Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Visalia Post Acute during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, dementia, unsteadiness, and high fall risk was outside the patio area without supervision and had an unwitnessed fall. Staff found the resident face down on the pavement with abrasions and a right arm injury, and x-ray confirmed a displaced proximal humerus fracture. Interviews showed the patio aide left before the end of shift, while the DON, Administrator, and CNA stated the resident should not have been outside without supervision.
A resident was observed in bed with side rails up on both sides at the head of the bed, but the OSR did not show a physician order for the rails. The LVN could not locate an order and stated one should have been present, and the DON also stated that side rails need a physician order. The facility P&P for bed safety and bed rails calls for consultation with the attending physician as part of the interdisciplinary evaluation.
A resident was observed lying in bed with his knees bent and feet pressed against the foot board because the bed was too short for him to extend his legs. He stated he had told multiple staff members he was uncomfortable and that his feet always hit the bottom of the bed, while the ADON acknowledged the bed needed to be longer. Maintenance logs did not document the issue, and the MT said he was unaware of the bed-length problem.
A resident’s oral meds were left on an over-bed table so she could take them after breakfast, and the RN confirmed she had placed atenolol, cranberry, iron, a stool softener, Vitamin C, and magnesium there. The ADON stated the resident had no self-administration assessment, and the facility’s oral medication policy required staff to remain with the resident until all meds were taken.
A facility failed to manage resident grievances effectively when one resident was not given a written response about being unable to visit a friend’s room, another resident’s repeated missing-clothes complaint was not logged, and a third resident said SSA did not follow through on help scheduling neck surgery. The grievance policy required verbal and written notification of findings and actions, but SSD stated written responses were not provided and some complaints were only logged if residents labeled them as grievances.
Social Services staff did not meet the qualification requirements. The SSD stated she had only a HS diploma despite serving in the role full time, and record review confirmed her file reflected a HS diploma; the SSA also stated she had only a HS diploma, and her file confirmed that as well. The job descriptions required a bachelor’s degree in SW or a related field with supervised experience, and the FAC Administrator acknowledged that neither staff member had a bachelor’s degree.
QAPI failed to address concerns about social services staffing qualifications, including the lack of a qualified SSD and SSA. The SSA stated she had only a HS diploma, and record review confirmed her education and role history. The job description required a bachelor's degree in social work or a related major with supervised experience, and the Adm confirmed the issue had not been addressed through the facility's QAPI program.
Incomplete grievance tracking and QAPI oversight: The facility failed to consistently identify, document, track, and analyze resident and family complaints through its QAPI process. Review of the grievance log showed only a few grievances and no details on the complaint, investigation, conclusion, remedies, or written response, while interviews revealed the SSD did not place all complaints on the grievance log and the Adm acknowledged that complaints and grievances were the same but were not always documented.
Failure to Report Abuse and Unexplained Injuries: The facility did not report an injury of unknown origin for a resident with Alzheimer’s disease, whose face showed bruising and discoloration that staff could not explain, and it also did not report a resident-to-resident physical abuse incident in which one resident yanked another resident’s hair. The DON/Administrator confirmed the incidents were not reported to CDPH as required by policy.
A facility failed to maintain infection control when a CNA used the same vital sign equipment for two residents without disinfecting it between uses, and another CNA assisted a resident with toileting without wearing the gown required under EBP for high-contact care. Staff also observed oxygen concentrator filters covered with lint for three residents, including residents with COPD and shortness of breath, despite policy requiring clean filters.
A resident admitted with weakness and unsteadiness on feet wanted to move to ALF, but staff did not coordinate the discharge plan with the receiving facility or keep the resident and RP informed. The SSD said the resident had been ready for a lower level of care for months, yet there was no follow-up with the ALF or transition services management company, and the discharge care plan lacked resident-specific goals and interventions.
A resident with Type 2 DM and ketoacidosis received Lispro insulin at 11:00 AM, but the lunch tray was not served until about an hour later. An LVN checked the blood sugar and gave 4 units of Lispro before the meal, and later acknowledged the insulin was fast acting and that she should have waited longer. The MAR, provider order, and manufacturer instructions all addressed giving Lispro before meals or within 15 minutes of a meal.
Pain medication was not managed effectively for a resident with right knee pain and osteoarthritis. The resident reported knee pain in the morning but did not receive PRN Tylenol until later in the day, and the ordered Tylenol for mild pain was also given when pain was rated 5/10 on two occasions. After those doses, pain was not reassessed within the facility’s stated 30 to 60 minute timeframe, and an LVN stated a provider should have been contacted for stronger pain medication.
An unlocked, unattended treatment cart was observed on a nurses’ station, and an LVN acknowledged it should have been locked when not in use. In addition, personal food items were found stored in the vaccine refrigerator alongside vaccines, and the IP stated food should not be stored with vaccines due to cross contamination. Facility policy required drugs and biologicals to be stored securely and separately from food.
Food safety deficiencies were identified in the kitchen and resident nutrition storage areas. A black linear substance was found inside the ice machine, opened dry goods were left unlabeled, undated, and not tightly sealed, and partially consumed resident food and drink items were stored in the nutrition refrigerator and freezer without labels or dates. In addition, an employee preparing gravy wore a beard net that did not cover the mustache, contrary to facility policy.
A resident bathroom call system was not operational in two rooms because one bathroom had a missing pull cord and another had a missing call button. CNAs confirmed the problems, and the Maintenance Director stated the issues had not been reported in the maintenance logbook at the nurse's station. The facility policy required regular environmental inspections and immediate correction of identified issues.
Physical Environment Not Maintained in Safe Condition: A resident room had large scuff marks and visible damage on the walls, and the bathroom vinyl flooring at the entrance was lifted and separating from the floor surface, creating an uneven area. The Maintenance Director confirmed the conditions and stated staff were supposed to report maintenance issues in the maintenance log at the nursing station, but these issues had not been reported for repairs.
A facility failed to provide the minimum square footage required by regulation for 11 of 50 resident rooms. During observation, rooms 41 through 51 did not meet the required minimum of 80 square feet per resident, and the Administrator acknowledged that these rooms did not meet regulatory requirements.
A resident evaluated by a vascular physician was suspected to have CVI and PAD and received new orders for a left leg arterial duplex and venous duplex to be done at the facility. Nursing documentation noted the new orders and indicated Social Services would follow up with scheduling, but the studies were never documented as ordered or completed. The ADON could not find evidence of follow-up, and the SSA reported she was not informed of the orders until about two months later, despite facility policy requiring immediate recording of treatment orders in the chart. This failure led to a delay in the resident’s ordered diagnostic treatment.
A resident with a history of left foot injury was observed with a swollen, crusty, and draining second toe, but there was no documented assessment, physician notification, or treatment initiated by nursing staff. Despite documentation of a healing scab a week prior, no follow-up or monitoring was recorded, and staff confirmed that required change of condition protocols were not followed.
A resident with wounds to the left foot and toe did not have their wounds reevaluated when treatment orders ended. Both the treatment nurse and DON confirmed that reevaluation and documentation were required, but no evidence of this was found in the records, and no relevant policy was provided.
A resident with a foot wound identified by a podiatrist did not receive a referral to the wound care physician as ordered. Nursing staff and the DON were unable to provide documentation of the referral or evidence that the wound care physician was notified, resulting in the wound going untreated. This was not in accordance with the facility's policy for providing foot care and treatment.
A resident with a care plan for skin breakdown was observed with a right arm wound showing green drainage. An LVN noticed the drainage, cleaned the wound, and applied antibiotic ointment but did not notify the physician of the change in condition, despite facility policy and confirmation from the ADON that notification was required.
A resident with a urinary tract infection did not receive a scheduled dose of IV ceftriaxone as ordered by the physician. Review of the MAR and interview with the ADON confirmed the dose was not administered or documented, despite facility policy requiring such documentation for IV medications.
A resident who was hospitalized for severe abdominal pain and later expressed a desire to return was not permitted readmission by the facility, despite having intact cognition and the facility's policy prioritizing such returns. The administrator and ADON confirmed the decision not to allow the resident back, resulting in an unnecessary hospital stay and a violation of the resident's rights.
A resident with cognitive impairment and requiring moderate to maximum assistance was discharged home alone via Uber, without notifying APS, despite staff concerns for safety. The resident left medications behind, and staff were unable to contact emergency contacts. The facility failed to provide a policy for reporting such safety concerns.
The facility failed to ensure that advance directives (ADs) were offered and completed for 20 out of 36 sampled residents. Interviews and record reviews revealed that many residents either did not have an AD on file, or their ADs were incomplete, lacking necessary documentation such as signatures, dates, or specific medical wishes. The facility's policy requires that residents be informed of their right to formulate an AD, but this was not adhered to, potentially impacting residents' healthcare decisions.
The facility failed to maintain sanitary conditions and ensure equipment was in good repair in the food service area. The dishmachine and ice machine lacked proper installation, and floor sink drains were unsanitary, with rust and standing water. Clean foodservice equipment was stored with debris, and staff did not follow proper cleaning procedures before sanitizing surfaces, contradicting facility policies and FDA guidelines.
The facility failed to follow infection control policies, with an LVN administering medications without gloves, inadequate infection surveillance by the IPN, improper storage of used toilet brushes by housekeeping staff, and incorrect handling of respiratory therapy equipment. These actions were contrary to the facility's established procedures, potentially leading to the spread of infections.
The facility failed to provide annual training on abuse, neglect, and exploitation to a significant portion of its staff, including CNAs, LVNs, DAs, and others. This deficiency was identified during a review of training records and confirmed by the Director of Staff Development, who acknowledged the lack of make-up sessions and documentation. The absence of training could lead to unawareness of abuse reporting requirements among staff.
The facility failed to notify the Office of the State Long-Term Care Ombudsman of transfers and discharges of four residents to a local hospital, denying them access to advocacy for their rights and options. The Medical Records Director was responsible for the notifications but could not provide evidence of doing so. Additionally, there was a lack of documentation regarding the residents' orientation and preparation for transfer, contrary to the facility's policy.
The facility failed to follow its policy on Binding Arbitration Agreements for four residents. The Admission Director did not adequately explain the agreement to two residents, and did not document verbal acknowledgment of understanding from any of the four residents. This resulted in the residents not being fully informed of their rights in case of a dispute.
A facility failed to provide a functioning wall light in a resident's room, as observed when the light above the bed did not turn on and the string to operate it was detached. The DSD and MS were unaware of the issue, despite a maintenance worksheet indicating the problem was corrected earlier. The facility's policy requires maintaining equipment in a safe and operable manner, which was not followed.
The facility failed to provide written bed-hold information to two residents during their hospital transfers, as required by policy. This omission could create uncertainty about their return to the facility and previous rooms.
The facility failed to maintain accurate MDSRM documentation for two residents, leading to potential unmet care needs and inaccurate medical records. One resident was incorrectly marked as being on transmission-based precautions, while another was inaccurately noted to have a tracheostomy. These errors were confirmed through interviews and record reviews, highlighting a lapse in the facility's documentation practices.
The facility failed to provide Baseline Care Plan (BCP) summaries to three newly admitted residents within 48 hours, as required. The BCP summaries lacked documentation of being provided, and there were no signatures from the residents or their representatives to confirm receipt. This oversight was contrary to the facility's policy, which mandates that a written summary be given and documented in the medical records.
The facility failed to ensure that the MD reviewed and countersigned VOs for two residents. A resident with respiratory issues was sent to the hospital based on a verbal order, but the signed order was missing from the chart. Similarly, another resident's chart lacked a signed VO for hospital transfer. The facility's policy requires practitioners to review and countersign VOs during their next visit, which was not followed.
A resident was found in a state of neglect, wearing a hospital gown with uncombed hair, long facial hair, and dirty fingernails. The resident expressed the need for grooming, and a nurse confirmed the lack of personal care provided. The facility's policy on Activities of Daily Living (ADL) was not followed, as the resident did not receive necessary care to maintain personal hygiene.
A facility failed to provide necessary care for a hospice resident with leg edema. Despite observations of pitting edema by the Hospice Nurse and RN, the condition was not documented in Weekly Nursing Assessments, and no treatment orders were provided by the MD after notification. This resulted in the resident not receiving required treatment for the swelling.
A facility failed to ensure proper communication and food safety for a resident receiving dialysis. The resident, with moderate cognitive impairment, was provided a paper bag lunch that was not consumed until hours later, risking foodborne illness due to inadequate temperature control. The facility's RD was unaware of the resident's eating habits, and the dialysis center did not allow food consumption during treatment. Documentation and communication between the facility and dialysis center were insufficient, leading to a deficiency in care.
A facility failed to provide routine dental services to a resident, as a dental referral indicated in the resident's Order Summary was missed. The resident was observed without teeth, and the facility's policy on Resident Rights was not followed, potentially leading to unnoticed dental issues.
A resident did not receive their prescribed therapeutic diet when drinks were left out for hours and a meal tray was missing a nectar-thick punch. The resident, who was non-verbal and had physical limitations, was unable to access the drinks independently. The facility's dietary manager confirmed the oversight, highlighting a failure to adhere to the therapeutic diet policy.
The facility failed to honor the food preferences of two residents, leading to an unpleasant dining experience. A resident was served chili beans despite disliking them, and another received a meal with tomatoes, which they disliked. Additionally, a resident with lactose intolerance was served dairy-based hot chocolate, contrary to a doctor's order. The facility also did not ensure a resident was aware of the menu in time to request an alternative meal.
The facility did not meet the required square footage for 11 rooms, with some rooms housing three residents in spaces below the 80 square feet per resident standard. Despite this, the facility maintained that the rooms were adequate for residents' needs, and no complaints were reported by the residents.
A resident's call light was found on the floor, out of reach, preventing the resident from calling for assistance. Staff interviews confirmed the oversight, and the facility's policy requires call lights to be accessible to residents.
The facility failed to report a scabies outbreak to the state health department, as required by its policy. Three residents were clinically diagnosed with scabies, but the outbreak was only reported to the local health department. The facility's policy mandates reporting to both local and state health departments for communicable diseases, which was not followed in this case.
A resident with confusion and behavioral issues was not referred to a psychiatrist despite recommendations from the interdisciplinary team and agreement from the primary doctor. The facility lacked a psychiatrist, and the referral was not made, contrary to the facility's policy.
The facility failed to provide a homelike environment for a resident when the bed linen was found to have a hole and discolored areas due to thinning. Both a CNA and an LVN confirmed the condition, and the DON acknowledged that such linen should not have been used, as per facility policy.
A facility failed to report an abuse allegation when a family member informed an LVN that a resident claimed a male staff member hit her. Despite knowing about the allegation for two weeks, the LVN did not report it, violating the facility's policy requiring immediate reporting of abuse suspicions.
The facility failed to provide podiatry services for two residents, resulting in long, jagged, and discolored toenails. Observations and interviews revealed that the facility staff relied on podiatry services for toenail care, but there was no evidence that the residents had received the necessary care.
Failure to Supervise Resident in Patio Area
Penalty
Summary
The facility failed to follow its policy and procedure titled, Safety and Supervision of Residents, when Resident 1 was outside the patio area without supervision. Resident 1 was admitted with muscle weakness, Alzheimer's disease, dementia, unsteadiness on feet, difficulty walking, dizziness, and a history of falling. The quarterly MDS showed a BIMS score of 3, indicating severe cognitive impairment, and the FROA identified Resident 1 as high risk for falls. The care plan also identified Resident 1 as at risk for falls. Resident 1 was found lying face down on the pavement outside the patio area after an unwitnessed fall, with abrasions under the chin and the right arm in a free-hanging position and unable to be lifted. The hospital x-ray showed a comminuted displaced proximal humeral fracture of the right upper extremity. Staff interviews indicated that all residents required supervision when outside the patio area and that no residents were allowed outside without a patio aide present. The patio aide stated he left the patio area before the end of his shift and was not aware Resident 1 was still outside unsupervised. The DON and Administrator stated Resident 1 should not have been outside the patio area without supervision, and the Administrator stated the patio aide should remain in the patio area until the end of shift.
Missing Physician Order for Bed Rails
Penalty
Summary
The facility failed to ensure that Resident 1 had a physician's order for the use of side rails. During an observation, Resident 1 was found lying in bed with side rails positioned up on both sides at the head of the bed. During a concurrent interview and record review, the LVN reviewed Resident 1's Order Summary Report and was unable to locate a physician order for the side rails, and stated that side rails should have a physician's order. The DON also stated that side rails need a physician's order. The facility policy titled, Bed Safety and bed Rails, dated August 20, 2022, states that if attempted alternatives do not adequately meet the resident's needs, the resident may be evaluated for the use of bed rails and that the interdisciplinary evaluation includes consultation with the attending physician.
Failure to Accommodate Resident's Bed Length Needs
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of Resident 2 when his bed was not long enough for him to extend his legs while lying in bed. During observation, Resident 2 was seen lying with his head of bed elevated, knees bent, and feet flat against the foot board. He stated that he slept "squished up" with his knees bent because the bed was too short and that he was uncomfortable. He also stated that he had told several staff members about the issue but was told the facility did not have longer beds. During interview, the ADON stated she could see that the bed needed to be longer for Resident 2. A CNA stated that when Resident 2 was first admitted, he told her his feet were always hitting the bottom of the bed, and she believed the issue should have been resolved by then. Review of the maintenance logs for March and April 2026 showed no documentation that Resident 2's bed was too short, and the MT stated he was unaware of the issue. The facility policy stated that resident needs and preferences, including adaptive devices and modifications to the physical environment, are evaluated upon admission and reviewed on an ongoing basis.
Medications Left at Bedside Without Self-Administration Assessment
Penalty
Summary
The facility failed to follow its policy and procedure when medications were left at the bedside for one resident. During a concurrent observation and interview in the resident’s room, the resident was sitting in a wheelchair at the end of the bed with an over-bed table next to her, and a medicine cup containing six pills was observed on the table. The resident stated the nurse had left the medications there so she could take them after breakfast. The nurse confirmed she had left the medications on the table because the resident wanted to take them after eating breakfast, and identified the medications as atenolol, cranberry capsule, iron tablet, stool softener, Vitamin C, and magnesium. The nurse stated the medications should not have been left on the table. The ADON stated the resident did not have an assessment for self-administration of medications and the medications should not have been left on the resident’s table. The facility policy titled, Administering Oral Medications, stated to remain with the resident until all medications have been taken.
Grievance Process Not Effectively Managed
Penalty
Summary
The facility failed to ensure an effective grievance process for three residents when complaints were not fully documented, investigated, or communicated in writing. The facility’s grievance policy stated that residents or their representatives would be informed verbally and in writing of the findings and actions taken, and that a written summary of the investigation would be provided to the resident. However, the Social Services Director stated the facility did not give Resident 122 anything in writing and was unaware that a written response was required. Resident 122, admitted with weakness and unsteadiness on feet, reported that a staff member would not allow her to visit her friend’s room. She stated she filed a grievance but never heard anything else about it and continued to have difficulty visiting her friend in the room. The grievance log showed the complaint was reported, but there was no documentation that Resident 122 received a written response describing the grievance, the actions taken, the conclusion, the remedies used, or the date the response was sent. Resident 66, who had a BIMS score of 15 and reported missing clothes for about six months, stated he spoke to Social Services multiple times and asked for his belongings inventory list, but the request was not fulfilled. Housekeeping and Social Services staff acknowledged the missing-clothes concern, and Social Services stated the clothes were eventually found, but the complaint was not entered in the grievance log. Resident 120, who had a BIMS score of 15 and diagnoses including spinal stenosis, stated she repeatedly asked Social Services for help scheduling neck surgery since admission, but Social Services did not follow through and she eventually stopped asking.
Social Services Staff Did Not Meet Qualification Requirements
Penalty
Summary
The facility failed to ensure that the Social Services Director and Social Services Assistant met the qualification requirements stated in the facility’s job descriptions and the regulation. During interview and record review, the Social Services Director stated she had 15 years of social service experience but only a high school diploma, and the employee file confirmed she had a high school diploma. The Human Resources Director reviewed the position history and stated she had served in the social services director role since 6/6/11 and had not held any other positions since then. The job description for Social Services Director, dated February 2024, required a bachelor’s degree in social work or human services and 2 years of supervised social work experience, with an MSW preferred. The Social Services Assistant also stated she had only a high school diploma and no degree, and the employee file confirmed the same. The Human Resources Director reviewed the position history and stated she began the social services assistant role on 10/15/23, although she had originally been hired at the facility on 3/8/17 for a different position. The job description for Social Services Assistant, dated November 2016, required a bachelor’s degree in social work or a related major and 1 year of supervised social work experience. The Facility Administrator stated she was aware that social services required a minimum of a bachelor’s degree in social services or a related field, and stated that neither the Social Services Director nor the Social Services Assistant had a bachelor’s degree.
QAPI Failed to Address Social Services Staffing Qualifications
Penalty
Summary
The facility failed to ensure its QAPI program addressed concerns related to social services staffing qualifications, including the lack of a qualified Social Services Director and Social Services Assistant, as part of its ongoing assessment and performance improvement activities. The report states that the QAPI program did not identify or address this concern, despite the facility's QAPI plan stating that QAPI is integrated into the responsibilities and accountability of all facility leadership. During interviews and record review, the Social Services Assistant stated she had no degree and only a high school diploma, and her employee file confirmed that education. The Human Resources Director reviewed the position history showing she began the social services assistant role on 10/15/23, and the job description for Social Services Assistant listed a bachelor's degree in social work or a related major and 1 year of supervised social work experience. The Administrator stated she was aware of the requirement for social services to have at least a bachelor's degree in social services or a related field, and later confirmed that the issue of the Social Services Director and Social Services Assistant qualifications had not previously been addressed through the facility's QAPI program.
Incomplete grievance tracking and QAPI oversight
Penalty
Summary
The facility failed to implement and maintain an effective QAPI program to ensure resident and family complaints were consistently identified, documented, tracked, and analyzed through the QAPI process. During review of the Facility Grievance Log on 03/04/2026, only three grievances were listed since March 2025, and the log did not show what each grievance was about, what actions the facility took to investigate, the conclusion, the remedies used to resolve the grievance, or the date a written response was sent to the resident or representative. During interviews on 03/05/2026 and 03/06/2026, the Grievance Committee and Administrator stated that complaints were not always entered on the grievance log. The Social Services Director stated complaints were not the same as grievances and that not all complaints were placed on the grievance log, including theft and lost property complaints. The Administrator acknowledged that complaints and grievances were the same, but said only formal grievances were logged and that other complaints may or may not be documented, with some entered in progress notes and some not documented at all. The facility's QAPI Plan dated June 2, 2025 listed complaints/grievances as monitored data.
Failure to Report Abuse and Injuries of Unknown Origin
Penalty
Summary
The facility failed to ensure that allegations of abuse and injuries of unknown origin were reported to the State Agency for three of 33 sampled residents. Resident 49, who had Alzheimer’s disease and was confused, was observed with red and purple bruising on the right upper and lower eyelids and bridge of the nose. Facility staff noted the injury as a new skin issue and documented discoloration around the right eye, but the Administrator later confirmed that the injury of unknown origin was not reported to the state agency district office. Staff interviews showed that the injury was first noted by nursing staff and that the resident could not recall how it occurred. The facility also failed to report a resident-to-resident physical abuse incident involving Resident 153 and Resident 22 to CDPH. Staff reported that Resident 153 reached out and yanked Resident 22’s hair in the dining area around lunch time. The Administrator stated she was the Abuse Coordinator and that the incident had been reported to the Ombudsman and law enforcement, but not to CDPH, and confirmed CDPH was not notified. The facility policy stated that all reports of resident abuse, including injuries of unknown origin, are to be reported to local, state, and federal agencies as required by current regulations.
Infection Control Failures With Shared Vital Sign Equipment, EBP Noncompliance, and Dirty Oxygen Filters
Penalty
Summary
The facility failed to maintain an effective infection control program when a CNA obtained vital signs for Resident 100 and then used the same blood pressure cuff and pulse oximeter for Resident 93 without disinfecting the equipment between residents. During interview, the CNA acknowledged the equipment was not disinfected and stated it should have been cleaned to prevent cross-contamination; she also stated disinfectant wipes were usually obtained from the room counter, but none were available at that time. The facility’s policy for cleaning and disinfecting non-critical resident-care items indicated durable medical equipment are to be cleaned and disinfected or sterilized between residents. The facility also failed to follow Enhanced Barrier Precautions for Resident 11, whose physician orders indicated EBP during high-contact activities due to a chronic wound. During observation, a CNA assisted Resident 11 with toileting without wearing a gown, despite a sign outside the room indicating staff must wear a gown and gloves when changing briefs or assisting with toileting. In addition, oxygen concentrator filters for Residents 6, 69, and 83 were observed covered with lint during room observations; the residents had diagnoses including shortness of breath and COPD. The facility’s oxygen concentrator policy indicated filters should be washed weekly and as needed, and the Infection Preventionist stated the filters should be kept clean as part of infection control practices.
Discharge planning and care plan failed to reflect resident’s ALF transfer goals
Penalty
Summary
The facility failed to coordinate discharge planning with the receiving facility and failed to communicate the discharge plan with the resident and the resident's responsible party for Resident 122. Resident 122 was admitted with diagnoses including weakness and unsteadiness on feet. During interviews, Resident 122 stated she was doing much better and wanted to move to an assisted living facility, but she had been waiting a long time and did not know what was happening with her move. The resident's family member stated the ALF had a bed available, but the resident could not transfer, and the family member was unsure what else needed to be done because of an insurance issue. The family member also stated she had not received help or updates from social services about the discharge plan. The Social Services Director stated the facility was waiting for a transition services management organization to approve the ALF placement, that the resident had been ready to move to a lower level of care since October 2025, and that social services had not followed up with the ALF or the transition services management company since September 2025. Staff interviews showed the LVN and RN supervisor were unaware of the discharge plan, and the MDS nurse confirmed the discharge care plan did not include a resident-specific goal with measurable outcomes or interventions to help the resident achieve those goals. The discharge care plan listed a preference to discharge to assisted living and general interventions, but the social service notes did not document contact with the ALF or transition services management organization since 9/23/25.
Insulin Given Too Early Before Meal
Penalty
Summary
The facility failed to administer insulin within professional standards when Lispro Insulin was given to a resident with Type 2 Diabetes Mellitus with Ketoacidosis one hour before the resident’s lunch meal. The resident was admitted to the facility with diagnoses including Type 2 Diabetes Mellitus with Ketoacidosis. On 3/4/2026, an LVN checked the resident’s blood sugar at 11:00 AM and administered 4 units of Lispro Insulin at that time. During a concurrent observation, the resident was seen beginning lunch at 12:10 PM, and the speech therapist stated the lunch tray was served at 12:05 PM. The LVN later stated Lispro was fast acting and that she should have waited longer to check the resident’s blood sugar and administer insulin. The MAR showed the blood sugar check and Lispro administration at 11:00 AM, and the provider order summary directed Lispro to be injected before meals. The manufacturer’s instructions stated Lispro should be administered within 15 minutes before a meal or immediately after a meal.
Pain Medication Given Outside Ordered Parameters and Pain Not Reassessed Timely
Penalty
Summary
Effective pain management was not provided for a resident with right knee pain and osteoarthritis. The resident had been admitted and re-admitted to the facility with diagnoses including right knee pain, and a physician progress note documented osteoarthritis contributing to joint pain, stiffness, and reduced functional mobility. During an observation and interview, the resident stated she told a female staff member about right knee pain in the morning but did not receive the PRN pain medication until 5:00 PM. The physician order for Tylenol 325 mg, 2 tablets by mouth every 6 hours as needed for mild pain, was reviewed along with the resident’s MAR showing the medication was administered on six occasions in February 2026. Two of the documented administrations occurred when the resident reported pain at a level of 5 out of 10, which was above the ordered indication for mild pain. During interview, an LVN stated a physician should have been called for a stronger pain medication appropriate for the reported pain level because the ordered Tylenol was for mild pain only. In addition, after the medication was given on two occasions when the resident reported pain at 5 out of 10, the pain level was not reassessed until more than two hours later. The facility’s pain assessment policy stated acute pain or significant worsening of chronic pain should be assessed every 30 to 60 minutes after onset and reassessed as indicated until relief is obtained.
Unlocked Treatment Cart and Food Stored with Vaccines
Penalty
Summary
The facility failed to safely store and label drugs and supplies in accordance with accepted standards of practice when a treatment cart on Station 3 was observed unlocked and unattended across from the nurses’ station. During observation, the cart remained unlocked and unattended, and an LVN acknowledged that it should have been locked when not in use to prevent unauthorized access to treatment supplies. The ADON later reviewed the facility policy titled Storage of Medications, which stated that drugs and biologicals are to be stored in a safe, secure, and orderly manner and that drawers and carts containing biologicals must be locked when not in use. The facility also stored personal food items in the infection prevention vaccine refrigerator. During observation, one personal food container, one box of soft cheese, and one container of dip were stored directly alongside boxes of vaccines. The IP stated that food should not be stored with vaccines due to cross contamination. Facility policies titled Medication Storage and Storage of Medications indicated that employee lunches and other foods are not to be stored in the refrigerator and that medications are to be stored separately from food and labeled accordingly.
Food Storage, Ice Machine, and Personal Hygiene Deficiencies
Penalty
Summary
Food safety standards were not maintained in the kitchen and resident nutrition storage areas. During observation with the Certified Dietary Manager, a black linear substance was found inside the ice machine and came off when wiped with a paper towel. In the dry goods storage area, two open bags of pasta noodles and one open cornstarch were found without open dates and were not tightly sealed. The facility policy required opened dry food items to be tightly closed, labeled, and dated, and the ice machine manual stated cleaning/sanitizing should be performed at least every three months. In the Station 2 medication room, a partially consumed bottled drink was found in the residents' nutrition refrigerator unlabeled and undated, and a partially consumed frozen yogurt was found in the residents' nutrition freezer without a label or date. An RN stated the drink and yogurt were not supposed to be stored there in that condition. In the kitchen, an employee preparing gravy was observed wearing a beard net but not covering the mustache, and the CDM stated the beard net should have covered the mustache. The facility's policy required facial hair to wear beard restraint.
Missing Bathroom Call Light Components
Penalty
Summary
The facility failed to ensure the resident call system was operational and accessible in two resident bathrooms. In one room bathroom, the call light system was observed with a missing required pull cord, which would prevent residents from summoning staff assistance when needed. In another room bathroom, the call light system was observed to be broken with a missing call light button, also preventing residents from summoning staff assistance when needed. During observation, the missing pull cord and broken call light button were confirmed by CNAs during interviews. The Maintenance Director stated he had not been notified of the call light issues and explained that staff were supposed to report maintenance concerns by documenting them in the maintenance logbook at the nurse's station. A review of the logbook showed the broken call lights had not been reported. The facility policy stated environmental services inspections were to be performed regularly and that opportunities were to be corrected immediately.
Physical Environment Not Maintained in Safe Condition
Penalty
Summary
The facility failed to ensure the physical environment was maintained in safe, clean, and well maintained condition when room [ROOM NUMBER] had large scuff marks and visible damage on the room walls and bathroom walls. During observation on 3/2/26 at 2:20 PM, multiple large scuff marks and visible damage were observed on the walls in the room, and the wall surfaces appeared worn and in need of repair. The facility also failed to maintain the bathroom flooring in room [ROOM NUMBER] when the vinyl flooring at the bathroom entrance was lifted and separating from the floor surface. During observation on 3/2/26 at 2:45 PM, the raised vinyl flooring was noted to create an uneven surface. On 3/3/26 at 10:30 AM, the Maintenance Director confirmed the wall and flooring conditions and stated staff were supposed to report maintenance issues by logging them in the maintenance log at the nursing station. The Maintenance Director also confirmed the issues had not been reported for repairs.
Resident Rooms Did Not Meet Required Square Footage
Penalty
Summary
The facility failed to provide the minimum square footage required by regulation for 11 of 50 resident rooms. During observation, resident rooms 41 through 51 did not meet the required minimum of 80 square feet per resident, including rooms measuring 227.2 square feet for 3 residents, 219.2 square feet for 3 residents, and rooms 43 through 51 measuring 234.5 square feet for 3 residents. During interview, the Administrator acknowledged that rooms 41 through 51 did not meet regulatory requirements.
Failure to Follow Up on Vascular Diagnostic Orders
Penalty
Summary
The deficiency involves the facility’s failure to follow up on physician orders for diagnostic vascular studies for one resident. A vascular physician documented in a progress note that the resident was suspected to have both chronic venous insufficiency (CVI) and peripheral arterial disease (PAD) and ordered left leg arterial and venous duplex studies to be done at the facility. A subsequent nursing progress note the same day documented that the resident had returned from the vascular appointment with new orders from the vascular MD for a left leg arterial duplex and a left leg venous duplex, and that Social Services would follow up with appointments for these procedures. During surveyor review with the Assistant Director of Nursing, there was no documentation that the ordered arterial and venous duplex studies had been followed up on or completed, and the ADON acknowledged that the orders should have been entered on the physician orders and followed up. The Social Service Assistant stated that when a resident has an order for treatment outside the facility, the nurse is supposed to provide her a copy of the order so she can arrange the appointment and transportation, but she was not made aware of this resident’s orders until approximately two months after they were written. The facility’s policy on Medication and Treatment Orders required that verbal orders be recorded immediately in the resident’s chart with specific details, but the documentation and follow-up process for these ordered studies did not occur as required, resulting in a delay of treatment.
Failure to Assess, Notify Physician, and Treat Change in Condition for Resident's Foot Injury
Penalty
Summary
The facility failed to assess, notify the physician, and treat a change in condition for a resident who presented with a swollen left foot, drainage, and dry, crusty debris covering the second toe and nail bed. Observation revealed the resident's left foot was swollen, with debris between the toes and a dried scab on the inside of the foot. The second toenail bed and top of the toe were covered with lumpy, yellow, crusty debris. A review of the resident's Shower/Bed Bath Sheet from seven days prior indicated a healing scab on the left foot, but there was no documented response or follow-up action by the licensed nurse, despite the form prompting for such action. During further evaluation, an LVN noted the second toe was swollen, dry, had drainage, and appeared infected, with no current treatments being administered. The CNA reported the resident had a history of injuring her left foot during a transfer, and the second toe had looked like a cauliflower since the initial injury. The LVN and DON both confirmed that a change of condition should have been completed, the physician notified, and new orders implemented when the skin issue was identified, but there was no evidence of ongoing treatment or monitoring. The facility's policy required physician notification and intervention for significant changes in a resident's condition, which was not followed in this case.
Failure to Reevaluate Wounds at End of Treatment Orders
Penalty
Summary
The facility failed to reevaluate wounds for a resident when treatment orders were ending. According to progress notes, the resident returned from a hospital appointment with a bleeding left second toe, where the nail was not intact, and a skin tear on the left lateral foot. Orders were given to cleanse and treat both wounds with bacitracin every shift, monitor for infection and worsening for 14 days, and follow up with a wound doctor. The Treatment Administration Record showed that the last day of treatment and monitoring for these wounds was on 7/6/25 during the day shift. Interviews with the treatment nurse and the Director of Nursing confirmed that wounds should have been reevaluated at the end of the treatment period, with documentation in the progress notes indicating whether treatment should continue or be discontinued. However, neither staff member could provide documentation that the wounds were reevaluated at the end of the treatment period. Additionally, the facility was unable to provide a policy regarding wound reevaluation at the end of treatment orders.
Failure to Refer Resident for Wound Care as Ordered by Podiatrist
Penalty
Summary
The facility failed to follow physician orders regarding foot care for one resident who had a wound on the left dorsal forefoot, as identified during a podiatry evaluation. The podiatrist documented the presence of a 3x3 cm wound, applied a dressing, notified nursing staff, and instructed that wound management be deferred to the wound care physician. The podiatrist also indicated that if further recommendations were needed from a podiatry standpoint, a specific reconsult should be requested. Despite these instructions, there was no documentation that the resident was referred to the wound care physician as ordered. Both the treatment nurse and the DON confirmed during interviews and record reviews that they could not provide evidence of a referral or that the wound care physician had been notified. The facility's policy requires that residents receive foot care and treatment in accordance with professional standards, including the management of medical conditions to prevent complications, but this was not followed in this instance.
Failure to Notify Physician of Wound Change
Penalty
Summary
A deficiency occurred when the facility failed to notify a physician of a change in condition for a resident whose wound worsened. The resident, identified as being at risk for skin breakdown, had a care plan that required staff to check skin during daily care and notify the physician of abnormal findings. On observation, the resident was found with steri-strips on her right arm near the elbow, with green drainage visible on the wound, which is often a sign of infection. A Licensed Vocational Nurse (LVN) reported noticing green drainage from the resident's wound the previous day, cleaned the wound, applied triple antibiotic ointment, and left it uncovered, but did not notify the physician of this change. The LVN confirmed that the physician should have been notified. The Assistant Director of Nursing also stated that the physician should have been informed when green drainage was observed. Facility policy required nurses to notify the attending physician of significant changes in a resident's condition and to document such changes in the medical record.
Missed IV Antibiotic Dose Due to Failure to Follow Physician's Order
Penalty
Summary
The facility failed to follow a physician's order for a resident who was prescribed intravenous ceftriaxone to treat a urinary tract infection. The physician's order specified that the antibiotic was to be administered once daily for seven days. Review of the resident's care plan confirmed the need for medication administration as ordered. However, documentation on the Medication Administration Record showed that the ceftriaxone dose was not given on one of the scheduled days, and the Assistant Director of Nursing was unable to provide evidence that the medication was administered. Facility policy required documentation of all IV medication administration, including date, time, and clinician initials, but this was not completed for the missed dose.
Failure to Permit Resident Readmission After Hospitalization
Penalty
Summary
The facility failed to permit a resident to return after a hospitalization, despite the resident expressing a desire to return and the facility's own policy stating that residents discharged to the hospital or on therapeutic leave would be given priority readmission. The resident, who had intact cognition as indicated by a BIMS score of 14, was initially transferred to the hospital due to severe abdominal pain. After her condition improved, both the hospital social worker and the resident herself communicated with the facility regarding her return. The administrator and assistant director of nursing confirmed that the facility would not allow the resident to return, citing a lack of available beds and later stating that the resident would not be permitted to return even if a bed became available. This action resulted in the resident remaining unnecessarily in the hospital and violated the facility's stated policy and the resident's rights.
Failure to Notify APS for Resident Discharge with Safety Concerns
Penalty
Summary
The facility failed to notify adult protective services (APS) when a resident was discharged home alone, despite staff concerns about the resident's cognitive status and safety. The discharge summary indicated that the resident required moderate to maximum assistance with activities such as bed mobility, transfer, dressing, bathing, grooming, hygiene, and toilet use. The resident was also incontinent of both bladder and bowel. The care plan noted cognitive impairment, with interventions to anticipate needs and provide memory cues. On the day of discharge, the resident was sent home via Uber without any accompanying person, and medications were left behind as the discharge was uncertain until shortly before the ride arrived. Interviews with facility staff revealed that the resident was confused on the day of discharge, and attempts to contact the resident's emergency contacts were unsuccessful. The Licensed Vocational Nurse (LVN) expressed concern about discharging the resident without anyone knowing, and the Assistant Director of Nursing (ADON) confirmed that the resident had episodes of confusion during their stay. The Social Service Director (SSD) stated that safety concerns should have been reported to APS, but no facility policy was provided to support this procedure.
Failure to Ensure Completion of Advance Directives
Penalty
Summary
The facility failed to ensure that advance directives (ADs) were offered and completed for 20 out of 36 sampled residents. This deficiency was identified through interviews and record reviews conducted with the Social Services Assistant (SSA) and the Medical Records Director (MRD). The review revealed that many residents either did not have an AD on file, or their ADs were incomplete, lacking necessary documentation such as signatures, dates, or specific medical wishes. During the interviews, the SSA and MRD were unable to provide documentation of ADs for several residents, including Residents 113, 73, 411, 128, 104, 135, 2, 111, 77, 312, 311, 81, 51, 68, 313, 36, 101, 43, 109, and 84. In many cases, the AD forms were found to be blank or incomplete, with missing acknowledgments or signatures. The SSA acknowledged these deficiencies, noting that some residents' ADs were not transferred correctly during a system change from matrix charting to point-click-care charting. The facility's policy and procedure on advance directives, dated 2001, requires that residents be informed of their right to formulate an AD and that the existence of any ADs be determined upon admission. However, the facility failed to adhere to this policy, as evidenced by the lack of completed ADs for the majority of the sampled residents. This failure had the potential to result in residents' healthcare wishes not being honored, as there was no documentation to guide medical decisions in the event that residents became incapacitated.
Sanitation and Equipment Maintenance Deficiencies in Food Service Area
Penalty
Summary
The facility failed to maintain sanitary conditions and ensure equipment was in good repair in the food service area, as observed during a survey. The dishmachine and ice machine were not installed according to the manufacturer's guidelines, lacking a visible floor drain and proper air gap to prevent backflow of potentially contaminated water. The Maintenance Supervisor was unaware of these requirements, and the Certified Dietary Manager confirmed the absence of a drain or air gap for the new ice machine. This non-compliance with the facility's policies and the FDA Food Code posed a risk of contamination. Additionally, the facility did not maintain floor sink drains in a sanitary manner. Observations revealed that the floor sink drain under a foodservice steamer was covered in an orange-colored substance, identified as rust, and had missing or cracked portions, preventing adequate cleaning. Another floor sink drain was full of standing water, which frequently overflowed onto the kitchen floor, creating unsanitary conditions. The Certified Dietary Manager acknowledged these issues, and the Maintenance Supervisor admitted the need for further investigation to identify the problem. The facility also failed to properly clean and sanitize food contact surfaces. Clean foodservice equipment was stored on shelves with scattered dried food debris, and staff used a sanitizing solution without prior cleaning with detergent. The Certified Dietary Manager admitted to not incorporating a wash with detergent step before sanitizing, believing that sanitizing alone was sufficient. This practice contradicted the facility's policies and the FDA Food Code, which require cleaning to remove organic matter before sanitization to prevent contamination.
Infection Control Deficiencies in Medication Administration and Housekeeping
Penalty
Summary
The facility failed to adhere to its infection control policies and procedures in several instances. A Licensed Vocational Nurse (LVN) was observed administering medications to two residents without using gloves, directly touching the pills with ungloved hands. This action was contrary to the facility's policy on administering medications, which requires staff to follow infection control procedures, including the use of gloves. The Director of Nursing confirmed that the pills should not be touched by hand and should be placed directly into the pill cup. The Infection Preventionist (IPN) did not conduct adequate surveillance activities as per the facility's infection control policies. The IPN was responsible for monitoring hand hygiene and other infection control practices but failed to document the time of surveillance, actions taken to correct non-compliance, or any analysis of the data collected. The adherence rates for hand hygiene were low, ranging from 65% to 75%, and there was no record of corrective actions or education provided to staff to address these deficiencies. Additionally, the facility's housekeeping staff did not follow proper procedures for storing cleaning equipment. Used toilet brushes were found stored alongside clean supplies such as unopened boxes of gloves on housekeeping carts. This improper storage practice was acknowledged by the housekeeping staff and the Infection Prevention Nurse Consultant, who confirmed that used toilet brushes should not be stored with clean supplies. Furthermore, respiratory therapy equipment for a resident was not labeled or stored correctly, with tubing not being replaced as required by the facility's policy, which mandates changing the tubing every seven days.
Failure to Provide Required Abuse and Neglect Training
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the Abuse, Neglect, Exploitation, and Misappropriation Prevention Program by not providing annual training to a significant portion of its staff. Specifically, 17 out of 73 Certified Nursing Assistants (CNAs), 7 out of 31 Licensed Vocational Nurses (LVNs), 4 out of 12 Dietary Aids (DAs), 2 out of 4 cooks, 2 out of 20 Feeding Assistants (FAs), 1 out of 3 Speech Language Pathologists (SLPs), 1 out of 2 Respiratory Therapists (RTs), 1 out of 6 Restorative Nursing Assistants (RNAs), 2 out of 3 Occupational Therapists (OTs), 1 Minimum Data Set Coordinator (MDSC), and 1 out of 7 Registered Nurses (RNs) did not receive the required training. This lack of training was confirmed during an interview and record review with the Director of Staff Development, who acknowledged that the staff had not attended make-up sessions and no additional documentation was provided. The absence of documented training for these staff members indicates a failure to ensure that they are aware of what constitutes abuse, neglect, and exploitation, as well as the reporting requirements. This deficiency was identified during a review of the facility's annual training records and its policy and procedure document dated April 2021, which mandates staff orientation and training. The failure to provide this essential training had the potential for abuse in residents to go unnoticed and unreported within the facility.
Failure to Notify Ombudsman of Resident Transfers and Discharges
Penalty
Summary
The facility failed to provide the Office of the State Long-Term Care Ombudsman (OSLTCO) with a Notice of Transfer for three residents who were transferred to a local hospital and one resident who was discharged to a hospital. This failure resulted in the residents not having immediate access to an advocate who could inform them of their transfer or discharge options and rights. The Medical Records Director (MRD) was responsible for notifying the Ombudsman but was unable to provide evidence of notification or confirmation of receipt from the Ombudsman's office. In the case of Resident 51, the Assistant Director of Nursing (ADON) and the Social Services Director (SSD) were involved in the transfer process, but there was no documentation of the notification to the Ombudsman or evidence of nursing documentation in the Nursing Progress Notes regarding the resident's orientation and preparation for transfer. Similarly, for Resident 68, there was no record of notification to the Ombudsman, and the ADON could not find documentation of the resident's orientation and preparation for transfer. Resident 127 was transferred to the hospital due to respiratory issues, but the MRD was not aware of the requirement to notify the Ombudsman for hospital transfers. Resident 159 was discharged to a hospital for a CT scan, and again, there was no notification to the Ombudsman. The facility's policy and procedure indicated that notice of transfer should be provided to the resident and representative as soon as practicable and to the LTC Ombudsman when practicable, but this was not followed in these cases.
Failure to Properly Explain and Document Binding Arbitration Agreement
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the Binding Arbitration Agreement (BAA) for four sampled residents. The Admission Director (AD) did not explain the BAA to two residents in a manner they could understand before they signed the agreement. Specifically, Resident 62 and Resident 134 were not adequately informed about the BAA, with Resident 62 not understanding the form and Resident 134 not recalling the signing or explanation of the form. The BIMS scores for these residents were 12 and 15, respectively, indicating moderate cognitive impairment for Resident 62 and intact cognition for Resident 134. Additionally, the AD did not document a verbal acknowledgment of understanding the BAA from any of the four residents, including Residents 62, 134, 101, and 135. The facility's policy requires that the terms and conditions of the BAA be explained to the resident or their representative, ensuring their understanding, and that a verbal acknowledgment of understanding be documented. However, the AD only obtained signatures from the residents without documenting their acknowledgment or understanding, which resulted in the residents not being fully aware of their rights in case of a dispute with the facility.
Failure to Maintain Functioning Wall Light in Resident's Room
Penalty
Summary
The facility failed to ensure a functioning wall light was provided in a resident's room, specifically for Resident 139. During an observation, it was noted that the light above the resident's bed did not turn on, and the string to operate the light was detached. The Director of Staff Development (DSD) was unaware of the issue until it was pointed out during the observation. The Maintenance Supervisor (MS) also stated he was not aware of the broken light, although the facility's Departmental Maintenance Worksheet indicated that the light chord was broken and was supposedly corrected two days prior. The facility's policy and procedure for maintenance service requires the maintenance department to maintain equipment in a safe and operable manner at all times, which was not adhered to in this instance.
Failure to Provide Written Bed-Hold Information
Penalty
Summary
The facility failed to provide written information on bed-hold policies to two residents, Resident 51 and Resident 68, during their transfers to an acute care hospital. The Admissions Director stated that the facility's admission packet included a form discussing bed-hold upon admission, and that nurses should inform residents or their representatives about bed-hold before a transfer. However, during a review of Resident 51's medical record, it was found that there was no evidence that written information about bed-hold was provided when the resident was transferred to a hospital on June 24, 2024. Similarly, Resident 68 was transferred to a hospital on January 25, 2025, for evaluation and treatment of a scalp laceration after a fall, but there was no evidence that the resident or their representative received written information about bed-hold. The facility's policy and procedure on bed-holds and returns indicated that residents should receive written notice about bed-hold policies at least twice: in the admission packet and at the time of transfer, or within 24 hours if the transfer was an emergency. The failure to provide this information had the potential to create uncertainty for the residents regarding their ability to return to the facility and their previous rooms.
Inaccurate MDSRM Documentation for Two Residents
Penalty
Summary
The facility failed to ensure the accuracy and timeliness of the Minimum Data Set Resident Matrix (MDSRM) for two residents, leading to potential unmet care needs and inaccurate medical records. For Resident 135, the MDSRM inaccurately indicated that the resident was on transmission-based precautions (TBP), despite interviews with the Licensed Vocational Nurse (LVN) and the Minimum Data Set Coordinator (MDSC) confirming that the resident had not been on TBP since October 2024. Additionally, the MDS sections reviewed did not reflect any respiratory therapy or issues with shortness of breath, further highlighting the inaccuracy in the resident's assessment. Similarly, for Resident 152, the MDSRM incorrectly marked the presence of a tracheostomy, even though observations and record reviews confirmed that tracheostomy care had been discontinued since December 17, 2024. The MDSC admitted to not updating the matrix to reflect this change, despite the facility's policy requiring complete and accurate documentation. These inaccuracies in the MDSRM could lead to potential care discrepancies and misinformed medical decisions for the residents involved.
Failure to Provide Baseline Care Plan Summaries
Penalty
Summary
The facility failed to provide a Baseline Care Plan (BCP) summary to three newly admitted residents within the required 48-hour timeframe. During interviews and record reviews, it was found that the BCP summaries for Residents 311, 312, and 313 were incomplete. Specifically, the section indicating that a printed BCP summary was provided was left blank, and there were no signatures from the residents or their representatives to confirm receipt of the BCP summaries. The Assistant Director of Nursing (ADON) was unable to provide documented evidence that the BCPs were given to the residents or their representatives. The facility's policy and procedure on Baseline Care Plans, dated March 2022, requires that a written summary of the BCP be provided to the resident or their representative in a language they understand, and that this provision be documented in the medical records. However, this policy was not followed for the three residents in question, as evidenced by the lack of documentation and confirmation of receipt. This oversight had the potential to impact the care and safeguards necessary for the residents within the first 48 hours of their admission.
Failure to Countersign Verbal Orders for Two Residents
Penalty
Summary
The facility failed to ensure that the Medical Doctor (MD) reviewed and countersigned verbal orders (VO) for two residents, Resident 101 and Resident 127. For Resident 127, a Licensed Vocational Nurse (LVN) noted crackles in the right lung and diminished breath sounds in the left lung, indicating difficulty breathing. The resident was on oxygen at 3 liters, and the MD gave a verbal order to send the resident to the hospital. However, the signed VO was not found in the resident's chart. Similarly, for Resident 101, the Minimum Data Set Coordinator (MDSC) acknowledged that a VO should have been given for the resident to be sent to the hospital, but the signed VO was missing from the resident's chart. The facility's policy requires practitioners to review and countersign verbal orders during their next visit, which was not adhered to in these cases.
Failure to Provide ADL Support for a Resident
Penalty
Summary
The facility failed to adhere to its policy and procedure for Activities of Daily Living (ADL) for one of the sampled residents, identified as Resident 81. During an observation, Resident 81 was found sitting on his bed wearing a hospital gown, with uncombed long hair, and long facial hair. His fingernails were long and contained a blackish substance. Resident 81 expressed the need for grooming, including shaving and nail trimming, and was waiting for a Certified Nursing Assistant (CNA) to assist. A Registered Nurse (RN) confirmed that Resident 81 had not been showered, combed, or changed, and acknowledged the need for shaving and nail trimming. A CNA noted that Resident 81 frequently scratched his legs and private area, leading to dirty fingernails. The facility's policy indicated that residents should receive care to maintain or improve their ability to perform ADLs, which was not followed in this instance.
Failure to Address Edema in Hospice Resident
Penalty
Summary
The facility failed to provide appropriate care and treatment for a resident in hospice care who was experiencing edema in both legs. Weekly Nursing Assessments did not document the presence of edema, despite observations of pitting edema by the Hospice Nurse and Registered Nurse. The Hospice Nurse had notified the Medical Doctor about the condition, but no treatment orders were provided. This lack of documentation and follow-up resulted in the resident not receiving necessary services and treatment for the swelling in her legs. The Assistant Director of Nursing and Nursing Consultant reviewed the resident's Physician's Progress Notes and found no documentation addressing the pitting edema since the initial notification to the physician. The facility's policies and procedures require that changes in a resident's condition be documented and communicated to ensure quality care, but these protocols were not followed in this case. The failure to document and address the resident's edema represents a deficiency in the care provided by the facility.
Inadequate Communication and Food Safety for Dialysis Resident
Penalty
Summary
The facility failed to ensure proper communication between its Registered Dietitian (RD) and the RD at the dialysis center regarding the safe provision of lunch for a resident who required dialysis three times a week. The resident, who had moderate cognitive impairment, was provided with a paper bag lunch containing a turkey or tuna sandwich, which was not consumed until six to seven hours later, potentially placing the food in the temperature danger zone. The facility's RD was unaware that the resident did not eat at the dialysis center and usually ate upon returning to the facility, which could lead to foodborne illness due to inadequate time/temperature control. Interviews revealed that the resident left the facility with a packed lunch but often did not consume it until returning from dialysis. The Certified Dietary Manager confirmed the contents of the lunch, which included a sandwich, apple sauce, a fresh apple, crackers, and cookies, but no fluids. The RD at the dialysis center stated that residents were not allowed to eat during dialysis for infection control purposes, and there was no provision for storing food at the center. The resident sometimes ate in the lobby after dialysis, but this was not consistently documented or communicated between the facility and the dialysis center. The facility's documentation and communication processes were insufficient, as there were no fields on the forms to document whether the resident arrived with a lunch or consumed it at the dialysis center. The facility's best practice workflow for dialysis communication emphasized the need for ongoing coordination between the nursing home and dialysis staff, but this was not effectively implemented. The lack of proper documentation and communication regarding the resident's meal consumption and storage led to a deficiency in providing safe and appropriate dialysis care services.
Failure to Provide Routine Dental Services
Penalty
Summary
The facility failed to provide routine dental services to one of the six sampled residents, identified as Resident 106. During an observation in Resident 106's room, it was noted that the resident did not have teeth. A subsequent interview and record review with the Social Services Assistant revealed that a dental referral for Resident 106, which was indicated in the Order Summary dated June 1, 2024, was missed. The facility's policy and procedure on Resident Rights, dated September 2009, states that residents have the right to choose a physician and treatment and participate in decisions and care planning. This oversight had the potential for poor eating and unnoticed dental issues such as broken or loose teeth.
Failure to Provide Therapeutic Diet as Ordered
Penalty
Summary
The facility failed to provide a therapeutic diet as ordered for a resident, identified as Resident 311, which led to deficiencies in meeting the resident's nutritional needs. On one occasion, two sippy cups containing nectar-thick liquids were left on the resident's nightstand from 8 a.m. until 12:54 p.m., rendering the drinks out-of-range in temperature and unsuitable for consumption. The resident, who was non-verbal, had no teeth, and a contracted left hand, was unable to access the drinks independently. When a CNA noticed the drinks, they were given to the resident, who drank quickly, indicating thirst. The Certified Dietary Manager confirmed that the drinks should not have been left at the bedside and were not suitable for consumption after sitting out for such an extended period. Additionally, the resident's lunch tray was missing an 8-ounce nectar-thick punch drink, which was part of the prescribed therapeutic diet. The Licensed Vocational Nurse delivering the tray confirmed the absence of the drink, and the Certified Dietary Manager acknowledged that the drink was missed in the kitchen and the tray was not properly checked before delivery. The facility's policy on therapeutic diets emphasizes the importance of adhering to physician-ordered diets to support treatment and care plans, which was not followed in this instance.
Failure to Honor Food Preferences and Dietary Needs
Penalty
Summary
The facility failed to honor the food preferences of two residents, resulting in an unpleasant dining experience. Resident 28 was served chili beans despite having a standing order for chicken noodle soup and a documented dislike for beans. The Certified Dietary Manager (CDM) acknowledged the oversight, confirming that the meal tray did not comply with Resident 28's meal ticket instructions. Additionally, Resident 51 was served a meal containing tomatoes, which was listed as a disliked item on their meal ticket. The CDM admitted to making a mistake by serving the three-bean chili, which included tomatoes, despite being aware of Resident 51's aversion to tomato products. The facility also failed to ensure that Resident 51 was aware of the menu in time to request an alternative meal. Resident 51, who is bed-bound and has multiple medical issues, expressed confusion about the facility's rules for ordering alternate meals. The resident was unable to see the menu posted on the wall and was told that requests for alternative food items were not accepted if made too late. The CDM confirmed that there were specific times for ordering alternate food, requiring at least one hour's notice before lunch or dinner. Furthermore, the facility did not provide an alternative milk product for Resident 311, who has lactose intolerance. Despite a doctor's order to discontinue dairy-based nourishment, Resident 311 was served hot chocolate containing dairy. The CDM was aware of the oversight and acknowledged that the dietary staff had not been informed of the new orders in a timely manner. This failure to accommodate Resident 311's dietary needs was contrary to the facility's policy of providing alternative meals for personal food preferences or refusals.
Facility Fails to Meet Room Size Requirements
Penalty
Summary
The facility failed to provide the minimum square footage as required by regulation for 11 out of 50 rooms. During observations, it was noted that rooms housing three residents did not meet the required 80 square feet per resident. Specifically, one room measured 227.2 square feet, another 219.2 square feet, and a third 234.5 square feet, all of which were below the required space for three residents. Despite the deficiency, the facility maintained that the rooms were adequate for the residents' needs, with sufficient closet and storage space, bed stands, and room for nursing care and ambulation. The Administrator and Maintenance Supervisor acknowledged the issue but noted that residents had not complained about the room sizes.
Resident's Call Light Not Within Reach
Penalty
Summary
The facility failed to ensure that a resident's call light was within easy reach, which is essential for the resident to alert staff for assistance. During an observation and interview, it was noted that the call light was on the floor and not accessible to the resident. The resident attempted to locate the call light by feeling around his bed but was unsuccessful. This situation was confirmed by a Certified Nursing Assistant (CNA) who acknowledged that the call light should always be within the resident's reach. Further interviews with staff, including a Licensed Vocational Nurse (LVN) and another CNA, confirmed that the call light was not placed within reach after the resident was laid back in bed. The Director of Nurses (DON) also stated that the call light should be placed within reach. The facility's policy and procedure on the call system indicated that residents should have a means to call staff for assistance, which was not adhered to in this instance.
Failure to Report Scabies Outbreak to State Health Department
Penalty
Summary
The facility failed to implement its policy and procedure regarding the reporting of a scabies outbreak to the state health department. This deficiency was identified during a review of records and interviews with staff members. Three residents were clinically diagnosed with scabies by the wound doctor on the same day. The facility's Infection Preventionist and Treatment Nurse confirmed these diagnoses. However, the Director of Nursing stated that while the outbreak was reported to the local health department, it was not reported to the state health department as required by the facility's policy. The facility's policy on communicable disease outbreaks defines an outbreak as one case of a highly communicable infection or three or more cases of the same infection within a specified period and area. The policy mandates that the administrator is responsible for communicating data about reportable diseases to the health department. Despite this, the facility did not adhere to its policy, resulting in the state health department being unaware of the scabies outbreak among the residents.
Failure to Refer Resident for Psychiatric Evaluation
Penalty
Summary
The facility failed to ensure a psychiatrist referral was made for a resident, resulting in a delay of psychiatric evaluation. The resident, who was alert but confused and exhibited behaviors such as wandering and taking others' property, was seen by a psychologist who recommended considering the restart of Seroquel. However, the interdisciplinary team (IDT) did not agree with this recommendation and suggested a referral to a psychiatrist for further evaluation. The primary medical doctor agreed with the IDT's plan. Despite the IDT's recommendation and agreement from the primary doctor, the referral to a psychiatrist was not made. The Social Service Director (SSD) acknowledged that at the time of the recommendation, the facility did not have a psychiatrist available, and the resident was not referred externally. The Director of Nursing (DON) confirmed that the resident should have been referred to a psychiatrist. The facility's policy indicated that social services should coordinate referrals based on physician evaluation, but this was not documented in the resident's medical record.
Failure to Provide Homelike Environment Due to Damaged Bed Linen
Penalty
Summary
The facility failed to provide a homelike environment for one of three sampled residents when the bed linen was not in good repair. During an observation and interview, it was noted that the resident's bed sheet had a hole and two areas where the sheet was discolored due to thinning. Certified Nursing Assistant (CNA) 1 and Licensed Vocational Nurse (LVN) 1 both confirmed the condition of the sheet. The Director of Nursing (DON) stated that bed sheets with holes and discoloration should not have been used. The facility's policy and procedure indicated that torn linen should not be used to ensure a clean and comfortable bed for residents.
Failure to Report Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of abuse for one of the sampled residents when a family member informed an LVN about the abuse. The family member reported that every time a male staff member walked by, the resident would say he hits her. Despite being aware of this allegation, the LVN did not report it to the management as required by the facility's policy. This failure was confirmed during interviews with the family member, the LVN, and other staff members, including the DON and the Social Service Director, who were unaware of any recent abuse allegations. The facility's policy mandates that any suspicion of abuse must be reported immediately, defined as within two hours of the allegation, but this protocol was not followed in this case. During the investigation, it was revealed that the LVN had been informed of the resident's distress and allegations approximately two weeks prior but failed to take the necessary steps to report it. The facility's policy and procedure document, reviewed during the investigation, clearly states that all reports of resident abuse must be reported to local, state, and federal agencies and thoroughly investigated by facility management. The DON confirmed that the staff member should have adhered to the policy and reported the allegation immediately. This lapse in protocol had the potential to delay the investigation and place other residents at risk for abuse.
Failure to Provide Podiatry Services
Penalty
Summary
The facility failed to provide podiatry services for two residents, resulting in both having long, jagged, and discolored toenails. Resident 2 was observed walking in the hallway with open-toe sandals, revealing long and discolored toenails. A review of Resident 2's Order Summary Report indicated a need for podiatry consultation due to mycotic and hypertrophic nails, but there was no evidence that Resident 2 had received podiatry care. The Director of Nursing (DON) confirmed that the facility staff does not provide toenail care and relies on the podiatrist for such services. Resident 1 had a podiatry progress note indicating a follow-up was needed two months after August 2023, but there was no evidence of subsequent podiatry care. Shower sheets from April and May 2024 indicated that Resident 1's toenails needed clipping. During an observation, Resident 1 was found to have long, jagged toenails with debris underneath. Certified Nursing Assistant (CNA) 1 and Licensed Vocational Nurse (LVN) 1 both stated that podiatry services were responsible for toenail care. The Social Service Director (SSD) confirmed that nursing staff should report the need for podiatry services to social services, but Resident 1 had not been seen by podiatry since August 2023. The DON acknowledged that both residents needed podiatry services and that their toenails did not look good.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 234 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Visalia
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Delta Healthcare & Wellness Center, Lp | 1.2 mi | ★★★★★ | 3 | 0 |
| Kaweah Health Skilled Nursing Center | 2.1 mi | ★★★★★ | 11 | 0 |
| Sequoia Vista | 3.7 mi | ★★★★★ | 12 | 0 |
| Linwood Meadows Care Center | 4.1 mi | ★★★★★ | 0 | 0 |
| Westgate Gardens Care Center | 4.2 mi | ★★★★★ | 4 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.