Below average — CMS composite of the measures below.
The next survey window likely opens around December 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 Vineyards At Fowler during CMS and state inspections, most recent first.
A resident with multiple chronic conditions but no cognitive impairment reported that a CNA showed her a nude video of another CNA, describing the content as the CNA naked in a bathroom with only a small towel or his nude behind visible. An LVN received the allegation, notified the IP and the Administrator (the abuse coordinator), and acknowledged that such conduct could constitute abuse and should be reported immediately. The IP, DSD, and DON all recognized that staff are mandated reporters and that facility policies require reporting all abuse allegations to the Administrator, SA, ombudsman, APS, and law enforcement within strict timeframes, including completion of an SOC 341. Despite these policies and job description requirements for the Administrator, DON, charge nurse, CNA, and IP to report abuse allegations, the facility did not complete the SOC 341 or report the allegation to the ombudsman, SA, or local law enforcement, and the ombudsman confirmed no report was received, resulting in a deficiency for failure to timely report suspected abuse.
Unqualified Dietary Supervisor Documentation: The facility failed to verify that the Dietary Supervisor met one of the seven required qualification pathways under HSC 1265.4. Staff reported to the Dietary Supervisor for kitchen training and daily operations, while the RD oversaw resident assessments, weight meetings, and sanitation audits. The Dietary Supervisor said she completed a high school ROP course and had a Food Handler Card, but the facility could not produce documentation showing graduation from a state-approved dietetic service supervision program.
Food Prep Sink Lacked Required Air Gap: The facility failed to ensure the food prep sink had the required air gap to prevent contamination. Kitchen staff identified the one-compartment sink next to the fridge as the food prep sink, and both the DS and RD confirmed it did not have an air gap. The DS was unsure whether an air gap was required and believed there may have been a waiver, while the ADM later stated an air gap was required and should have been present.
Improper Dumpster Storage and Overflow: 3 of 3 outdoor dumpsters behind the building were observed with lids open, and one dumpster was overflowing with boxes that prevented the lid from closing securely. KS stated the lids were required to stay closed to prevent pests, the DS said the area should be kept clear to prevent unwanted pests, and the ADM stated the lids should remain closed for infection control and the dumpsters should not be overflowing.
Inaccurate EMAR documentation for unavailable psychotropic medication. A resident with depression, Alzheimer’s disease, dementia, and severe cognitive impairment had brexpiprazole ordered by the PMHNP, but the medication was not available for administration on multiple occasions. Despite this, nurses documented the dose as administered and, on other dates, as refused. Staff stated the medication was still awaiting pharmacy delivery and insurance approval, and the DON stated the physician was not contacted and the EMAR entries were inaccurate because the medication was not available.
Medication error rate exceeded the allowed threshold, with an LVN giving a multivitamin with minerals instead of the ordered multivitamin for one resident and giving senna instead of ordered senna-docusate for another resident. The same resident’s routine inhaler was also not available during med pass. Staff interviews confirmed the ordered meds were not the same as what was given and that routine meds should be available and administered as ordered.
Expired meds were found in a med storage room, including Simethicone and Dulaglutide past their expiration dates. In addition, an LPN administered lactulose to a resident using the EMAR order, but the bottle in the med cart had a different dose direction than the EMAR. The resident had diagnoses including depression, anxiety, heart failure, and quadriplegia, and the facility policy required expired drugs to be disposed of and medication label changes to be reflected accurately.
Inaccurate MDS Coding for Anxiety Medication: A resident with anxiety, depression, and mood disorder had lorazepam use omitted from MDS Section N. The MDSN stated the resident was taking medication for anxiety but the section was not marked, and both the DON and ADM stated MDS assessments are expected to be accurate and are the responsibility of the staff member completing them.
PASARR Level I screenings were not updated for two residents after changes in condition involving depression and psychotropic medications. One resident was readmitted with depression, anxiety, and heart failure and was prescribed duloxetine, lorazepam, and mirtazapine, while another resident had depression, Alzheimer's disease, and dementia and was prescribed mirtazapine. The MDS nurse stated new PASARR screenings should have been completed, but no evidence of updated screenings was found.
Nurse staffing data was not posted in a visible location for residents, families, and visitors. During observation with the ADM, the staffing sheet was not displayed outside the business office, even though it was supposed to be placed in the clear folder taped to the window for easy viewing. The facility policy stated the staffing sheet must be readily available in a readable format and posted daily at the beginning of each shift.
Routine medications were not available for two residents when an LPN prepared meds and found one resident's psychotropic medication and another resident's inhaler missing. One resident had Alzheimer's disease, dementia, and severe cognitive impairment, and the other had asthma and shortness of breath. The LPN stated one medication was still being processed by pharmacy and the other was not in the med room or cart; the DON and other nurses stated routine meds should be available for administration.
A resident with dysphagia, hemiplegia, hemiparesis, and muscle weakness did not receive a standing order for a strawberry health shake with lunch. The resident’s meal tray lacked the ordered supplement, and CNA staff and the DS stated health shakes are used for residents with weight loss and should be matched to the meal ticket and served as ordered.
Two residents did not receive ordered adaptive eating equipment during meals. One resident with dx including dementia, dehydration, and adult failure to thrive was given thickened liquids with plastic straws despite a meal ticket order for liquids by spoon and no straws; the RNA stated she did not know the order and acknowledged aspiration could occur. Another resident with dx including dysphagia, hemiplegia, hemiparesis, and muscle weakness was served drinks in regular cups without a sippy cup, and the CNA stated the meal ticket should have been followed. The DON stated staff were expected to check meal trays against meal tickets and provide ordered adaptive equipment.
A facility failed to ensure each bedroom held no more than four residents. Surveyors observed two resident bedrooms with more than four residents, although the rooms were described as meeting resident needs, with adequate square footage, storage, bedside stands, space for nursing care, and accessible wheelchair and toilet facilities.
Insufficient square footage was identified in multiple resident rooms after an environmental tour with the MS. Six rooms were measured and found not to meet the 80 sq ft per resident requirement, including 2-bed and 4-bed rooms. Observations noted residents had reasonable privacy, adequate storage, bedside stands, and enough room for nursing care and ambulation.
Two CNAs spoke loudly and disrespectfully to a resident, accusing her of taking a roommate's remote control and calling her a liar, which was witnessed by an LVN. The resident, who had no cognitive impairment and multiple medical conditions, reported feeling hurt by the staff's behavior. Facility staff and policy confirmed that such conduct violated the requirement to treat residents with dignity and respect.
A nurse diverted controlled medications intended for two residents, failing to document and properly discard discontinued drugs as required by facility policy. This resulted in the residents not receiving their prescribed pain medications, with discrepancies discovered during medication audits. The facility did not consistently follow its own protocols for controlled substance management and documentation.
Licensed nurses failed to accurately document and reconcile controlled substances for two residents, resulting in discrepancies between medication removals and the Medication Administration Record (MAR), with no documentation of refusals, wastage, or returns. The facility's inventory logs contained calculation errors, and required audits were not performed as per policy, leading to delayed detection of potential diversion and risk of medication errors.
Licensed nurses administered PRN pain medications intended for severe pain to residents experiencing only mild or moderate pain, contrary to physician orders and facility policy. This included giving higher doses of narcotics for lower pain scores, as documented in medication administration records and confirmed by staff interviews.
Staff did not promptly inform a resident, the resident's doctor, and a family member about important events such as injury, decline, or room changes that affected the resident.
A resident with multiple medical conditions and a history of non-compliance left the facility without staff knowledge and did not return. Despite being aware of the resident's behavior, staff did not follow the facility's elopement policy, failed to notify administration or authorities promptly, and did not initiate a search, resulting in the resident being missing overnight.
A resident with multiple medical conditions left the facility without signing out and was not accounted for during shift changes. LVNs on duty failed to notify the ADM, DON, or authorities as required by policy, and staff did not initiate a search or follow elopement procedures, resulting in a delayed response and the resident's whereabouts being unknown overnight.
The facility did not update and review its facility-wide assessment annually as required by policy. The last documented review was in August 2023, and although an assessment was completed in September 2024, it had not been reviewed or revised. This oversight could potentially affect all residents.
The facility failed to maintain an effective infection control program due to the lack of a surveillance plan to track and monitor infections. The new Infection Preventionist (IP) had not been shown how to manage infection data and was awaiting guidance. The Director of Nursing (DON) and Administrator expected the IP to track infections daily and identify trends monthly, but the IP had not been performing these duties.
A resident with mobility issues was unable to get out of bed due to the facility's failure to provide a necessary specialized wheelchair. Despite expressing a desire to participate in activities, the resident had to rely on a borrowed wheelchair from another resident. Staff interviews revealed that the facility had not ordered the required equipment, and the administrator was unaware of the need.
A resident with quadriplegia and intact cognition did not receive proper nail care as required by their care plan. Despite the facility's policy for routine nail trimming, staff interviews revealed that the resident's nails were not regularly trimmed, and there were no refusals of care documented. The DON acknowledged the oversight, but the resident's nails remained untrimmed upon follow-up observation.
A resident with COPD and a history of respiratory issues was receiving supplemental oxygen without a physician's order, contrary to facility policy. Observations showed varying oxygen flow rates, and staff confirmed the absence of a documented order, highlighting a deficiency in respiratory care management.
The facility did not ensure RN coverage for eight consecutive hours daily, as required by policy. On two occasions, RNs worked fewer or nonconsecutive hours, failing to meet the regulation. The DON and RN were unaware of the consecutive hour requirement, and the administrator expected compliance with this regulation.
A facility failed to ensure a PRN psychotropic medication for a resident had a 14-day stop date, as required by policy. The resident, diagnosed with schizoaffective disorder, was prescribed aripiprazole for agitation without an end date. Interviews with the DON, Administrator, and Pharmacist confirmed the requirement for a 14-day stop date, highlighting a lapse in policy adherence.
A resident with schizoaffective disorder was readmitted to an LTC facility with hospital discharge instructions for daily aripiprazole. The facility incorrectly transcribed the medication as a PRN order for agitation. Staff, including an LVN and the DON, confirmed the error, and the pharmacist identified it as a medication error.
The facility was found to have exceeded the resident capacity in two rooms, with one room housing seven residents and another eight, contrary to the policy limiting occupancy to four residents per room. Despite the rooms being comfortable, the Administrator confirmed the policy breach.
A facility failed to provide the required 80 sq ft of living space per resident in six multiple occupancy rooms, as identified through observations and interviews. Despite having privacy and storage, the rooms did not meet the space requirement, with measurements ranging from 64.9 to 78.9 sq ft per resident. The DON and Administrator were aware of the issue and had requested a waiver.
A resident's MDS assessment contained six errors, including misreporting cognitive status, wandering behavior, UTI history, fall incidents, weight gain, and the use of a wander alarm. The resident, diagnosed with psychosis, exhibited disorganized thinking and attempted to leave the facility, yet these behaviors were not accurately recorded. Additionally, the resident had a UTI and experienced a fall, both of which were not reflected in the MDS. The resident's weight gain and use of a wander guard were also inaccurately documented.
A facility failed to develop a comprehensive care plan for a resident with new confusion and hallucinations. Despite documented episodes and family reports of new confusion after admission, no care plan addressed the altered level of consciousness. Staff interviews confirmed the resident's confusion, and the facility's policy on comprehensive care planning was not followed.
A resident in a long-term care facility experienced new confusion and hallucinations, which were linked to an untreated urinary tract infection (UTI). Despite abnormal urinalysis results indicating a UTI, a culture and sensitivity test was not performed due to a lack of a separate physician's order required by the facility's contracted lab. This oversight resulted in the resident's UTI remaining untreated, exacerbating her symptoms.
A resident with a history of psychological issues and elopement risk left the facility unsupervised, despite being identified as needing constant supervision. The resident was found wandering on a nearby street after staff failed to maintain line-of-sight supervision. The facility's policy emphasized the need for adequate supervision, which was not followed, leading to the resident's unsupervised departure.
A facility failed to conduct a Trauma Informed Care Evaluation for a resident, as required within 48 hours of admission. The Social Services Director admitted to not completing the evaluation due to being overwhelmed with work. The resident's family member confirmed that no inquiry about trauma history was made during a care plan meeting, contrary to facility policy.
A facility failed to conduct a Social Services Evaluation for a newly admitted resident, which is crucial for assessing mood, behaviors, and support systems. The Social Services Director, who was new to the role, did not complete the evaluation due to a lack of training on required assessments, despite facility policies mandating comprehensive information gathering upon admission.
Failure to Timely Report Alleged Sexual Abuse to Required Agencies
Penalty
Summary
The deficiency involves the facility’s failure to immediately report an allegation of abuse involving a cognitively intact resident to required external agencies, as mandated by federal and state regulations and the facility’s own abuse policies. A resident with diagnoses including COPD, DM2 with neuropathy, asthma, epilepsy, bipolar disorder, major depressive disorder, PTSD, and age-related cognitive decline, but with an MDS BIMS score of 15 indicating no cognitive impairment, reported that a CNA showed her a nude video of another CNA. The resident described the video as showing the CNA naked in a bathroom with only a small towel over his privates or his nude behind as he was getting into or out of the shower. The resident stated she was shocked that an employee would show her such a video and reported the incident to staff, after which she was interviewed by the Administrator and identified the CNA who allegedly showed her the video. Multiple staff interviews and policy reviews confirmed that the conduct described by the resident met the facility’s definition of potential abuse, specifically sexual abuse, which includes forced observation of pornography. The LVN who first received the allegation from the resident stated that staff are required to protect residents from abuse, ensure dignity and respect, and report abuse allegations right away. The LVN reported the allegation to the Infection Preventionist and then to the Administrator, who served as the abuse coordinator, but did not complete the SOC 341 form herself. The LVN acknowledged that showing a resident a video of a naked person was not acceptable, could be considered a form of abuse, and that the alleged sexual incident should have been reported to the required government agencies. The Infection Preventionist, Director of Staff Development, and DON each confirmed that all facility staff are mandated reporters and that the facility’s Abuse, Neglect and Exploitation and Abuse Prevention and Prohibition Program policies require reporting all alleged violations involving abuse to the Administrator, state agency, adult protective services, ombudsman, and law enforcement within specified timeframes, including within two hours for abuse allegations. The IP stated that the SOC 341 should have been completed and the allegation reported within two hours. The DSD stated that the SOC 341 should have been completed and that the abuse coordinator was responsible for reporting to law enforcement and the ombudsman. The DON acknowledged that the facility did not report the allegation because the resident did not report distress after seeing the video, despite recognizing that it was inappropriate for staff to show a nude video to a resident and that failure to report abuse allegations could jeopardize the facility’s license. A subsequent interview with the ombudsman confirmed that he was not aware of the allegation and had no SOC 341 on file. The facility’s job descriptions for the Administrator, CNA, charge nurse, DON, and IP all required reporting allegations of abuse and compliance with abuse reporting policies, yet the allegation involving this resident was not reported to the required government agencies as mandated. The report also documents that the CNA accused of showing the video denied the allegation but acknowledged that it would be considered abuse to show a resident a naked video and that SOC 341 should be completed and submitted immediately to ensure prompt facility response. The CNA noted that delayed reporting of alleged abuse could result in continued occurrences. Despite this, and despite the facility’s written policies outlining mandated reporting duties, timeframes, and penalties for failure to report, the allegation involving the resident and the nude video was not reported to the ombudsman, state survey agency, or local law enforcement. The DON explicitly stated that the facility did not maintain mandated reporting for this incident because they did not report the allegation, confirming the core deficiency of failure to timely report suspected abuse as required. The facility’s policies and job descriptions further emphasized that facility staff are mandated reporters under the Elder Justice Act and state regulations, that the facility will not impede reporting, and that failure to report within mandated timeframes may result in civil money penalties, exclusion from federal health care programs, and disciplinary action up to and including termination. The policies also defined sexual abuse to include forced observation of pornography and required telephone and written reports to the ombudsman or local law enforcement within specified timeframes for incidents including emotional or psychological abuse. Despite these clear written requirements and staff awareness that the alleged conduct could constitute abuse, the facility did not complete the SOC 341 or submit required reports for the resident’s allegation, and the ombudsman confirmed no report was received. This sequence of inaction by facility leadership and staff in response to a reported potential sexual abuse incident constitutes the documented deficiency.
Unqualified Dietary Supervisor Documentation
Penalty
Summary
The facility failed to ensure the Dietary Supervisor was qualified to perform the duties of a dietary supervisor because it could not provide documentation that the Dietary Supervisor completed a state-approved program in dietetic service supervision. The report states that the Dietary Supervisor’s Food Handler Card, high school transcripts, and Regional Occupational Program course documentation were not sufficient to meet the requirements under HSC 1265.4, which recognizes seven qualification pathways for the role. During interviews, kitchen staff stated they reported to the Dietary Supervisor, who was responsible for training kitchen staff, while the Registered Dietitian came onsite to observe the tray line and relay issues to the Dietary Supervisor rather than directly to staff. The Registered Dietitian stated he assessed residents, attended weight meetings, conducted sanitation audits, and helped ensure the kitchen functioned well, but the Dietary Supervisor served as the day-to-day manager of the kitchen, handled staff evaluations and performance, managed daily operations and ordering, and was responsible for staff training. The Dietary Supervisor stated she had worked at the facility since 2015, had temporarily assumed the role after the prior CDM went on medical leave, and continued in the position afterward. The Dietary Supervisor stated she completed a Valley Regional ROP program while in high school and believed she met qualification requirements under the pathway requiring graduation from a state-approved program with at least 90 hours of instruction in dietetic service supervision. However, she also stated her qualification documents had been misplaced and the certificate could not be obtained. The Administrator stated the facility reviewed the Dietary Supervisor’s qualifications but could not confirm that her education met any of the seven recognized pathways and could not provide documentation showing graduation from a state-approved program in dietetic service supervision. The report also notes the Dietary Supervisor had a California Food Handler Card, high school transcripts showing a Restaurant Careers course, and a course outline describing culinary arts exposure and ServSafe-related competencies, but these documents did not demonstrate compliance with the regulatory qualification pathway.
Food Prep Sink Lacked Required Air Gap
Penalty
Summary
The facility failed to ensure the food preparation sink was equipped with a required air gap to prevent contamination. During an observation in the kitchen, the one-compartment sink located next to Fridge 2 was observed with beans soaking, and Kitchen Staff 1 identified that sink as the food preparation sink. Kitchen Staff 1 stated the two-compartment sink was used only as a backup if the dishwasher was not functioning and was unsure what an air gap was, while also stating the piping to the sink had not been altered. The Dietary Supervisor stated an air gap was intended to prevent contamination of food if the sink overflowed, but was unsure whether an air gap was required and believed the facility may have a waiver. During a later observation, the Registered Dietitian and Dietary Supervisor both confirmed the one-compartment sink used as the food preparation sink did not have an air gap. The Administrator later stated that an air gap was required and should have been present. The report cited FDA Food Code 2022, section 5-402.11, stating that equipment and fixtures used for food preparation or utensil washing must be installed with an air gap or air brake as required to prevent backflow of sewage into the equipment.
Improper Dumpster Storage and Overflow
Penalty
Summary
The facility failed to ensure garbage was stored and disposed of in a manner that prevented unsanitary conditions when 3 of 3 outdoor dumpsters behind the building were observed with lids open, and one dumpster was overflowing with boxes that prevented the lid from closing securely. During the observation, the dumpsters were noted with all three lids in the open position. Kitchen staff stated the dumpster lids were required to remain closed at all times to prevent pests, and the Dietary Supervisor stated the dumpsters were required to remain closed and the surrounding area kept clear to prevent unwanted pests. The Dietary Supervisor also stated the facility's location next to agricultural orchards placed it at increased risk for pests. The Administrator stated her expectation was for the dumpster lids to remain closed at all times for infection control purposes and that the dumpsters should not be overflowing. The facility policy titled, Disposal of Garbage and Refuse, stated dumpsters shall be kept covered when not being loaded and the surrounding area shall be kept clean so that accumulation of debris and insect/rodent attractions are minimized.
Inaccurate EMAR documentation for unavailable psychotropic medication
Penalty
Summary
The facility failed to ensure professional standards of practice were followed for one sampled resident with depression, Alzheimer’s disease, dementia, and severe cognitive impairment. Resident 46 had brexpiprazole ordered by the PMHNP, but the medication was not available for administration on multiple occasions. The EMAR nevertheless documented the medication as administered on 12/10/25, 12/18/25, 12/19/25, 1/5/26, and 1/6/26, and documented it as refused on 12/8/25, 12/12/25, and 12/13/25 even though the medication was not available on those dates. During medication observation, an LVN stated the medication was still waiting for pharmacy delivery and that she would contact the pharmacy to follow up. In a later interview, the LVN stated she did not know why the EMAR showed administration entries and said the medication had not been delivered because the pharmacy was still processing it and waiting for insurance approval. She stated she did not notify the physician that the medication was unavailable and was unsure whether the DON had contacted the physician. Another LVN stated she signed the EMAR indicating administration even though she was not aware the medication was unavailable and acknowledged it was an error to document the medication as administered when it was not. The DON stated she discussed the cost of the medication with the PMHNP because insurance did not cover it, and the PMHNP rewrote the order stating insurance should approve it. The DON stated insurance did not approve the medication, the PMHNP instructed staff to place it on hold until approval was obtained, and she did not recall discussing the medication with the primary physician or contacting the pharmacist for an alternative equivalent medication. The DON reviewed the EMAR and stated the administration and refusal documentation was inaccurate because the medication was not available, and that her expectation was to verify medication availability before documenting administration or refusal.
Medication Administration Errors and Missed Routine Medication
Penalty
Summary
The facility failed to ensure the medication error rate remained below 5 percent; the reported error rate was 9.68 percent, with 31 opportunities for error and three medication errors identified for three of six sampled residents. The deficiency involved medication administration errors for two residents, including administration of medications that did not match the physician’s orders and failure to provide a routine medication that was ordered. For one resident with depression, Alzheimer’s disease, dementia, and severe cognitive impairment, an LVN administered multivitamin with minerals even though the physician’s order was for multivitamin. The LVN crushed the medication, mixed it with applesauce, and documented it as given. During interview, the LVN stated she gave multivitamin with minerals because it was the only over-the-counter medication available and said it was the same medication. Other nurses stated the physician’s order had to be followed and that the ordered medication and the medication given were not the same. For another resident with asthma, shortness of breath, and constipation, an LVN administered senna instead of the ordered senna-docusate, and the resident’s routine inhaler was not available to administer at the time of medication pass. The LVN stated she gave senna because it was the only over-the-counter medication available and stated the inhaler should have been available as a routine medication. Other nurses stated the resident should have received the medications as ordered and that senna and senna-docusate are not the same medications. The DON stated routine medications should be readily available, nurses should follow the physician’s orders, and medication errors are harmful to residents.
Expired Medications and Mismatched Lactulose Labeling
Penalty
Summary
The facility failed to ensure proper storage and disposal of medications and biologicals in accordance with policy and procedure. During a concurrent observation and record review in the medication storage room, two expired medications were found: a bottle of Simethicone 80 mg with an expiration date of 12/2024 and an injectable vial of Dulaglutide 1.5 mg with an expiration date of 10/15/25. The DON stated expired medications are to be destroyed following the policy on destruction of medications, and the facility policy indicated unused or expired drugs shall be disposed of in accordance with state laws and regulations. The facility also failed to ensure Resident 21’s lactulose was stored and labeled consistently with the physician order in the EMAR. Resident 21 was readmitted with diagnoses including depression, anxiety, and heart failure, and the OSR showed an order for Lactulose Oral Solution 10 gm/15 mL, 45 mL by mouth three times a day for constipation related to quadriplegia. During observation, an LVN prepared and administered 45 mL of lactulose to the resident, but the medication bottle in the cart had directions to administer 30 mL. During interview and record review, the LVN stated she followed the physician order in the EMAR and did not realize the bottle directions differed from the EMAR. Other licensed nurses stated that when medication directions differ from the EMAR, the nurse receiving the order is responsible for notifying pharmacy and placing a change-of-direction sticker on the bottle or blister pack until the corrected label is received. The DON stated licensed nurses should compare the EMAR and the medication bottle or blister pack to avoid medication error, and the facility policy on medication labels stated that if directions change, the provider pharmacy is informed so the new container will show an accurate label.
Inaccurate MDS Coding for Anxiety Medication
Penalty
Summary
The facility failed to ensure an accurate MDS assessment for one of four sampled residents, Resident 21, when the resident’s use of lorazepam for anxiety was not correctly coded in the MDS dated [DATE]. Resident 21’s admission record dated 1/8/26 showed a re-admission to the facility with diagnoses that included anxiety, depression, and mood disorder. The MDS dated 11/15/25 showed a BIMS score of 14, indicating no cognitive impairment. During a concurrent interview and record review on 1/9/26, the MDSN reviewed Resident 21’s MDS Section N and stated the resident was taking medication for anxiety but Section N was not marked. The MDSN stated she did not code the resident as taking medication for anxiety and that she should have marked Section N. The MDSN stated it was her responsibility to ensure the MDS was accurate and that the data had to be captured correctly because it was used for payments. The DON and ADM both stated their expectation was for MDS assessments to be accurate, and that each staff member completing an MDS was responsible for the accuracy of their own assessment.
PASARR Screening Not Updated After Mental Health Changes
Penalty
Summary
The facility failed to ensure that Level I PASARR screenings were completed and that the state mental health authority or state intellectual disability authority was notified promptly after a significant change in condition for two residents. Resident 21 was readmitted with diagnoses including depression, anxiety, and heart failure, and the order summary showed psychotropic medications including duloxetine, lorazepam, and mirtazapine. A PASARR Level I screening from 9/12/23 was in the record, but the MDS nurse stated a new screening should have been completed after the readmission and initiation of psychotropic medications, and there was no evidence that it was done. Resident 46 was admitted with diagnoses including depression, Alzheimer's disease, and dementia. The order summary showed mirtazapine, and the MDS nurse stated a new PASARR Level I screening should have been completed after the diagnosis of major depression and again after the start of mirtazapine, but no evidence of a new screening was found in the record. The DON stated PASARR Level I screenings are completed at the acute hospital and that updated assessments should be ensured when a resident's condition changes, while the ADM stated PASARR Level I screenings are completed in the acute hospital and sent to the facility on admission.
Nurse Staffing Data Not Posted
Penalty
Summary
The facility failed to ensure that nurse staffing data was posted in a visible location for residents, families, and visitors. During a concurrent observation and record review on 1-8-26 at 12:30 p.m. with the administrator outside the business office, the nurse staffing data was not displayed. The administrator stated that the staffing data belongs in the empty clear folder taped to the outside of the window, where it should be visible to residents and visitors as they enter the facility. A review of the facility policy titled, Nurse Staffing Posting Information, dated 12/18/25, stated that nurse staffing must be readily available in a readable format to residents, staff, and visitors at any given time and posted on a daily basis at the beginning of each shift.
Routine Medications Not Available for Administration
Penalty
Summary
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist was not met when two residents did not have routine medications available for administration. Resident 46 had diagnoses including depression, Alzheimer's Disease, and dementia, and her MDS showed a BIMS score of 4, indicating severe cognitive impairment. During observation, the LVN prepared Resident 46's medications but stated that brexpiprazole was not available for administration. The EMAR showed brexpiprazole 0.5 mg was ordered to be given each morning with a start date of 12/07/25. Resident 5 had diagnoses including asthma, shortness of breath, and constipation. During observation, the LVN prepared Resident 5's medications but stated the resident's routine inhaler was not available for administration. The EMAR showed fluticasone propionate/salmeterol HFA 115-21 mcg/actuation was ordered as one puff by mouth daily for cough variant asthma with a start date of 08/08/2025. Resident 5 was observed lying in bed with the head of the bed elevated and working on crossword puzzles, and the LVN stated the resident was hard of hearing and communication required writing on a white board. During interview, the LVN stated she checked the medication room and medication cart for Resident 5's inhaler but it was not available, so she faxed pharmacy to send the medication. She also stated Resident 46's medication was not available because, according to pharmacy, it was still being processed, and she did not remember notifying the physician that the prescribed medication was unavailable. Other licensed nurses stated routine medications should be available for administration and refills should be ordered before supplies run low. The DON stated licensed nurses were expected to ensure routine medications were available and to call pharmacy for new medications and to ensure all medications were available.
Missed Ordered Health Shake
Penalty
Summary
The facility failed to ensure food preferences were accommodated for one of four sampled residents when Resident 16 did not receive a standing physician-ordered strawberry health shake with lunch. During a concurrent observation and interview in the dining room, Resident 16 was seated in a wheelchair with a lunch tray in front of her, and the tray did not include the strawberry health shake listed on her meal ticket. CNA 1 reviewed the meal ticket and stated there should have been a milk shake with the meal tray, and also stated health shakes are ordered for residents experiencing weight loss. Resident 16's admission record showed diagnoses including dysphagia, hemiplegia, hemiparesis, and muscle weakness. Her meal ticket listed a diet order of National Dysphagia 2 (Mechanical Soft), Regular, thin liquids, and a standing order for a four-ounce carton of Ready Care Strawberry Shake. During interviews, CNA 2 stated CNAs are supposed to compare the food with the meal ticket to ensure the food matches the order and that nutritional supplements such as health shakes are ordered for residents with poor appetite and weight loss. The DS stated CNAs are responsible for ensuring residents receive their milkshakes, and the DON stated she expected residents with orders for health shakes to be served as ordered.
Failure to Provide Ordered Adaptive Eating Equipment
Penalty
Summary
The facility failed to ensure adaptive eating equipment was provided for two sampled residents during meal service. Resident 14 was observed in the dining room being assisted with meals while drinking thickened water and juice. Plastic straws were placed in each drink even though the resident’s meal ticket directed, “Liquids by spoon no straws.” The RNA stated it was her first time assisting the resident and that she did not know not to use a straw, and she acknowledged the resident could aspirate from using a straw. Resident 14’s record showed diagnoses including dehydration, dementia, and adult failure to thrive. The Dietary Supervisor stated that straws were not recommended for residents at high risk of aspiration and that residents ordered not to use straws are unable to safely suck fluids through them. The supervisor also stated that using a straw could cause residents to aspirate. Resident 16 was observed in a wheelchair during lunch with drinks served in regular cups without handles, and no sippy cup was provided on the meal tray. The CNA stated she thought the resident only used a sippy cup when in bed, then reviewed the meal ticket and stated the order should have been followed and all fluids placed in a sippy cup. Resident 16’s record showed diagnoses including dysphagia, hemiplegia, hemiparesis, and muscle weakness. The DON stated staff were expected to check meal trays against meal tickets and ensure ordered adaptive equipment was provided, and the facility policy stated appropriate utensils should be placed on the resident’s food tray at each meal.
Excess Residents in Bedroom
Penalty
Summary
The facility failed to ensure each bedroom accommodated no more than four residents. During the survey period, surveyors observed rooms [ROOM NUMBERS] and 14, and both resident bedrooms had more than four residents. The report states that each room met the required needs of the residents and had adequate square footage, closet and storage space, bedside stands, room for nursing care, and accessible wheelchair and toilet facilities. The report also notes that the health and safety of residents would not be adversely affected by the continuance of the waiver.
Insufficient Square Footage in Multiple Resident Rooms
Penalty
Summary
The facility failed to provide the minimum of at least 80 square feet per resident in multiple rooms, specifically Rooms 1, 6, 8, 10, 11, and 16. During a concurrent observation and interview with the Maintenance Supervisor, an environmental tour was conducted and six rooms were measured. The measured rooms were documented as 145.96 square feet for 2 beds, 312.0 square feet for 4 beds, 159.17 square feet for 2 beds, 147.17 square feet for 2 beds, 147.25 square feet for 2 beds, and 300.9 square feet for 4 beds, and the Maintenance Supervisor stated these rooms did not meet the minimum square footage requirement of 80 square feet per resident. During observations throughout the survey period, residents had a reasonable amount of privacy, closets and storage space were adequate, bedside stands were available, there was sufficient room for nursing to provide care and for residents to ambulate, and toilet facilities and wheelchairs were accessible.
Failure to Treat Resident with Dignity and Respect During Staff Interaction
Penalty
Summary
Two Certified Nurse Assistants (CNAs) spoke loudly and disrespectfully to a resident, accusing her of taking her roommate's remote control and adjusting the television to face herself. The CNAs called the resident a liar and engaged in an argument with her, raising their voices in a manner that was described as unprofessional and hurtful by the resident. This interaction was witnessed by a Licensed Vocational Nurse (LVN), who confirmed that the CNAs were yelling at the resident and making inappropriate statements, including calling the resident a liar and referencing the possibility of losing their jobs. The resident involved had no cognitive impairment, as indicated by a Brief Interview for Mental Status (BIMS) score of 13, and had a medical history including type 2 diabetes mellitus, protein-calorie malnutrition, stimulant abuse, bipolar disorder, major depressive disorder, post-traumatic stress disorder, and chronic pain syndrome. The incident was corroborated by interviews with staff, including another CNA, the LVN, the Registered Nurse (RN), the Director of Nursing (DON), and the Infection Preventionist (IP), all of whom stated that staff should not yell at residents and must treat them with dignity and respect. The facility's policies on promoting and maintaining resident dignity and resident rights were reviewed and indicated that all staff must speak respectfully to residents and avoid yelling or scolding. The deficiency was identified through interviews and record reviews, which established that the CNAs' actions failed to honor the resident's right to a dignified existence, self-determination, and respectful communication. The staff's behavior was found to be inconsistent with facility policy and placed the resident at potential risk for emotional distress, as directly stated in the report.
Controlled Substance Diversion and Failure to Protect Resident Property
Penalty
Summary
The facility failed to protect residents' rights and ensure proper management of controlled substances, resulting in the misappropriation of medications intended for two residents. Specifically, a Licensed Vocational Nurse (LVN) diverted controlled medications prescribed for two residents for personal use and failed to document and discard discontinued medications according to facility policy. The LVN removed two bubble packs of oxycodone, each containing 30 pills, from the controlled substance drawer after a resident's discharge, documented a zero count in the inventory log, and removed the corresponding record sheet, making the medication untraceable. This action was discovered during a shift change audit when the missing medications were identified, and the LVN later admitted to taking the medications. The facility's procedures required that discontinued controlled substances be handed off to the Director of Nursing (DON) for proper destruction, but this protocol was not followed. In another instance, the same LVN signed out multiple doses of hydrocodone-acetaminophen for a second resident on the controlled drug record, but these administrations were not documented on the Medication Administration Record (MAR). The resident had moderate cognitive impairment and was prescribed pain medication as needed. The discrepancies were identified after the initial drug diversion incident, revealing that the medications were not administered as ordered and were unaccounted for. The facility's policy required daily visual audits of controlled substances, but the DON only conducted these audits Monday through Friday, leaving weekends unmonitored until the following Monday. Both residents involved had significant medical histories, including chronic pain, recent surgery, and cognitive impairment, making the proper administration and accountability of their medications critical. The failures in following established protocols for controlled substance management, documentation, and destruction led to residents not receiving their prescribed medications as ordered and placed them at risk for inadequate pain management and anxiety. The facility's lack of adherence to its own policies and procedures directly contributed to the deficiency.
Failure to Accurately Document and Reconcile Controlled Substances
Penalty
Summary
The facility failed to maintain accurate controlled substance records, documentation, and reconciliation in accordance with its own policies and procedures for two of three sampled residents. Licensed nurses did not accurately document or account for controlled substances on the Controlled Drug Records and Medication Administration Records (MAR), resulting in discrepancies between medication removals and documentation. Specifically, for one resident with a history of muscle weakness, liver failure, diabetes, and recent spinal surgery, multiple removals of oxycodone were recorded on the Controlled Drug Record but not reflected on the MAR, with no documentation of refusal, wastage, or return. For another resident with multiple fractures, chronic pain, and osteoporosis, hydrocodone removals were similarly not documented on the MAR, and there was no record of refusal, wastage, or return. Interviews with nursing and pharmacy staff revealed that the facility's process required licensed nurses to verify controlled substances upon delivery, document receipt, and update inventory logs. Each shift change required two nurses to count and reconcile controlled substances, and any discrepancies were to be resolved before the end of the shift or reported to the DON and Administrator. However, review of the Shift Change Controlled Substance Inventory Log showed multiple calculation inaccuracies, with incorrect counts recorded on several dates. The DON acknowledged that required audits were not performed as stipulated by facility policy. The facility's policy mandated that all controlled substances be accounted for and that documentation on the Controlled Drug Record must match the MAR. The policy also required that any discrepancies be resolved or reported immediately, and that staff not leave until discrepancies were addressed. Despite these requirements, the facility did not ensure accurate documentation or reconciliation of controlled substances, leading to delayed detection of potential diversion and placing residents at risk for medication errors.
Failure to Administer PRN Pain Medications According to Physician Orders
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary medication administration, specifically regarding the use of PRN pain medications. Licensed nurses administered pain medications prescribed for severe pain to three residents, even when their assessed pain levels were only mild to moderate. This was not in accordance with the physician's orders, which specified different medications and dosages based on the severity of pain as measured by a standardized pain scale. For example, one resident with chronic pain syndrome and diabetes received Hydrocodone-Acetaminophen and Tramadol for pain levels reported as 3 out of 10, despite these medications being ordered for moderate to severe pain. Another resident with a history of muscle weakness, liver failure, and recent spinal surgery was administered two tablets of Oxycodone for pain levels of 3 or 4 out of 10, even though the physician's order specified this dosage only for severe pain. A third resident with multiple fractures and chronic pain was also given Hydrocodone-Acetaminophen for pain scores below the threshold indicated in the physician's order. Interviews with nursing staff confirmed that PRN pain medications were to be administered according to the pain scale and physician's orders, and that deviations from this practice could result in medication errors. Facility policies and procedures reviewed during the survey also required adherence to the pain scale and physician's orders when administering PRN medications. Despite these policies, the records showed repeated instances where higher doses or stronger medications were given for lower pain scores than prescribed.
Failure to Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors as a deficiency in the facility's process for keeping relevant parties informed about significant events impacting the resident's care or condition.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Policy Non-Compliance
Penalty
Summary
A deficiency occurred when a resident left the facility without staff knowledge and did not return, despite being known for non-compliance with sign-out procedures. The resident, who had diagnoses including a left femur fracture, alcoholic cirrhosis, bipolar disorder, and pancreatic pseudocyst, was cognitively intact according to a recent BIMS assessment. Staff interviews revealed that the resident frequently left the facility without signing the Leave of Absence (LOA) binder or notifying staff, and this behavior was known to multiple staff members. On the day of the incident, staff failed to notice the resident's absence in a timely manner. Several staff members, including LVNs and CNAs, acknowledged that the resident did not sign out and was not accounted for during shift changes. Although staff were aware of the facility's policy to notify administration and authorities when a resident was missing, this protocol was not followed. Communication lapses occurred between staff and administration, with delayed or missed notifications and no immediate search or alert initiated. The facility's policy and procedure for elopement and wandering residents required prompt action to locate missing residents and notify authorities if the resident could not be found. However, staff did not implement these procedures, resulting in the resident being unaccounted for overnight. The failure to provide adequate supervision and follow established protocols directly led to the deficiency cited in the report.
Failure to Notify Administration and Authorities of Missing Resident
Penalty
Summary
Licensed Vocational Nurses (LVN) 3 and 4 failed to follow facility policy and procedure when a resident left the facility and did not return. The resident, who had diagnoses including a non-displaced intertrochanteric fracture of the left femur, alcoholic cirrhosis, bipolar disorder, and pancreatic pseudocyst, was cognitively intact according to a recent BIMS assessment. Staff interviews revealed that the resident did not sign out in the leave of absence binder and was not accounted for during shift changes. LVN 3 observed the resident in the facility earlier in the day but did not see him leave and failed to notify the Administrator, Director of Nursing, or authorities when the resident was discovered missing at the end of the shift. LVN 4, who received the report from LVN 3, became concerned about the resident's absence but only sent a text message to the Administrator and DON, without receiving a response. LVN 4 did not make further attempts to contact facility leadership or authorities until the following day. Certified Nursing Assistant (CNA) 1, who worked the night shift, also noted the resident's absence but did not initiate a search or notify the appropriate personnel as required by facility policy. The Director of Nursing confirmed that the required notifications and search procedures were not followed, and the facility's policy on elopement and missing residents was not implemented. The facility's policies clearly state that staff must alert personnel and notify the Administrator and authorities if a resident is missing and cannot be located on the premises. Despite these protocols, staff failed to act promptly, resulting in a delayed emergency response and a period during which the resident's location and medical status were unknown.
Failure to Update Facility-Wide Assessment Annually
Penalty
Summary
The facility failed to ensure that the facility-wide assessment was updated and reviewed annually, as required by their policy. The policy, implemented in June 2024, stated that the assessment should be reviewed and updated as necessary and at least annually. However, the Facility Assessment Tool showed that the last documented review and update occurred on August 31, 2023. During interviews, the Administrator admitted that the assessment had not been reviewed prior to this date and that it was his responsibility to ensure it was done. Although the assessment was reportedly completed on September 10, 2024, it had not been reviewed or revised by the time of the survey. This oversight had the potential to affect all residents residing in the facility.
Inadequate Infection Control Surveillance
Penalty
Summary
The facility failed to maintain an effective infection control program by not establishing and implementing a surveillance plan to identify, track, and monitor infections. The Infection Preventionist (IP), who had been in the position for two months, was unable to provide evidence of tracking and trending infections monthly. The IP stated she had not been shown how to handle infection information and was waiting for guidance from a corporate infection control consultant. Despite having access to the previous IP, who still worked at the facility, the new IP had not received instruction on tracking, monitoring, or trending infections for surveillance purposes. The Director of Nursing (DON) and the Administrator both expressed expectations that the IP should track infections daily and identify trends monthly. The DON was unaware that the IP had not been performing these duties and expected the IP to look for infection trends, such as clusters of urinary tract infections (UTIs). The Administrator expected the IP to implement a surveillance system that included mapping infections by room and unit at the end of each month. This system was intended to facilitate the identification of infections and provide necessary in-services to decrease the spread of infection.
Failure to Provide Necessary Wheelchair for Resident
Penalty
Summary
The facility failed to support a resident's choice to be out of bed by not providing the necessary specialized wheelchair needed for the resident. Resident #26, who was admitted to the facility with a medical history of abnormalities of gait and mobility, lack of coordination, and weakness, expressed a desire to get out of bed more frequently to participate in activities. Despite this, the resident did not have a wheelchair and was dependent on staff for chair/bed-to-chair transfers. The facility's policy on resident rights emphasized the importance of promoting and facilitating resident self-determination, including the right to choose activities and schedules. Interviews with staff and the resident's responsible party revealed that Resident #26 required a special wheelchair with a high back due to slumping over when tired. However, the facility had not provided this equipment, and staff had to borrow a wheelchair from another resident. The Director of Rehabilitation acknowledged the need for a reclining wheelchair but stated that one had not been ordered due to cost. The Director of Nursing confirmed that residents should not have to borrow equipment and that necessary equipment should be ordered promptly. The facility administrator was unaware of the resident's need for a wheelchair, indicating a lack of communication and coordination among staff.
Failure to Provide Adequate Nail Care for Resident
Penalty
Summary
The facility failed to provide adequate nail care for a resident, identified as Resident #4, who was unable to perform activities of daily living (ADLs) independently due to quadriplegia and other physical impairments. Despite having a care plan that required staff assistance for personal hygiene, including nail care, Resident #4's fingernails were observed to be long and untrimmed. The facility's policy mandated routine nail care, but interviews with staff revealed that the resident's fingernails were not regularly trimmed, and there were no documented refusals of care by the resident. Resident #4, who had intact cognition and required moderate assistance with personal hygiene, reported that staff occasionally offered to trim their nails but failed to follow through when asked to return later. Interviews with CNAs and an LVN confirmed that nail trimming was part of the bathing routine, yet none had trimmed Resident #4's nails. The Director of Nursing acknowledged the oversight and stated that staff were expected to offer nail trimming on shower days and as needed. Despite this acknowledgment, an observation the following day showed that Resident #4's nails remained untrimmed.
Lack of Physician's Order for Supplemental Oxygen
Penalty
Summary
The facility failed to obtain a physician's order for the use of supplemental oxygen for a resident with a history of acute respiratory failure with hypoxia, acute pulmonary edema, and chronic obstructive pulmonary disease (COPD). The resident, who was readmitted to the facility, was observed receiving supplemental oxygen at varying levels without a corresponding physician's order in their electronic health record. The facility's policy requires oxygen to be administered under a physician's order, except in emergencies, which was not adhered to in this case. Observations and interviews revealed that the resident was receiving oxygen therapy at different flow rates, yet there was no documented order for this treatment. The Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) confirmed the absence of a physician's order for the supplemental oxygen. The resident's care plan indicated the need for oxygen therapy, but the lack of a formal order constituted a deficiency in following the facility's policy and ensuring proper respiratory care management.
Failure to Ensure RN Coverage for Eight Consecutive Hours
Penalty
Summary
The facility failed to ensure a registered nurse (RN) was on duty for eight consecutive hours daily, as required by their policy and regulations. The facility's policy, implemented in October 2022, mandates the utilization of RN services for at least eight consecutive hours per day, seven days a week. However, the nursing schedule for September 2024 showed no RNs were scheduled to work on September 5, 2024, and RN #5's time card indicated she only worked 1.40 hours that day. Additionally, on September 8, 2024, RN #7 worked nonconsecutively for seven hours, failing to meet the eight-hour consecutive requirement. Interviews conducted on September 20, 2024, revealed that the Director of Nursing (DON) was unaware of the requirement for RNs to work eight consecutive hours. The DON was out sick from September 1 to September 5, 2024, and believed she had scheduled adequate RN coverage during her absence. RN #7 also stated she was unaware of the need to work eight consecutive hours. The facility administrator expressed an expectation for the facility to have an RN on duty for at least eight consecutive hours daily.
Failure to Implement 14-Day Stop Date for PRN Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a PRN psychotropic medication for a resident had a 14-day stop date, as required by their policy. The policy, implemented in October 2022, mandates that PRN orders for psychotropic drugs should be used only when necessary to treat a diagnosed specific condition and for a limited duration of 14 days. If the attending physician deems it appropriate to extend the PRN order beyond 14 days, they must document their rationale in the resident's medical record. However, for Resident #12, who was diagnosed with schizoaffective disorder and had a BIMS score indicating intact cognition, the facility did not include an end date for the PRN order of aripiprazole, an antipsychotic medication prescribed for agitation. The deficiency was identified through interviews and record reviews. The Director of Nursing and the Administrator both acknowledged that PRN psychotropic medications should have a 14-day stop date and must be reviewed and updated every 14 days. The Pharmacist also confirmed that PRN psychotropic medications should have a 14-day stop date unless otherwise addressed by the physician. Despite these acknowledgments, the order for Resident #12's medication lacked the required stop date, indicating a lapse in adherence to the facility's policy and regulatory requirements.
Medication Transcription Error for Resident with Schizoaffective Disorder
Penalty
Summary
The facility failed to accurately transcribe hospital discharge medication orders for a resident, leading to a deficiency in medication administration. The resident, who had a medical history of schizoaffective disorder, was initially admitted to the facility and later readmitted. Upon readmission, the hospital discharge summary indicated that the resident was to receive aripiprazole, an atypical antipsychotic, as a daily oral tablet. However, the facility's order summary incorrectly transcribed this medication as an as-needed order for agitation, which was not in accordance with the hospital's discharge instructions. Interviews with facility staff, including an LVN and the DON, confirmed that the transcription error occurred when the resident returned to the facility. The DON acknowledged that the medication should not have been entered as a PRN order unless specified by the hospital. The pharmacist also noted that the admission nurse should have verified the accuracy of the orders, identifying the transcription as a medication error. This error was recognized by the facility's administration, who stated that the order would be reviewed and corrected to align with the hospital's physician orders.
Exceeding Resident Capacity in Rooms
Penalty
Summary
The facility failed to comply with regulations limiting the number of residents per room, as observed in two specific rooms. The facility's policy, implemented in October 2022, stated that resident bedrooms should not accommodate more than four residents. However, a Client Accommodations Analysis dated September 19, 2024, indicated that two rooms were approved for eight residents each, despite the policy. Observations on September 20, 2024, revealed that one room housed seven residents and another housed eight residents. Although the rooms were described as comfortable with adequate space and amenities, the number of residents exceeded the facility's stated policy and regulatory requirements. The Administrator acknowledged that a maximum of four residents should reside in a room, yet the facility had two rooms with eight beds each.
Deficiency in Resident Room Space Requirements
Penalty
Summary
The facility failed to provide the required 80 square feet of living space per resident in six of its multiple occupancy rooms. This deficiency was identified through observation, interviews, and a review of facility documents and policies. The facility's policy, implemented in October 2022, mandates that resident bedrooms must measure at least 80 square feet per resident in multiple occupancy rooms. However, a Client Accommodation Analysis conducted in September 2024 revealed that the living space per resident in Rooms 1, 6, 8, 10, 11, and 16 was below the required standard, with measurements ranging from 64.9 to 78.9 square feet per resident. During a concurrent observation and interview, the Department Head of Maintenance confirmed that these rooms did not meet the 80 square feet requirement. Despite this, the observation noted that residents had privacy, adequate storage space, and unobstructed bathrooms, and there were no resident complaints about the space. Interviews with the Director of Nursing and the Administrator confirmed their awareness of the requirement and the deficiency. The Director of Nursing acknowledged the issue and mentioned that a waiver had been requested for the affected rooms, while the Administrator confirmed the submission of a waiver request, anticipating a citation for the deficiency.
Inaccurate MDS Assessment for Resident
Penalty
Summary
The facility failed to ensure an accurate Minimum Data Set (MDS) assessment for a resident, resulting in six incorrect entries. These errors included misreporting the resident's cognitive status, wandering behavior, urinary tract infection (UTI) history, fall incidents, weight gain, and the use of a wander/elopement alarm. The inaccuracies in the MDS assessment did not reflect the resident's actual status and had the potential to lead to unmet care needs. The resident was admitted with diagnoses including psychosis and exhibited disorganized thinking, as evidenced by an incident where the resident attempted to leave the facility. Despite this, the MDS inaccurately indicated that disorganized thinking and wandering behavior were not present. Additionally, the resident had a documented UTI within the last 30 days, but the MDS incorrectly reported no UTI. The resident also experienced an intercepted fall, which was not recorded in the MDS. Further errors included the resident's weight gain, which was significant enough to be noted as a change in condition, yet was not accurately reflected in the MDS. The resident was also equipped with a wander guard, an electronic monitoring device, which was not acknowledged in the MDS. These discrepancies were identified through interviews and record reviews with facility staff, including the Director of Social Services, the Director of Nursing, and the MDS Coordinator.
Failure to Implement Comprehensive Care Plan for Resident with New Confusion
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident who experienced a new onset of confusion and hallucinations. The resident, a female admitted to the facility, was noted to have moderate cognitive impairment according to her Minimum Data Set (MDS) assessment. Progress notes documented episodes of yelling, confusion, and hallucinations, which were discussed in a care conference with the resident's family. Despite these documented behaviors, there was no care plan addressing the resident's altered level of consciousness, which was confirmed during a review with the Clinical Resource Registered Nurse. Interviews with facility staff, including the Social Services Director and a Certified Nursing Assistant, confirmed the resident's episodes of confusion. The resident's family also reported that the confusion was new and had started after admission to the facility. The facility's policy on the admission of residents emphasizes the importance of developing comprehensive care plans based on gathered information, but this was not adhered to in the case of this resident, leading to unmet needs for monitoring and safety.
Failure to Conduct Urine Culture Leads to Untreated UTI
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality for a resident who was assessed with a new onset of confusion and hallucination. The resident, an elderly female, was admitted to the facility and later exhibited symptoms such as yelling, talking about a fire, and slight confusion. A physician ordered a urinalysis and a culture and sensitivity test to determine if a urinary tract infection (UTI) was present, which could explain the confusion. However, the culture and sensitivity test was not performed, leaving the UTI untreated. The resident's urinalysis showed several abnormal results indicative of a UTI, including positive white blood cells, high levels of leukocyte esterase, positive nitrates, positive protein, positive red blood cells, and many bacteria. Despite these findings, the culture and sensitivity test was not conducted due to a lack of a separate physician's order, which was required by the facility's contracted laboratory for residents with a urinary catheter. This oversight was not recognized by the facility's staff, including the Infection Preventionist Nurse and Licensed Vocational Nurse, who were unaware of the laboratory's policy and procedures. Interviews with facility staff and the resident's family confirmed the resident's episodes of confusion and hallucinations, which were new since her admission to the facility. The staff acknowledged that confusion is a common sign of UTI in the elderly, yet there was no follow-up on the urinalysis results to ensure the culture and sensitivity test was completed. This lack of follow-up and awareness of the laboratory's requirements led to the resident's UTI going untreated, contributing to her ongoing confusion and hallucinations.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision for a resident with a history of psychological problems and previous elopement attempts. On the morning of 5/12/24, the resident, who was identified as an elopement risk, managed to leave the facility unsupervised. The resident was found 20 minutes later wandering on a nearby street, which posed a potential risk for injury. The resident's care plan had previously identified her as an elopement risk, and staff were instructed to keep her in their line of sight and use a call phone to request assistance rather than leaving her unattended. On the day of the incident, a Licensed Vocational Nurse (LVN) heard the wander guard alarm and saw the resident outside the facility. The LVN attempted to convince the resident to return but, fearing aggression, left the resident to seek additional help. During this time, the resident left the premises. The Activities Director noticed the resident's empty wheelchair in the parking area and alerted the staff. Multiple staff members, including a Registered Nurse (RN), searched for the resident, who was eventually found by the RN and two Certified Nursing Assistants (CNAs) following her on the street. The facility's policy on elopements and wandering residents emphasized the need for adequate supervision and stated that alarms should not replace necessary supervision. Despite this policy, the staff's actions on 5/12/24 did not align with the required supervision protocols, leading to the resident's unsupervised departure from the facility. Interviews with staff revealed that the resident was known to be quick and had previously eloped, highlighting the need for constant supervision, which was not provided on this occasion.
Failure to Conduct Trauma Informed Care Evaluation
Penalty
Summary
The facility failed to ensure that a Trauma Informed Care Evaluation was conducted for one of the residents, identified as Resident 1. This evaluation is crucial for understanding a resident's life experiences to deliver effective care and treatment. The Social Services Director (SSD) admitted that she did not complete the evaluation for Resident 1 within the required 48 hours after admission, as per her responsibilities. The SSD acknowledged her oversight, attributing it to being overwhelmed with work since she started at the facility on March 7, 2024. The deficiency was identified during a review of Resident 1's records and an interview with the resident's family member, who confirmed that they were not asked about any history of trauma or mental illness during a care plan meeting. The facility's policy mandates that such evaluations be conducted upon admission to gather comprehensive information for care planning. The SSD's job description also emphasizes the importance of providing medically related social services in compliance with state and federal regulations, which includes conducting trauma-informed evaluations.
Failure to Complete Social Services Evaluation for New Resident
Penalty
Summary
The facility failed to complete a Social Services Evaluation for a recently admitted resident, which is a requirement to help residents achieve the highest possible quality of life. The resident, a female, was admitted to the facility without this evaluation being conducted, which is essential for assessing mood and behaviors, adjustment to the new environment, mental health history, support systems, and behavioral interventions. This oversight was identified during a review of the resident's admission record and confirmed in an interview with the Social Services Director (SSD). The SSD, who started working at the facility shortly before the resident's admission, acknowledged the absence of the evaluation and attributed it to a lack of training on the necessary assessments. The facility's policy mandates that upon admission, designated staff must gather comprehensive information to develop care plans and assist residents in adjusting to the facility. The SSD's job description also emphasizes the responsibility to provide medically related social services in compliance with state and federal regulations, which was not fulfilled in this instance.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 355 citations issued within 25 miles in the last 12 months — 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Fowler
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Fowler Care Center | 1.7 mi | ★★★★★ | 2 | 0 |
| Manning Gardens Care Center, Inc | 4.7 mi | ★★★★★ | 21 | 0 |
| Rolling Hills Care Center | 5 mi | ★★★★★ | 21 | 0 |
| Grace Healthcare Center | 5.5 mi | ★★★★★ | 33 | 0 |
| Bethel Lutheran Home | 5.7 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 July 2026) and official state health department websites.