 4 included pureed fish with tarragon sauce, pureed tartar sauce, pureed creamed spinach, pureed Cajun country rice, pureed sweet corn salad, pureed fruit Bavarian, and milk. During the observation, the Dietary Supervisor noted the rice was stickier and starchier than it should be, and the salad did not hold its shape. The Dietary Supervisor stated the rice should not be too sticky and that if it were too sticky it could get stuck in a resident’s throat causing choking. The Dietary Supervisor also stated the watery corn salad could cause choking and aspiration if consumed by residents. The facility’s policy, diet manual, standardized recipes for pureed starch and salad, and the IDDSI guidance all stated that Level 4 pureed foods should be smooth, free of lumps, hold their shape, not be too firm or sticky, not weep, and pass the required testing methods including the spoon tilt test.
Failure to Inform Resident Representative About Advance Directive Rights
Penalty
Summary
The facility failed to discuss and provide a resident's representative with information regarding formulating an advance directive for one sampled resident. Resident 87 was originally admitted on 1/18/2019 and readmitted on 5/31/2025 with diagnoses including dementia and hypertension. The resident's MDS dated 12/31/2025 indicated severely impaired cognition and the need for substantial/maximal assistance with ADLs, and the H&P dated 12/10/2025 stated the resident did not have the capacity to understand and make medical decisions. During a concurrent interview and record review on 2/11/2026, RN 3 reviewed Resident 87's Advance Directive Acknowledgment form dated 5/21/2023, which showed the resident placed a thumb-mark and declined assistance in formulating an advance directive. RN 3 stated that, based on the resident's H&P and MDS, Resident 87 had no capacity to make healthcare decisions and did not have the capacity to understand the Advance Directive Acknowledgment form. RN 3 stated that the resident's responsible party or representative should have been provided the form and materials regarding the resident's right to formulate an advance directive. The facility's policy stated that upon admission, the admission staff or designee will inform the resident of the right to execute an Advance Healthcare Directive.
Failure to Follow Up on Required PASARR Level II Evaluation
Penalty
Summary
The facility failed to follow up on a PASARR I screening that indicated Resident 3 required a PASARR Level II mental health evaluation. Resident 3 was admitted to the facility with diagnoses including unspecified dementia, schizoaffective disorder, bipolar disorder, and depression. The MDS dated 12/15/2025 showed moderately impaired cognition, substantial/maximal assistance needed for eating and oral hygiene, and dependence on staff for toileting hygiene and dressing. The PASARR I screening dated 11/28/2024 stated that a serious mental health Level II evaluation was required. During interview and record review, the MDS Nurse stated that when a resident is admitted from a GACH, the GACH initiates the PASARR I screen and the facility reviews it on admission. The MDS Nurse reviewed Resident 3's records and stated there was no documented evidence that follow-up was made after the PASARR I screening identified the need for a Level II mental health evaluation. The MDS Nurse stated the PASARR II evaluation was missed and that she did not follow up with a PASARR representative regarding the required evaluation. The facility policy stated that designated staff will review PASARR completion on admission, check the PASARR portal weekly for Level II determinations and evaluator reports, report PASARR status to the DON, and place the evaluator report in the medical record for IDT review.
Smoking Care Plan Lacked Specific Supervision and Safety Interventions
Penalty
Summary
The facility failed to revise Resident 10’s comprehensive person-centered care plan to include specific, individualized interventions for smoking supervision, monitoring, and access to smoking materials after ongoing non-compliance with smoking safety protocol was identified. Resident 10’s record showed diagnoses including paraplegia, hemiplegia and hemiparesis following cerebral infarction, and tobacco use. The smoking care plan, initiated in 2023, identified that he was a smoker who used a cigarette holder with staff assistance, had a potential safety hazard related to smoking, was non-compliant with safety, and refused to surrender smoking materials. The plan included general interventions such as instructing the resident about smoking risks, facility smoking policy, notifying the charge nurse if policy violations were suspected, observing for burns, and supervising smoking, but it did not include the more specific interventions identified during the survey. Record review showed additional information that was not reflected in the care plan. A progress note documented that Resident 10 became upset during smoke breaks if the activity assistant did not assist him quickly enough. The MDS indicated he was cognitively intact, dependent on staff for dressing, eating, and oral hygiene, and currently used tobacco. An interdisciplinary care conference note stated he spent time on the patio for smoke breaks. A smoking assessment found he was non-compliant with the smoking policy regarding the smoking schedule, smoking in different areas, use of a smoking apron, and keeping his own smoking materials, and recommended supervised smoking with his materials secured at the nurse’s station. A later smoking behavior care plan noted that he did not follow the smoking schedule, smoked by himself, and had other residents light cigarettes for him, but the interventions remained general and did not address the specific supervision and access issues. During interview, Resident 10 stated that in the past other residents held his cigarettes to his mouth because he could not hold them himself, and that he kept one to two or more cigarettes on him at any time. The AD stated he smoked often, other residents had lit his cigarettes in the past, and he refused to let staff keep his cigarettes and lighter or he became upset. The AD also stated the receptionist worked from 8:00 a.m. to 8:00 p.m. and notified activities staff if the resident went to the smoking patio alone, but this process was not included in the care plan. The ADON and DON both reviewed the smoking care plans and stated they lacked more specific interventions regarding other residents lighting cigarettes, activity staff monitoring, burn prevention, access to cigarettes and lighters, and staff roles in monitoring smoking activities.
Failure to Reconcile Pending Ophthalmology Consult on Readmission
Penalty
Summary
The facility failed to ensure vision services were provided in accordance with professional standards of practice for one resident when it did not reconcile and clarify a pending ophthalmology consult after the resident returned from a GACH. Resident 11 had been admitted and later re-admitted with HTN, and an optometry consultation on 11/17/2025 recommended referral to an ophthalmologist for cataract evaluation. Physician orders included an ophthalmology consult for cataracts of both eyes and a cataract evaluation appointment that was later cancelled when the resident was transferred to the hospital. On readmission, the GACH medication reconciliation/physician order form did not include an ophthalmology consult order, and the resident’s MDS indicated moderate cognitive impairment and substantial assistance with eating and oral hygiene. During interviews, the resident stated she wanted an eye examination because she could not see the television clearly while in bed. The ADON and RN 5 were unable to locate an active ophthalmology order, and RN 4 stated she reviewed prior discontinued orders but did not obtain clarification from the physician about whether the ophthalmology consult should continue or be discontinued. The facility’s readmission policy stated nurses are to review and reconcile pertinent orders from the previous admission, including pending doctor’s appointments and other orders as indicated.
Failure to Post Actual Daily Nursing Staffing Information
Penalty
Summary
The facility failed to ensure that staffing information showing the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care was posted daily on 2/11/2026 and 2/12/2026. During observation, surveyors found a framed document posted in nurse's station 1 titled, Census and Direct Care Service Per Patient Day (DHPPD), dated 2/11/2025 on 2/11/2026 and dated 2/12/2025 on 2/12/2026. RN 5 stated that the DSD was responsible for posting the daily nursing postings, and the DSD later stated that the DHPPD hours posted were projected hours rather than actual hours. During interview and record review, the DSD confirmed that the dates on the posted DHPPD documents were incorrect and should have been 2/11/2026 and 2/12/2026. AP/PR stated that she was responsible for calculating the actual nursing hours worked by licensed and unlicensed staff, but that these hours were not calculated on the day worked and were instead calculated on the next business day. AP/PR stated that actual hours for 2/11/2026 were calculated on 2/12/2026, and that actual hours for 2/12/2026 would not be calculated until 2/13/2026. The facility policy required that within two hours of the beginning of each shift, the number of licensed and unlicensed nursing personnel directly responsible for resident care be posted in a prominent location, with the date, staff type, and total number of staff recorded on the form.
Buprenorphine Given by Wrong Route
Penalty
Summary
The facility failed to ensure buprenorphine was administered sublingually as ordered for one resident who had diagnoses including muscle weakness and anxiety disorder and whose history and physical stated the resident could make needs known but could not make medical decisions. The physician’s order called for buprenorphine hydrochloride 2 mg tablets, two tablets sublingually four times a day for opioid use disorder. During a concurrent medication administration observation and interview, an LVN gave the resident the buprenorphine tablets with water, and the resident swallowed the medication. The LVN did not instruct the resident to place the tablets under the tongue and allow them to dissolve completely without swallowing or chewing. The LVN stated this was a medication error and that giving the medication by the wrong route could affect its efficacy. An RN stated sublingual medication should be given as ordered because giving it another route would prevent the desired effect, and the facility policy required medications to be administered safely and as prescribed using the right method of administration.
Failure to Provide Ordered Nutritional Supplement
Penalty
Summary
The facility failed to ensure that Resident 93 received a physician-ordered Magic Cup nutritional supplement. Resident 93 was admitted with diagnoses including metabolic encephalopathy, dysphagia, and epilepsy, and the MDS dated 2/5/2026 indicated severely impaired cognition and dependence on staff for eating, oral hygiene, toileting hygiene, dressing, personal hygiene, and mobility. The order summary showed an order for Magic Cup twice daily beginning 2/3/2026, and the care plan for risk for weight changes/dehydration/malnutrition related to dysphagia included an intervention for nutrition supplement as ordered. During an observation on 2/10/2026 at 1:00 p.m., Resident 93's lunch tray and meal ticket were reviewed, and the meal ticket indicated a standing order for 4 ounces of Magic Cup. CNA 2 observed that no Magic Cup was on the tray and stated that the tray should have included it because it was listed as a standing order. The RD later confirmed that Resident 93 had an order for Magic Cup twice a day at lunch and dinner, explained that it is a nutrition supplement providing extra calories and protein, and stated that dietary aides were responsible for placing it on the tray and nursing was responsible for checking tray accuracy before service. Facility policy stated that physician-prescribed diet orders would be provided by the Food & Nutrition Service Department, and the tray card system was the responsibility of the Food & Nutrition Service Director.
Failure to Maintain Clean and Homelike Shower Facilities
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for a resident by not maintaining cleanliness in the shower rooms. The resident, who had diagnoses including osteoarthritis of the left hip and immunodeficiency, reported that the shower rooms were not always clean and described smelling mold and observing black spots in the shower area during use. The resident expressed discomfort with the condition of the shower facilities, specifically noting black discoloration on the corners of the floors and around the soap rest in one of the shower booths. Multiple observations by facility staff, including maintenance assistants, the maintenance supervisor, the administrator, and the DON, confirmed the presence of black discolorations in the shower booth. These areas included around the soap rest, the cracks where the mosaic tile floors met the tile walls, and the corner edge of the tiled wall near the grab bar. Staff acknowledged that these areas were dirty and required cleaning, and the DON stated that the shower rooms should have been in better condition. Further interviews revealed that the janitor responsible for cleaning the shower rooms did not have a set schedule or checklist for deep cleaning and performed deep cleaning based on perceived need. The janitor was unable to remove the black spots and had not reported the issue to supervisors due to their absence. Facility policies reviewed indicated that residents should be provided with a clean, sanitary, and orderly environment, and that environmental surfaces should be disinfected regularly and when visibly soiled.
Failure to Notify Responsible Party of Care Conference
Penalty
Summary
The facility failed to inform the responsible party (RP) of a resident with moderately impaired cognition and multiple chronic conditions, including Parkinson's disease, rheumatoid arthritis, and type 2 diabetes, about an Interdisciplinary Team (IDT) Care Conference. The resident, who was dependent on staff for most activities of daily living and unable to make medical decisions, attended the care conference without the RP being notified or invited to participate. Review of the resident's records confirmed the absence of documentation showing that the RP was informed of the meeting. Interviews with the RP, Social Services Director (SSD), and Director of Nursing (DON) confirmed that the RP was not notified prior to the care conference, despite facility policy and federal and state regulations requiring such notification and involvement. The facility's policies emphasized the importance of including residents' families or legal representatives in care planning, but this was not followed in this instance, resulting in the RP not being able to participate in decisions regarding the resident's care, treatment, and services.
Failure to Provide Timely Remicade IV Treatment Due to Communication Breakdown
Penalty
Summary
The facility failed to provide timely intervention after being notified by an outpatient infusion clinic that a resident could not receive their scheduled Remicade (infliximab) IV treatment due to their admission to the facility. The resident, who had diagnoses including Parkinson's Disease, rheumatoid arthritis, and type 2 diabetes mellitus, was dependent on staff for multiple activities of daily living and had moderately impaired cognition. On 5/5/2025, RN 1 received a call from the outpatient clinic indicating they could not administer the Remicade IV. RN 1 notified the resident's physician but did not inform the Director of Nursing (DON) or take further steps to ensure the resident received the necessary treatment while admitted. The resident expressed concern to RN 1 on multiple occasions about the timing of the Remicade IV therapy, stating that the treatment improved mobility and ease of movement. RN 1 did not inform the DON of the situation until nearly a month later, after the resident inquired again about the therapy. The DON confirmed that timely notification would have allowed the facility to coordinate and provide the treatment. The facility's policy required timely, integrated, and efficient care, but the lack of communication and follow-up resulted in a delay of the resident's Remicade IV treatment.
Failure to Provide Continuous Oxygen Therapy as Ordered
Penalty
Summary
Facility staff failed to ensure that a resident received continuous oxygen therapy as ordered by the physician. The resident, who had diagnoses including cerebral palsy, chronic pulmonary edema, and bronchopneumonia, was admitted with a physician's order for oxygen at two liters per minute via nasal cannula to be administered continuously. The resident's care plan also specified the need for continuous oxygen therapy and outlined interventions to maintain the prescribed oxygen setting. During an observation in the activities room, the resident was found sitting without oxygen in place and no oxygen administration supplies nearby. The resident was unsure why the oxygen was not being used. A Licensed Vocational Nurse confirmed that the resident was not receiving oxygen at that time, despite being aware of the physician's order. The Director of Nursing also confirmed that the resident should have been receiving continuous oxygen according to the order and facility policy.
Medication Administration and Physician Order Deficiencies
Penalty
Summary
The facility failed to administer a physician-prescribed medication for itchiness to a resident diagnosed with prurigo nodularis, a chronic skin condition causing itchy bumps. The resident, who was moderately impaired cognitively and dependent on staff for personal care, did not receive the prescribed Triamcinolone cream on two occasions during the evening shift. This oversight was confirmed by a registered nurse who acknowledged the potential for discomfort and skin breakdown due to the missed medication. Additionally, the facility did not adhere to its medication administration policy by failing to obtain a physician's order before administering the COVID-19 vaccine to two residents. Both residents had severe cognitive impairments and were dependent on staff for daily activities. The facility used an outside pharmacy to administer the vaccine but did not secure the necessary physician's orders, as confirmed by the Infection Preventionist and the Director of Nursing. This lapse was attributed to a misunderstanding that the vaccine administration by an outside entity did not require a physician's order. The facility's policy on administering medications, which mandates adherence to prescribers' orders, was not followed in these instances. The lack of physician orders for the COVID-19 vaccine and the missed administration of the prescribed cream highlight deficiencies in the facility's medication management practices.
Failure to Provide Coordinated Hospice Services
Penalty
Summary
The facility failed to provide appropriate hospice services to a resident, identified as Resident 30, who was admitted to hospice care. The deficiency was identified through interviews and record reviews, which revealed that there was no documented evidence of hospice staff being physically present in the facility to provide hospice-related services to the resident. The resident, who had been admitted to the facility with diagnoses including dementia, psychotic disturbance, mood disturbance, Parkinson's disease, and heart failure, was severely impaired in cognition and dependent on assistance for daily activities. Despite an order to admit the resident to hospice on 10/23/2024, there was no record of hospice staff signing in to confirm their presence in the facility. Additionally, the facility lacked a designated staff member to coordinate care and services between the hospice provider and the facility. Interviews with the MDS Nurse and the Social Services Director revealed that there was no specific hospice coordinator, and any nursing staff or the Social Services Director would contact the hospice agency directly if needed. This lack of coordination was contrary to the facility's policy, which required a designated Social Service or Nursing Designee to coordinate care and communication between the facility and hospice staff. The facility's policy and procedure for the Hospice Program outlined the responsibilities of the designated coordinator, including collaborating with hospice representatives, coordinating facility staff participation in hospice care planning, and ensuring communication with hospice representatives and other healthcare providers. However, the absence of a designated coordinator led to a failure in ensuring well-coordinated and comprehensive hospice services for Resident 30.
Infection Control Deficiencies in Oxygen Tubing and Laundry Transport
Penalty
Summary
The facility failed to implement its infection control and prevention program in two key areas. Firstly, the facility did not ensure that a resident's nasal cannula oxygen tubing was properly labeled and kept off the floor. During an observation, it was noted that the oxygen tubing for a resident with chronic pulmonary disease and respiratory failure was touching the floor and was not dated. The Director of Nursing confirmed that the tubing should be changed weekly and labeled with the date of change to prevent contamination and infection. The facility's policy requires oxygen cannula and tubing to be changed every seven days, and the CDC guidelines highlight the risk of contamination from floors. Secondly, the facility did not adhere to its policy regarding the transportation of clean laundry. An observation revealed that laundry staff transported a cart of clean clothes uncovered, contrary to the facility's policy that mandates clean laundry to be covered during transport to prevent contamination. The Infection Preventionist confirmed that clean laundry should always be covered to maintain cleanliness and prevent infection. The facility's policy specifies that clean linen must be protected from dust and soiling during transport and storage.
Failure to Timely Complete Quarterly MDS Assessment
Penalty
Summary
The facility failed to ensure the timely completion of a Quarterly Minimum Data Set (MDS) assessment for a resident, which is a standardized assessment and care screening tool. This deficiency was identified during a review of the resident's records and interviews with the facility's MDS Nurse. The resident in question was originally admitted to the facility in May 2021 and readmitted in May 2022, with diagnoses including neuropathy and difficulty in walking. The resident was noted to have intact cognition and required supervision for most activities of daily living. The deficiency was discovered when reviewing the Centers for Medicare and Medicaid Services (CMS) Submission Report, which indicated that the assessment was completed more than 14 days after the assessment reference date (ARD). The ARD was set for October 18, 2024, and the assessment should have been completed by November 1, 2024. However, it was not completed until November 20, 2024. The facility's policy, last reviewed and revised in November 2024, requires that the resident assessment coordinator ensures timely assessments, with Quarterly Assessments not conducted less frequently than three months following the most recent OBRA assessment.
Failure to Document Non-Pharmacological Interventions Before Opioid Administration
Penalty
Summary
The facility failed to ensure that licensed nurses provided non-pharmacological interventions before administering PRN opioid pain medication to two residents, leading to a deficiency in pain management. Resident 7, who was admitted with chronic obstructive pulmonary disease and a history of falling, had a care plan that included assisting with positions of comfort. However, the facility's records showed that hydrocodone-acetaminophen was administered multiple times without documentation of non-pharmacological interventions being attempted first. Similarly, Resident 8, who was admitted with bilateral osteoarthritis of the knees, had a care plan that included non-pharmacological interventions such as repositioning and relaxation techniques. Despite this, the facility's records indicated that hydrocodone-acetaminophen was administered on several occasions without any documented evidence of non-pharmacological interventions being attempted first. Interviews with the Director of Nursing and Registered Nurse 1 confirmed the lack of documentation for non-pharmacological interventions prior to administering opioid medications. The facility's policy, which was last reviewed and revised on 11/6/2024, emphasized the importance of attempting non-pharmacological interventions to alleviate pain without medication due to potential side effects. However, this policy was not adhered to, resulting in the deficiency.
Deficient Food Storage and Labeling Practices
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and preparation practices in the kitchen, as observed during a survey. A bag of wheat bread and a bag of English muffins were found without an open date label, which is required to inform kitchen staff when to discard the bread. The Dietary Manager (DM 1) acknowledged that labeling is necessary to ensure food items remain safe for consumption and prevent potential foodborne illnesses. Additionally, a resident's food from home stored in the resident's refrigerator was found without a label or received date, which is against the facility's policy. Registered Nurse 1 (RN 1) confirmed that leftover food brought by visitors is stored in the resident's refrigerator and should be labeled with the resident's name and the date received to ensure it is discarded after 72 hours. The facility's policy, titled 'Food Receiving and Storage,' mandates that foods be received and stored in compliance with safe food handling practices. Another policy, 'Food Brought by Family/Visitors, Receiving and Storage,' requires that food brought by family or visitors be labeled and stored in a manner that distinguishes it from facility-prepared food, with perishable items stored in resealable containers labeled with the resident's name and use-by date.
Failure to Conduct Quarterly Rehabilitation Screen
Penalty
Summary
The facility failed to implement its policy on rehabilitation screening by not conducting a quarterly rehabilitation screen for one of the sampled residents, identified as Resident 68. The resident was originally admitted with diagnoses including vascular dementia, psychotic disturbance, and cerebral palsy, which significantly impaired their cognitive and physical abilities. According to the facility's order summary report, Resident 68 was supposed to have a rehabilitation screen upon admission and quarterly thereafter. However, a review of the Rehabilitation Screening Forms revealed that no quarterly screen was conducted for Resident 68 in August 2024, as required. During interviews, the Director of Rehabilitation (DOR) confirmed the absence of the required quarterly rehabilitation screen for Resident 68 and acknowledged the importance of these screens in assessing the need for rehabilitation services. The facility's policy on rehabilitation screening and the PCC-UDA Schedule Guide emphasized the necessity of accurate, complete, and timely entries in the electronic medical record, including the completion of quarterly Rehab Screening Forms. The failure to conduct the quarterly screen placed Resident 68 at risk of not maintaining, improving, or restoring their functional abilities.
Lack of POLST Policy Leads to Incomplete Resident Form
Penalty
Summary
The facility failed to develop a specific policy and procedure for the Physician Orders for Life-Sustaining Treatment (POLST) form, which is crucial for outlining a resident's end-of-life care preferences. This deficiency was identified during a review of Resident 101's records, who was admitted with diagnoses including hyponatremia, lung disease, and metabolic encephalopathy. The review revealed that Resident 101 lacked the capacity to make decisions, and their POLST form was incomplete, missing the signature of either the resident or their legally recognized health care decision maker. This oversight was confirmed during an interview with a registered nurse, who acknowledged the importance of having a completed POLST form to ensure the resident's safety and adherence to their care preferences. Further investigation revealed that the facility's administrator admitted to the absence of a specific policy for the POLST form. The facility's governing board is responsible for establishing and reviewing policies, as indicated in their administrative management policy. However, the lack of a POLST-specific policy could lead to confusion among staff and potential delays in care. The administrator's job description emphasizes the need to direct operations in compliance with regulations and to establish policies that reflect the facility's goals, yet this critical policy was not in place, contributing to the deficiency.
Failure to Document COVID-19 Vaccine Eligibility Screening
Penalty
Summary
The facility failed to implement its COVID-19 vaccine policy by not ensuring that residents were screened for eligibility before administering the vaccine. This deficiency was identified for two residents, Resident 30 and Resident 68, who were both administered the COVID-19 vaccine without documented evidence of eligibility screening. The facility's policy requires screening for contraindications, medical precautions, and prior vaccinations before offering the vaccine. Resident 30, who has diagnoses including dementia, psychotic disturbance, and Parkinson's disease, was admitted to the facility in 2014. The resident's Minimum Data Set (MDS) indicated severely impaired cognition and dependence on assistance for daily activities. Similarly, Resident 68, with diagnoses of vascular dementia and cerebral palsy, was admitted in 2022 and also had severely impaired cognition and dependence on assistance. In both cases, the Infection Preventionist (IP) failed to document the screening for vaccine eligibility, leaving the relevant section of the COVID-19 Vaccine Consent & Declination form blank.
Infection Control Breach by LVN
Penalty
Summary
The facility failed to implement proper infection control practices when a Licensed Vocational Nurse (LVN 1) did not wear an isolation gown and face shield before entering the room of a resident who was under novel respiratory precautions due to suspected COVID-19 infection. The resident, admitted with conditions including hemiplegia and atrial fibrillation, was placed on contact and droplet isolation as per physician's orders and care plan due to respiratory symptoms. Despite the presence of signage indicating the need for an isolation gown, N-95 mask, and face shield, LVN 1 entered the resident's room wearing only an N-95 mask and gloves. The Director of Nursing confirmed that staff should adhere to the posted novel respiratory precautions signage, which serves as a communication tool for the necessary isolation precautions. The facility's Infection Prevention Quality Control Plan, last reviewed in February 2024, outlines the requirement for personal protective equipment to prevent the spread of infection. The failure of LVN 1 to comply with these guidelines had the potential to result in the spread of infection, placing residents, staff, and visitors at risk of COVID-19.
Resident's Call Light Not Within Reach
Penalty
Summary
The facility failed to ensure a resident's call light was within reach, which could delay resident care and assistance with activities of daily living. On 5/23/2024, Resident 2's call light was observed hanging behind the headboard frame, out of reach. Resident 2, who was admitted with a diagnosis of cerebral infarction and required maximum assistance with various activities, was unable to find or use the call light to call for help. This was confirmed during an interview with Resident 2, who stated he could not call staff for assistance. Certified Nursing Assistant 1 (CNA 1) confirmed that the call light was stuck behind the headboard and admitted she had not checked its placement since starting her shift. The Director of Nursing (DON) also stated that call lights should be within reach to promptly provide residents with needed assistance. The facility's policy, last reviewed on 2/1/2024, indicated that residents should have a means to call staff for assistance from their bed, toileting, and bathing facilities, and that the call system should remain functional at all times.
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 4,195 citations issued within 25 miles in the last 12 months — including the 27 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 Panorama City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Terrace Post Acute | 1.2 mi | ★★★★★ | 26 | 0 |
| Panorama Gardens Nursing And Rehabilitation Center | 1.6 mi | ★★★★★ | 22 | 0 |
| The Rehabilitation Center Of North Hills | 1.8 mi | ★★★★★ | 8 | 0 |
| California Healthcare And Rehabilitation Center | 2.1 mi | ★★★★★ | 43 | 0 |
| The Care Center On Hazeltine, Llc | 2.2 mi | ★★★★★ | 12 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.