Below average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Pavilion At Sunny Hills during CMS and state inspections, most recent first.
Incomplete Informed Consent for Psychotropic Medications: The facility failed to ensure psychotropic medication consent forms included the ordered behavioral manifestations, and one form also lacked duration information. Several residents had orders for antidepressant, antianxiety, or antipsychotic medications tied to specific symptoms such as sadness, anxiety, restlessness, tearfulness, or disorganized thinking, but the consent documents did not fully reflect those indications. The DON and ADON verified the missing information during record review.
Advance directive information and assistance were not properly documented for four residents. The facility did not follow up after providing educational materials to three residents, did not document that assistance in formulating an AD was offered, and did not provide a resident’s representative with written AD information. Records showed one resident had impaired cognition with fluctuating capacity, another had intact cognition, another had decision-making capacity, and one had no capacity to understand or make decisions; the SSD and DON acknowledged the missing documentation and incomplete AD/POLST process.
A facility failed to document required nonpharmacological interventions before giving multiple psychotropic meds and failed to complete ordered monitoring for side effects and orthostatic BP. Residents receiving Ativan, mirtazapine, sertraline, bupropion, hydroxyzine, alprazolam, and olanzapine had repeated administrations without the required documentation, and two residents on olanzapine had orthostatic BP readings charted as identical in sitting and lying positions. The DON and ADON acknowledged the findings.
Failure to Notify Ombudsman and Provide Transfer/Bed-Hold Notices The facility failed to send the Notification of Proposed Transfer/Discharge to the Ombudsman for several residents and failed to provide written transfer and bed-hold notice to a resident’s representative. Records showed transfers to acute care, a death, and an AMA discharge, but the required Ombudsman notifications were not documented. The DON and ADON verified the missing notifications, and one resident had no capacity to make decisions.
A facility failed to follow physician orders to rotate injection sites for several residents receiving insulin, and for one resident also receiving Lovenox. Records showed repeated injections into the same abdominal or arm sites, and staff interviews confirmed the sites were not rotated as ordered. The facility also failed to complete an admission/readmission assessment and initial VS for a resident who returned from the hospital weak and on IV abx for pneumonia before the resident later became unresponsive and died.
A facility failed to provide proper GT feeding care for several residents. One resident’s enteral formula was not labeled with the start time, two residents did not receive the full ordered GT feeding dose and one had a feeding bottle still labeled with an outdated rate after an order change, and another resident’s enteral feeding syringe was not changed daily as ordered. Staff, including an LVN, ADON, and DON, verified the findings during observation and record review.
Surveyors found multiple failures in respiratory care, including oxygen and nebulizer tubing and humidifiers that were not dated or labeled, tubing left out of storage bags, and oxygen being delivered at rates that did not match physician orders. Several residents received oxygen without a documented order, one resident’s CPAP order lacked required settings, and staff acknowledged the equipment and documentation issues.
A facility failed to provide complete dialysis care for residents receiving hemodialysis. Records for one resident with ESRD were incomplete, including missing access-site location entries on dialysis communication forms and no documented bruit/thrill checks on non-dialysis days, and intake/output documentation was inconsistent. Two residents with fluid restriction orders had MAR entries that used only check marks instead of documenting actual fluid amounts, and staff confirmed bedside water intake was not fully counted. For another resident on HD, no emergency dialysis kit was observed at the bedside, and an LPN confirmed it was missing.
Medication Rooms A and B repeatedly had temperatures above the labeled storage range while multiple drugs and IV emergency kit meds requiring cooler storage were kept inside. In addition, an Anasept spray bottle was left on a resident’s TV stand, and a cup with topical cream plus a Calma Plex packet were left at another resident’s bedside even though both residents lacked capacity and were not able to self-administer meds.
Kitchen Food Safety and Sanitation Deficiencies: Surveyors observed unlabeled opened food, expired refrigerated items, dirty food-contact surfaces and equipment, damaged utensils and cutting boards, wet items stored before fully air-drying, an unmonitored emergency food storage room, poor glove/hand hygiene during puree prep, and dirty refrigerator fans. The DSS verified multiple findings, and the issues affected food prepared for residents in the facility.
Failure to Follow Infection Control Practices: A PT assistant transferred a resident on EBP without a gown, an LVN performed wound care without proper hand hygiene between glove changes, personal items and Sani-Cloth wipe containers were kept in direct contact with clean linen in the laundry room, and a resident’s urinary catheter drainage bag was observed touching the floor. Staff and the DON/ADON verified the observations, and the resident on EBP had a GT and the wound care resident had multiple pressure injuries and deep tissue injuries.
The facility failed to keep oxygen concentrators clean and safe for two residents, with grayish dust-like particles observed on the equipment at bedside. Staff also used personal BP machines brought from home to obtain BP readings for two other residents, and the LVNs stated the devices had not been checked by maintenance. The DON stated staff should use facility-provided equipment rather than personal devices.
Failure to Assess Safe Self-Administration of Bedside Medications: Two residents were observed with medications at bedside, including saline nasal spray, a Salonpas Lidocaine Plus roll-on, and maximum strength Neuropathy cream. Although both residents had capacity to understand and make decisions, the record lacked physician orders, self-administration assessments, and, for one resident, a care plan addressing safe self-administration. An LVN, DSD, and DON all verified the medications were at bedside and that no self-administration assessment or order was in place.
Failure to notify the physician and responsible party of a resident’s significant weight loss. A resident with severe impaired cognition lost 9 lbs. in one month, dropping from 74 lbs. to 65 lbs., but the medical record did not show documentation that the MD or responsible party were informed. Facility policy required timely notification of the resident, physician, and representative for a significant change in condition, and staff interviews confirmed the lack of documentation.
The facility failed to develop comprehensive care plans for two residents' individualized needs. One resident had a CPAP order for bedtime and PRN use, but no care plan addressed CPAP use. Another resident lost a hearing aid, had difficulty hearing and communicating, and the care plan did not address hearing loss, hearing aid use, or communication needs.
A facility failed to keep two residents’ care plans aligned with current physician orders. One resident’s pain care plans did not include ordered nonpharmacological interventions to be used before pain meds, despite orders for multiple analgesics and a diagnosis of fibromyalgia. Another resident’s fall risk care plan did not include the ordered pad alarm in bed, even though the resident was high risk for falls and was observed with the alarm in place.
Failure to assist a resident in gaining access to hearing services occurred when the resident’s hearing aid was lost in the facility and no care plan addressed the resident’s hearing difficulty or communication needs. The resident, who was cognitively intact and had been admitted with a hearing aid, was observed unable to hear, required staff to speak very close to the ear and repeat statements, and reported frustration because the hearing aid was missing. CNA and SS staff confirmed the resident had difficulty communicating without the hearing aid, and the DON acknowledged the findings.
Failure to Assess Pain Before Wound Care Treatment: An LVN did not assess a resident’s pain before starting ordered wound care for multiple pressure injuries, despite a physician order to assess pain before, during, and after treatment. The resident reported pain during the procedure and rated it 7/10, and the LVN later acknowledged the pre-treatment pain assessment was missed.
A resident with severely impaired cognition experienced a 9-lb. loss in one month and ongoing weight loss, but the record did not show timely physician or RP notification or prompt IDT review. The resident also had documented poor PO intake without clear follow-up in the chart, and during a breakfast observation the tray was missing ordered hashbrowns listed on the meal ticket. Staff interviews confirmed the weight-loss and intake thresholds that should have triggered notification and monitoring.
IV access care was not properly maintained for two residents. One resident with a PICC line did not have the ordered insertion-site and arm circumference measurements documented, and another resident’s peripheral IV was observed without a date or label showing when it was inserted. The DON and DSD verified the missing documentation and labeling expectations.
Failure to document nonpharmacological pain interventions before opioid administration. Three residents had orders for pain meds that included repositioning, quiet environment, hot/cold application, relaxation, distraction, music, and other comfort measures before dosing. However, the MAR and record review showed repeated administration of hydrocodone-acetaminophen, Percocet, and Tramadol without documentation that the ordered nonpharmacological interventions were provided first; the ADON verified the findings and the DON acknowledged them.
An LVN did not complete the ordered final GT flush after administering medications to a resident with a PEG tube, a controlled substance waste for another resident was done by only one nurse and not documented on the accountability record, and an LVN handled and administered finasteride without gloves despite the medication’s cytotoxic caution labeling and hazardous drug status.
The facility failed to follow medication orders for two residents. One resident on apixaban had an order for shift-by-shift bleeding monitoring, but the MAR did not show the required assessment after the anticoagulant dose was given. Another resident with HTN had orders to hold carvedilol and nifedipine if systolic BP was below 110 mmHg, yet both meds were administered when the systolic BP was 108 mmHg. The DON and nursing staff verified the findings.
Medication administration errors exceeded the allowed rate when two residents did not receive ordered medications during observation. An LVN withheld ferrous sulfate for one resident with anemia and did not administer riluzole or cyclosporine eye drops to another resident with ALS because the medications were not available, resulting in a 12% error rate.
Pureed Diet Recipe Not Followed: The facility failed to follow the menu/recipe for 16 residents on a pureed diet. During observation, a Dietary Aide prepared pureed tamale pie and added 30 mL scoops of margarine instead of the recipe amount of 1 tsp per scoop. The aide later reviewed the recipe and confirmed the correct amount, and the Administrator, RD, and DSS acknowledged the findings.
A facility assessment failed to include a contingency plan for staffing needs. The assessment was intended to identify the resources needed to care for residents competently during routine operations and emergencies, but the review did not address staffing contingencies. During interview, the Administrator stated the contingency plan was part of the emergency plan and acknowledged the finding.
Incomplete and inaccurate resident medical record documentation: A resident with a PICC line had blank and missing IV MAR initials and missing IV site documentation, while another resident’s chart contained an advance directive that did not match the POLST and included a DPOA for property management in the advance directive section. Two residents with dialysis access also had BP readings documented on the access arm despite orders and care plans to avoid that arm, and staff verified the documentation was inaccurate.
A resident receiving hospice care had an incomplete hospice calendar that did not document the scheduled SN visits, and the facility record also lacked hospice visit notes for the reviewed period. The resident had been admitted to hospice under routine LOC, and interviews with an LVN, social services staff, the DON, and the Administrator confirmed the hospice binder and medical record were not accurate or complete.
A resident admitted to the facility was observed receiving oxygen via nasal cannula, but the medical record did not show a baseline care plan addressing oxygen use within 48 hours of admission. The ADON verified no baseline care plan had been formulated at admission, and the DON later confirmed the finding.
A resident with a fractured tibia and fibula was transferred by a CNA using a mechanical lift without the required second staff member. The resident reported being raised too high, not having her leg properly supported, and hitting her neck/head on the headboard with pain afterward. The record did not show documentation of the report, physician notification, or continued monitoring, and the LPN did not notify the MD after assessing no injury.
A resident’s floormat was left propped against the side of the bed during a mechanical lift transfer, with the mat touching the bedding. CNA 2 stated he moved the mat off the floor and leaned it against the bed, and the DON acknowledged this was an infection control concern.
A resident admitted from acute care with atrial fibrillation, a Zio cardiac monitor, urinary retention, and rectal bleeding did not have these conditions reflected in the comprehensive care plan. Although transfer documents and physician orders directed cardiac monitoring, PVR checks with I/O catheterization parameters, and monitoring for rectal bleeding, the January care plan contained no problems or interventions for the Zio patch, urinary retention, or rectal bleeding. Nursing leadership and an RN later confirmed these issues were present and should have been included in the care plan.
A resident with physician orders for PVR checks every six hours over several days had a documented PVR of 337 cc, above the ordered threshold for I/O catheterization. The record showed no evidence that an I/O catheterization was performed, that the MD was notified of the continued urine retention, or that further reassessment and monitoring occurred, and the resident’s care plan did not include a urinary retention problem. An RN later confirmed that facility expectations included MD notification, reassessment, monitoring, and care plan development in such circumstances.
A resident experienced a rapid, unplanned weight loss of 12 lbs. (about 6%) within less than a month, triggering thresholds outlined in the facility’s weight management P&P for closer monitoring and intervention. Despite weekly weights showing a 7 lb. loss in nine days and an additional 5 lb. loss shortly thereafter, the nutritional assessment initially documented no weight change, and the RD did not conduct follow-up until weeks after the weight decline began, even though she acknowledged such a loss would be concerning and required follow-up. An IDT note later summarized the ongoing weight loss, and leadership staff were informed of these findings.
A resident’s daughter reported to nursing staff that a CNA was unable to meet the resident’s needs and was harassing the resident, and this was documented as a change of condition using an SBAR tool. Despite facility policy requiring person-centered, comprehensive care plans to be developed and revised by the IDT, review of the medical record showed no care plan problem or interventions were added to address the reported unmet needs or alleged harassment. Two LVNs confirmed during interviews that no care plan was developed in response to this change of condition and acknowledged that care plans are intended to ensure goals and interventions are created and updated as needed.
Two residents receiving respiratory treatments did not have their nebulizer and oxygen equipment stored and labeled according to facility policy, and required oxygen in use signage was missing from their room entrances. For one resident, surveyors found a nebulizer mask and tubing left on a nightstand without a bag, name, or date, while the resident was also using an oxygen concentrator and had portable oxygen tanks in the room with no oxygen in use sign posted. For another resident with asthma using oxygen via concentrator and nasal cannula, oxygen tubing wrapped around a portable tank on the wheelchair was not bagged or labeled, and no oxygen in use sign was posted outside the room. Staff, including an OT, a CNA, an LVN, and the IP, confirmed these observations and acknowledged that facility policies required the equipment to be bagged, dated, and labeled, and signage to be posted when oxygen was in use.
A resident with severe cognitive impairment was placed in a wheelchair with a lap buddy and pressure pad alarm without a physician's order, informed consent, or a care plan. Staff confirmed the use of these devices to prevent unassisted movement, but medical record review and interviews revealed that required assessments and documentation were not completed prior to their application.
Two residents did not receive required care and monitoring after significant events. One resident with severe cognitive impairment had abnormal neurological findings documented after returning from the hospital, but the physician was not notified as required. Another resident was not monitored or documented for required periods following an unwitnessed fall. These failures were confirmed by facility leadership and were not in accordance with facility policy.
A resident with impaired decision-making capacity reported alleged abuse and mistreatment to an acute care hospital RN, who then informed facility staff. The LVN on duty failed to immediately notify the Administrator or report the allegation to required authorities, resulting in an eight-hour delay before the Administrator became aware and submitted the necessary reports. This delay did not comply with the facility's policy for immediate reporting of abuse allegations.
A resident received PRN acetaminophen and baclofen, but the administration was not documented in the MAR or progress notes. An LVN confirmed giving the medications but failed to record them, and this was later verified by an RN. The DON acknowledged that documentation should occur immediately after administration.
A resident did not receive necessary care and services, including suctioning, daily weight monitoring, and medication administration, as per physician orders. The facility failed to document and implement these orders, notify the physician of medication refusals, and provide required catheter and wound care. These deficiencies were confirmed through interviews and medical record reviews.
The facility was found non-compliant with State laws and its own policy as an LVN and a CNA were observed not wearing their name badges, which are required for staff identification. The CNA stated her badge had fallen off, while the LVN admitted her badge was on the cart. The ADON confirmed that name badges should be worn at all times.
A resident in hospice care did not receive prescribed latanoprost eye drops for glaucoma due to a failure in communication and documentation by the facility staff. The medication was received, but the order was not documented or administered until days later, causing the resident to experience eye discomfort. Interviews with staff confirmed the oversight, with the LVN admitting to forgetting to verify and carry out the order.
A resident with Type 2 Diabetes Mellitus did not receive proper insulin administration due to a failure by nursing staff to prime the Tresiba insulin pen as per manufacturer's instructions. The LVN and RN involved were unaware of the priming requirement, which was confirmed by the ADON. This oversight risked incorrect medication dosing.
Incomplete Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure informed consent for psychotropic medications was complete for five sampled residents. The deficiency involved missing information in consent forms for antidepressant, antianxiety, and antipsychotic medications, specifically the behavioral manifestations tied to the medications as ordered by the physician, and in one case the duration of use. The facility’s informed consent policy required disclosure of material information for psychotherapeutic drugs, including the reason for treatment and the nature of the procedures, probable frequency, and duration. For Resident 3, who had no capacity to understand and make decisions, physician orders included sertraline for depression manifested by verbalization of sadness, mirtazapine for depression manifested by poor intake, Ativan PRN for anxiety manifested by verbalization of anxious for 30 days, and ABH for psychosis manifested by disorganized thinking. The consent form for sertraline did not include the behavioral manifestation, the consent form for mirtazapine did not include the behavioral manifestation, the Ativan consent form did not include the duration of use, and the ABH consent form did not include the behavioral manifestation. Medication administration records showed these medications were given during the review period. For Resident 6, who also had no capacity to understand and make decisions, physician orders included bupropion for depression manifested by verbalization of sadness, hydroxyzine for anxiety manifested by restlessness, and sertraline for depression manifested by tearfulness. The consent forms for bupropion, hydroxyzine, and sertraline did not include the behavioral manifestations related to the ordered uses. For Resident 69, who had capacity to make decisions, the order for alprazolam was for anxiety manifested by inability to relax, but the consent form did not include that behavioral manifestation. For Resident 231, who was cognitively intact, the order for fluoxetine was for depression manifested by tearfulness, but the consent form did not include that behavioral manifestation. For Resident 9, whose assessment showed severe cognitive impairment, the order for olanzapine was for psychotic disorder manifested by disorganized thinking, but the consent form listed psychosis and did not include the specific manifested behavior. The DON and ADON acknowledged the findings during interviews.
Advance Directive Information and Assistance Not Properly Documented
Penalty
Summary
The facility failed to ensure the necessary services for formulation of an advance directive were provided for four sampled residents. The report states that the facility did not follow up on advance directive status after educational materials were provided to Residents 41, 231, and 232, and did not ensure assistance in formulating an advance directive was offered to those residents. The facility also failed to provide Resident 225’s representative with written information regarding the right to formulate an advance directive. For Resident 41, the record showed no advance directive on the POLST, the Social Services Evaluation documented that the advance directive was not offered, and the resident had moderately impaired cognition with fluctuating capacity to understand and make decisions. Social Services Coordinator 3 verified that documentation was not available showing assistance was offered to the resident’s representative, and stated that educational materials had been provided but follow-up was not completed to determine whether the resident accepted or declined. For Resident 231, the record showed no advance directive on the POLST, the Social Services Evaluation documented that the advance directive was not offered, and the resident had intact cognition with a BIMS score of 14. Resident 231 stated she did not recall being offered assistance. For Resident 232, the record showed decision-making capacity, but the Social Services Evaluation documented that the advance directive was not offered and there was no documentation that assistance was offered. For Resident 225, the H&P showed no capacity to understand and make decisions, but the medical record did not show that advance directive information was provided to the representative, and there was no documented assessment or evaluation for the advance directive. The SSD acknowledged that the conversation with the family member was not documented and that the POLST and advance directive were not completed.
Unnecessary Psychotropic Medication Use and Inaccurate Monitoring
Penalty
Summary
The facility failed to ensure residents were free from unnecessary psychotropic medications and failed to follow ordered monitoring for psychotropic drug use for multiple residents. The report identified deficiencies involving Resident 3, Resident 6, Resident 9, Resident 69, and Resident 226, with surveyors reviewing medical records, MARs, physician orders, and facility policy. The facility’s policy required nonpharmacological interventions to be attempted unless clinically contraindicated, and required monitoring and documentation of resident response and side effects related to psychotropic medications. For Resident 3, the record showed orders for Ativan, mirtazapine, and sertraline, including orders for nonpharmacological approaches before administration and monitoring for side effects and behavior. The MAR showed Ativan was administered on multiple occasions, mirtazapine was administered on multiple evenings, and sertraline was administered on multiple mornings. The medical record did not show documented evidence that the ordered nonpharmacological interventions were provided before these administrations. The record also did not show the resident was monitored for mirtazapine side effects on one evening shift, and did not show behavior monitoring related to sertraline on one evening shift. For Resident 6, the record showed orders for bupropion, hydroxyzine, and sertraline, along with orders for nonpharmacological interventions before administration. The MAR showed repeated administration of each medication across numerous dates and times. The medical record did not show documented evidence that the ordered nonpharmacological interventions were provided before the administrations of bupropion, hydroxyzine, or sertraline. Resident 69 had an order for alprazolam with a required nonpharmacological approach before use, and the MAR showed repeated PRN administrations, but the record did not show documented evidence that the interventions were provided before those doses. Resident 9 and Resident 226 both had orders for olanzapine with orthostatic blood pressure monitoring. For Resident 9, the record showed weekly sitting and lying blood pressure monitoring, but the readings were documented as the same for both positions on the reviewed dates. For Resident 226, the record showed daily lying and sitting blood pressure monitoring for 10 days, but the documented readings were also the same for both positions on the reviewed dates. The ADON and DON were interviewed and acknowledged the findings, and the DON stated the orthostatic blood pressure readings should not be the same for the different positions.
Failure to Notify Ombudsman and Provide Required Transfer/Bed-Hold Notices
Penalty
Summary
The facility failed to timely notify and accurately send the Notification of Proposed Transfer/Discharge to the Office of the State LTC Ombudsman and failed to provide written notice to a resident’s representative regarding the reason for transfer and bed-hold rights for multiple residents. The deficiency involved Residents 49, 98, 221, 222, and 223, based on interview, medical record review, and facility policy review. The facility’s policy stated that the Ombudsman’s name, address, and phone number were part of transfer/discharge requirements, that transfer/discharge documentation must be placed in the medical record, and that residents and/or representatives must receive written notice of bed-hold rights at admission and before transfer to a hospital or therapeutic leave. Resident 49 was readmitted to the facility and later transferred to an acute care hospital for abdominal CT scan and further evaluation related to abdominal distention with tenderness. The medical record included physician orders allowing transfer to the hospital, but the Notice of Proposed Transfer and Discharge forms dated for the transfer did not show they were sent to the Ombudsman, and there was no documentation that the Ombudsman was notified. During interview and concurrent record review, the ADON verified the notification was not sent. Resident 221 was admitted and later transferred to an acute care hospital for evaluation with a physician order that also included a seven-day bed hold if admitted, but the Notice of Proposed Transfer and Discharge did not show it was sent to the Ombudsman and no documentation showed the Ombudsman was notified. Resident 222 was readmitted and later discharged due to death; the record showed an order to release the body to a mortuary provider, but there was no documented evidence that the Ombudsman was notified of the death. Resident 223 was admitted and later discharged home AMA with a responsible party, but the record also lacked documentation that the Ombudsman was notified. For Resident 98, who had no capacity to understand and make decisions, the record showed a physician order to transfer to an acute care hospital with a seven-day bed hold if admitted, but there was no written notification to the resident’s representative about the reason for transfer and bed hold, and no documentation that the Ombudsman was notified. The DON and ADON verified these notifications were not completed as documented.
Failure to rotate injectable medication sites and complete readmission assessment
Penalty
Summary
The facility failed to provide care according to physician orders for multiple residents whose insulin and other injectable medications were ordered to have injection sites rotated. For Resident 6, the record showed orders for regular insulin before meals and at bedtime and insulin glargine at bedtime, both with instructions to rotate the site of administration. The location of administration report showed repeated injections into the same LLQ abdominal site on multiple occasions. During interview, an LVN verified the orders and confirmed the sites were not rotated, stating the sites should be rotated to prevent complications from repeated injections at the same site. For Resident 7, the physician ordered insulin glargine at bedtime with instructions to rotate the site of administration. The location of administration report showed repeated administrations to the left arm on multiple occasions. During interview, an LVN reviewed the MAR and verified the insulin sites were not rotated, stating the sites should be rotated as ordered. For Resident 9, the physician ordered Humulin R insulin before meals and at bedtime with instructions to rotate the site of administration. The location of administration report showed repeated injections into the LLQ abdomen on multiple occasions. An LVN reviewed the MAR and verified the insulin sites were not rotated and stated the sites should be rotated. For Resident 230, the physician ordered Humulin regular insulin before meals and at bedtime, along with NPH insulin in the morning and at bedtime, with instructions to rotate injection sites. The location of administration report showed repeated administrations into the LUQ abdomen for both insulin types on multiple occasions. An LVN verified the findings and stated the injection site should be rotated with each insulin administration. For Resident 201, the physician ordered Lovenox in the morning and Lispro insulin before meals and at bedtime with instructions to rotate injection sites. The location of administration report showed repeated Lovenox injections in the LUQ and LLQ abdomen and repeated Lispro injections in the LLQ, RUQ, LUQ, and RLQ on consecutive administrations. The ADON verified and acknowledged that the injection sites for both the anticoagulant and insulin were not rotated. The facility also failed to complete an assessment for Resident 222 upon readmission. Resident 222 was readmitted from the hospital, was awake and alert but weak, and was to receive IV ceftriaxone for pneumonia. The record showed that later the same day the resident became unresponsive, had no detectable pulse or respirations, and was pronounced deceased. Review of the medical record failed to show documented evidence of the assessment and vital signs when the resident was readmitted three hours before the change in condition. The ADON stated the Admit/Readmit Evaluation should have been completed and initial vital signs should have been taken as soon as possible, and the DON stated a thorough assessment and initial vital signs should be completed for every admission or readmission.
Enteral Feeding Orders Not Followed and Supplies Not Properly Labeled
Penalty
Summary
The facility failed to provide necessary care and services related to GT enteral feeding for four residents. The report states that the facility did not ensure enteral feeding formula was labeled with the start time for one resident, did not administer the complete ordered dose of GT enteral feeding for two residents, and did not change one resident’s enteral feeding syringe daily. The report also states these failures had the potential for the residents to have complications related to the use of GT and/or to put the residents at risk for weight loss and/or dehydration. For one resident, the physician ordered Glucerna 1.2 at 45 mL/hr for 20 hours starting at 1200 hours, but during observation the GT feeding bottle was running without a start time label. The LVN stated the bottle should have been labeled with the resident’s name, ordered rate, and the date and time the feeding was started so staff would know when to discard it after 24 hours. The LVN verified the bottle was not labeled with the start time. For another resident, the physician ordered Glucerna 1.5 at 90 mL/hr for 12 hours starting at 1800 hours and later changed the order to 75 mL/hr for 15 hours starting at 1800 hours. The feeding bottle was observed without a start time label, and later the bottle was still labeled with the earlier rate and duration even though the order had changed. The feeding pump history showed the resident was still receiving the earlier ordered rate and volume, and the LVN verified the new rate and duration should have been changed. For a third resident, the physician ordered Glucerna 1.2 at 65 mL/hr for 20 hours to provide 1300 mL, but the feeding pump history showed the resident had not received the full prescribed amount, and the ADON verified the ordered dose had not been delivered. For the fourth resident, the physician ordered the enteral feeding syringe to be changed every day shift daily, but the syringe at bedside was labeled with a date several days earlier. The LVN verified the syringe had not been changed as ordered. The facility’s policies reviewed in the report stated enteral formulas should be administered as ordered, labeled with the required information including date and time prepared and hung, and enteral feeding syringes should be replaced every 24 hours.
Respiratory Care and Oxygen Equipment Not Provided as Ordered or Properly Maintained
Penalty
Summary
The facility failed to provide required respiratory care and services for multiple residents who were receiving oxygen therapy or CPAP therapy. Surveyors observed several residents with oxygen tubing, humidifiers, nebulizer tubing, or storage bags that were not dated and labeled as required by the facility’s own policies. In multiple instances, tubing that should have been stored in a bag when not in use was observed hanging on equipment, coiled on a wheelchair, or otherwise left outside the storage bag. The facility’s policy also required oxygen equipment not in use to be protected from dust and dirt, and staff acknowledged that the tubing and storage bags should be labeled and changed weekly. For one resident, oxygen was being administered at 3 liters per minute even though the physician’s order called for 2 liters per minute. For another resident, oxygen was being administered at 3 liters per minute when the order called for 4 liters per minute, and the resident stated she was receiving 4 liters per minute. Surveyors also found residents receiving oxygen without a documented physician’s order for that therapy. One resident’s record showed no order for oxygen use even though oxygen was in place at the bedside, and another resident’s record likewise lacked an order for oxygen therapy despite the resident receiving oxygen through a nasal cannula. The facility also failed to obtain a physician’s order for CPAP machine settings for one resident. The resident stated the CPAP machine had been brought from home and used at night, while the record only showed an order for hours of use and did not include the oxygen concentration, duration, flow, or PEEP pressure as referenced in the facility’s policy and manufacturer guidance. In addition, surveyors observed a resident’s oxygen tubing touching the floor, a humidifier without a date label, and the absence of a posted no-smoking sign outside the room. Another resident’s humidifier, nasal cannula, and storage bag were observed without dates or labels, and a nonsampled resident’s oxygen humidifier was also observed without a date label.
Dialysis care records, fluid monitoring, and bedside emergency kit deficiencies
Penalty
Summary
The facility failed to provide safe, appropriate dialysis care and services for residents receiving hemodialysis. The report identified deficiencies involving incomplete dialysis communication records, lack of documented monitoring of dialysis access, inaccurate monitoring of fluid restriction, and failure to keep an emergency dialysis kit at a resident’s bedside. The facility’s dialysis management policy stated that residents requiring dialysis care should receive services consistent with professional standards of practice and a comprehensive person-centered care plan meeting the resident’s goals and preferences. For one resident with ESRD who was dependent on renal dialysis, the record showed a left upper arm AV shunt/AV fistula and a schedule for hemodialysis three times weekly. The dialysis communication record for multiple treatment dates was incomplete because the access site location was left blank. The medical record also did not show licensed nurse documentation of bruit and thrill checks on days the resident did not receive dialysis treatments, and there was no physician’s order found for that monitoring. The resident’s intake and output orders were also not accurately reflected in the MAR, with inconsistent entries for shift intake and 24-hour intake documentation. For two other residents with kidney disease and dialysis-related diagnoses, physician’s orders required a 1500 ml fluid restriction with nursing and dietary allocations and monitoring of intake and output every shift. Their MARs showed only check marks for fluid restriction monitoring on each shift, without documentation of the specific amount of fluid consumed. One resident was observed with a 500 ml water pitcher at the bedside, and staff confirmed that only tray fluids were being recorded on the intake log, not the bedside water pitcher. In addition, for another resident receiving hemodialysis, the emergency dialysis kit was not observed at the bedside, and an LVN confirmed that no kit was present.
Improper Medication Storage and Unsecured Medications in Resident Rooms
Penalty
Summary
Drugs and biologicals were not properly stored in Medication Rooms A and B, and medications were also left unsecured in resident areas. Facility observations and record review showed multiple medications in both medication rooms were kept at temperatures above the labeled storage range of 68 to 77 degrees Fahrenheit. In Medication Room A, the temperature log documented repeated readings of 78 degrees Fahrenheit across April, May, and June 2026, and the ADON confirmed the room was still at 78 degrees Fahrenheit during observations. Medications observed in that room included injectable dextrose, injectable metronidazole, acetaminophen 500 mg, acetaminophen 325 mg, and loperamide, all of which had product labels directing storage at 68 to 77 degrees Fahrenheit. Medication Room B also had repeated temperature readings of 78 degrees Fahrenheit in April and June 2026. During observations, the ADON confirmed the room temperature was 78 degrees Fahrenheit and described the room as warm. Medications observed in that room included injectable dextrose, injectable metronidazole, docusate sodium sulfate, bisacodyl suppositories, acetaminophen suppositories, and hemorrhoidal suppositories, with labels directing storage at 68 to 77 degrees Fahrenheit, 59 to 77 degrees Fahrenheit, or below 77 degrees Fahrenheit. The DON acknowledged that both medication rooms contained drugs labeled for storage at 68 to 77 degrees Fahrenheit and stated that proper storage temperature was important to maintain potency. In addition to the storage issues, a white spray bottle of Anasept was found on top of a resident's television stand in the room of a resident who had no capacity to make decisions. An LVN verified the spray bottle had been left in the room and stated it should not have been there. In another room, a medication cup containing a white cream, a tongue depressor, and a packet of Calma Plex were observed on a bedside drawer for a resident who had no capacity to understand and make decisions and was not able to self-administer medications. An LVN stated the topical cream should have been discarded and the packet of Calma Plex should have been kept in the treatment cart. The DON acknowledged that medications should not be left at the bedside for residents without capacity.
Kitchen Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure food safety and sanitation requirements were met in the kitchen during observations, interviews, and policy review. The facility served food prepared in the kitchen to 168 of 172 residents, and surveyors observed multiple food storage and sanitation issues during the kitchen tour with the DSS. These included opened bags of chicken breasts in Freezer A that were not labeled with opened or use-by dates, juice boxes connected to the dispenser without opened dates, and a box of prune juice labeled with the date 3/10/26, with the DSS stating she did not know whether that date was the received or opened date. Surveyors also observed multiple refrigerated food items past their use-by dates, including Italian dressing labeled 6/27/26, jelly labeled 6/27/26, ham slices labeled 6/28/26, and yogurt and pudding labeled 6/28/26. The DSS verified these findings. In addition, multiple kitchen items and food-contact surfaces were observed with debris, food residue, stains, or other contamination, including plastic bin contents, a mixer bowl, a meat slicer, a utensil drawer, a pizza slicer, a stained cutting board, and a blender with white food residue during puree preparation. The DSS verified the equipment and bins should be clean, and Dietary Aide 1 was observed removing the blender to be washed. Surveyors further observed chipped spatulas, a melted green plastic container lid, a cracked blue plastic container lid, and a heavily marred cutting board. Several food-contact items were also observed wet after cleaning, including water pitchers, cups, plastic bins, trays of bowls, and scoopers stored while still visibly wet. The emergency food supply room did not have a thermometer, and the DSS stated the room temperature was not being monitored after the emergency food supply was moved there a week earlier. During puree preparation, Dietary Aide 1 was observed removing gloves and donning new gloves without washing hands first, including while preparing tamale pie puree and pureed carrots. The refrigerator fans in Refrigerator A and Refrigerator B were also observed with blackish and fuzzy residue, and the Administrator, RD, and DSS were informed and acknowledged the findings.
Failure to Follow Infection Control Practices
Penalty
Summary
The facility failed to implement its infection prevention and control program for three sampled residents. For a resident on enhanced barrier precautions due to gastrostomy tube use, a PT assistant transferred the resident from bed to wheelchair while wearing gloves but without a gown, even though the resident’s door had an EBP sign posted. The PT assistant later verified that the gown should have been used during the transfer, and the DON confirmed staff were expected to wear the proper PPE when providing care to residents on EBP. For another resident receiving wound care for multiple pressure injuries and deep tissue injuries, an LVN was observed cleansing the resident’s wounds and then removing gloves, putting on new gloves from her pocket, and continuing wound care without performing hand hygiene after removing the soiled gloves and before donning the new gloves. The LVN later verified that hand hygiene was not performed after cleansing the wounds and after glove removal, and stated she was used to keeping pairs of gloves in her pocket. The DON was informed and acknowledged the findings. The facility also had infection control issues in the clean laundry room and with catheter care. Personal items including a cellphone, lunch bag, purse, drinking bottle, and water bottle were observed in direct contact with clean linen and clean resident clothing, along with containers of Sani-Cloth disinfectant wipes on the clean linen folding table. In addition, a resident with an indwelling urinary catheter was observed with the drainage bag touching the floor. Staff and management verified these observations, and the ADON and DON stated the catheter drainage bag should not touch the floor.
Unsafe Maintenance of Oxygen Equipment and Personal BP Devices
Penalty
Summary
The facility failed to maintain essential equipment in safe operating condition for one sampled resident and three nonsampled residents. During the initial tour, Resident 52’s oxygen concentrator was observed at bedside with grayish, dust-like particles, and Resident 52’s record showed the resident had no capacity to understand and make decisions. Later observation with RN 3 confirmed the oxygen concentrator still had grayish dust-like particles. Resident 231’s oxygen concentrator was also observed at bedside with grayish, dust-like particles, and Resident 231’s record showed a physician’s order for continuous oxygen at 2 to 3 liters per minute via nasal cannula. LVN 12 later verified that Resident 231’s oxygen concentrator had grayish dust-like particles. The facility also allowed staff to use non-facility issued blood pressure machines for resident assessments. During medication administration observation, LVN 4 used a personal automatic wrist BP machine brought from home to obtain Resident 171’s BP, and the device had the LVN’s first name written on it. LVN 4 stated the machine had not been checked by maintenance to ensure it was functioning properly. During another medication administration observation, LVN 11 used a personal automatic wrist BP machine and then a personal automatic arm BP machine to check Resident 235’s BP, and the devices were labeled with the LVN’s first name. LVN 11 also stated the machines belonged to her, were bought from a store, and had not been checked by maintenance to ensure proper function. The DON stated the facility should provide medical equipment for resident assessments and that staff should not use personal equipment brought from home.
Failure to Assess Safe Self-Administration of Bedside Medications
Penalty
Summary
The facility failed to ensure that two residents were assessed for safe self-administration of medications kept at bedside. Resident 5, who had been admitted and later readmitted to the facility and whose H&P showed capacity to understand and make decisions, was observed sitting in bed with a bottle of saline nasal spray on the overbed table and stated it was her medication used to spray her nose. The resident’s record did not show a physician’s order for the saline nasal spray, did not show an order for self-administration, and did not contain documentation of an assessment showing the resident could safely self-administer the medication. An LVN verified the nasal spray was at the bedside and stated the resident should have no medication at bedside and that other residents could get and use the spray. Resident 108, who also had capacity to understand and make decisions per the H&P, was observed with a Salonpas Lidocaine Plus roll-on and a jar of maximum strength Neuropathy cream on the overbed table and stated both were her medications used when she had pain. The resident’s record did not show a physician’s order for either medication, did not show an order for self-administration, and did not contain documentation of an assessment for safe self-administration. The resident’s plan of care did not address safe self-administration of these medications. The DSD verified the medications were at bedside and stated the resident should have no medication at bedside and that other residents could get and use the medications. The DON later confirmed that an IDT assessment was needed for self-administration and verified both residents had no physician’s order, assessment, or care plan for self-administration.
Failure to Notify Physician and Responsible Party of Significant Weight Loss
Penalty
Summary
The facility failed to ensure the physician was informed of a change in condition for Resident 13, specifically a significant weight loss. Resident 13 was admitted and later readmitted to the facility, and the MDS assessment showed severe impaired cognition. The resident’s weights and vitals summary showed a weight of 74 lbs. on 2/3/26 and 65 lbs. on 3/4/26, reflecting a loss of 9 lbs. or 12.2% in one month, followed by a weight of 62 lbs. on 4/4/26. The medical record did not show documentation that the physician or responsible party were informed of the resident’s current weight of 65 lbs. and the 9-lb. weight loss. The facility’s policy required immediate or as soon as practicable notification of the resident, physician, and resident representative when there was a significant change in physical, mental, or psychosocial status or a need to alter treatment significantly. During interview, LVN 4 stated that weight loss of 5 lbs. in a week or 5% in a month required physician notification, SBAR initiation, and monitoring, but confirmed there was no documentation that Resident 13’s physician or responsible party were informed of the 9-lb. weight loss. The DON stated that more than 10% weight loss in one month was considered severe and that the licensed nurse should compare weights, notify the physician and family when a significant variance was noted, and initiate an SBAR for monitoring.
Incomplete Care Plans for CPAP Use and Hearing Loss
Penalty
Summary
The facility failed to ensure the comprehensive care plan was developed to reflect the individual care needs of two residents. For Resident 106, the medical record showed a physician's order dated 6/25/26 for CPAP continuously at bedtime and as needed for respiratory distress, but the care plan report did not show a problem or interventions related to the resident's use of the CPAP machine. During interview and record review, the ADON verified there was no care plan for the CPAP machine, and the DON later verified the same finding. For Resident 144, the resident was observed in bed and was unable to hear when spoken to, requiring staff to talk close to the resident's ear. The resident stated she had lost her hearing aid in the facility and felt frustrated because she was not able to hear. The MDS showed hearing was adequate with the use of a hearing aid and the resident's BIMS score was 14, indicating cognitive intactness, but the care plan report did not show a care plan for difficulty hearing or for the use and care of the hearing aid. Interviews with CNA 2, the Social Services Coordinator, and LVN 13 confirmed the resident had difficulty hearing and that no plan of care had been developed to address communication or hearing aid use.
Care plans did not reflect ordered interventions for pain management and fall prevention
Penalty
Summary
The facility failed to ensure the comprehensive person-centered care plan was revised to reflect current care needs and interventions for two residents. For one resident, the care plan for pain management did not include the physician-ordered nonpharmacological interventions to be attempted before administration of pain medications. For another resident, the care plan for fall risk did not include the physician-ordered pad alarm in bed as an intervention, even though the resident was observed with the pad alarm in place and was identified as high risk for falls. Resident 3 was readmitted to the facility and had capacity to understand and make decisions. The medical record showed physician orders for acetaminophen, hydrocodone-acetaminophen, morphine sulfate, and tramadol that each required nonpharmacological approaches before pain medication administration, including repositioning, dim light/quiet environment, hot/cold application, relaxation techniques, distraction, music, and other interventions every shift. The care plan problems for use of Norco, risk for pain related to fibromyalgia, and use of morphine sulfate were reviewed, but the interventions did not include the ordered nonpharmacological approaches. Resident 154 was admitted to the facility and had no capacity to understand and make decisions. The resident’s fall risk evaluation identified the resident as high risk for falls, and a physician ordered a pad alarm in bed for unassisted attempts to get up and for safety. During observation, the resident was seen in bed with the pad alarm in place, and CNA 3 verified its use because the resident was getting up unassisted from bed. However, the fall care plan dated 6/2/26 did not include the pad alarm intervention, and the DON and ADON verified that omission.
Failure to Support Hearing Communication After Lost Hearing Aid
Penalty
Summary
Assist a resident in gaining access to vision and hearing services was deficient for Resident 144, who was admitted with a hearing aid and had an MDS assessment indicating hearing was adequate with the use of the hearing aid. The resident’s BIMS score was 14, indicating cognitive intactness. During the initial tour, the resident was observed in bed and unable to hear, and stated that the hearing aid had been lost in the facility. Record review and interviews showed the resident’s hearing aid was lost between 6/14/26 and 6/16/26, and the Care Plan Report did not show a care plan addressing the resident’s hearing difficulty or the use and care of the hearing aid. On observation, the resident had difficulty communicating, required repeated statements spoken very close to the ear, and had no alternative communication in the room. The resident stated feeling frustrated because she had lost her hearing aid and was not able to hear. CNA 2 confirmed the resident had a hard time hearing without the hearing aid, Social Services Coordinator 3 verified there was no plan of care to communicate effectively with the resident, and the DON acknowledged the findings.
Failure to Assess Pain Before Wound Care Treatment
Penalty
Summary
The facility failed to ensure necessary care was provided to prevent pressure injuries for one resident reviewed for pressure ulcer/injury care. Facility policy stated that assessment and treatment of a resident’s pain are integral components of pressure ulcer prevention and management, and that pain affecting movement or mood may contribute to immobility and delayed healing or non-healing of an existing pressure ulcer or pressure injury. Resident 231 had physician orders for daily wound care to multiple pressure injuries, including deep tissue injuries and Stage 3 pressure injuries on the left and right buttocks, ischium, and posterior legs, along with an order to assess pain before, during, and after treatment each day shift. The care plan also included pain management/medication as ordered for the deep tissue injury areas. During an observed wound care treatment, the LVN did not assess the resident’s pain before starting the treatment. The resident complained of pain during the wound care, at which time the LVN assessed the pain and the resident rated it as 7 on a 0-10 scale. The LVN later acknowledged that pain should have been assessed before initiating wound care so medication could be given if needed for comfort.
Failure to Monitor Severe Weight Loss and Provide Ordered Meal Item
Penalty
Summary
The facility failed to ensure Resident 13’s severe weight loss was monitored and addressed in a timely manner. Resident 13 had severely impaired cognition and weighed 74 lbs. on 2/3/26, then 65 lbs. on 3/4/26, reflecting a 9-lb. loss in one month, a 12.2% severe weight loss. The record also showed a 10-lb. loss over three months and a 12-lb. loss over six months. The facility’s records did not show that the physician or the resident’s responsible party were informed of the 65-lb. weight or the weight loss, and the weight management committee did not document review of the weight loss until 4/13/26. The record also showed poor PO intake that was not addressed in the documentation. On 2/26/26 and 2/27/26, Resident 13 ate 26-50% of meals and 0-25% of one lunch meal, and alternative meals were not always offered. The licensed nurse weekly summary dated 3/4/26 stated there were no nutritional concerns within the prior week, and the record did not show documentation addressing the poor intake or notifying the physician or responsible party. Staff interviews indicated that poor intake of less than 50% for three consecutive meals should prompt physician notification and an SBAR, but that did not appear in the record for the documented meals. Resident 13’s nutritional assessment dated 3/2/26 documented a usual body weight of 73 to 78 lbs., a goal weight of 75 to 80 lbs., and interventions including multivitamins, minerals, and a fortified no added salt diet. A later dietary progress note dated 3/27/26 documented the 65-lb. weight and noted intake of 25 to 100%, often 50-75%, with staff feeding, Remeron use, hypertension medication, and a recent UTI with antibiotic treatment. During a breakfast observation, Resident 13 was assisted by CNA 1 and had bread, eggs, oatmeal cereal, milk, cranberry juice, and Boost on the tray, but the meal ticket also listed hashbrowns and the tray did not include them. CNA 1 and LVN 14 verified the missing hashbrowns, and LVN 14 stated the resident should have had them on the tray.
IV Access Monitoring and Labeling Deficiencies
Penalty
Summary
The facility failed to provide necessary care and services to maintain IV access for two residents receiving IV therapy. For one resident with a PICC line inserted into the left upper arm, the physician’s order required measurement of the IV line from the insertion site and arm circumference on the night shift every 7 days, but the medical record showed no documented measurement or nurse initials for the scheduled 6/23/26 check. The resident’s PICC insertion record showed the line had been inserted on 6/17/26, and the IV MARs for June 2026 did not contain evidence that the required assessment was completed on the missed date. For another resident observed with a peripheral IV in the left hand, the IV site was seen without a date or label indicating when it had been inserted. The resident’s record did not show a physician’s order for use of the peripheral IV. During interview, the DSD confirmed that the nurse who inserted the IV was expected to label the dressing with the date and initials, and stated that when the peripheral IV was no longer needed it should be discontinued to prevent infection. The DON also verified that the licensed nurse who inserted the peripheral line was expected to label the dressing with the date and initial.
Failure to Document Nonpharmacological Pain Interventions Before Opioid Administration
Penalty
Summary
The facility failed to provide and document nonpharmacological pain interventions before administering ordered pain medications for three residents reviewed for unnecessary medications. The facility’s Pain Assessment and Management policy stated that both non-pharmacological and pharmacological interventions should be developed and implemented for pain management, and that non-pharmacological interventions could include repositioning, environmental changes, hot or cold applications, relaxation techniques, distraction, music, and other comfort measures. Resident 3 was readmitted to the facility and had no capacity to understand and make decisions. The resident had orders for hydrocodone-acetaminophen, including a standing order for pain management and an order listing nonpharmacological approaches to be attempted prior to administration. The MAR showed multiple administrations of hydrocodone-acetaminophen in June 2026 for pain levels ranging from 5 to 9, but the medical record did not show documented evidence that the ordered nonpharmacological interventions were provided before those doses. Resident 6 was also readmitted to the facility and had no capacity to understand and make decisions. The resident had an order for hydrocodone-acetaminophen as needed for severe pain and a corresponding order for nonpharmacological approaches prior to administration. The MAR showed hydrocodone-acetaminophen was given on three occasions in June 2026 for pain level 8, but the record did not show documentation that the nonpharmacological interventions were provided first. Resident 69 had capacity to make decisions and had standing orders for Percocet and Tramadol, each with nonpharmacological approaches listed prior to administration. The MAR showed repeated administration of both medications throughout June 2026, but the medical record did not show documented evidence that the ordered nonpharmacological interventions were provided before those doses. The ADON verified these findings during concurrent review, and the DON was informed and acknowledged them.
Medication Administration and Controlled Substance Handling Errors
Penalty
Summary
Safe and effective pharmaceutical services were not ensured for a resident with a gastrostomy tube when an LVN administered medications through the tube but did not perform the final flush as ordered. The resident had physician orders to flush the feeding tube with 30 mL of water before and after medication administration, and the facility policy also required a minimum of 30 cc of water after the final medication. During observation, the LVN crushed and administered glycopyrrolate and docusate sodium, gave lactulose through the tube, and used 10 mL water flushes between medications, but did not flush the tube with 30 mL of water after the last medication. Controlled substance handling was also not completed according to facility policy for a resident receiving pregabalin. A pregabalin bubble pack was observed in the medication cart with a count of 75 capsules, while the Drug Control Receipt Record/Disposition Form showed 76 capsules. The LVN stated one capsule had been dropped on the floor and wasted by himself, but the facility policy required wasted controlled medications to be destroyed by two nurses and documented on the accountability record. The resident’s Drug Control Receipt Record/Disposition Form did not show documentation of the waste. A third resident’s finasteride was handled without the use of gloves during medication preparation and administration. The resident had an order for finasteride 5 mg daily with instructions to use gloves when handling Proscar if pregnant, and the medication bubble pack had a yellow sticker indicating cytotoxic caution and glove use. During observation, the LVN prepared and administered the finasteride without wearing gloves. The consultant pharmacist identified finasteride as a NIOSH hazardous drug requiring glove use for safe handling.
Failure to Follow Medication Orders and Monitoring Requirements
Penalty
Summary
The facility failed to ensure that Resident 3’s anticoagulant therapy was monitored for signs and symptoms of bleeding as ordered. Resident 3 had no capacity to understand and make decisions, had an order to receive apixaban 5 mg by mouth twice daily for AFib/DVT prophylaxis, and also had a physician order to monitor for abnormal or unexplained bruising, petechiae, internal bleeding, nosebleeds, and bleeding gums every shift and notify the physician if present. The MAR showed the apixaban dose was given on the evening shift, but the monitoring section for signs and symptoms of bleeding was not completed for that shift. The facility also failed to follow physician orders for Resident 228’s blood pressure medications. Resident 228 had decision-making capacity and was ordered to receive carvedilol 6.25 mg twice daily and nifedipine 60 mg daily, with both medications to be held if systolic blood pressure was below 110 mmHg. The MAR showed that both medications were administered when the resident’s systolic blood pressure was 108 mmHg. During interviews, the LVN verified that blood pressure medications should be checked against the ordered parameters before administration and confirmed that the medications were given despite the systolic blood pressure being below the ordered threshold. The ADON verified the missing anticoagulation monitoring for Resident 3, and the DON acknowledged both findings. The facility’s medication administration policy required medications to be given in accordance with physician orders and vital signs to be checked as indicated.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to keep the medication error rate below 5%, with a reported error rate of 12% after two residents did not receive prescribed medications during medication administration observations. Facility policy stated medications must be administered in accordance with the orders. The deficiency involved Resident 171, who was admitted with a diagnosis of anemia and had no capacity to understand and make decisions, and Resident 148, who was admitted with a diagnosis of amyotrophic lateral sclerosis and had a BIMS score of 15, indicating cognitive intactness. For Resident 171, an LVN administered multiple ordered medications but did not give ferrous sulfate 324 mg, ordered one tablet by mouth every Monday, Wednesday, and Friday. The LVN stated the medication would not be administered at that time and had not contacted the prescriber to clarify the order. For Resident 148, an LVN administered some medications but did not give riluzole 50 mg via PEG tube twice daily or cyclosporine ophthalmic emulsion 0.05% one drop in both eyes every 12 hours because the medications were not available. The LVN stated the riluzole bubble pack was empty and the cyclosporine eye drops were not in the medication cart, and both medications were still unavailable later that day.
Pureed Diet Recipe Not Followed
Penalty
Summary
The facility failed to ensure the menu was followed for 16 residents who received a pureed diet out of 168 residents who received food from the kitchen. Review of the facility’s policy showed menus were to meet basic nutritional needs based on individual nutritional assessment, the individualized plan of care, and established national guidelines, and were to be periodically updated. The facility also had a tamale pie recipe for the dysphagia/pureed diet that directed staff to add five teaspoons of margarine for every five portions of tamale pie. During observation of pureed tamale pie preparation, a Dietary Aide measured 10 scoops of tamale pie into a blender and added 10 scoops of margarine using a 30 mL scoop, then added water and blended the mixture. During interview and concurrent recipe review, the Dietary Aide stated he usually prepared the puree and said he followed the recipe by adding one tablespoon of margarine for every scoop of tamale pie. He then reviewed the recipe and verified it called for five teaspoons of margarine for every five scoops, or one teaspoon per scoop, and verified the scoop used for margarine was 30 mL. The Administrator, RD, and DSS were informed of the findings and acknowledged them.
Facility Assessment Missing Staffing Contingency Plan
Penalty
Summary
The facility-wide assessment dated 9/17/25 failed to include a contingency plan for staffing needs. The report states that the assessment was intended to determine what resources were necessary to care for residents competently during day-to-day operations, including nights and weekends, and during emergencies, but the review did not address or include a contingency plan for staffing needs. On 7/1/26 at 1607 hours, the Administrator was interviewed and stated that the contingency plan was part of the emergency plan. The Administrator was informed of the finding and acknowledged it.
Incomplete and inaccurate resident medical record documentation
Penalty
Summary
The facility failed to ensure medical records were complete and accurately documented for five sampled residents. For one resident with a PICC line, the IV MAR contained blank and/or missing initials for ordered IV-related tasks, including flushing the line, monitoring the IV site, checking blood return, and administering piperacillin-tazobactam. The resident’s IV insertion site and arm circumference were also not documented on one day. An RN verified the MAR should have been initialed by the nurse, and the DON stated the assigned RN was expected to complete the IV MAR documentation. For another resident, the medical record contained an advance directive copy that did not match the resident’s actual advance directive status. The record showed a POLST with DNR status, while the advance directive in the chart indicated CPR should be attempted. The social services coordinator stated the advance directive had been uploaded into the electronic medical record but nursing had not been informed. The DON was informed and acknowledged the findings. In a separate record review, a resident’s chart contained a Durable Power of Attorney for management of property and personal affairs in the section for advance directives, and the SSD acknowledged that the submitted form was not an advance directive and that no advance directive was available in the record. Two residents with ESRD and dialysis access had blood pressure documentation recorded on the left arm despite orders and care plans directing staff not to take blood pressure or blood draws on the access arm. The records showed multiple BP readings documented on the left arm for both residents. One resident stated staff never took BP on the left upper arm, and the other resident stated the same. An RN verified the findings and stated taking BP on the left arm could damage the AV shunt or fistula. The DON also verified the BP documentation was inaccurate and stated the access arm should not be used because of the risk to the AV shunt.
Incomplete Hospice Calendar and Missing Visit Notes
Penalty
Summary
The facility failed to provide necessary care and services for one of two final sampled residents reviewed for hospice services. Resident 10 was admitted to hospice under routine level of care, and the resident's H&P dated 9/12/25 showed the resident had the capacity to understand and make decisions. The facility's hospice P&P stated that hospice services should meet professional standards and that staff should monitor hospice care through observation, resident or representative interviews, and review of the resident's record for pertinent documentation. Review of Resident 10's June 2026 hospice calendar showed the scheduled hospice skilled nurse visits were not documented as required, and the calendar did not reflect the resident being scheduled for skilled nurse visits two times a week. The resident's facility medical record and hospice record also did not contain visit notes from the hospice skilled nurse for the reviewed dates. During interviews, LVN 7, Social Services Coordinator 2, the DON, and the Administrator acknowledged that the hospice binder, calendar, and medical record should be accurate and complete, and that the hospice visit notes should be available in the resident's record.
Baseline Care Plan Not Initiated for Oxygen Therapy
Penalty
Summary
The facility failed to ensure the baseline care plan was initiated upon admission for one of 34 sampled residents, Resident 225, specifically for the resident's use of oxygen. Facility policy stated that completion and implementation of the baseline care plan within 48 hours of admission is intended to promote continuity of care and communication among staff, increase resident safety, and provide a written summary of the initial plan of care and services. Review of Resident 225's plan of care did not show a baseline care plan addressing oxygen use. Resident 225 was admitted to the facility on [DATE] and was observed on 6/29/26 in bed receiving oxygen therapy from an oxygen concentrator at 1.5 liters per minute via nasal cannula. During an interview and concurrent medical record review on 7/1/26, the ADON verified that no baseline care plan had been formulated when the resident was admitted. On 7/2/26, the DON was informed and verified these findings.
Mechanical Lift Transfer and Post-Incident Monitoring Deficiency
Penalty
Summary
The facility failed to ensure that Resident 5 received proper care during a mechanical lift transfer and failed to document and monitor the resident after she reported hitting her neck and/or head and having pain. Resident 5 was admitted with a fractured tibia and fibula and a long-leg immobilizer, and her H&P noted she had the capacity to understand and make decisions. The facility’s mechanical lift competency for CNA 5 required an assistant for all lifting preparation, transferring from, and transferring to procedures so one staff member could maneuver the machine and another could assist and safeguard the resident to avoid injury. Resident 5 stated that CNA 5 transferred her from her wheelchair to her bed using a mechanical lift without a second staff member assisting, raised her too high, did not properly support her fractured leg, and caused pain. She also stated that when the lift was lowered, she hit her neck on the headboard and had additional pain. CNA 5 acknowledged transferring the resident by herself and stated she should have had a second staff member assist. CNA 1 stated the resident later reported that CNA 5 had transferred her alone, raised her too high, and caused her to hit her head on the headboard. The closed medical record did not show documentation that Resident 5 reported hitting her neck or head or complained of pain or discomfort to her neck or head. The record also did not show physician notification or continued monitoring for potential injury and pain. LVN 2 stated she was notified of the incident, assessed the resident, and found no injury, but did not document elsewhere and did not notify the physician. The DON stated that if a resident reported hitting her head on the headboard during a transfer and continued to have pain the next day, the nurse should notify the physician and perform neurological checks, and verified the record lacked documentation of the report, physician notification, and continued monitoring.
Infection Control Lapse With Floormat Placement
Penalty
Summary
Provide and implement an infection prevention and control program was cited after staff failed to follow infection control standards for one sampled resident. During an observation and concurrent interview, CNAs were using a mechanical lift to transfer the resident from bed to a wheelchair while the resident remained lying in bed. A floormat was observed propped up lengthwise against the left side of the resident’s bed and upper grab bar, with the upper portion of the mat touching the resident’s bedding. CNA 2 stated he had moved the floormat off the floor and leaned it against the resident’s bed while performing the transfer, and acknowledged that items on the floor are considered contaminated and that the mat should have been placed against the wall instead of the bed. The DON later stated that items on the floor are considered dirty and acknowledged that leaning the floormat along the resident’s bed was an infection control concern.
Failure to Revise Care Plan for Cardiac Monitor, Urinary Retention, and Rectal Bleeding
Penalty
Summary
The facility failed to ensure a comprehensive, person-centered care plan was revised to reflect specific care needs for one sampled resident following admission from an acute care hospital. Facility policy titled “Comprehensive Care Plans-Timing” (revised 1/2025) required that each resident have a person-centered, comprehensive care plan developed, reviewed, and revised by the interdisciplinary team, with involvement of the resident and/or representative. For this resident, admitted in January 2026 and discharged in February 2026, review of the January 2026 plan of care showed no care plan problem addressing the presence of a Zio patch, a wearable cardiac monitor that was documented as present on admission in a Wound Weekly Monitoring Assessment dated 1/15/16 and referenced in the Discharge to SNF Summary and Transfer Order dated 1/14/26 as a cardiac monitor requiring follow-up for atrial fibrillation. The same resident’s January 2026 plan of care also lacked care plan problems for urinary retention and rectal bleeding, despite these conditions being identified and ordered for monitoring and intervention. The Discharge to SNF Summary and Transfer Order dated 1/14/26 documented urinary retention as a reason for the acute care hospitalization, and an Order Summary Report dated 1/15/26 included a physician’s order for PVR checks every six hours for three days with in-and-out catheterization if PVR exceeded 250 cc and MD notification if two or more consecutive catheterizations were required. Additionally, an Order Summary Report dated 1/17/26 contained a physician’s order to monitor signs and symptoms of rectal bleeding, yet no corresponding care plan problem was initiated. During interviews, RN 1 confirmed the Zio patch was present on admission and agreed it should have been care planned, and the ADON verified that care plans for urinary retention and rectal bleeding were absent and should have been revised to reflect these problems.
Failure to Follow Physician Orders and Monitor Urinary Retention
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary care and services related to urinary retention and bladder management for one resident. The facility’s policies required licensed nurses to document and implement physician orders and outlined expectations for bowel and bladder retraining, including assessment of continence status and voiding patterns. For this resident, the January care plan did not include a problem for urinary retention. A physician’s order dated mid-January directed staff to check post-void residual (PVR) every six hours for three days, to perform an in-and-out (I/O) catheterization if the PVR was greater than 250 cc, and to notify the physician if there were two or more consecutive catheterizations every six hours for three days. On a specific date in January at 1200 hours, the Medication Administration Record documented a PVR of 337 cc, which exceeded the ordered threshold for I/O catheterization. There was no documentation in the progress notes or closed medical record that an I/O catheterization was performed in response to this elevated PVR, that the physician was notified of the continued urine retention, or that the resident was reassessed or further monitored after the 337 cc residual was identified. The 337 cc PVR entry was the last documented PVR in the ordered sequence. During interview and concurrent record review, an RN confirmed that if a resident continued to retain urine after three days, the physician should be notified, reassessment and monitoring should occur, and a care plan problem should be created, and verified that these steps were not documented for this resident. These failures had the potential to negatively impact the resident’s well-being.
Failure to Timely Address Significant Resident Weight Loss
Penalty
Summary
The facility failed to ensure timely nutritional intervention for a resident who experienced significant, rapid weight loss. The facility’s Weight Management policy, revised in 12/2024, required monitoring and intervention for residents with sudden changes in nutritional intake, a loss or gain of 5 lbs. since the last recorded weight, or weight changes greater than 5% in one month, among other thresholds. The resident was admitted in mid-January 2026 with a goal weight of 185–190 lbs., and the nutritional assessment dated 1/21/26 documented “no weight change” despite subsequent weight records showing a decline. The Weight and Vitals Summary showed the resident’s weight decreased from 187 lbs. on 1/15/26 to 180 lbs. on 1/24/26 (a 7 lb. loss in nine days), and then to 175 lbs. on 2/1/26, totaling a 12 lb. loss (approximately 6.4%) in less than a month. Despite these documented changes, the facility did not address the resident’s significant weight loss in a timely manner. The resident’s weight remained 175 lbs. on 2/8/26, and an IDT Progress Note dated 2/9/26 recorded no change for one week, a 5 lb. loss over two weeks, and a 12 lb. (6%) loss over three weeks since admission. During interview, the RD stated she received copies of the weekly weights and acknowledged that a 7 lb. weight loss in nine days would be concerning and require follow-up, and that the resident had experienced significant weight loss of 6% from admission. The RD reported that she did not follow up with the resident until 2/9/26 and stated that, ideally, she should have followed up earlier. The Administrator, Administrator Assistant, ADON, and DON were informed of and acknowledged these findings.
Failure to Update Care Plan After Reported Staff Inability to Meet Needs and Harassment
Penalty
Summary
The deficiency involves the facility’s failure to develop a comprehensive, person-centered care plan addressing a reported change of condition and allegation of staff misconduct for one resident. The facility’s policy on Comprehensive Care Plans requires that each resident have a person-centered, comprehensive care plan developed, reviewed, and revised by the interdisciplinary team, including the resident and representative when applicable. For this resident, an SBAR: Change of Condition dated 1/31/26 documented that the resident’s daughter reported a CNA was unable to meet the resident’s needs and was harassing the resident. Despite this documented change of condition and allegation, review of the resident’s plan of care showed no care plan problem was developed to address the daughter’s report that staff were not meeting the resident’s needs and the allegation of harassment. During interviews and concurrent medical record reviews, LVN 2 and LVN 3 each verified that no care plan problem had been developed following the reported change of condition on 1/31/26. LVN 2 stated that the purpose of developing a care plan related to a change of condition is to ensure goals and interventions are being met or revised as needed, and LVN 3 stated that the importance of a care plan is to create and update resident goals and interventions as needed. The Administrator was later informed of and acknowledged these findings. The facility’s inaction in updating the care plan after the documented report from the resident’s daughter constituted a failure to develop a comprehensive care plan that reflected the resident’s individual care needs and the reported concerns.
Failure to Properly Store Respiratory Equipment and Post Oxygen in Use Signage
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policies and procedures for nebulizer and oxygen therapy for two residents. For one resident with a physician’s order for albuterol-ipratropium via nebulizer every six hours, surveyors observed the nebulizer mask lying face down and the nebulizer tubing connected to the machine on the nightstand, not stored in a plastic bag, and not labeled with the resident’s name or date, contrary to the facility’s nebulizer therapy policy. This resident was also using an oxygen concentrator at the bedside with two portable oxygen tanks present, but there was no “oxygen in use” signage posted outside the room as required by the facility’s oxygen therapy policy. The OT and an LVN both confirmed the mask and tubing were not bagged, dated, or labeled, and verified the absence of the required oxygen signage. For another resident with asthma and an order to use oxygen via nasal cannula as needed to maintain oxygen saturation above 92%, surveyors observed oxygen tubing curled around a portable oxygen tank in an oxygen holder on the back of the resident’s wheelchair. The tubing was not stored in a plastic bag and was not labeled, despite the facility’s oxygen therapy policy requiring oxygen delivery equipment to be changed weekly, stored in a plastic bag at the bedside when not in use, and used for a single resident only. This resident was on oxygen therapy via concentrator and nasal cannula at the time of observation, yet there was no “oxygen in use” signage posted outside the room entrance. A CNA and an LVN both verified that the tubing was not bagged or labeled and that the required oxygen signage was not present. The Infection Preventionist later acknowledged that oxygen and nebulizer tubing should be changed, bagged, and dated weekly and as needed, and that oxygen in use signage should be posted for all rooms with residents using oxygen.
Failure to Obtain Physician Order and Consent for Restraint Devices
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary restraints by not obtaining a physician's order or informed consent for the use of a lap buddy and pressure pad alarm on the resident's wheelchair. Observations and interviews confirmed that the resident was using these devices, but a review of the medical record showed no documentation of a physician's order, informed consent, or a care plan addressing their use. The facility's policies require a physician's order, informed consent, and a resident-centered care plan for any physical restraint, including devices such as lap buddies and alarms that the resident cannot remove easily. The resident in question had severe cognitive impairment, as indicated by a BIMS score of 00 and documentation that the resident lacked capacity to make decisions. Staff interviews revealed that the devices were used to alert staff if the resident attempted to get up unassisted, due to episodes of leaning forward. Despite this, there was no evidence that the required assessments, orders, or consents were completed prior to the application of these devices. Further interviews with nursing staff and facility administration confirmed the absence of a physician's order, informed consent, and a care plan for the use of the lap buddy and pad alarm. The facility's own policies, as reviewed, clearly outline the steps required before applying such devices, including assessment by the interdisciplinary team and ongoing documentation, none of which were present in this case.
Failure to Report Abnormal Neuro Findings and Monitor Post-Fall Residents
Penalty
Summary
The facility failed to provide necessary care and services to maintain the highest practicable well-being for two residents. For one resident with severe cognitive impairment, after returning from the hospital following a fall with a forehead laceration, neurological assessments documented fixed pupil reactions on multiple occasions. Despite these abnormal findings, there was no evidence that the physician was notified as required by facility policy. The Assistant Director of Nursing (ADON) confirmed that these findings were abnormal and should have been reported and documented. For another resident with intact cognition, following an unwitnessed fall, the medical record did not contain documentation of post-fall monitoring during the morning and night shifts. Facility policy requires 72-hour monitoring and documentation after a fall, including assessments and physician notification. The ADON verified that there was no documentation to show the resident was monitored as required during these shifts. Facility policies reviewed included requirements for neurological assessments, documentation after significant events, and post-fall management, all of which were not followed in these cases. The failures were confirmed through observation, interviews, and medical record review, and were acknowledged by facility leadership.
Failure to Timely Report Alleged Abuse to Authorities
Penalty
Summary
The facility failed to report an allegation of abuse in a timely manner for one of four sampled residents. According to the facility's policy, all alleged violations involving abuse, neglect, exploitation, or mistreatment must be reported immediately, but not later than two hours after the allegation is made if it involves abuse or results in serious bodily injury. In this case, a resident who lacked capacity to make decisions was transferred to an acute care hospital, where she informed the hospital RN that she did not want to return to the facility due to alleged abuse and mistreatment. The hospital RN relayed this information to the facility staff around midnight. However, the LVN who received the information only reported it to the RN supervisor on duty and did not notify the Administrator, CDPH L&C Program, Long-Term Care Ombudsman, or local law enforcement as required by policy. The Administrator, who serves as the facility's Abuse Coordinator, was not informed of the allegation until approximately eight hours after it was made. Only after being notified did the Administrator report the incident to the appropriate authorities. Both the LVN and the Administrator acknowledged that the allegation should have been reported immediately according to facility policy. The delay in reporting had the potential to delay the investigation and prevent prompt corrective actions.
Failure to Document PRN Medication Administration in Medical Record
Penalty
Summary
The facility failed to ensure accurate documentation of medication administration for one resident. According to the facility's policy, medications must be administered and documented in accordance with physician orders and professional standards. A review of the resident's medical record and Medication Administration Record (MAR) revealed that two tablets of acetaminophen 325 mg and one tablet of baclofen 5 mg, which were ordered to be given as needed, were not documented as administered on a specific date and time. The progress notes also lacked documentation of these medications being given. Interviews with the resident's family member and the LVN confirmed that the medications were administered between 1200-1300 hours, but the LVN acknowledged failing to document the administration in the MAR. The RN corroborated that the LVN had verified the administration verbally but was unable to document it. The Director of Nursing was informed of these findings and acknowledged the expectation that licensed nurses document medication administration immediately after giving medications.
Failure to Provide Necessary Care and Services
Penalty
Summary
The facility failed to provide necessary care and services to maintain the highest practicable well-being for a resident, identified as Resident 2. The facility did not ensure that Resident 2 had a physician's order for suctioning as per the discharge order from the acute care hospital. Despite the resident's care plan indicating the need for suctioning to maintain a clear airway, the order was not documented or implemented by the nursing staff upon admission. This oversight was confirmed during an interview with an LVN, who acknowledged that the suctioning order was missing and should have been entered by the nurse receiving the physician's orders. Additionally, the facility did not adhere to the physician's instructions to weigh Resident 2 daily and administer Lasix medication as needed based on weight changes. The resident's medical records lacked documentation of daily weight monitoring, which was a critical component of managing the resident's heart failure and COPD. Interviews with the LVN and ADON confirmed the absence of a physician's order for daily weight monitoring, which was a deviation from the prescribed care plan. The facility also failed to notify the physician and responsible party of Resident 2's repeated refusals of medications and supplements. The resident's MAR indicated multiple instances of medication refusal, yet there was no documentation of physician notification or a COC/SBAR being completed. Furthermore, the facility did not provide the necessary indwelling urinary catheter care and wound care treatments as ordered by the physician. The TAR showed blank entries for several dates, indicating that these treatments were not performed. The ADON confirmed that blank entries meant the care was not provided, and the Administrator and DON were made aware of these findings.
Non-Compliance with Name Badge Policy
Penalty
Summary
The facility failed to comply with State laws and its own policies and procedures regarding employee identification, as evidenced by two staff members, an LVN and a CNA, not wearing their name badges. During an observation and interview, the CNA was found without her name badge and stated it had fallen off, but she intended to put it back on. Similarly, the LVN was observed without her name badge and acknowledged that the purpose of the badges was for residents and families to identify staff members. The LVN admitted that the badge was on the cart instead of being worn. The Assistant Director of Nursing (ADON) confirmed that name badges are expected to be worn at all times as part of the staff uniform.
Failure to Administer Prescribed Eye Drops for Resident
Penalty
Summary
The facility failed to provide necessary care and services for a resident by not following up with the hospice for an order of latanoprost eye drops, which are used to treat glaucoma. The resident was admitted for hospice care, and an order for the eye drops was issued by the hospice physician. The medication was received by the facility nurse, but the order was not documented in the resident's medical records or administered until several days later. This oversight resulted in the resident experiencing eye discomfort for weeks before receiving the prescribed treatment. The facility's policies and procedures require that nursing home staff obtain and communicate orders from hospice physicians to the resident's attending physician in a timely manner. However, the order for the eye drops was not communicated or documented, leading to a delay in treatment. Interviews with facility staff, including the MDS nurse, hospice case manager, and DON, confirmed the lapse in following up on the order. The LVN who received the medication admitted to forgetting to verify and carry out the order, resulting in the resident not receiving the necessary eye drops until a later date.
Failure to Prime Insulin Pen Before Administration
Penalty
Summary
The facility failed to provide necessary pharmaceutical services for a resident by not following the manufacturer's instructions for administering insulin using a Tresiba insulin pen. During a medication administration observation, a Licensed Vocational Nurse (LVN) was seen preparing and administering the Tresiba insulin pen without priming it as required. The manufacturer's instructions specify that the pen should be primed by selecting two units, holding the pen with the needle pointing up, and ensuring a drop of insulin is visible at the needle tip before selecting the prescribed dose. This step was omitted by the LVN, who directly selected the prescribed dose and administered it to the resident. The resident involved had a diagnosis of Type 2 Diabetes Mellitus and was prescribed a daily dose of 12 units of Tresiba insulin. The LVN, along with a Registered Nurse (RN), admitted to being unaware of the priming requirement. The Assistant Director of Nursing (ADON) confirmed the findings and acknowledged that the insulin pen should be primed before selecting the dose. This oversight in following the correct procedure for insulin administration posed a risk of the resident not receiving the correct amount of medication.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Fullerton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Greenfield Care Center Of Fullerton, Llc | 0 mi | ★★★★★ | 1 | 0 |
| Terrace View Care Center | 0 mi | ★★★★★ | 25 | 0 |
| St Elizabeth Healthcare Center | 0.4 mi | ★★★★★ | 22 | 0 |
| Park Vista At Morningside | 1.1 mi | ★★★★★ | 16 | 0 |
| St. Catherine Healthcare | 1.8 mi | ★★★★★ | 19 | 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 October 2026) and official state health department websites.