Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
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 Villa Gardens Health Care Unit during CMS and state inspections, most recent first.
Failure to Maintain Required RN Coverage: The facility failed to ensure RN coverage for 8 consecutive hours on multiple days when the scheduled registry RN called off or did not show up and the DON was on vacation. The DSD and DON confirmed there was no RN coverage on those dates, and the DON stated the facility assessment required one RN for 8 hours per day and that the facility did not have a nursing services policy or sufficient staffing.
Medication administration was not carried out according to orders and facility policy for two residents. An LVN left crushed Famotidine unattended on the med cart, used only one resident identifier before giving meds, did not give Famotidine 30 minutes before GT feeding, and failed to flush the GT between Keppra and Metoprolol as ordered. For another resident, an LVN used only a wristband instead of two identifiers before administering medication, despite policy requiring at least two resident identifiers.
Food items in the kitchen dry storage area and walk-in refrigerator were found expired, dirty, and not clearly labeled. An opened container of vinegar, molasses, and ketchup had dried drippings or residue on the outside, two salad dressing containers were labeled with an unclear date, and two unopened containers of cooking wine were covered in dust and identified as expired. The facility policy required food and open packages to be covered, labeled, dated, and discarded when past the use-by or expiration date.
Improperly Covered Outside Dumpsters: The facility failed to keep outside dumpsters fully covered as required by its Solid Waste Disposal policy. Multiple observations showed dumpsters near the kitchen loading dock and door without lids or with lids that did not completely close, including dumpsters overflowing with trash. The IPN, DDS, and DES all reviewed the photos and policy and confirmed the dumpsters were not kept closed as required.
The facility failed to maintain infection prevention practices in several areas. An open box of gloves was left on top of a dirty linen hamper, a resident’s nasal cannula was left on a wheelchair seat instead of being stored properly, and a resident’s tube feeding machine and IV pole had dried formula stains. Soiled towels and a used Hoyer sling were left in the room rather than placed in the soiled linen cart, an LPN doffed PPE improperly in a resident room, and the medication room contained personal items, food, expired respiratory supplies, and clutter.
Late Medicare Coverage Notice: The facility failed to ensure a resident received sufficient notice before the last covered day for Medicare Part A services. The resident had heart failure, osteoarthritis, and depression, and was cognitively independent per MDS. The NOMNC showed coverage ending the next day, and the DON stated the resident was informed on the same day the notice was issued, despite facility guidance calling for generic notice two days before the LCD.
Wheelchair Cluttered With Resident Belongings: A resident’s wheelchair at the bedside was found overflowing with blankets, pillows, linens, towels, and leg braces. CNA, IPN, LVN, and DON all stated the items should not have been left on the wheelchair, and the resident said the messy room did not feel like home and she preferred it clean and organized.
Medication administration errors exceeded the allowed rate when an LVN gave a GT medication at the wrong time relative to tube feeding and administered two GT meds back-to-back without the ordered flush between them. The resident involved had dementia, dysphagia, aphasia, and a GT, and the orders required specific timing for Famotidine and 10 mL water flushes before and after each med.
Failure to Obtain Culture Before Antibiotic Orders: A resident with DMAC and other complex medical conditions was ordered azithromycin, ethambutol, and rifampin for MAC, but the facility did not ensure a culture was obtained before the antibiotic therapy was started. The IPN confirmed no culture was done and stated the hospital and physician were not followed up to verify whether a lab/culture had been obtained, despite the facility’s Antibiotic Stewardship Program requiring review of culture status before antibiotic ordering.
A facility failed to follow its policy on advance directives by not informing a resident with chronic kidney disease and thrombocytopenia about their right to formulate an advance directive. The absence of an acknowledgment form in the resident's chart was confirmed by both an LVN and the Social Services Director, despite the facility's policy requiring this documentation upon admission.
A resident with Parkinson's, dementia, and incontinence experienced multiple falls due to the facility's failure to identify causative factors and update the care plan with specific interventions. Despite a history of falls and confusion, the care plan lacked measures to address nighttime incontinence and confusion, leading to repeated falls and injuries.
The facility failed to follow its oxygen therapy policy for two residents. One resident received oxygen with an empty humidifier bottle, risking nasal membrane drying. Another resident received more oxygen than prescribed, and empty oxygen tanks were improperly stored in the room. Staff interviews confirmed these deficiencies.
The facility failed to follow proper food handling practices, as observed in the kitchen and resident's refrigerator. Food items were found without labels indicating the date they were opened, and expired bread was present in the dry storage area. Staff acknowledged the risk of bacterial growth and potential foodborne illness due to these deficiencies, which violated the facility's policies on food labeling and storage.
The facility failed to properly dispose of garbage, resulting in two dumpsters being uncovered and overflowing with trash. This was confirmed by the Director of Dining Services, who acknowledged the dumpsters should have been covered to prevent attracting animals. The facility's policy requires garbage containers to be maintained with lids to prevent pest attraction and ensure sanitation.
The facility failed to adhere to infection control practices for several residents. A visitor entered a COVID-19 isolation room without proper PPE, and staff did not ensure nasal cannula tubing was stored correctly for a resident. Another resident on Enhanced Barrier Precautions was not properly protected by staff during care, and a nebulizer was not stored in a clean bag, increasing infection risk.
A resident with an indwelling catheter did not receive proper catheter care as a nurse failed to cap the drainage tube with a sterile sheath during irrigation, contrary to the facility's policy. The resident, who required substantial assistance and had a history of chronic conditions, was at risk due to this oversight. The facility's policy emphasized maintaining a closed system to prevent contamination, which was not adhered to during the procedure.
A resident with type 2 diabetes was administered an incorrect insulin dose due to a transcription error, and the nurse failed to document the administration properly. Additionally, there was no documented evidence of monitoring for signs of hypoglycemia and hyperglycemia, despite recommendations. This lack of documentation and adherence to policies placed the resident at risk of inappropriate diabetes management.
A resident with functional quadriplegia and severe cognitive impairments was found to have their call light on the floor, out of reach, contrary to the facility's policy requiring call systems to be accessible. This deficiency was observed during staff interviews and record reviews.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to ensure there was a Registered Nurse (RN) on duty for eight consecutive hours, seven days a week, on 1/18/2025, 1/19/2025, 1/21/2025, and 1/22/2025, based on the facility assessment. During interviews and record review, the Director of Staff Development stated the facility did not have RN coverage on those dates because the RN scheduled through the registry called off or did not show up, and the Director of Nursing was on vacation from 1/18/2025 to 1/26/2025. The facility assessment was reviewed with the DON, who stated it indicated one RN for 8 hours per day and that the regulations required RN coverage for 8 hours a day. The DON also confirmed there was no RN coverage on 1/18/2025, 1/19/2025, 1/21/2025, and 1/22/2025, stated the facility was not able to get a replacement RN for those dates, and stated the facility did not follow the regulations to have RN coverage for those days. The DON further stated the facility did not have a policy for nursing services or sufficient staffing.
Medication Administration Errors and Identification Failures
Penalty
Summary
Pharmaceutical services were not provided in accordance with the facility’s policy and physician orders for two residents. For one resident with dementia, dysphagia, aphasia, and dependence for many activities of daily living, the record showed orders for Famotidine 40 mg once daily for GERD to be given 30 minutes prior to GT feeding, and for the GT to be flushed with 10 ml of water before and after each medication. During a medication administration observation, an LVN left crushed Famotidine unattended in a cup on top of the medication cart while in the resident’s room, then administered the medication using only one resident identifier. The LVN stated the medication should not have been left unattended and that two identifiers should have been used. The same resident’s GT medication administration did not follow the ordered flushing instructions. During a later observation, the LVN flushed the tube with 10 ml of water initially, then gave Keppra and Metoprolol back-to-back without flushing between the medications. The LVN stated he should have flushed between medications and that he did not follow the physician’s order. RN staff stated the Famotidine should have been given 30 minutes before the GT feeding started and that medications should not be left unattended on the medication cart. For a second resident with diagnoses including left knee replacement, Parkinson’s disease, dysarthria, anarthria, and lack of coordination, the medication pass observation showed the LVN identified the resident by wristband only and did not use a second identifier. The LVN stated only one identifier was used, and later acknowledged that two identifiers are important to correctly identify the resident and prevent medication errors. The DON and RN supervisor also stated that two resident identifiers should be used before medication administration, and the facility policy required at least two resident identifiers.
Food Storage Items Left Expired, Undated, and Dirty
Penalty
Summary
Food was not handled, prepared, and stored in accordance with the facility's policy in the kitchen dry storage area and walk-in refrigerator. During a concurrent observation and interview on 12/2/2025 at 7:49 AM with [NAME] 1, two unopened containers of cooking wine were observed covered in dust and labeled with the dates 11/14/2022 and 11/13/2025; [NAME] 1 stated both containers were expired. One opened gallon container of vinegar had dried drippings on the exterior, and one unopened container of vinegar was labeled with a handwritten date of 10/8/2023; [NAME] 1 stated the date indicated when the products were received or delivered and noted that the manufacturer's expiration date was not printed on the container or label. [NAME] 1 was observed wiping dust off both vinegar containers. Additional food items were observed in unclean or improperly labeled condition. One opened gallon container of molasses had dried drippings and dried material on the cap, and [NAME] 1 stated the container was dirty. One opened container of ketchup had drippings on the exterior. Two salad dressing containers/dispensers were labeled with the date 11/1/25, and [NAME] 1 stated she did not know what the date referred to; one of the two containers had drippings on the holder/cover. During review of the facility's policy and procedure titled Food and Supply Storage, revised 1/2025, the policy stated that all food, non-food items, and supplies used in food preparation shall be stored to prevent contamination, and that unused portions and open packages shall be covered, labeled, and dated, with food past the use-by or expiration date discarded.
Improperly Covered Outside Dumpsters
Penalty
Summary
The facility failed to ensure that two of three dumpsters containing garbage and refuse were covered or entirely covered as required by its Solid Waste Disposal policy. During an observation next to the kitchen loading dock and door, two dumpsters were seen without lids and another dumpster had a lid that did not completely cover the container. The Infection Prevention and Control Nurse reviewed the photo documentation and confirmed that one dumpster overflowing with trash did not have a lid or cover, and stated that open dumpsters can attract flies and other pests that could contaminate food and kitchen equipment. Further observations showed the same condition persisted on later dates, with one dumpster observed overflowing and not entirely closed and then two of three dumpsters observed overflowing and not completely covered or closed. The Director of Dining Services and the Director of Environmental Services both reviewed the facility policy titled Solid Waste Disposal and confirmed that the dumpsters were not covered or completely closed as shown in the photographs. The policy dated 1/20/25 stated that lids should be kept closed on all outside trash receptacles.
Infection Control Lapses in Resident Rooms and Medication Storage
Penalty
Summary
The facility failed to follow infection prevention and control practices in multiple resident care areas. In Resident 31’s room, an open box of medium-sized disposable gloves was observed sitting on top of the resident’s dirty linen hamper. Staff entered and exited the room without addressing the gloves. Registered Nurse Supervisor 2 stated this was an infection control issue because the gloves were no longer clean. The Infection Preventionist Nurse later stated there was cross-contamination between the glove box and the dirty linen hamper, and the Director of Nursing stated it was not appropriate to store gloves on top of the dirty linen hamper. In Resident 36’s hallway and therapy area, the resident’s oxygen equipment was not handled according to policy. The resident, who had bronchiectasis, COPD, and a history of falls, was observed with an oxygen tank in the rear storage basket of the wheelchair and a nasal cannula connected to the tank, with the cannula end left on the seat of the wheelchair instead of being stored in a pouch. The Occupational Therapist stated the cannula should have been stored in a pouch. The Infection Preventionist Nurse stated leaving the oxygen tubing on the wheelchair was improper handling and increased infection risk, and the DON stated staff did not follow the oxygen therapy policy. Resident 5’s room contained several infection control issues. The resident had diagnoses including dementia, dysphagia, aphasia, and a gastrostomy tube, and was dependent for multiple activities of daily living. The resident’s tube feeding machine had dried beige formula on the top surface, and the IV pole had dried beige splatter on the body and feet. Soiled white towels were left on top of the trash bin, and a used Hoyer lift sling was left in the room near the resident’s wheelchair instead of being placed in the soiled linen cart. LVN 1 was also observed doffing PPE in the resident’s room by reaching behind the back with used gloves while removing the gown, and the Infection Preventionist Nurse stated this was not acceptable because it could spread infection. In addition, the medication room contained personal items, food, expired and used respiratory items, toothbrushes, drinks, and other clutter, and the DON stated the medication storage room should be clean and free of clutter.
Late Medicare Coverage Notice
Penalty
Summary
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. The facility failed to ensure that one of three sampled residents, Resident 38, received sufficient notice before the resident's last coverage date for Medicare Part A services. Resident 38 was admitted with diagnoses including heart failure, osteoarthritis, and depression. The resident's MDS dated 11/23/2025 indicated the resident was independent in cognitive skills for daily decision making and required varying levels of assistance with dressing and toileting tasks. A review of Resident 38's NOMNC dated 11/26/2025 showed the effective date of coverage for current services would end on 11/27/2025. During interview, the DON stated Resident 38 was informed on 11/26/2025 regarding the resident's last covered date of 11/27/2025. The DON also stated the facility used the SNF notices - Quick Reference for guidance with issuance of the NOMNC form, and the facility's undated guidance stated generic notice was to be issued two days before the effective date, or last paid day/LCD.
Wheelchair Cluttered With Resident Belongings
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment for one sampled resident when the resident’s wheelchair, located at the bedside, was found overflowing with personal belongings. During observation, the wheelchair contained 2 blankets, 2 pillows, white linens, towels, and bilateral lower leg braces. The resident’s record showed admission and readmission for TIA, functional quadriplegia, and pneumonia, and the MDS dated 9/6/2025 indicated severely impaired cognitive skills for daily decision making and dependence in eating, hygiene, dressing, transfers, and mobility-related activities. During interview, CNA 1 stated the resident’s leg braces, blankets, pillows, and linens should be stored in the closet or in a black bag rather than left on the wheelchair, and that the room should be kept clean, organized, and free of clutter to avoid spread infection and ensure safety. The resident stated the messy room did not feel like home and that she liked her room clean and organized. The IPN stated the wheelchair should be free of clutter, clean linens should be kept in a clean plastic bag, and mixing dirty and clean items could cause cross contamination. The LVN and DON also stated the pillows and other personal belongings should not be left on the wheelchair.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure its medication error rate remained below 5 percent. During medication administration observation for one resident with dementia, dysphagia, aphasia, and a gastrostomy tube, surveyors identified 3 medication errors out of 25 opportunities, resulting in a 12 percent medication error rate. The resident had orders for Metoprolol Tartrate 12.5 mg via GT daily with parameters to hold for SBP less than 110 or HR less than 60, Levetiracetam 100 mg/ml solution 5 ml via GT twice daily for seizure prophylaxis, GT flushes with 10 ml of water before and after each medication, Osmolite 1.2 calorie enteral feeding via pump twice daily, and Famotidine 40 mg daily for GERD to be given 30 minutes prior to the start of GT feeding. During observation, an LVN gave Famotidine at 12:45 PM while stating the GT feeding would start at 3:00 PM, and an RN later stated the medication should have been given 30 minutes before the feeding start time. On another observed med pass, the LVN flushed the GT with 10 ml of water initially, then administered Keppra and Metoprolol back-to-back without flushing between the medications, and stated he should have flushed between them but did not follow the physician's order. RN staff stated the order required flushing 10 ml between medications and that medications ordered 30 minutes prior to GT feeding should be given 30 minutes before turning on the feeding. The facility policy stated medications are to be administered in accordance with prescriber orders, and the enteral feeding policy directed staff to review physician orders for completeness, including water flushes and medication administration.
Failure to Obtain Culture Before Antibiotic Orders
Penalty
Summary
The facility failed to implement its Antibiotic Stewardship Program when it did not ensure that a culture was obtained before ordering antibiotic therapy for one sampled resident. Resident 36 was admitted with diagnoses including Disseminated Mycobacterium Avium-Intracellulare Complex (DMAC), carrier of other infectious diseases, and antineoplastic chemotherapy. The resident’s MDS dated 11/6/2025 indicated moderate impairment in cognitive skills for daily decision making and dependence for toileting hygiene, with substantial to maximal assistance needed for several other activities of daily living. Resident 36’s discharge instructions from the acute care hospital were received by the facility on 10/30/2025. Physician orders dated 10/30/2025 included Azithromycin 500 mg by mouth every Monday, Wednesday, and Friday for MAC and Ethambutol HCL 400 mg, 2 tablets by mouth every Monday, Wednesday, and Friday for MAC. A later physician order dated 11/3/2025 added Rifampin 300 mg, 2 capsules by mouth every Monday, Wednesday, and Friday for MAC. During interview and record review, the Infection Preventionist Nurse stated that Resident 36 did not have a culture done, that all infections should have a lab/culture before administering an antibiotic, and that neither the hospital nor the physician was followed up with to determine whether a culture had been obtained. The facility policy titled Antibiotic Stewardship Program stated that the Infection Preventionist will collect and review whether a culture was obtained before ordering antibiotic.
Failure to Provide Advance Directive Information
Penalty
Summary
The facility failed to adhere to its Advance Directive policy by not informing and providing written information to a resident regarding their right to formulate an advance directive. This deficiency was identified for one of the two sampled residents, who was admitted with chronic kidney disease and thrombocytopenia. The resident's medical records, including the Face Sheet and Minimum Data Set, indicated fluctuating capacity for decision-making, yet the facility did not ensure the presence of an advance directives acknowledgment form in the resident's chart. During interviews, both a Licensed Vocational Nurse and the Social Services Director confirmed the absence of the required acknowledgment form, which should have been completed and placed in the resident's medical record. The facility's policy, revised in March 2024, mandates that social services staff inform residents about their rights concerning advance directives upon admission and document this in the medical record. The lack of this documentation could lead to conflicts in executing the resident's healthcare decisions during emergencies.
Failure to Prevent Falls and Update Care Plan
Penalty
Summary
The facility failed to prevent falls for a resident by not identifying the causative factors of the resident's falls and not revising the care plan with new, resident-specific interventions. The resident, who had a history of falls, Parkinson's Disease, dementia, and incontinence, experienced multiple falls over a period of time. Despite these incidents, the care plans from July to September did not include interventions to address the resident's nighttime incontinence and confusion. The resident was found on several occasions sitting on the floor, confused, and wet with urine, indicating a lack of adequate supervision and intervention. The resident's falls were often unwitnessed, and the circumstances surrounding the falls, such as attempting to reach for something or being confused about their surroundings, were not adequately addressed in the care plan. The facility's policy required immediate interventions and care plan updates, which were not consistently implemented. Interviews with facility staff, including the DON, revealed that the resident had a history of falls and unsteady gait, and was incontinent at night. However, there was no documented evidence of interventions to address these issues. The facility's policies on post-fall assessment and falls prevention emphasized the need for immediate interventions and care plan updates, which were not followed, leading to repeated falls and injuries for the resident.
Oxygen Therapy Policy Violations
Penalty
Summary
The facility failed to adhere to its oxygen therapy policy for two residents, leading to potential adverse effects. For Resident 8, the facility did not ensure that the humidifier bottle attached to the oxygen concentrator was dated and filled with water. During an observation, it was noted that Resident 8 was receiving 4 liters of oxygen per minute via nasal cannula with an empty and undated humidifier bottle. This oversight could result in nasal membrane drying, as the humidifier is intended to add moisture to the oxygen flow, preventing such issues. In the case of Resident 37, the facility did not follow the physician's order for oxygen therapy. The resident was observed receiving 4 liters per minute of oxygen via nasal cannula, despite the physician's order specifying 2 liters per minute. Additionally, empty portable oxygen cylinder tanks were stored in the resident's room alongside full tanks, contrary to the facility's policy, which requires empty tanks to be stored separately. This practice poses a risk of oxygen toxicity and potential safety hazards. Interviews with facility staff, including LVNs and the Director of Nursing, confirmed these deficiencies. Staff acknowledged the importance of following physician orders and the facility's policies to prevent harm to residents. The facility's policy on oxygen therapy, revised in July 2022, outlines the proper procedures for administering oxygen and managing equipment, which were not followed in these instances.
Improper Food Handling and Labeling Practices
Penalty
Summary
The facility failed to adhere to proper food handling practices as per its policy and procedure, which was observed during a survey. In the kitchen, multiple food items inside walk-in refrigerators were found without labels indicating the date they were opened. This included a large container of cranberries, a grocery bag with various food items, and a large pan of breaded meat. The cook was unaware of the origin of the grocery bag and acknowledged that it should not have been in the refrigerator. Additionally, expired bread items were found in the dry storage area, which the Director of Dining Services and the Registered Dietician confirmed should have been discarded to prevent potential health risks. In the resident's refrigerator near the nurse's station, several food items lacked labels indicating the opened date, resident's name, room number, or the date the food was prepared. This included a small container of red sauce and multiple containers of ice cream. Licensed Vocational Nurses expressed concerns about the lack of labeling, emphasizing the risk of bacterial growth and potential foodborne illness. The facility's policies required all prepared foods and foods not in original containers to be covered, labeled, and dated, and foods brought in by family members to be labeled with the resident's name, room number, and date of preparation or opening.
Improper Garbage Disposal and Overflowing Dumpsters
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse as per their policy, which resulted in two out of three dumpsters being uncovered and overflowing with trash. This was observed during a visit to the facility's garbage area, where the Director of Dining Services confirmed the issue, noting that the dumpsters should have been covered to prevent attracting animals. Additionally, empty boxes were found between the dumpsters, and one dumpster's lid was only partially covering it due to the overflow. The facility's policy, reviewed during the investigation, mandates that garbage containers be maintained in good condition with lids to prevent pest attraction and maintain sanitation.
Infection Control Deficiencies in PPE Usage and Equipment Storage
Penalty
Summary
The facility failed to implement appropriate infection control practices for several residents, as outlined in their policy and procedure. For Resident 199, a visitor entered the resident's room, which was under novel respiratory isolation due to COVID-19, without wearing the required personal protective equipment (PPE) such as a gown, N-95 mask, gloves, and face shield or goggles. The visitor was not educated on the necessity of these precautions, despite the presence of a sign indicating the required PPE. The Infection Preventionist Nurse confirmed the oversight and emphasized the importance of following isolation precautions to prevent the spread of infection. Resident 37's infection control measures were compromised when the nasal cannula tubing was not stored in a bag after use and was observed touching the floor. The facility's policy requires that oxygen tubing be changed if it becomes dirty or contaminated, which includes contact with the floor. Staff interviews revealed a lack of adherence to these protocols, as the nasal cannula was left exposed, increasing the risk of infection. For Resident 24, who was on Enhanced Barrier Precautions due to a gastrostomy tube and colonization with a multidrug-resistant organism, a staff member failed to don a gown before checking the gastrostomy tube placement. This oversight was acknowledged by the staff member, who later corrected the error. Additionally, Resident 19's handheld nebulizer was not stored in a clean bag when not in use, contrary to the facility's policy, which could lead to contamination and respiratory infection. Interviews with staff confirmed the importance of storing such equipment properly to prevent infection.
Failure to Follow Catheter Irrigation Policy
Penalty
Summary
The facility staff failed to adhere to its manual catheter irrigation policy when a Licensed Vocational Nurse (LVN) did not cap the drainage tube of an indwelling catheter with a sterile protective sheath during the irrigation process for a resident. This oversight was observed during a procedure where the LVN cleansed the connection site, disconnected the catheter from the drainage tubing, and placed the tubing on a clean disposable absorbent pad without capping it. The LVN then proceeded to flush the catheter with normal saline and reconnected the tubing without using a sterile sheath, contrary to the facility's policy. The resident involved had a history of benign prostatic hyperplasia, chronic systolic congestive heart failure, and chronic obstructive pulmonary disease, and required substantial assistance with daily activities. The resident's physician had ordered regular flushing of the indwelling catheter due to sediment buildup. The facility's policy, which was not followed, emphasized maintaining a closed urinary drainage system to prevent contamination. Both the Director of Nursing and the Administrator acknowledged that the LVN did not follow the established policy, which could potentially lead to an infection if bacteria entered the drainage tubing.
Insulin Administration and Monitoring Deficiencies
Penalty
Summary
The facility staff failed to accurately and completely document the insulin dose administered to a resident on a specific date. The resident, who had a history of type 2 diabetes and other medical conditions, was given an incorrect dose of insulin according to the sliding scale prescribed by the physician. The Sliding Scale Insulin Administration Record indicated that the resident's blood sugar level was 197, which required 8 units of insulin, but the record showed that 15 units were administered. Additionally, the licensed nurse who administered the insulin did not initial the record, which is against the facility's policy for charting medications. The Director of Nursing (DON) confirmed that a transcription error occurred, and the wrong amount of insulin was recorded. The DON stated that the nurse should have documented 8 units instead of 15 units and should have initialed the record after administering the insulin. This failure to follow the facility's charting guidelines and medication administration policies placed the resident at risk of receiving inappropriate diabetes management and care. Furthermore, the facility staff did not have documented evidence for monitoring the resident for signs and symptoms of hypoglycemia and hyperglycemia, as recommended by the pharmacist and indicated in the resident's care plan. The Medical Doctor (MD) stated that monitoring for these symptoms is a standard nursing practice and does not require a written order. However, the lack of documentation in the Medication Administration Record (MAR) and Treatment Administration Record (TAR) suggests that the monitoring was not consistently performed or recorded, which could lead to unmonitored and untreated adverse reactions from insulin therapy.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call light was within reach for a resident, identified as Resident 24, who was completely immobile due to functional quadriplegia and had severe cognitive impairments. The resident was dependent on staff for all activities of daily living, including eating, personal hygiene, and toileting. During observations, the call light was found on the floor, out of the resident's reach, which was confirmed by both a Certified Nursing Assistant and a Licensed Vocational Nurse. The facility's policy required that call lights be within reach at all times to enable residents to request assistance. The deficiency was identified during a review of the resident's records and through direct observation and interviews with staff. The facility's policy, dated February 2009, clearly stated the necessity of having call systems accessible to residents to ensure they can request help, especially in emergencies. Despite this policy, the call light for Resident 24 was not accessible, which could prevent the resident from calling for assistance when needed.
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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 Pasadena
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pasadena Grove Health Center | 1.6 mi | ★★★★★ | 25 | 0 |
| Foothill Heights Care Center | 1.7 mi | ★★★★★ | 23 | 0 |
| Pasadena Nursing Center | 1.7 mi | ★★★★★ | 27 | 0 |
| Cedar Pine Post Acute | 1.8 mi | ★★★★★ | 11 | 0 |
| Gem Tcu | 1.8 mi | ★★★★★ | 28 | 0 |
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