Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Vasona Creek Healthcare Center during CMS and state inspections, most recent first.
Psych Consult Not Completed as Ordered: A resident with major depressive disorder and schizophrenia had a psych consult ordered, but the consult was not completed as planned. The record showed the in-house psych provider asked for the reason for the referral, yet there was no documentation that the facility provided it. Later notes indicated the consult was denied due to insurance and DMH referral was requested, but there was no documentation that this referral or any further follow-up occurred.
Staff used an alarmed emergency exit door located next to a resident room for routine entry and exit despite posted signs stating it was for emergency use only and that an alarm would sound. The MD and DON confirmed the door was intended solely for emergencies and that staff were aware an alarm would sound when it was opened, yet some staff continued to use it during non-emergencies. This practice conflicted with the facility’s homelike environment policy, which required maintaining comfortable sound levels.
Staff failed to maintain an emergency exit door alarm in active status when social services staff turned off the alarm on a clearly marked emergency-only exit door near a resident room to hold a conference outside. The MD confirmed the door was intended only for emergencies and that the alarm should sound when opened, and the DON verified during testing that opening the door did not trigger an alarm, contrary to facility expectations that the alarm remain on at all times.
A resident with chronic pain syndrome and rheumatoid arthritis did not receive physician-ordered referrals for retinal screening and rheumatology consults. The social service assistant, responsible for arranging these consults and transportation, missed the orders, and there was no documentation that the referrals were completed, contrary to facility policy.
A resident with multiple mental health and physical care needs did not receive ordered psychiatric and dermatology consults, and was observed with long, untrimmed fingernails and dry skin, despite staff awareness and facility policy requiring proper nail care.
A facility failed to document three doses of intravenous vancomycin for a resident with functional quadriplegia, aphasia, and osteomyelitis of the sacrum. The physician had ordered the antibiotic for sepsis, but the MAR showed missing documentation for specific times. The DON confirmed the missing entries and noted that missed doses should be reported and documented, as per facility policy.
A resident with hypothyroidism did not receive the correct dosage of levothyroxine as ordered by a physician. Despite a tele-visit where the dosage was increased to 150 mcg, the facility continued administering lower doses for several months. This discrepancy was confirmed by an LPN during a record review.
A resident was inappropriately diagnosed with diabetes and received insulin without supporting evidence, as the facility failed to document necessary lab results or symptoms. The attending physician was unaware of the insulin orders made by a covering physician, and the resident's responsible party was not informed of the treatment changes, violating facility policies.
The facility failed to properly store and label medications in three medication carts. Discontinued medications for three residents were not removed, and an insulin pen lacked patient-specific labeling and an open date. LVNs acknowledged the oversight, and the DON confirmed the need for proper medication management.
A resident admitted with a coccyx wound did not have a physician's order for wound treatment documented until eight days later, and treatments were not recorded until the same time. Additionally, there was no documentation of weekly wound assessments during the first week after admission, contrary to facility policies.
A resident received incorrect dosages of prednisone due to the facility's failure to follow physician's orders for a steroid tapering regimen. The resident was given a higher dosage than prescribed for six days and missed one dose entirely. The error occurred because the previous order was not discontinued, and both dosages were administered concurrently. The facility's policy requires clarification of any ambiguities with the physician, which was not done.
A facility failed to administer prescribed respiratory therapy (RT) treatments for six residents, impacting their respiratory function. Despite orders for five daily treatments, residents received RT less frequently, with some receiving it only two or three times a day. The deficiency was confirmed through interviews and record reviews, highlighting a lack of policy for implementing physician's orders.
The facility failed to secure a medication room containing an ADU, leading to potential unauthorized access. Expired medications were found in refrigerators, and temperature logs were incomplete, risking medication efficacy.
A facility failed to ensure immediate reporting of suspected abuse when an LVN documented an incident where a resident's spouse was heard speaking aggressively to the resident over the phone. Despite the facility's policy requiring immediate reporting, the incident was not communicated to the Administrator or DON, leading to a deficiency. The resident had severe cognitive impairment and a history of multiple medical conditions.
The facility failed to resubmit a new Level I PASARR for a resident with mental health diagnoses after 30 days and inaccurately completed a PASARR for another resident by omitting a psychosis diagnosis. The responsibility for ensuring PASARR accuracy lay with the nursing department and admission team, but the omissions were not caught, despite the residents' medical histories and medications.
A resident with severe cognitive impairment and a history of falls sustained a laceration on the forehead after a fall. The LVN cleaned the wound and sent the resident to the hospital, but upon return, no treatment orders were documented. Interviews and observations confirmed the lack of compliance with the facility's wound care policy, as no orders were written for the wound care, despite the resident having a bandage on the forehead.
A facility failed to follow its Enhanced Barrier Precautions (EBP) policy during wound care for a resident with a pressure ulcer. Staff did not wear gowns, as required by the policy, which mandates gown and glove use to prevent MDRO transmission. The resident had a history of congestive heart failure and a stage I pressure injury. Interviews confirmed the resident should have been on EBP, indicating a lapse in infection prevention protocols.
A room in the facility was found to house five residents, exceeding the regulatory limit of four. This was confirmed through interviews with the DON, Maintenance Director, and Administrator, as well as a memorandum. The Administrator noted that the facility had been receiving a yearly waiver for this room.
The facility did not provide the required 80 square feet of living space per resident in 16 rooms, as revealed by a Client Accommodations Analysis. Despite this, staff reported no impact on care provision, and the facility received annual waivers for these rooms.
The facility failed to document scheduled treatments for 13 residents, including topical creams and ointments for rashes and wound healing, as well as heel protectors for skin breakdown. Interviews and observations confirmed that treatments were not administered as ordered, with multiple days lacking documentation. The assistant director of nursing acknowledged the issue, highlighting a systemic problem in care and documentation practices.
The facility failed to document chest percussion therapy for three residents as ordered, with missing records for multiple sessions over several days. A licensed nurse confirmed the lack of documentation and no record of treatment refusal, contrary to the facility's policy requiring all services to be documented.
A resident's responsible party was not informed of a change in the resident's condition and a new medication order for elevated blood pressure. Despite facility policy requiring notification, there was no documentation of communication with the responsible party.
A facility failed to accurately complete an MDS for a resident, compromising intervention development. The resident, admitted with abnormal posture and walking difficulties, experienced an unwitnessed fall. A licensed nurse confirmed the fall should have been coded on the MDS, but it was incorrectly marked as 'No' for falls during the specified time frame.
A resident's clinical record contained inaccurate late entries made by an LPN, documenting care for dates after the resident had been transferred to a hospital. The LPN acknowledged the error, stating the notes were intended for another resident but could not identify which one. This failure to maintain accurate records could compromise care monitoring and intervention.
A facility failed to accurately complete an MDS for a resident with multiple diagnoses, including sepsis and diabetes, who experienced an unwitnessed fall. The fall was not properly coded in the MDS, as confirmed by an MDS nurse during a review.
The facility failed to document weekly Skin & Wound Evaluations for a resident with a skin condition and did not complete Nursing Weekly Summaries for two residents. These omissions were confirmed by an LPN, who acknowledged that both evaluations and summaries should be conducted weekly according to facility policy.
The facility failed to accurately complete the Elopement Risk Observation/Assessment for two residents, leading to incorrect elopement risk scores. One resident, on Seroquel, was reported missing and later returned safely. Another resident, on Trazodone, also had an inaccurate assessment. These errors were confirmed by an LPN during a record review.
The facility failed to notify the Ombudsman office of a resident's hospital transfer, despite the resident's increased confusion and refusal of medication. Interviews and record reviews confirmed the lack of notification, which was contrary to the facility's policy.
A resident with alcohol dependence missed ten doses of Zenpep due to the facility's failure to follow up with the pharmacy in a timely manner. The medication was unavailable from 9/21/23 to 9/24/23, and the facility did not contact the pharmacy until 9/24/23, resulting in multiple missed doses.
A resident with diabetes, anemia, and hyperlipidemia did not receive all the food items listed on his lunch tray slip, missing soup and a second serving of milk. LVN E acknowledged the missing items, and dietary staff confirmed the Standing Orders should have been followed.
The facility failed to ensure proper infection control measures, with staff improperly wearing face masks and not screening a resident's family member for COVID-19 before entry. These lapses were confirmed through observations, staff interviews, and a review of the Visitors Screening Log.
Psych Consult Not Completed as Ordered
Penalty
Summary
The facility failed to ensure a psychiatric consultation was completed as ordered for one resident with diagnoses including major depressive disorder and schizophrenia. The resident had a physician order dated 9/28/25 to refer to psych consult, and a progress note dated 10/10/25 documented that a referral was sent for an in-house psych consult with the provider expected to arrive on 10/13/25. There was no documentation that the psych consult was completed on that date. An email dated 10/24/25 showed the facility followed up on the pending consult, and the in-house psych provider asked for the reasons for each referral. There was no documentation that the facility provided the reason for the resident's referral. The resident's record then showed no further documentation until 12/1/25, when a progress note stated the resident was referred for psych consult but denied due to insurance and asked to refer to DMH. There was no documentation that a DMH referral was sent or that any further follow-up occurred after that note.
Improper Non-Emergency Use of Alarmed Exit Door Disrupting Homelike Environment
Penalty
Summary
Facility staff failed to honor residents’ right to a safe, clean, comfortable, and homelike environment by using an alarmed emergency exit door for non-emergency purposes, contrary to posted signage and facility policy. During an observation, surveyors noted a door located next to a resident room that led outside and was clearly marked with signs stating it was for emergency exit only and that an alarm would sound if opened, instructing individuals to use another exit. In interviews, the maintenance director confirmed the door was only to be used during emergencies and that staff were aware an alarm would sound if it was opened. The DON also confirmed the door was intended for emergency use only but acknowledged that some staff used this door to enter and exit the facility during non-emergencies, despite the loud alarm it produced. Review of the facility’s “Homelike Environment” policy indicated the facility was to maximize characteristics of a personalized, homelike setting, including maintaining comfortable sound levels, which conflicted with staff’s non-emergency use of the alarmed door. No specific resident medical histories or conditions were described in the report, but the door in question was located next to a resident room, and the deficiency centered on the impact of the alarm noise on maintaining comfortable sound levels as required by the facility’s homelike environment policy.
Emergency Exit Door Alarm Turned Off by Staff
Penalty
Summary
Facility staff failed to ensure an emergency exit door alarm was functioning to keep the environment as free of accident hazards as possible. An emergency exit door located next to a resident room had signage stating it was for emergency use only and that an alarm would sound if opened, and another sign instructing individuals not to open the door because the alarm was on and to use another exit. During an observation, the DON opened this emergency exit door and no alarm sounded. In interviews, the MD confirmed the door was intended for emergency use only and that the alarm should sound when opened, and later explained that social services staff had turned off the alarm so they could hold a conference outside, despite staff not being permitted to turn off the emergency door alarm and the expectation that it remain on at all times. No specific residents, medical histories, or conditions were described in the report, and the deficiency centered on the non-functioning emergency door alarm and staff actions that led to it being turned off.
Failure to Arrange Physician-Ordered Referrals
Penalty
Summary
The facility failed to follow its own policies and procedures to ensure that physician orders for referrals were carried out for a resident. Specifically, a resident with chronic pain syndrome and rheumatoid arthritis had physician orders for a retinal screening and a rheumatology consult. These orders were documented in the clinical record, but there was no evidence that the referrals were arranged or that the resident was seen for these consultations. During interviews and record reviews, the social service assistant confirmed that she was responsible for arranging the consults and transportation but had missed the consult orders. The assistant director of nursing also confirmed that the physician orders for the consults were not carried out as required. The facility's policy stated that social services should coordinate and document physician-ordered referrals and arrange transportation, but this was not done for the resident in question.
Failure to Provide Ordered Consultations and Nail Care
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards for a resident with multiple diagnoses, including major depressive disorder, schizophrenia, adult failure to thrive, and a need for assistance with personal care. The resident required partial to maximal assistance with personal hygiene, bathing, and toileting. Observations revealed that the resident had long fingernails on several digits, with overgrowth of skin and dryness around the nails. The assistant director of nursing confirmed that the resident's fingernails were long and needed trimming, and facility policy indicated that proper nail care is necessary to prevent skin problems. Additionally, the facility did not follow through on physician orders for psychiatric and dermatology consultations for the resident. Although orders for these consults were documented, interviews with staff, including an LVN, the social service assistant, and the director of nursing, confirmed that there was no evidence the consultations had been completed or documented in the resident's clinical record. The staff acknowledged that the orders should have been followed and arrangements made for the resident to be seen by the appropriate specialists.
Failure to Document Vancomycin Administration
Penalty
Summary
The facility failed to ensure that physician orders were carried out or documented as written for a resident, resulting in a deficiency. Specifically, three doses of intravenous vancomycin, an antibiotic, were not documented on three separate days for a resident who was admitted with functional quadriplegia, aphasia, and osteomyelitis of the sacrum. The physician had ordered vancomycin to be administered three times a day for sepsis, but the medication administration record (MAR) showed missing documentation for specific dates and times. During an interview and concurrent record review, the Director of Nursing (DON) confirmed the missing documentation and stated that if a dose of medication is missed, the nurse should notify the provider and document it in a progress note. The facility's policy on administering medications requires that medications be administered in accordance with prescriber orders and that the administration details be recorded in the resident's medical record. The lack of documentation for the vancomycin doses indicates a failure to adhere to this policy.
Failure to Implement Physician's Order for Medication Dosage
Penalty
Summary
The facility failed to implement a physician's order in a timely manner for a resident diagnosed with hypothyroidism. The resident was admitted with a prescription for levothyroxine sodium 50 mcg daily. On a subsequent tele-visit with an endocrine clinic, the physician ordered an increase in the dosage to 150 mcg daily. However, the facility did not adjust the medication dosage as per the new order until several months later. The resident continued to receive the initial dosage of 50 mcg until it was slightly increased to 75 mcg, but the prescribed 150 mcg was not administered until much later. This delay in implementing the physician's order was confirmed by a licensed nurse during an interview and record review. The facility's policy mandates that medications be administered according to the prescriber's orders, which was not adhered to in this case.
Inappropriate Insulin Administration and Lack of Communication
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality and facility policies for a resident who was diagnosed with diabetes and received insulin orders without documented evidence supporting the diagnosis. The resident, who had a history of aphasia following a stroke and a urinary tract infection, was admitted without a diabetes diagnosis. Despite this, insulin orders were made by a covering physician without documented laboratory results or symptoms meeting the diagnostic criteria for diabetes as per the American Diabetes Association guidelines. The resident's A1c levels were within normal range, and there was no evidence of high blood sugar readings prior to the administration of insulin. The insulin orders were entered into the system by a registered nurse based on a phone endorsement from another nurse, but neither could provide evidence of the high blood sugar reading that supposedly justified the insulin prescription. The attending physician, who was on leave at the time, confirmed that there was no documented reason for the insulin orders and that the resident was not on any medications that could have caused elevated blood sugar levels. The facility's policy required physicians to document relevant tasks and review the resident's care program, which was not adhered to in this case. Additionally, the facility failed to inform the resident's responsible party about the new insulin orders, as required by their policy on resident rights and changes in condition. The responsible party was not notified of the insulin treatment and only discovered it after noticing the resident's lethargy and questioning the staff. The lack of communication and documentation regarding the insulin orders and the resident's condition change violated the facility's policies and the resident's rights.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications in three out of six medication carts. Discontinued medications for three residents were not removed from active stock. Specifically, a multi-dose vial of insulin lispro belonging to a resident who was discharged over a month ago was found in Medication Cart 3A. Similarly, a Humulin N vial for another resident and a Lantus vial for a third resident, both of whom were no longer in the facility, were found in Medication Cart 1A. The Licensed Vocational Nurses (LVNs) responsible for these carts acknowledged that these medications should have been removed. Additionally, an insulin glargine-yfgn pen was found in Station 4 Medication Cart without any patient-specific labeling or an open date. The LVN responsible for this cart was unable to identify the pen's owner or when it was opened. According to the manufacturer's prescribing information, such pens should be discarded 28 days after opening. The Director of Nursing confirmed that medications belonging to discharged residents should be removed to prevent errors, and insulin pens should be labeled with the resident's name and open date. The facility's policy on medication labeling and storage was not adhered to, contributing to these deficiencies.
Incomplete Medical Record for Resident with Coccyx Wound
Penalty
Summary
The facility failed to maintain a complete medical record for a resident who was admitted with a coccyx wound. Upon admission, the resident had non-blanchable redness with open skin on the coccyx, but the facility did not document obtaining a physician's order for wound treatment until eight days later. Additionally, the facility did not document any treatments for the coccyx wound until eight days after admission, and there was a lack of documentation for weekly wound assessments during the first week after admission. Interviews with the wound treatment nurse and the assistant director of nursing confirmed these documentation gaps. The facility's policies require that wound treatments be documented in the treatment administration record and that weekly wound assessments be recorded in the medical record. However, these protocols were not followed, as evidenced by the absence of documentation for the initial wound treatment order, the delay in recording wound treatments, and the missing weekly wound assessment for the first week after admission.
Failure to Follow Physician's Orders for Steroid Tapering
Penalty
Summary
The facility failed to follow physician's orders for a resident's steroid tapering regimen, resulting in the resident receiving incorrect dosages of prednisone. The resident, who was admitted with multiple diagnoses including atrial fibrillation, chronic obstructive pulmonary disease, pulmonary hypertension, bronchiectasis, and bacterial pneumonia, was prescribed a tapering dosage of prednisone to reduce inflammation. However, the facility administered a higher dosage than prescribed for six days and missed one dose entirely. Specifically, the resident received 55 mg of prednisone daily from September 4 to September 9, instead of the prescribed 25 mg, and did not receive any prednisone on September 11. The discrepancy arose from a failure to discontinue the previous order of 30 mg of prednisone when the new tapering order was issued. Licensed nurses administered both the old and new dosages concurrently, leading to the excessive dosage. The facility's policy on physician orders requires that any ambiguities or concerns be clarified with the ordering physician before execution, but this was not done. The Director of Nursing confirmed the errors and acknowledged that the orders should have been clarified with the physician, as the specific dates in the order did not align with the intended tapering schedule.
Failure to Administer Prescribed Respiratory Therapy
Penalty
Summary
The facility failed to ensure that respiratory therapy (RT) treatment orders were carried out as prescribed for six residents, potentially impacting their physical well-being. Residents 3, 5, 6, 7, 8, and 9 did not receive the ordered five times daily chest physiotherapy, which is crucial for optimizing their respiratory function. The deficiency was identified through interviews and record reviews, revealing that the residents received RT less frequently than ordered, with some receiving it only two or three times a day. Resident 5, with a history of COVID-19, was supposed to receive chest physiotherapy five times daily but only received it two to three times on several days. Similarly, Resident 6, who had respiratory disorders, was scheduled for five daily treatments but received only one to three treatments on various days. Resident 3, diagnosed with bronchiectasis, also did not receive the prescribed five daily treatments, with some days showing no treatment at all. The deficiency was further confirmed through interviews with the Director of Nursing (DON) and the Director of Staff Development (DSD), who acknowledged the failure to administer the treatments as ordered. The respiratory therapist noted the challenge of providing five daily treatments, indicating that three times a day was more feasible. The facility lacked a policy addressing the implementation of physician's orders for treatments, contributing to the inconsistency in administering RT as prescribed.
Medication Storage and Monitoring Deficiencies
Penalty
Summary
The facility failed to ensure the proper storage and security of medications in two of its medication rooms. During an inspection, it was observed that the medication room containing the facility's automated dispensing unit (ADU) was left unlocked when not in use, allowing potential unauthorized access to medications. Additionally, expired medications were found in the medication refrigerators in two different stations. Specifically, an expired eye drop solution for a resident and an expired multi-dose tuberculin solution vial were identified, both of which had not been removed from the storage. Furthermore, the facility did not consistently monitor the temperature of a medication refrigerator as per the guidelines. The temperature log for November 2024 showed that the temperature was not recorded ten times within the month, indicating a lack of adherence to the policy of monitoring and recording refrigerator temperatures twice daily. This oversight could lead to ineffective medications or loss of drug potency due to unmonitored temperatures.
Failure to Report Suspected Abuse
Penalty
Summary
The facility failed to ensure that staff immediately reported an incident of suspected abuse involving a resident. According to the facility's policy, any suspected abuse must be reported immediately to the Director of Nursing Services or, in their absence, to the Nurse Supervisor on duty. However, a Licensed Vocational Nurse (LVN) documented an incident in the progress notes where a resident's spouse was heard speaking aggressively to the resident over the phone, but there was no indication that the LVN reported this suspected abuse to the appropriate authorities. The resident involved had a medical history that included severe cognitive impairment, as indicated by a Brief Interview for Mental Status (BIMS) score of 3. The resident was admitted to the facility with conditions such as dysphasia following a stroke, schizophrenia, parkinsonism, major depressive disorder, and anxiety disorder. Despite the facility's policy requiring immediate reporting of suspected abuse, both the Administrator and Director of Nursing were unaware of the incident until it was brought to their attention during the survey. This lack of communication and failure to follow protocol led to the deficiency noted in the report.
Failure to Resubmit and Accurately Complete PASARR Screenings
Penalty
Summary
The facility failed to resubmit a new Level I Preadmission Screening and Resident Review (PASARR) for a resident who was admitted on 05/14/2024 with a medical history of bipolar disorder, major depressive disorder, and anxiety disorder. The resident's initial PASARR was negative due to an exempted hospital discharge, which required a new Level I Screening if the resident remained in the facility longer than 30 days. Interviews with the Director of Nursing (DON), Marketing Director, and Administrator revealed that the facility did not complete the necessary screening on the 31st day, as expected. Another resident was admitted on 03/15/2024 with a medical history that included unspecified moderate dementia, anxiety disorder, and unspecified psychosis. The PASARR Level 1 Screening for this resident inaccurately indicated no serious diagnosed mental disorder, omitting the diagnosis of psychosis. Interviews with the Social Services Director, DON, and Marketing Director highlighted that the responsibility for ensuring the accuracy of PASARRs lay with the nursing department and admission team. The omission of the psychosis diagnosis was not caught, despite the resident being on antipsychotic medication. The Administrator confirmed that the admission team was responsible for reviewing PASARRs and involving the clinical team if inconsistencies were found. The medical records staff was tasked with auditing charts to ensure PASARR presence and to identify any clinical changes that might warrant a Level II evaluation. However, the facility failed to capture the psychiatric diagnosis and medication for the second resident, leading to an inaccurate PASARR.
Failure to Obtain Treatment Orders for Resident's Laceration
Penalty
Summary
The facility failed to obtain treatment orders for a laceration on a resident's forehead, which was identified during a review of non-pressure related skin integrity issues. The resident, who had a history of severe cognitive impairment and was at risk for falls, sustained a fall resulting in an open cut with active bleeding. The licensed vocational nurse (LVN) cleaned the wound, applied adhesive strips, and sent the resident to the hospital for further treatment. Upon the resident's return, no new treatment orders were provided, and the facility did not document any orders for the assessment or treatment of the wound. Interviews with staff revealed that the lack of treatment orders was not in compliance with the facility's wound care policy, which required a physician's order for wound care procedures. The Director of Nursing and the Administrator both acknowledged that treatment orders should have been written for the resident's wound care. Observations confirmed that the resident had a bandage on their forehead, but there were no documented orders for the adhesive strips or dressing applied to the wound.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to adhere to its Enhanced Barrier Precautions (EBP) policy during wound care treatment for a resident with a pressure ulcer. The policy mandates the use of gowns and gloves during high-contact resident care activities, including wound care, to prevent the transmission of multi-drug-resistant organisms (MDROs). However, during an observation, staff members, including a Licensed Vocational Nurse and an Infection Control Preventionist, did not wear gowns while performing wound care on a resident with a pressure ulcer, despite wearing surgical masks and gloves. The resident involved had a medical history of congestive heart failure and required assistance with personal care. The resident was admitted with a stage I pressure injury and was receiving care for it. The facility's policy clearly indicated that residents with chronic wounds should be placed on EBP, which includes the use of gowns and gloves. Interviews with the Infection Control Preventionist and the Director of Nursing confirmed that the resident should have been on EBP, highlighting a lapse in following the facility's infection prevention protocols.
Room Capacity Exceeded in LTC Facility
Penalty
Summary
The facility failed to comply with the regulation that limits the number of residents per room to four, as evidenced by room [ROOM NUMBER] accommodating five residents. This deficiency was identified through interviews and document reviews. A memorandum dated 11/15/2021 confirmed that room [ROOM NUMBER] had five beds. During the entrance conference, the Director of Nursing acknowledged the presence of a room housing more than four residents. Both the Maintenance Director and the Administrator confirmed the existence of this room. The Administrator mentioned that the facility had been receiving a yearly waiver for this room and had not received any concerns regarding the number of residents it housed.
Facility Fails to Meet Minimum Room Size Requirements
Penalty
Summary
The facility failed to provide the required minimum living space of 80 square feet per resident in 16 out of 62 resident rooms. The Client Accommodations Analysis, dated January 1, 2023, revealed that several rooms had less than the required square footage, with measurements ranging from 70 to 76 square feet per resident. This deficiency was confirmed through interviews and document reviews conducted by the surveyors. During interviews, the Maintenance Director acknowledged that the facility had between 10 to 20 rooms that did not meet the minimum standard. Despite this, staff members, including a Licensed Vocational Nurse, a Certified Nursing Assistant, and the Director of Nursing, reported no impact on their ability to provide care due to the smaller room sizes. Additionally, the Administrator mentioned that the facility annually received a waiver for rooms with less than 80 square feet per resident and had not received any complaints regarding room size.
Failure to Document Scheduled Treatments for Residents
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards of practice for 13 of 28 sampled residents. This deficiency was identified through interviews, observations, and record reviews, revealing that there were multiple days where there was no documentation of scheduled treatments being administered. The lack of documentation was noted across various treatments, including topical creams and ointments for conditions such as rashes, itchiness, and wound healing, as well as the application of heel protectors for skin breakdown prevention. For instance, Resident 1 had a physician's order for a topical cream to be applied every shift, yet there were 15 days in August 2024 without documentation of this treatment. Similarly, Resident 2 had orders for hydrocortisone cream and nystatin powder, with 5 and 12 days respectively lacking documentation of administration. Resident 3 also reported that staff did not apply the prescribed lotion to his face in the evenings, with 12 days missing documentation. These instances were corroborated by interviews with the residents, who were cognitively intact and able to confirm the lapses in their care. The facility's policy and procedure on charting and documentation, as well as the job description for LPNs, emphasize the importance of documenting all services provided to residents. However, the assistant director of nursing confirmed that there were multiple days where treatments were not documented as administered. This failure to document treatments as ordered was consistent across several residents, indicating a systemic issue within the facility's care and documentation practices.
Failure to Document Chest Percussion Therapy
Penalty
Summary
The facility failed to provide chest percussion therapy as ordered for three residents, which was identified through interviews and record reviews. Resident 1, diagnosed with pulmonary fibrosis and emphysema, had a physician's order for chest percussion therapy four times daily. However, documentation for the therapy at 2:00 p.m. and 8:00 p.m. was missing from 8/3/24 to 8/11/24. Similarly, Resident 2, with pulmonary edema, had an order for therapy five times daily, but records for the 5:00 p.m. and 8:00 p.m. sessions were left blank during the same period. Resident 3, suffering from chronic respiratory failure, also had an order for therapy five times daily. Documentation was missing for the 5:00 p.m. and 8:00 p.m. sessions from 8/1/24 to 8/11/24, and all sessions on 8/2/24 were undocumented. During an interview, a licensed nurse confirmed the absence of documentation and verified that there was no record of the residents refusing treatment. The facility's policy mandates that all services provided must be documented, including the date and time of treatment or any refusal by the resident.
Failure to Notify Responsible Party of Change in Condition
Penalty
Summary
The facility failed to notify the responsible party (RP) of a change in condition and a new medication order for one of the residents. The resident, who had a designated RP, experienced elevated blood pressure, and the physician ordered hydralazine to manage this condition. However, there was no documentation indicating that the RP was informed of the elevated blood pressure and the new medication order. During an interview and record review, a licensed nurse confirmed the absence of documentation regarding the notification to the RP. The facility's policy mandates prompt notification of the resident, attending physician, and resident representative about changes in the resident's medical condition. Despite this policy, the facility did not adhere to the requirement, leading to the deficiency.
Inaccurate MDS Coding for Resident Fall
Penalty
Summary
The facility failed to accurately complete a Minimum Data Set (MDS) for one of the sampled residents, which compromised the ability to develop and implement necessary interventions. The clinical record of a resident, who was admitted with diagnoses including abnormal posture and difficulty in walking, indicated an unwitnessed fall occurred in the facility. During an interview and record review, a licensed nurse confirmed that the fall should have been coded on the resident's MDS. However, the MDS section J1800 was incorrectly coded as 'No', indicating no fall occurred during the specified time frame, when it should have been coded 'Yes'. This error was confirmed by the licensed nurse, who acknowledged the discrepancy in the MDS coding.
Inaccurate Documentation in Resident's Clinical Record
Penalty
Summary
The facility failed to accurately document in the clinical record for a resident when the resident's clinical record contained progress notes pertaining to a different, unknown resident. This issue was identified during a review of the resident's clinical record, which indicated that the resident was admitted with diagnoses including abnormal posture and difficulty in walking. The resident experienced an unwitnessed fall and was transported to an acute hospital, never returning to the facility. Despite this, late entries were made in the resident's clinical record for dates after the resident had been transferred, indicating the resident was still present and being monitored at the facility. During interviews, it was acknowledged by the involved licensed nurse that the late entries were mistakenly documented in the wrong resident's clinical record. The nurse admitted that the notes were intended for another resident but could not provide the correct resident's name. The facility's policy requires maintaining complete and accurately documented clinical records for each resident, which was not adhered to in this instance, potentially compromising the facility's ability to monitor and implement interventions for the correct resident.
Inaccurate MDS Completion for Resident Fall
Penalty
Summary
The facility failed to accurately complete a Minimum Data Set (MDS) for a resident, which compromised the ability to develop and implement necessary interventions. The resident, who had multiple diagnoses including sepsis, diabetes, respiratory failure, muscle weakness, and difficulty in walking, experienced an unwitnessed fall in the facility. During a review, it was confirmed that the fall was not properly coded in the MDS, as section J1800 was incorrectly marked as 'No' instead of 'Yes', indicating that the resident did not fall during the specified time frame. This error was acknowledged by the MDS nurse during an interview and record review.
Failure to Document Weekly Evaluations and Summaries
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards of practice for two residents. For one resident, there was no documentation of weekly Skin & Wound Evaluations after an initial evaluation was completed, despite the resident having a skin condition that required treatment with Clotrimazole Cream. The facility's policy required weekly evaluations for residents with skin conditions, but this was not adhered to, as confirmed by a licensed nurse during an interview and record review. Additionally, the facility did not consistently complete the Nursing Weekly Summary for two residents. The summaries, which are meant to document various aspects of a resident's condition, were not completed after specific dates for both residents. This lack of documentation was acknowledged by a licensed nurse, who confirmed that the summaries should be completed weekly according to the facility's policy. The absence of these assessments potentially compromised the facility's ability to identify and address the residents' needs effectively.
Inaccurate Elopement Risk Assessments for Two Residents
Penalty
Summary
The facility failed to accurately complete the Elopement Risk Observation/Assessment for two residents, compromising its ability to identify those at risk for elopement and implement necessary interventions. Resident 1, who was admitted with a diagnosis of subarachnoid hemorrhage, had a physician's order for Seroquel, a psychotropic medication. However, the assessment incorrectly indicated that Resident 1 was not on any psychotropic medications, resulting in an inaccurate elopement risk score. This oversight was confirmed during an interview with a licensed nurse, who acknowledged the error. Subsequently, Resident 1 was reported missing from the facility and was later returned safely by the local police. Similarly, Resident 2, admitted with conditions including trigeminal neuralgia and osteoporosis, had a physician's order for Trazodone, another psychotropic medication. The assessment for Resident 2 also failed to recognize the presence of psychotropic medication, leading to an incorrect elopement risk score. This error was confirmed by the same licensed nurse during a record review. The facility's policy on wandering and elopements emphasizes the importance of identifying residents at risk and maintaining accurate clinical records, which was not adhered to in these cases.
Failure to Notify Ombudsman of Hospital Transfer
Penalty
Summary
The facility failed to ensure the Ombudsman office was notified of a hospital transfer for one of the sampled residents. Resident 2, who was admitted with a diagnosis of metabolic encephalopathy, exhibited increased confusion and refused medication, leading to a doctor's order for hospital transfer. Despite the facility's policy requiring notification to the Ombudsman office, there was no documentation or fax confirmation that this notification occurred for Resident 2's transfer on the specified date. Interviews with social services staff and the Ombudsman office confirmed the lack of notification. Social services staff indicated that notifications should be sent weekly via fax, with a confirmation sheet to verify the transmission. However, the fax confirmation sheet for Resident 2 was missing, and the Ombudsman office confirmed they did not receive any notification for Resident 2's transfer during the relevant period. This oversight was contrary to the facility's policy, which mandates that a copy of the transfer notice be sent to the Ombudsman office.
Failure to Administer Prescribed Medication
Penalty
Summary
The facility failed to ensure that a resident received medication as ordered, which had the potential to compromise the resident's health and well-being. The resident, who was admitted with a diagnosis of alcohol dependence, had a physician order for Zenpep to be taken with meals. However, from 9/21/23 to 9/24/23, the medication administration record indicated that ten scheduled doses of Zenpep were not administered because the medication was unavailable. Licensed nurses documented the absence of the medication but did not follow up with the pharmacy until 9/24/23, resulting in multiple missed doses. During an interview, a registered nurse confirmed that the facility did not follow up with the pharmacy in a timely manner, which could have prevented the missed doses. The facility's policy on administering medications states that medications should be administered in a safe and timely manner, as prescribed. The failure to adhere to this policy led to the resident missing critical doses of their prescribed medication.
Failure to Provide Food According to Standing Orders
Penalty
Summary
The facility failed to provide food in accordance with Standing Orders for one of four sampled residents. Resident 1, who had diagnoses including diabetes, anemia, and hyperlipidemia, did not receive all the food items listed on his lunch tray slip dated 4/30/24. Specifically, his lunch tray was missing soup and a second serving of milk. During an observation and interview, LVN E acknowledged the missing items and requested LVN G to retrieve them. Dietary staff C confirmed that the Standing Orders on the lunch tray slip, which reflected Resident 1's preferences, should have been provided.
Infection Control Deficiencies
Penalty
Summary
The facility failed to implement proper infection prevention and control measures, as observed during a survey. Staff members were seen wearing face masks improperly, with their noses uncovered, while in resident care areas. This was noted in the rehabilitation gym and in resident rooms, where residents were either improperly masked or not masked at all. Interviews with staff confirmed that there was an awareness of the mask-wearing policy, but it was not consistently followed. The facility's policy and local public health guidelines both require face masks to cover the nose and mouth, especially during the Winter Respiratory Virus Period from November 1 through March 31. Additionally, the facility did not ensure that a family member of a resident was screened for COVID-19 before entering the facility. The family member was allowed to enter and move through the facility without documentation of a temperature check or symptom screening. Interviews with staff revealed that the screening process was not followed, and a review of the Visitors Screening Log confirmed the absence of the required documentation. This lapse in protocol could potentially lead to the spread of infection within the facility.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 431 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Los Gatos
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Terraces Of Los Gatos | 0.7 mi | ★★★★★ | 0 | 0 |
| Stonebrook Health And Rehabilitation | 1.5 mi | ★★★★★ | 2 | 0 |
| Woodlands Healthcare Center | 1.9 mi | ★★★★★ | 2 | 0 |
| Plum Tree Care Center | 2 mi | ★★★★★ | 0 | 0 |
| Childrens Hc Org No Ca -pediatric Hospital D/p Snf | 2.3 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.