Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Westview Healthcare Center during CMS and state inspections, most recent first.
Unlabeled Food Items in Storage: Multiple food items were observed in the walk-in refrigerator and dry storage areas without required labels or use-by dates, including onions, carrots, tomatoes, cilantro, potatoes, hamburger buns, apples, and oranges. The DD acknowledged the missing dates and stated all food needs to be labeled with a use-by date; the facility policy also required all food items in storeroom, refrigerator, and freezer to be labeled and dated.
Confidential resident information was left visible on med carts during med passes when an LPN placed empty bubble packs, an empty Ozempic pen, and an empty Arnuity Ellipta box with pharmacy labels facing outward or left them unattended. The labels were visible to staff, visitors, and residents passing by, and the DON stated staff were expected to cover or turn over resident information left on the cart.
Psychotropic medications were used without required monitoring and documentation for several residents. A resident with PTSD, depression, and anxiety had orders for multiple psychotropics, but the DON confirmed there was no documentation of target behavior monitoring or non-drug interventions. Another resident’s Buspirone dose was increased without documented clinical rationale, a resident’s PRN Ativan order was extended without documented reevaluation, and staff did not document nonpharmacological interventions or side effect monitoring. Additional residents receiving Seroquel and Duloxetine also lacked documented behavior or side effect monitoring.
Medication administration errors and unclear orders affected multiple residents. An LPN gave the wrong probiotic to a resident, another nurse failed to properly prepare and assist with a new inhaler for a resident with COPD, several PRN pain medication orders were incomplete or overlapping and were not clarified, one resident’s ferrous sulfate and levothyroxine were scheduled too close together despite a 4-hour separation order, and nursing staff did not document notifying the MD when a resident’s BS remained above 200 as ordered.
IV medication documentation was entered by LVNs instead of the administering RN. For multiple residents receiving IV ABXs or IV fluids, the MARs were initialed by LVNs while notes either said an RN gave the dose without naming the RN or had no RN documentation at all. Staff and the DON stated that only RNs administered the IV meds, but the charting reflected LVN initials and incomplete administration notes.
Failure to provide and document ordered hand splint services for two residents. One resident with hemiplegia/hemiparesis had a right resting splint ordered daily, but observations showed the splint was not on after breakfast and task records showed it was not applied on multiple days. Another resident with hemiplegia, hemiparesis, dysphagia, and dementia had a left resting hand splint ordered for 6 hours daily, but documentation did not consistently show when it was put on or removed, and staff confirmed it was not always applied for the ordered time.
Staff failed to dispose of a dropped clopidogrel dose in the designated drug disposal container and instead placed it in an open trash receptacle on the med cart. Multiple opened E-kits were found with incomplete or missing removal logs and were not replaced within the required timeframe, and discontinued meds for a discharged resident were stored in an unlocked cabinet rather than secured for destruction. In addition, a resident’s Ozempic pen was unavailable during med pass, and the nurse had to call the pharmacy for a refill after discovering the medication was not on hand.
A medication pass revealed multiple errors involving three residents. An LPN failed to prime a new Breztri inhaler before giving it to a resident with COPD, gave chewable aspirin instead of the ordered enteric-coated form, handled finasteride without gloves despite hazardous-drug labeling and an order requiring gloves, measured diclofenac gel with the wrong device instead of the ordered 2 g dose, and did not recognize that an Ozempic pen was nearly empty, resulting in a late injection. The DON stated staff were expected to follow prescriber orders, manufacturer instructions, hazardous-drug precautions, and timely refill practices.
Medications and biologicals were found unsecured in resident rooms, including tablets in a medicine cup, ophthalmic drops, pink NS ampoules, an unlabeled cup with white powder, and prefilled NS syringes left on nightstands or in a bedside drawer. Staff stated bedside storage was not allowed, that the resident could overuse or ingest the items, and that one resident with severe cognitive impairment had accessible syringes with one tip cap removed.
QAPI was ineffective when the facility did not identify or develop corrective action plans for IV medication documentation and RNA services not being performed daily per physician order. The ADM stated the QAPI committee met quarterly, reviewed PIPs, quality measures, and grievances, and was not aware of the IV documentation or RNA service issues; the current annual PIP was falls reduction, and the committee had not identified these concerns during the last meeting.
Staff failed to follow infection control practices in several observed areas, including wound care, dining assistance, EBP care, laundry handling, and reusable equipment cleaning. A treatment nurse did not perform hand hygiene between glove changes and placed scissors on an unclean surface during wound care for a resident with paraplegia and a stage 4 pressure ulcer. A CNA assisted a resident with food without hand hygiene, other staff provided direct care to residents on EBP without required gowns, a laundry aide used the same apron for dirty and clean linens, and an LN did not disinfect a BP cuff between resident uses.
CNA Stood While Assisting A Resident With Eating: A CNA was observed standing while assisting a resident with severe cognitive impairment and dementia during lunch in the dining room. The CNA confirmed the practice, and the DSD and DON stated staff were expected to sit with residents while helping them eat to maintain dignity. Facility policies required residents to be treated with dignity and to receive meal assistance with attention to safety, comfort, and dignity.
Missed Scheduled Showers for Two Residents: Two residents did not receive showers according to the posted shower schedule or their preferences. One resident who needed lift assistance reported going more than 5 days without a shower, with the last documented shower recorded in the ADL task record and no refusal documented. Another resident with moderate cognitive impairment and substantial shower assistance needs stated she had not received showers since readmission, and the bathing task record did not show showers provided or documentation of refusal. The DSD and DON confirmed showers were expected as scheduled and that missed showers should be documented.
Failure to Provide Transfer/Discharge Notice for Hospital Transfer: A resident with anoxic brain damage, dysphagia, and malnutrition was sent to the hospital after becoming weak, confused, drowsy, and febrile with abnormal vital signs. The DON acknowledged that the Notice of Proposed Transfer/Discharge was not completed for the hospital transfer, so the RP was not effectively informed of the transfer details, appeal rights, or bed-hold information.
Care Plan Did Not Address Shower Refusals: A resident with multiple diagnoses, including below-knee amputation, fall history, and depression, was cognitively intact and needed setup help with personal hygiene. Although the ADL care plan stated the resident would be bathed and groomed daily, it did not address refusals of showers or bathing. Shower documentation showed repeated refusals and no showers or bed baths over the review period, and the resident was observed with strong body odor. The DON and ADON confirmed there was no care plan for shower refusals, despite facility policy requiring care plans to reflect services not provided due to refusal.
Missed Nutritional Risk Assessments for Residents With Weight Loss: The facility did not complete required quarterly RD nutritional risk assessments for two residents who were losing weight. One resident with amputations, lymphoma, and mental health diagnoses lost 9 pounds over 3 months, and another resident with anoxic brain damage, dysphagia, and malnutrition lost 13 pounds over 6 months. Staff and the RD confirmed the assessments were missed during a gap in RD coverage, despite documented weight loss and ongoing nutritional concerns.
A resident with CHF, chronic respiratory failure with hypoxia, and severe cognitive impairment had an order for continuous O2 at 1.5 L/min via NC, but multiple O2 sat entries were documented on room air. The resident was observed wearing O2 via NC, and an LN, CNA, and DON all acknowledged the room-air charting was incorrect and that the resident was always on oxygen.
Failure to identify PTSD triggers for a resident with PTSD, depression, anxiety, agoraphobia, and a history of sexual assault. The resident was cognitively intact, but the care plan did not include trauma triggers or interventions, and the SSD and DON acknowledged no trauma-informed care assessment had been completed to identify triggers.
A resident with multiple respiratory and cardiac conditions, including respiratory failure, COPD, and RSV, had physician orders and a care plan for continuous O2 at 2 L/min via nasal cannula with titration allowed only during activity or therapy to maintain O2 sats above 90%. Nursing documentation on the morning of the incident reflected O2 at 2 L/min with an O2 sat of 96%, but later observation found the resident’s O2 concentrator set at 3.5 L/min while the resident remained in bed without increased activity. An LN, the DON, and a nurse supervisor all confirmed there was no documentation of a drop in O2 saturation or any clinical indication or progress note explaining the increase in liter flow, despite facility policies requiring adherence to MD orders and recording of O2 flow rate and route after adjustments.
A resident with dementia and severe cognitive impairment was in a hallway near the dining room when another cognitively impaired resident in a wheelchair came up from behind and grabbed her breasts with both hands. The ADON directly observed the contact, and the affected resident later stated that someone had touched and squeezed her breasts in the hallway. Staff reported that the resident who initiated the contact had a history of prior inappropriate behavior toward a female resident and was being closely monitored. The facility’s abuse prevention policy required that residents be protected from abuse by anyone, including other residents, but this incident occurred despite that requirement.
A resident who lacked decision-making capacity had an RP/POA spouse and a physician order requiring that any change in medications, treatments, diagnoses, behaviors, or care plan be approved by the spouse. The RP had arranged for the resident’s psychiatric care through an outside psychiatrist and, during a care conference, verbally and in writing withheld consent for any psychiatric, psychological, or mental health services from the facility’s contracted psychiatrist (PD) or other contracted mental health providers, requesting that they be removed from the resident’s provider list. Despite this, the resident’s profile and face sheet continued to list the contracted PD, the ADON acknowledged the RP’s request but did not remove the PD’s name or notify the PD, and the PD later arrived at the resident’s room with a list that included the resident, prompting the RP to intervene. Surveyors found no evidence that the facility acted on the RP’s request or prevented the PD’s access to the resident’s information, contrary to the facility’s resident rights and privacy policies.
A resident with type 2 DM on Jardiance and scheduled insulin, and with a history of stroke and DKA, had only PRN blood glucose monitoring initially and later an order for routine AM and HS checks. Documentation showed multiple blood glucose readings above 200 mg/dL, including several over 400 mg/dL on consecutive days, but there was only one documented MD notification despite these elevations. The resident was later transferred to the hospital with worsening hypoxemia and was found to have blood glucose greater than 500, requiring ICU treatment. The DON reported that blood sugars were expected to be monitored regularly and that MD notification was expected for readings above 200 mg/dL, and the facility’s diabetes protocol called for twice-daily monitoring for residents on insulin and practitioner notification for repeated readings above 250 mg/dL with a change in condition.
A resident with post-stroke hemiplegia, aphasia, and DM with ketoacidosis was admitted for short-term care, with the daughter identified as the responsible party. Social services staff documented voicemail and phone contact to invite the responsible party to a care conference and noted that the party would attend by phone, but there was no follow-up documentation confirming that the conference occurred with the representative’s participation. An IDT conference note later indicated a care conference was held with SSD, ADON, and DOR, but the Nursing Services section was left incomplete and there was no record that the representative was involved. The MDSC confirmed the resident was nonverbal, tube-fed, and bedbound, that SSD schedules conferences within the first week of admission, and that there was no documentation of contact with the representative, contrary to facility policy requiring resident/representative participation and documented notification for care planning.
A document containing residents’ protected health information (PHI), including names, room numbers, cognitive (A&O) status, code status, diagnoses, and medication administration details, was observed left on top of a medication cart in a hallway. A nurse admitted he had left the document there and acknowledged it violated residents’ rights to privacy and confidentiality. When shown photos of the document on the cart, the DON confirmed it should not have been there. Facility policy on PHI requires all personnel to manage and protect resident information to prevent unauthorized disclosure.
A resident with multiple chronic conditions and moderate cognitive impairment had an Advance Health Care Directive (AD) designating two individuals as Power of Attorney for Health Care (POA). The facility failed to maintain the current AD in the electronic record and instead relied on emergency contacts not named in the AD for notifications and decision-making. As a result, the designated agents were not notified of the resident's death by the facility, learning of it only through the mortuary. Staff later confirmed the AD was not uploaded or referenced as required by facility policy.
A resident with significant physical disabilities and intact cognition was struck in the face by another resident with severe cognitive impairment and a history of aggressive behavior. The incident occurred in the smoking area, resulting in physical injury and psychosocial distress for the victim. Witnesses and staff confirmed the altercation, and facility records indicated that preventive measures to monitor and separate residents with aggressive tendencies were not effectively implemented prior to the event.
Care plans were not updated and documentation was incomplete for three residents after two were involved in a physical altercation and another reported abuse by a CNA. Despite the incidents being reported, the required care plan updates and clinical documentation were not completed as per facility policy.
A resident with normal cognition and a history of stroke was physically abused by a roommate with moderate cognitive impairment, who threw a hard plastic cup of thickened liquid at the resident's face during an argument over cigarettes. The incident resulted in the resident being covered in fluid and sustaining a red mark on the cheek, and was confirmed by both residents and the DON. This event represents a failure to protect a resident from physical abuse as required by facility policy.
A cognitively impaired resident with diabetes was subjected to sexual abuse when another resident, known for prior inappropriate behaviors, grabbed and placed the resident's hand on his groin. This incident, witnessed and reported by another resident, was not the first occurrence, and previous inappropriate actions by the perpetrator had not been properly reported or addressed by staff.
Staff failed to report an allegation of abuse involving two residents to enforcement agencies within the required two-hour timeframe. Despite being notified of the incident, the Administrator delayed reporting for three days, contrary to facility policy and federal regulations. The resident involved had a documented history of inappropriate behavior that had not been previously reported or addressed.
A resident with dementia and moderate memory impairment was inappropriately touched by another resident, also with moderate memory impairment, in a hallway after an activity event. The incident was witnessed by staff, and the affected resident was unable to communicate well but showed visible signs of distress. Facility records confirmed the incident, and the DON acknowledged it occurred, but there was no evidence of consent. This resulted in a failure to protect the resident from abuse, contrary to the facility's abuse prevention policy.
Discontinued controlled medications, including a bottle of lacosamide and several blister packs, were found improperly stored with non-controlled and active medications, lacking required count sheets and not secured in the DON's office as per facility policy. Nursing staff confirmed these medications should have been removed from active storage and properly documented until destruction.
Surveyors found expired medications, loose pills, and a misplaced blister pack in medication carts, as well as unlabeled creams left at the bedside of two residents. LNs and the DON confirmed these practices were not in line with facility policies, which require proper labeling, timely disposal of expired drugs, and secure storage of all medications.
Surveyors identified multiple infection control deficiencies, including an unlabeled G-tube water flush bag for a resident with severe cognitive impairment, a medication cart not cleaned of residue from a previously crushed medication, and a CNA providing high-contact care to a resident on Enhanced Barrier Precautions without wearing a gown, despite facility policy and posted signage.
A resident with mild memory impairment was inaccurately assessed as a non-smoker in the MDS and related documentation, despite self-reporting cigar use and staff confirmation. The MDS Coordinator acknowledged the inconsistency between the resident's actual tobacco use and the documented assessments.
A resident with diagnoses of unspecified psychosis and major depressive disorder was not provided with a required PASRR Level II evaluation after readmission. The DON was unaware of the need for the evaluation, and no follow-up was conducted, resulting in the resident not receiving the necessary assessment as indicated by the facility's screening process.
Four residents did not have comprehensive care plans addressing their needs, including three residents who smoked and one with rashes. In several cases, staff confirmed the absence of required care plans or failed to implement existing plans, such as not storing smoking materials as directed. These deficiencies were identified through interviews, record reviews, and direct observation.
A resident with cognitive impairment and hearing loss did not receive needed assistance with hearing aids, which remained unused for two months. The resident repeatedly requested help and education on using and charging the devices, but staff failed to provide support due to unclear communication and lack of documented orders, despite facility policy requiring such assistance.
A resident with severe cognitive deficits and total dependence on staff for ADLs was observed with long, dirty fingernails on her left hand. Despite care plan requirements and facility policy mandating daily grooming and nail care, staff failed to provide this assistance, as confirmed by both a nurse and the DON.
Two residents with severe cognitive and physical impairments were found without accessible call lights, despite care plans and facility policy requiring call lights to be within reach. Staff confirmed the call lights were not positioned appropriately, leaving the residents unable to request assistance as needed.
Several rooms did not meet the required minimum square footage per resident, with some providing only 65 to 78.12 square feet instead of the mandated 80 or 100 square feet. Observations showed the rooms were clutter-free and accessible for residents with mobility aids, and neither residents nor staff reported issues related to space or care delivery.
A resident with long-term kidney disease and breathing problems was not allowed to return to the facility after hospitalization due to the interference of her POA, her daughter, with medical care. Despite the facility's policy allowing return within the bed-hold period, the resident was discharged on the same day she was sent to the hospital, as confirmed by the Administrator and DON.
A resident with COPD and kidney failure was prescribed Prednisone for five days post-hospital discharge, but the LTC facility continued the medication for 17 additional days. This oversight led to severe oral thrush and fluid retention. Despite family communication and multiple NP visits, the error was not corrected, and the facility's policies on medication orders were not followed.
A resident with cognitive impairment was injured during an altercation with another resident who was cognitively intact. The incident involved one resident striking the other with a wheelchair armrest, causing a skin tear. The altercation was witnessed by staff, and the resident admitted to the act. The facility's abuse prevention policy was not effectively implemented to protect the resident from harm.
A facility failed to provide a resident's legal representative with timely access to medical records. The representative requested the resident's vaccination records, but the facility did not provide them within the 72-hour timeframe as per policy. The records were requested on August 2, 2024, but were not provided until August 9, 2024, resulting in a deficiency.
A resident with multiple health issues was discharged without a 30-day notice, limiting their ability to appeal. The discharge was ordered and executed on the same day, with the Social Services Director confirming the notification and discharge times. The DON acknowledged the facility's practice of not issuing 30-day notices, and no documentation of a discharge notice was found.
A resident did not receive routine baths as per their schedule, leading to feelings of discomfort and dissatisfaction. Despite being scheduled for showers twice a week, the resident only received one partial bath in a month. Facility staff confirmed the lack of documentation and adherence to the bathing schedule, contrary to the facility's policy.
The facility failed to maintain effective pest control and sanitary conditions in the kitchen, with flies and worm-like creatures observed in the food preparation area. The Dietary Manager acknowledged the presence of flies and mentioned monthly pest control visits, but live flies were still found near the stove, sink, and storage room. Deteriorating floor tiles and an opening in the wall were noted, with numerous worm-like creatures present. Pest control logs indicated significant insect activity in previous months.
The facility failed to store foods according to professional standards for food safety. Opened and unlabeled food items were found, a stained cutting board was not properly maintained, and brownish puffy substances were observed on storage racks. These issues were acknowledged by the Dietary Manager and had the potential to increase the risk of foodborne illnesses for 164 residents.
The facility failed to protect residents' personal and medical information when dietary tray tickets containing sensitive details were discarded in the general trash. The Dietary Manager and Registered Dietitian acknowledged the issue, recognizing it as a potential HIPAA violation. Facility policies mandate that such information should be kept confidential and disposed of properly.
Unlabeled Food Items in Storage
Penalty
Summary
The facility failed to store food in accordance with food safety standards when multiple food items in the kitchen were observed without labels or use-by dates. During observation in the walk-in refrigerator, a plastic container of onions, a plastic bag of approximately 8 whole carrots, a cardboard box of [NAME] tomatoes, and a plastic bag of cilantro were all found without a received date or use-by date. The cilantro was observed wet inside the bag with numerous brown discolored leaves. In interview at the time of observation, the Dietary Director stated there were no labels on the onions, carrots, tomatoes, or cilantro and acknowledged that all food needs to be labeled with a use-by date. Additional unlabeled food items were observed in the dry food storage areas. Two plastic tubs containing whole potatoes had no use-by date, a plastic bag of hamburger buns was open with no dates labeled on the bag, and a sign on the bread rack directed staff to label bread with the open date and discard it after 5 days of being opened. In the dry food storage room refrigerator, a cardboard box containing 10 apples and another cardboard box containing over a dozen oranges were also observed without use-by dates. The Dietary Director stated there were no dates on the apples or oranges. The facility policy titled, Labeling and Dating of Foods dated 2023 stated that all food items in the storeroom, refrigerator, and freezer need to be labeled and dated.
Confidential Resident Information Left Visible on Medication Carts
Penalty
Summary
The facility failed to keep resident personal and medical records private and confidential when nursing staff left pharmacy labels and other resident-identifying information visible on medication carts during medication passes. During an observation, an LN prepared medications for Resident 122 and placed multiple empty bubble packs on their side on top of the med cart with the pharmacy labels facing outward. The labels contained confidential resident information, and the LN left the bubble packs on the cart while entering the resident’s room to administer medications, leaving them visible to staff and visitors passing by. During another medication pass, an LN prepared medications for Resident 134 and removed an empty Ozempic pen and an empty Arnuity Ellipta box from the med cart. The LN placed both items, with pharmacy labels affixed, on top of the med cart and left them unattended while she went to the medication storage room. The items were visible and accessible to residents and staff in the hall. The DON stated nursing staff were expected to keep resident records confidential by turning pharmacy labels over if left on the med cart. Facility policies stated access to resident personal and medical records would be limited to authorized staff and that the facility would safeguard the privacy and confidentiality of resident records.
Psychotropic medications given without required monitoring and documentation
Penalty
Summary
The facility failed to ensure five sampled residents were free from unnecessary psychotropic medication use when monitoring, documentation, and nonpharmacological interventions were not consistently provided or documented. The deficiencies involved Resident 7, Resident 140, Resident 8, Resident 11, and Resident 156, all of whom had orders for psychotropic medications related to depression, anxiety, mood disorder, or sleep-related symptoms. Surveyor interviews with the DON and ADON confirmed missing documentation and lack of monitoring for target behaviors, side effects, and the use of non-drug interventions. Resident 7 had diagnoses including PTSD, major depressive disorder, and anxiety, and had orders for Remeron, Wellbutrin SR, Ativan, and Buspirone for symptoms such as inability to sleep, tearfulness, anxiety, and restlessness. During review with the DON, the record did not show what interventions were used to help with anxiety and depression, and the DON stated the documentation only showed check marks that made it difficult to determine what worked. The DON also confirmed there was no documentation that Resident 7 was monitored for target behaviors related to Remeron. Resident 140 had diagnoses including major depressive disorder and anxiety and was receiving Buspirone. Her dose was increased from 10 mg three times daily to 20 mg every 8 hours for anxiety manifested by restlessness. During review, the ADON could not find documentation by the prescriber or nursing staff to justify the increase, and the DON stated nonpharmacological interventions for anxiety were not being implemented. Resident 8 had diagnoses including anxiety, major depressive disorder, and bipolar disorder and had PRN Ativan orders. The DON stated there was no documentation that the PRN order was reevaluated to extend it beyond 14 days, the ADON confirmed Resident 8 was not monitored for side effects or behaviors related to Ativan, and nursing staff did not document what nonpharmacological interventions were used. Resident 11 had a diagnosis of mood disorder and received Seroquel in the morning and at bedtime. The DON stated there was no documentation that Resident 11 was monitored for side effects or target behaviors related to Seroquel, and nursing staff did not implement nonpharmacological interventions for the mood disorder. Resident 156 had depression, moderate cognitive impairment, and an order for Duloxetine for depression manifested by verbalized sadness. The care plan identified depression and risk for suicidal thinking or abnormal behavior with antidepressant use, but the clinical record contained no documented evidence that target behaviors were monitored. The DON confirmed there was no behavior monitoring for the antidepressant and stated such monitoring was important to determine the medication's efficacy.
Medication Administration and Order Clarification Failures
Penalty
Summary
Medication administration was not carried out in accordance with physician orders for several residents. For one resident with orders for lactobacillus, a nurse prepared and administered saccharomyces boulardii instead during the morning medication pass. The nurse later confirmed that the incorrect probiotic had been given and stated that Culturelle, which contains lactobacillus, should have been administered instead. The DON stated nursing staff were expected to correctly identify the ordered OTC medication by reviewing the MAR and selecting the correct medication from the med cart. A resident with COPD was given a Breztri Aerosphere inhaler without proper preparation and without effective nurse assistance during administration. The nurse removed a new inhaler from the manufacturer’s box, shook it, and handed it to the resident, who then pressed the inhaler multiple times and stated that nothing was coming out. The nurse confirmed the resident administered more than the ordered one puff and stated she was not aware of any special handling or preparation required for the new inhaler. The DON stated staff were expected to review the physician’s order and the manufacturer’s labeling, educate the resident on the number of puffs, and intervene when the resident could not get the inhaler to dispense properly. Several pain medication orders were incomplete or unclear and were not clarified before administration. One resident’s oxycodone/APAP order listed severe pain with a pain scale that the DON stated was not accurate, and the DON said the order should have been clarified because it was not clear whether the medication was to be given as needed for severe pain or routinely. Another resident had overlapping APAP and oxycodone orders for moderate pain, and the DON confirmed nursing staff should have clarified when each medication was to be used. Additional residents had APAP and tramadol orders that did not specify the pain level or timing for administration, and the DON stated those orders should have been clarified. For another resident, ferrous sulfate was scheduled at 8 a.m. and 8 p.m. while levothyroxine was scheduled at 6 a.m., despite an order stating the medications should be separated by at least 4 hours; the DON confirmed the schedule did not meet that requirement. In addition, a resident with diabetes had an insulin glargine order requiring notification of the MD if blood sugar was greater than 200, but the DON stated the resident’s bedtime blood sugars were consistently over 200 and there was no documentation that nursing staff notified the physician.
IV medication documentation was entered by LVNs instead of the administering RN
Penalty
Summary
The facility failed to ensure that IV antibiotics and IV fluids were documented by the nurse who actually administered them for six residents. For Resident 13, who was admitted with type 1 DM, mild nonproliferative diabetic retinopathy, and paroxysmal atrial fibrillation, the MAR showed meropenem IV was initialed by LVNs on multiple shifts, while the accompanying notes stated the medication was administered by an RN or RN supervisor. One LVN stated she was not IV certified, said only an RN can administer IV medications, and acknowledged she signed the MAR and wrote that the RN administered the medication. The DON stated the facility’s practice was for RNs to prepare and administer the IV medication while LVNs signed the MAR and documented that the RN gave it. For Resident 146, admitted with acute respiratory failure and BPH, the MAR showed meropenem IV was initialed by an LVN, and the note did not identify an RN as the administrator. For Resident 85, who was admitted with osteomyelitis of the vertebra and had a PICC line for antibiotic treatment, the MARs showed repeated IV antibiotic doses of daptomycin and Teflaro were initialed by LVNs, while progress notes often stated the antibiotics were administered by an RN without naming the RN. Staff interviews confirmed that LVNs were not IV certified, that RNs administered the IV antibiotics, and that LVNs sometimes clicked the medication in the MAR while documenting in the notes that an RN gave the dose. For Resident 159, admitted with neuromuscular dysfunction of the bladder and sepsis, the MAR showed ceftriaxone IV was initialed by an LVN and there was no note stating an RN administered it. For Resident 94, admitted with acute osteomyelitis of the left femur and cervical cancer, ertapenem IV was signed by an LVN on multiple dates; some notes said an RN administered the dose but did not identify the RN, and other doses had no note at all. For Resident 151, admitted with senile degeneration of the brain, hypotension, and adult failure to thrive, the MAR showed IV sodium chloride and dextrose-sodium chloride were signed by LVNs, while one note said the fluid was given by RN without naming the RN and other doses had no supporting RN documentation. The facility policy stated that only persons licensed or permitted by the state to prepare, administer, and document medications may do so, and that the individual administering the medication documents it in the eMAR.
Failure to Provide and Document Ordered Hand Splint Services
Penalty
Summary
The facility failed to provide restorative nursing assistant services for two residents with orders for hand splints intended to support mobility and range of motion. Resident 72 had diagnoses including hemiplegia and hemiparesis following a nontraumatic intracerebral hemorrhage affecting the right dominant side, and had an order for a right resting splint for 2 hours daily. During observations on 5/5/26 and 5/6/26, the resident’s right hand was observed without the brace on after breakfast, despite a posted sign directing staff to apply the splint at breakfast and remove it at shift change. RNA staff stated there were no daily RNA services and that the resident was scheduled for splinting three times weekly, while the task record showed the splint was charted as applied only 12 days and not applied for 16 days in the reviewed date range. Resident 143 had diagnoses including hemiplegia, hemiparesis, dysphagia, and dementia, with a BIMS score of 8 indicating moderate cognitive impairment. The resident had an order for CNA donning and doffing of a left upper extremity resting hand splint for 6 hours or as tolerated, with skin monitoring before donning and after doffing. Task documentation showed the splint was sometimes recorded as applied without a removal time, and other times removed without a documented application time, with no days showing both application and removal after 6 hours as ordered. During observation, Resident 143 was found in bed with the splint on the nightstand, and the resident stated staff only put it on sometimes. LN 6 confirmed the splint had been removed before 2:30 p.m. and stated CNAs usually apply it and chart when it is applied and removed. The RNA acknowledged the splint had been applied at about 8:30 a.m. that day rather than for the ordered 6 hours, and acknowledged the documentation of donning and doffing was not done consistently. The DON also acknowledged the charting was not done accurately.
Medication Disposal, E-Kit Replacement, and Medication Storage Failures
Penalty
Summary
Nursing staff failed to dispose of a dropped medication dose in accordance with facility policy during a med pass observation. While preparing medications for a resident, an LN dropped a clopidogrel 75 mg tablet onto the med cart, picked it up, and threw it into the small open trash receptacle attached to the outside of the cart. The LN later stated dropped doses were supposed to be placed in the designated drug disposal container inside the med cart, and the DON confirmed that dropped or refused doses were to be disposed of in that designated container rather than the trash receptacle. The facility also failed to timely replace and document medications removed from emergency kits. During inspection of the medication storage room, multiple opened E-kits were found with red plastic ties and logs showing removals on several prior dates. One opened injectable/sublingual/nasal/oral suspension E-kit had no log inside even though the contents list showed a lidocaine 1% multidose vial had been removed. Staff stated that any medication removed from an E-kit should be documented on the emergency medication administration log and that the kit should be replaced within 72 hours, but the opened kits remained in use beyond that timeframe. In addition, discontinued medications were found stored in an unlocked cabinet instead of being secured for destruction, including six bubble packs for a discharged resident. For another resident, an Ozempic 1 mg dose pen was unavailable during a med pass, and the nurse had to leave the cart to check for another pen and then call the supplier pharmacy for a refill. The nurse stated she had not realized the medication was due for refill, and the DON stated staff were expected to monitor medication amounts and reorder on time so residents did not run out.
Medication Pass Errors With Inhaler Preparation, Wrong OTC Selection, Hazardous Drug Handling, and Late Injection
Penalty
Summary
The facility had a 14.29% medication error rate, with five medication errors identified out of 35 observed opportunities during a medication pass for three residents. The errors involved administration of medications not given in accordance with prescriber orders and included failure to follow special handling requirements for a hazardous medication. For one resident with COPD, an LPN prepared a new Breztri Aerosphere inhaler by shaking it and then handed it to the resident without priming it first. The resident pressed the inhaler multiple times and stated that nothing was coming out. The LPN later stated she was not aware of any special handling or preparation required for the new inhaler. The DON stated staff were expected to review the physician’s order and the manufacturer’s labeling when a medication came in a box, and that incorrect preparation could result in the resident not receiving the prescribed dose. For another resident, an LPN prepared aspirin, finasteride, and diclofenac gel. The LPN gave chewable aspirin even though the order was for enteric-coated delayed-release aspirin, did not wear gloves while handling finasteride even though the pharmacy label identified it as hazardous and the order required gloves, and measured diclofenac gel using an opaque medicine cup rather than the dosing card or ruler specified by the manufacturer. The LPN stated she thought gloves were only needed during administration, and she acknowledged that the amount she measured was not equivalent to the ordered 2 grams. The DON stated staff were expected to select the correct OTC medication, wear gloves when handling hazardous medication, and measure diclofenac gel correctly. For a third resident, an LPN prepared Ozempic for a weekly injection but did not recognize that the pen was nearly empty. She left to check for another pen and then called the supplier pharmacy for a refill. The resident’s Ozempic injection was administered late. The LPN stated she had not realized the medication was at the end because the level in the clear pen was difficult to see. The DON stated staff were expected to monitor medication amounts so refills could be ordered on time, and the facility policy stated medications are to be administered in accordance with prescriber orders and within the required time frame.
Medications and biologicals left accessible at residents’ bedsides
Penalty
Summary
The facility failed to ensure medications were safely stored for five sampled residents when drugs and biologicals were found at bedside or otherwise accessible in resident rooms. The report identified a medicine cup containing three tablets on top of one resident’s nightstand, a box of Dextran70-Hypromellose ophthalmic solution on another resident’s nightstand and later inside the nightstand drawer, four pink plastic ampoules on a third resident’s nightstand, an unlabeled medication cup containing white powder on a fourth resident’s bedside table, and three prefilled syringes of normal saline on a fifth resident’s nightstand. One resident was admitted with diagnoses including ulcer of the esophagus. During observation, a medicine cup with three tablets was left on the nightstand. An LN stated the tablets were the resident’s scheduled morning medications and that the resident would take them later. The DSD stated leaving medications at the bedside was not allowed and that the LN should not have prepared the medication without making sure the resident was ready to take them. The DON stated LNs were expected to never leave medications at the bedside because another resident could pick them up and because the resident might not receive the medications as ordered. Another resident, admitted with traumatic subcutaneous emphysema and assessed with intact cognition, had an order for Dextran70-Hypromellose ophthalmic solution as needed for dry eyes. The resident stated he used eye drops and applied them to himself. An LN stated the resident was not allowed to administer his own medication and later found the eye drops in the nightstand drawer. The LN stated medications at bedside could lead to overuse and that someone else could use them. A third resident with diffuse large B-cell lymphoma and pneumonitis due to inhalation of food and vomit, and with moderate cognitive impairment, had four pink ampoules of normal saline on the nightstand. An LN confirmed the ampoules were for wound care and stated they were not supposed to be at bedside and that someone, or the resident, might use or ingest them. A fourth resident with a wrist fracture, depression, muscle weakness, and moderate cognitive impairment had an unlabeled medication cup containing white powder on the bedside table beside a cup of water. The LN confirmed the cup was present and stated she did not know what it was and threw it away because it was not supposed to be at bedside. A fifth resident with dementia, depression, and severe cognitive impairment had three prefilled syringes of normal saline on the nightstand, with the protective outer cellophane removed and one syringe with the tip cap removed. The resident was confused and unable to answer questions about the syringes. The ADON validated the syringes were accessible and stated she did not know why they were stored there and that it was not safe. An LN stated the resident did not have wounds or skin issues requiring NS and said the syringes should not be stored at the bedside because the resident might attempt to swallow them.
QAPI Did Not Identify IV Medication Documentation and RNA Service Issues
Penalty
Summary
The facility failed to ensure its QAPI program was effective when it did not identify and develop corrective action plans for issues related to IV medication documentation and RNA services being performed daily per physician's order for a census of 154. The report states that the facility's QAPI committee met quarterly and reviewed PIPs, quality measures, and grievances, and that the Administrator was informed of issues by staff, visitors, and departments. The Administrator stated that issues addressed by QAPI were system issues rather than individual problems, and that the current annual PIP was falls reduction. During interview, the Administrator stated the QAPI committee did not identify any issues with IV medication administration documentation or RNA services during the last QAPI meeting on 4/15/26, and he was not aware these were issues. Review of the facility's 2026 QAPI Plan stated the QAPI team would decide what data to monitor routinely, review sources of information for gaps or patterns in systems of care, and use a systematic approach for in-depth analysis when needed. The report also references F684 for IV medication administration documentation and F688 for RNA services not provided daily.
Infection Control Failures During Resident Care, Dining, Laundry, and Equipment Use
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program in multiple observed situations involving resident care, dining assistance, laundry handling, and reusable equipment cleaning. The report documented that staff did not consistently perform hand hygiene, did not use required PPE for residents on enhanced barrier precautions (EBP), did not maintain a clean work environment during wound care, and did not disinfect a blood pressure cuff between resident uses. These events were observed by surveyors and confirmed in interviews with staff and the Infection Preventionist (IP). During wound care for Resident 24, who was admitted with paraplegia and a stage 4 sacral pressure ulcer, the Treatment Nurse did not perform hand hygiene between glove changes while removing old dressings from the left hip and right lower back. The nurse also placed scissors on top of the air mattress after cutting foam dressing and then reused the same scissors to cut additional dressing material for the wound on the right lower back. The nurse stated she might have forgotten to perform hand hygiene, and the IP stated that hand hygiene should be performed whenever gloves are removed and that the top of the air mattress was not a clean area unless a barrier was used. In the dining room, Resident 121, who had diagnoses including type 2 DM with diabetic neuropathy and osteoarthritis of the right hand, asked for help opening a milk carton. CNA 3 assisted without performing hand hygiene first and inserted a finger inside the carton while opening it. CNA 3 acknowledged she did not perform hand hygiene and stated she put her finger inside the carton because it would not open. The facility’s dining infection prevention policy required hand hygiene before and after handling food and resident care. Additional observations showed CNA 2, while caring for Resident 111, who had dysphagia and an order for EBP for a wound, entered the room wearing gloves only and assisted with teeth brushing, wiping the face, repositioning in the wheelchair, and brushing hair without a gown. The same issue was observed with an Occupational Therapy Assistant caring for Resident 119, who had a wedge compression fracture and multidrug-resistant organisms, when the assistant applied the resident’s back brace while wearing gloves but no gown despite EBP signage posted at the door. In the laundry room, a Laundry Aide wore the same apron while handling dirty laundry and then clean linens, and the linens touched the apron during transfer. Finally, LN 15 did not sanitize or disinfect a blood pressure cuff between use on Resident 122 and reuse with a different cuff during the same medication pass, stating she did not have wipes available on the cart.
CNA Stood While Assisting Resident With Meal
Penalty
Summary
The facility failed to maintain dignity for one of 37 sampled residents when a CNA was observed standing while assisting the resident with the lunch meal in the dining room. Resident 50 was admitted in February 2023 with diagnoses including dementia and abnormalities of gait and mobility, and the MDS dated 3/4/26 indicated severe cognitive impairment. The care plan, revised 3/18/26, identified self-care performance deficits related to cognitive and physical deficits from dementia and directed staff to assist with ADLs, including eating and meals. During a dining observation on 5/5/26 at 12:10 p.m., the CNA was seen standing while helping Resident 50 eat, including holding a spoon and serving melon. The DSD confirmed the observation and stated staff generally do sit with residents. When interviewed, the CNA confirmed standing while assisting the resident and stated a chair was not seen and the resident should not have to wait, while also stating staff were supposed to sit while assisting residents during dining to communicate better and for safety and that sitting beside the resident provides dignity. The DON later stated the expectation was for staff to sit with residents while assisting them with eating to maintain dignity. The facility's Dignity policy stated residents shall be treated with dignity and respect at all times, and the Assistance with Meals policy stated residents who cannot feed themselves will be assisted with attention to safety, comfort, and dignity.
Missed Scheduled Showers for Two Residents
Penalty
Summary
The facility failed to ensure resident choice and the shower schedule were followed for two sampled residents. Resident 128 stated she needed assistance to shower because she could not get out of bed without a lift device, and she reported she had not been assisted with a shower for over 5 days even though she did not refuse any showers. Her shower schedule showed she was to be showered on Monday and Thursday, but the bathing task record showed her last documented shower was on 4/30/26, and there were no shower sheets in the shower binder or progress notes documenting a refusal. Resident 156 was admitted and readmitted with diagnoses including a left wrist fracture, depression, and muscle weakness, and her MDS indicated moderate cognitive impairment and the need for substantial assistance with showers. She stated she had not had showers since readmission and did not know her shower schedule. The shower schedule posted at the nurses' station showed she was to receive showers every Wednesday and Saturday, but the bathing task record did not show showers provided since readmission and did not document a shower on the scheduled day reviewed. During interviews, the DSD confirmed that residents are expected to receive showers according to the schedule and that missed showers should be documented on the task record and in progress notes. The DSD also confirmed that Resident 156 had not received showers since readmission and that there was no documented evidence showing the showers were missed or refused. The DON stated showers were expected as scheduled unless the resident refused, and that refusals should be documented in the clinical record.
Failure to Provide Transfer/Discharge Notice for Hospital Transfer
Penalty
Summary
The facility failed to ensure that information regarding a hospital transfer was effectively communicated to the Responsible Party for Resident 14 when the Notice of Proposed Transfer/Discharge was not completed for the resident's transfer to the hospital on 8/12/25. Resident 14 had been admitted in November 2015 with diagnoses including anoxic brain damage, dysphagia, and moderate protein calorie malnutrition. The resident's MDS cognitive assessment dated 3/16/26 indicated the resident was rarely or never understood and had long- and short-term memory problems. Record review showed an SBAR communication form on 8/12/25 documenting that the resident seemed different than usual, was tired, weak, confused, or drowsy, had a temperature of 102.2, and was sent to an acute care hospital for further evaluation. A later SBAR form dated 12/4/25 documented abnormal vital signs, fever, pain, decreased meal consumption, increasing pain noted through body language, BP 80/53, pulse 143, RR 38, temperature 101.3, and NP orders to send the patient out to an acute care hospital. The Notice of Proposed Transfer/Discharge dated 12/4/25 included transfer reason, notification, appeal rights, bed-hold notice, and ombudsman notification, but the DON acknowledged during interview that the notice was not provided for the 8/12/25 hospital transfer and was missed.
Care Plan Did Not Address Shower Refusals
Penalty
Summary
The facility failed to ensure a comprehensive, person-centered care plan was developed for a resident who refused showers and bathing. The resident was admitted in 2023 with diagnoses including absence of the right leg below the knee, history of falling, and depression. The most recent MDS dated 4/18/26 indicated the resident was cognitively intact and required setup assistance from staff with personal hygiene. The ADL care plan dated 4/20/23 stated the resident required assistance with ADLs and that staff would ensure the resident was bathed and groomed daily, with interventions to assist with personal hygiene and grooming as needed, but it did not address refusals of showers, bathing, or personal hygiene. Review of shower and bathing documentation from 4/8/26 through 5/7/26 showed the resident did not receive any showers or bed baths, and the shower task documentation recorded refusals on 4/13, 4/27, 4/30, and 5/7/26. The resident was observed on 5/7/26 and 5/8/26 leaving the room in a wheelchair, dressed in street clothes, and noted to have strong body odor. Staff interviews indicated showers were scheduled for evening shifts and that refusals were typically re-offered and then documented after repeated refusals, with nursing notified. The DON and ADON confirmed the resident had no documented showers in the last 30 days and that there was no care plan addressing shower or bathing refusals, despite the facility policy requiring care plans to describe services not provided due to resident refusal and to be revised when the resident's condition changed.
Missed Nutritional Risk Assessments for Residents With Weight Loss
Penalty
Summary
The facility failed to ensure that quarterly nutritional risk assessments were completed for two residents with documented weight loss. Resident 7 was admitted with multiple diagnoses including left AKA, right BKA, lymphoma, major depressive disorder, anxiety disorder, agoraphobia, and PTSD. The record showed Resident 7 was cognitively intact, but her weight decreased from 119 pounds to 110 pounds over three months, a 7.6% loss. Her care plan and weight variance documentation noted weight loss and later recommended fortified foods and Ensure Plus, but the RD did not complete the required quarterly nutritional risk assessment during the period when the weight loss occurred. Resident 14 was admitted with anoxic brain damage, dysphagia, and moderate protein calorie malnutrition. The resident was rarely or never understood and had long- and short-term memory problems. The weight record showed a decline from 101 pounds to 88 pounds over six months, a 12.9% loss. The resident’s nutritional reviews documented poor intake, malnutrition, hospice status, and continued weight loss, but no quarterly nutritional risk assessment was completed after the last assessment in December 2025. The record also showed that after the resident was discharged from hospice, there was no new RD follow-up or intervention documented despite continued weight loss. During interviews, nursing and administrative staff stated that residents were weighed and weight loss was communicated, but the RD coverage at the facility had a gap after the full-time RD left and a part-time RD also left. The RD confirmed that quarterly and annual nutritional risk assessments were required and acknowledged that the assessments were not completed in March 2026 because of the gap in RD coverage. The Administrator also acknowledged that quarterly and annual nutritional risk assessments were missed during that time.
Incorrect Oxygen Saturation Documentation
Penalty
Summary
The facility failed to accurately document oxygen saturation levels for one resident whose record showed an order for continuous oxygen at 1.5 liters per minute via nasal cannula with a goal to maintain oxygen saturation greater than 90%. The resident’s admission record listed multiple diagnoses including congestive heart failure, hemiplegia and hemiparesis following cerebral infarction, chronic respiratory failure with hypoxia, diabetes, and chronic kidney disease. The resident’s MDS indicated severe cognitive impairment with a BIMS score of 2 out of 15, and the care plan included monitoring oxygen saturation via pulse oximetry every shift. A review of the resident’s oxygen saturation summary for a two-week period showed multiple measurements documented on room air with no supplemental oxygen used, despite the resident being observed wearing oxygen via nasal cannula with the concentrator set at 1.5 liters per minute. During interview, an LN stated the resident is always on oxygen at 1.5 liters per minute and that room-air documentation was incorrect. A CNA stated she charts oxygen saturations in the vital signs section and acknowledged that room-air entries could be overlooked if she was in a hurry, while the DON acknowledged the charting was incorrect and stated the resident has an order for continuous oxygen and is always wearing 1.5 liters per minute. The facility policy required recording the oxygen flow rate and route after oxygen setup or adjustment, and the vital signs policy required documenting the resident’s vital signs in the medical record.
Failure to Identify PTSD Triggers in Care Plan
Penalty
Summary
The facility failed to identify trauma triggers for a resident with PTSD, despite the resident’s history of sexual assault and documented diagnoses including PTSD, major depressive disorder, anxiety disorder, agoraphobia, lymphoma, and bilateral lower-extremity amputations. The resident was cognitively intact with a BIMS score of 15 out of 15. The care plan for depression/PTSD stated the resident was at risk for ineffective coping related to depression with underlying PTSD, but it did not reflect any PTSD triggers or interventions to mitigate triggers. Record review showed social history assessments documented the resident’s significant life event of sexual assault, but PTSD triggers were not identified. A nurse practitioner note documented PTSD, and during interviews the LN, SSD, and DON acknowledged the resident had PTSD and that no trauma-informed care assessment had been completed to identify triggers. The SSD stated the facility had not been conducting trauma-informed care assessments for residents with PTSD, and the DON acknowledged the resident’s PTSD care plan did not indicate triggers.
Undocumented Increase in Oxygen Flow Rate Contrary to Physician Orders
Penalty
Summary
The deficiency involves the facility’s failure to provide oxygen therapy according to physician orders and to document the rationale for changing the oxygen liter flow for one resident. The resident was admitted with multiple respiratory and cardiac diagnoses, including respiratory failure with hypoxia, COPD, acute and chronic respiratory failure with hypercapnia, diabetes, heart failure, and RSV. The resident’s MDS showed a BIMS score of 15, indicating intact cognition. Physician orders dated 3/27/26 directed continuous oxygen at 2 L/min via nasal cannula related to acute and chronic respiratory failure and bronchitis due to RSV, with a goal to maintain oxygen saturation above 90%. A separate order allowed titration of oxygen up or down as indicated during activity and/or therapy, with instructions to call the MD if more than 5 L/min was needed. The care plan also specified administering oxygen at 2 L/min via nasal cannula as ordered. On 4/9/26 at 7:00 a.m., the resident’s oxygen saturation was documented as 96% with oxygen via nasal cannula, and the nursing skilled charting form recorded continuous oxygen at 2 L/min. However, during an observation at 12:10 p.m. the same day, the resident was seen receiving oxygen via nasal cannula from a concentrator set at 3.5 L/min. The resident stated he used supplemental oxygen continuously. When the LN reviewed the chart, she stated the resident was ordered 2 L/min continuously and acknowledged the concentrator was set at 3.5 L/min, but she was unsure why it had been increased and noted the resident had not had increased activity. The DON and Nurse Supervisor both confirmed that the record contained no documentation of a drop in oxygen saturation or any indication or progress note explaining why the oxygen was titrated to 3.5 L/min, despite facility policies requiring verification of physician orders and documentation of oxygen flow rate and route after any adjustment, and requiring that prescribed treatment orders be carried out as written.
Failure to Protect Resident from Inappropriate Sexual Contact by Another Resident
Penalty
Summary
The facility failed to protect a resident from abuse when one resident inappropriately touched another resident’s breasts in a public hallway. Resident 1, who had dementia, dysphagia, and a BIMS score of 7 indicating severe cognitive impairment with significant memory problems and need for substantial supervision, was in a wheelchair in the hallway next to the dining room. The Assistant Director of Nursing (ADON) documented that Resident 2, also in a wheelchair, came up behind Resident 1 and was seen touching and grabbing Resident 1’s breasts with both hands. In a subsequent interview, Resident 1 reported that somebody touched and squeezed her breasts in the hallway, and identified the touching as occurring to her “tits,” while denying feeling scared or mad at that time. Resident 2 had dementia with severe behavioral disturbance, a history of a cerebral infarction, and a BIMS score of 5, also indicating severe cognitive impairment and need for substantial supervision. A licensed nurse (LN 1) stated that this was the first time she was aware of Resident 2 inappropriately touching another resident, but also stated that Resident 2 had been closely monitored by staff because of a past inappropriate incident toward a female resident. In an interview, Resident 2 claimed he was “putting her boobs back” and fixing Resident 1’s clothes because her breasts were showing. The Social Services Director (SSD) reported assessing both residents after the incident and stated that neither showed changes in behavior and that Resident 1 appeared happy. The facility’s undated Abuse Prevention Program policy stated that residents had the right to be free from abuse and that the facility was required to make every attempt to protect residents from abuse by anyone, including other residents, which did not occur in this incident.
Failure to Honor Resident’s Choice of Psychiatric Provider and RP Authority
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to choose his attending physician and to follow the directions of the resident’s Responsible Party (RP) and Power of Attorney (POA). The resident, admitted in 2016 with multiple diagnoses including aftercare for cerebral infarction, lacked capacity to make health-care decisions. The clinical record identified the resident’s wife as RP/POA, and a physician order dated 6/12/24 directed staff to call the spouse with any changes to medications, treatments, diets, diagnoses, behaviors, or care plan, and to obtain her approval for any and all changes. The resident’s depression care plan also included an intervention to encourage family to actively participate in the resident’s care. During a care conference in December 2025, the RP told the Social Services Assistant (SSA) that she did not want the resident to be seen by the facility’s contracted psychiatrist (PD) or any other psychiatric provider associated with or contracted by the facility, stating that the resident had been followed by an outside psychiatrist through his medical insurance for years. The RP provided a written letter addressed to the DON, Administrator, and nursing staff withholding consent for consultation or evaluation by any psychiatric, psychological, or mental health practitioner associated with or contracted by the facility and requested that such providers be removed from the resident’s list of care providers. Despite this, the resident’s profile and face sheet continued to list the contracted PD as a provider, and there was no documentation that the facility took steps to accommodate the RP’s request or to notify the PD of the restriction. In March 2026, the RP again raised her concerns with the Assistant DON (ADON), who acknowledged that the RP made all treatment decisions and that the resident was managed by an outside psychiatrist selected by the RP. The ADON told the RP that the PD’s name would be removed from the resident’s profile but admitted she did not do so and did not communicate the RP’s request to the PD. Later that same day, the PD came to the resident’s room with a list of residents to see, which included this resident’s name, and the RP intervened to prevent any evaluation. On review of the record on 3/27/26, surveyors confirmed that the PD’s name remained on the resident’s profile and that the facility’s own Resident Rights policy guaranteed the right to choose a physician and treatment, participate in care planning, and to have privacy and confidentiality, and prohibited unauthorized access or disclosure of resident information.
Failure to Monitor and Report Elevated Blood Glucose Levels per Orders and Policy
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards of practice for a resident with type 2 DM, prior DKA, hemiplegia/hemiparesis following cerebral infarction, and aphasia. The resident was admitted in mid-January 2026 with orders for Empagliflozin (Jardiance) via PEG tube once daily and Insulin Glargine 8 units subcutaneously every 12 hours. An order dated 1/18/26 for PRN fingerstick blood glucose testing for hypo/hyperglycemia was present, but there were no blood glucose results documented on the January 2026 MAR. On 2/4/26, a new order was written for blood sugar monitoring every morning and at bedtime. Review of the Blood Sugar Summary showed that 9 of 14 recorded readings were above 200 mg/dL, including multiple readings over 400 mg/dL. Despite these elevated readings, there was only one documented physician notification on 2/2/26 when the blood sugar was 445 mg/dL, and no other evidence of physician notification when blood sugars were over 200 mg/dL or when they exceeded 400 mg/dL on consecutive days (2/4/26 and 2/5/26). An SBAR dated 2/6/26 documented a blood sugar of 405 mg/dL on the night of 2/5/26 and noted that the resident’s O2 saturation remained in the low 80s on 5 liters of oxygen, prompting transfer to the hospital. The hospital discharge summary for the stay from 2/7/26 to 2/18/26 indicated the resident was found to have blood glucose greater than 500 and was treated in the ICU with IV fluids and antibiotics. The DON stated that the resident’s blood sugar order was initially PRN, that an order for AM and HS monitoring was later obtained, and that her expectation was for licensed nurses to notify the physician when blood sugar was above 200 mg/dL. The facility’s diabetes clinical protocol, revised March 2025, indicated that residents receiving insulin who are well controlled should have blood glucose monitored twice daily and that staff should notify the practitioner when there are two or more readings higher than 250 mg/dL within 24 hours accompanied by a new medical problem or change in condition.
Failure to Involve Resident Representative in Care Planning
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident representative was involved in the development and implementation of a person-centered care plan when a scheduled care plan conference was not conducted as planned. The resident was admitted in mid-January 2026 with hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, aphasia following cerebral infarction, and type 2 diabetes mellitus with ketoacidosis. The admission record identified the resident’s daughter as the responsible party (RP). An IDT note dated 1/19/26 by Social Services Assistant (SSA) 1 documented a voicemail left for the RP requesting a return call. A social service note dated 1/20/26 by SSA 2 documented that the RP was called and asked to attend a care conference at 2:30 p.m. and that the RP would participate over the phone. There was no subsequent social services documentation confirming that the care conference occurred or that the RP participated. An IDT conference note initiated 2/5/26 stated that a care conference was conducted that day with the Social Services Director (SSD), Assistant DON (ADON), and Director of Rehabilitation (DOR), and that the resident planned to discharge home with support; this note was signed by SSA 1 on 2/18/26. SSA 2 later stated she did not know if the RP attended the care plan conference, and SSA 1 stated that SSD 1 had created the IDT care conference note on 2/5/26 and that she completed it on 2/18/26 because SSD 1 had not finished her notes. The Minimum Data Set Coordinator (MDSC) confirmed that the SSD schedules care plan conferences, that the conference should be done within the first week of admission, and that the resident was nonverbal, on tube feeding, and bedbound. The MDSC acknowledged that the IDT conference note for this resident had sections completed by Dietary, Therapy, Activities, and Social Services, but the Nursing Services section was not filled out and there was no documentation that Social Services had spoken with the resident’s representative. The facility’s policy stated that residents and/or representatives are encouraged to participate in care plan development and that the SSD or designee is responsible for notifying them and maintaining records of such notices, including input if they are unable to attend.
Unsecured PHI Document Left on Medication Cart
Penalty
Summary
A deficiency occurred when a document containing residents’ personal and medical information was left unsecured on top of a medication cart in Station 3 hallway during a survey observation. The document included residents’ names, room numbers, cognitive status (A&O status), code status, diagnoses, and information about how they take medications (such as whether they take pills whole). During an interview, a licensed nurse acknowledged that he had left this document on top of the medication cart and stated that he was not supposed to do so and that it was a violation of residents’ rights. Later, when shown photographs of the document on the cart, the DON confirmed that the document should not have been there. The facility’s policy on Protected Health Information (PHI), revised April 2014, states that all personnel with access to resident and facility information are responsible for managing and protecting such information to prevent unauthorized release or disclosure. This failure to secure the document containing PHI for a census of 167 residents had the potential to compromise the privacy of residents, as noted in the survey findings.
Failure to Maintain and Honor Advance Directive Results in Improper Notification of Resident's Death
Penalty
Summary
The facility failed to maintain and utilize the current Advance Health Care Directive (AD) for a resident, resulting in the designated agents for Power of Attorney for Health Care (POA) not being notified of the resident's death. The resident, who had multiple diagnoses including multiple sclerosis, epilepsy, and dysphagia, was admitted in 2012 and had a moderate cognitive impairment as indicated by a BIMS score of 9 out of 15. The resident's AD, dated 2011, named two individuals as designated agents for health care decisions, but the facility's records listed other individuals as emergency contacts and responsible parties. Upon the resident's decline and subsequent death, the facility notified the first emergency contact, who was not listed as a designated agent in the AD, and coordinated post-mortem arrangements with this individual. The actual designated agents, as specified in the AD, were not contacted by the facility and only learned of the resident's death through the mortuary. Interviews revealed that the facility was unable to locate the AD in the electronic record at the time of the incident, despite the document having been faxed to the facility in 2013 and later found in past files. Facility staff, including the DON, Social Services Director, and Medical Records Assistant, confirmed that the AD was not uploaded into the electronic record when the system changed in 2022, and that the staff had been relying on the emergency contact rather than the designated agents for decision-making and notifications. The facility's policy required that advance directives be maintained in a readily retrievable location in the medical record and that the resident's wishes be communicated to direct care staff and physicians, but this was not followed in this case.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A deficiency occurred when a resident with amyotrophic lateral sclerosis, dysphagia, and cachexia, who was cognitively intact but physically dependent and used a wheelchair, was struck in the face by another resident in the facility's smoking area. The incident was reported by the affected resident, who stated that the other resident approached, used expletives, and slapped her on the left side of her face. Documentation indicated that the resident experienced swelling and redness to the left side of her face and a sore to her lower lip that reopened after the slap. The resident expressed psychosocial distress, fear, and a sense of being unsafe in the facility following the incident. The resident who committed the act had a history of hemiplegia, hemiparesis, diabetes, aphasia, and severe cognitive impairment. This resident was unable to provide a clear account of the incident due to communication difficulties. Witnesses, including another resident, confirmed observing the physical altercation, stating that the aggressor willfully struck the victim on the cheek. Staff interviews corroborated that the incident took place in the smoking area and that the aggressor had previously exhibited aggressive behavior. Facility records and staff interviews revealed that, prior to the incident, there were no effective measures in place to prevent the altercation or to monitor the residents for aggressive or inappropriate behaviors as outlined in the facility's abuse prevention and resident-to-resident altercation policies. The affected resident reported ongoing fear and discomfort, noting that the aggressor continued to be present in areas near her room after the incident, which contributed to her distress. The facility's failure to protect the resident from physical abuse resulted in both physical and psychosocial harm.
Failure to Update Care Plans and Document Incidents After Resident Altercations and Abuse Allegation
Penalty
Summary
The facility failed to ensure that care plans were updated and documentation was complete for three residents following significant incidents. Two residents were involved in a resident-to-resident altercation in the smoking area, where one resident, who was cognitively intact and had diagnoses including ALS and dysphagia, reported being struck in the face by another resident. The other resident involved had severe cognitive impairment, hemiplegia, and aphasia, and was unable to provide a personal account of the incident. Despite the altercation being reported and documented in progress notes and communication forms, neither resident had a care plan initiated or updated to address the incident. Additionally, another resident with moderate cognitive impairment, COPD, bipolar disorder, and adult failure to thrive, reported being pushed against the wall by a CNA during a brief change. This incident was reported as suspected abuse, but there was no documentation in the clinical record regarding the event, and no care plan was initiated to address the situation or the resident's needs following the report. Interviews with facility leadership confirmed that these incidents were not reflected in the residents' care plans and that documentation in the clinical records was incomplete or missing. Facility policies require that care plans be updated and incidents documented when there is a significant change in a resident's condition or following an altercation or abuse allegation, but these procedures were not followed for the residents involved.
Failure to Protect Resident from Physical Abuse by Roommate
Penalty
Summary
A deficiency occurred when a resident's right to be free from physical abuse was not protected. One resident, who had a history of stroke and difficulty speaking but demonstrated normal cognition, was subjected to physical abuse by his roommate. The roommate, who had a seizure disorder, stroke, and moderate cognitive impairment, threw a hard plastic cup filled with thickened liquid at the first resident's face during an argument. This incident resulted in the resident being covered in fluid and left a red mark on his cheek. The event was witnessed and documented by nursing staff, and both residents confirmed the altercation during interviews. The facility's policy states that residents have the right to be free from abuse, neglect, and exploitation. Despite this, the incident occurred following a disagreement between the two residents, with the aggressor stating the action was in response to a dispute over cigarettes. The Director of Nursing confirmed the details of the incident and acknowledged the resulting injury. The report identifies this as a failure to protect the resident from physical abuse as required by facility policy.
Failure to Protect Resident from Sexual Abuse by Another Resident
Penalty
Summary
A resident with a history of inappropriate behavior towards female residents was observed grabbing and placing another resident's hand on his groin area. This incident was witnessed by a third resident, who reported the event to staff. The resident who was subjected to this behavior was cognitively impaired and had multiple diagnoses, including diabetes mellitus. The resident who committed the act was noted in previous records to have engaged in inappropriate behaviors, such as being found in a female resident's room and touching another resident's arm in the hallway. These prior incidents were not reported or addressed with interventions to prevent further occurrences. Staff interviews confirmed knowledge of the resident's history of inappropriate conduct, and facility documentation acknowledged the abusive nature of the incident. The facility's policy states that residents have the right to be free from abuse, including sexual abuse by other residents. Despite this, the facility failed to implement measures to protect the cognitively impaired resident from abuse, resulting in a violation of the resident's rights.
Failure to Timely Report Alleged Abuse to Authorities
Penalty
Summary
The facility failed to report an allegation of abuse within the required regulatory timeframe for two residents. One resident, who had a history of inappropriate behaviors towards female residents and diagnoses including dementia, was reported by another resident to have grabbed and placed a female resident's hand on his groin. The incident was witnessed and reported to the Social Services Assistant, who then notified the Administrator. However, the Administrator did not report the allegation to the California Department of Public Health until three days after being notified, despite facility policy and federal regulations requiring reporting within two hours if the alleged violation involves abuse. Record review and staff interviews confirmed that the Administrator was aware of the incident but delayed reporting, and the Director of Nursing acknowledged that previous inappropriate behaviors by the same resident had not been reported or addressed with interventions. The facility's policy clearly stated that all reports of resident abuse must be promptly reported to the appropriate authorities, but this was not followed in this case.
Failure to Protect Resident from Sexual Abuse by Another Resident
Penalty
Summary
A deficiency occurred when a resident with dementia and moderate memory impairment was subjected to inappropriate sexual contact by another resident, who also had moderate memory impairment. The incident took place in a hallway after an activity event, where a staff member witnessed one resident fondling the other's breasts without consent. The affected resident was unable to communicate well and appeared surprised and distressed during the incident, as observed by the staff member. The facility's records, including the admission record and Minimum Data Set, confirmed the cognitive impairments of both residents involved. The Interdisciplinary Team note documented the incident based on the staff witness report, but there was no evidence that the affected resident had given consent for any physical contact. When interviewed, the resident who committed the act declined to participate and asked to be left alone. The Director of Nursing confirmed the incident and acknowledged that it was witnessed by staff. The facility's abuse prevention policy states that all residents have the right to be free from abuse, including sexual abuse, by anyone. Despite this policy, the facility failed to protect the resident from abuse by another resident, resulting in a violation of the resident's rights.
Improper Storage and Handling of Discontinued Controlled Medications
Penalty
Summary
The facility failed to maintain consistent pharmacy services for its residents, as evidenced by improper handling and storage of controlled medications. During an inspection, a discontinued bottle of lacosamide, a controlled substance, was found stored with non-controlled medications in the medication storage room and lacked a required count sheet. Licensed nursing staff confirmed that discontinued controlled medications should have been taken to the DON's office for secure storage with proper documentation, in accordance with facility policy. The DON also stated that all discontinued controlled medications were expected to be brought to her office for secure storage until destruction with the facility's pharmacist. Additionally, an inspection of a medication cart revealed seven blister packs of discontinued controlled medications stored alongside active medications. Licensed nursing staff acknowledged that discontinued controlled medications should not remain in the medication cart and should be given to the DON. Facility policies reviewed indicated that all unused controlled substances must be securely locked and documented until disposal, and discontinued drugs should be placed in designated bins for destruction. These findings demonstrate a failure to follow established procedures for the handling and storage of controlled medications.
Medication Storage and Labeling Deficiencies Identified
Penalty
Summary
Surveyors identified multiple failures in the facility's medication storage and handling practices. Expired pharmaceutical products, including a multi-dose vial of Humulin R insulin and two multi-dose inhalers, were found in medication carts at both the front and back stations. Licensed nurses confirmed the presence of these expired medications and acknowledged that they should have been discarded according to facility policy and manufacturer guidelines. Facility policies reviewed indicated that staff are required to check expiration dates prior to administration and to place outdated drugs in designated bins for destruction. Additionally, loose pills were discovered in two medication carts, and a blister pack was found behind a drawer in one of the carts. Licensed nurses confirmed these findings and stated that loose pills and misplaced blister packs should not be present in the carts. The Director of Nursing reiterated that medication carts are expected to be free of loose medications and maintained in a clean, safe, and sanitary manner, as outlined in the facility's storage policy. Further deficiencies were observed in resident rooms, where unlabeled medicine cups containing creams were found at the bedside of two residents. Staff interviews confirmed that these creams were intended for the residents' use but should not have been left at the bedside and should have been discarded after use. Facility policy requires that all drugs and biologicals be stored in locked compartments, and the Director of Nursing confirmed that medications should not be left at the bedside.
Infection Control Program Deficiencies Identified
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several observed deficiencies. In one instance, a resident with severe cognitive impairment and a history of dysphagia and gastrostomy was receiving enteral feeding via a G-tube. The water flush bag used for this resident was found hanging at the bedside without a label, contrary to facility policy and staff expectations, which require labeling with the resident's name and the date and time the bag was started. Both the licensed nurse and the Director of Nursing confirmed that the bag should have been labeled. During a medication administration observation, a licensed nurse was seen using a medication cart that had not been cleaned of white powder residue from a previously crushed medication. The nurse acknowledged that the residue was from a crushed acetaminophen tablet and that medication cart surfaces should be cleaned prior to medication administration. The Director of Nursing also stated that the expectation was to keep medication preparation areas clean and sanitary, as outlined in the facility's policy. Additionally, a certified nursing assistant provided high-contact care to a resident on Enhanced Barrier Precautions (EBP) without wearing a gown, despite clear signage and policy requirements. The resident had an indwelling catheter and was identified as requiring EBP due to risk factors. The CNA admitted to not wearing a gown during activities such as teeth brushing, brief changing, and dressing, and acknowledged awareness of the requirement. The facility's infection preventionist confirmed that gowns and gloves are required during high-contact care for residents on EBP, as specified in the facility's policy.
Inaccurate Assessment of Resident's Tobacco Use
Penalty
Summary
The facility failed to accurately assess a resident's tobacco use during the Minimum Data Set (MDS) assessment process. The resident, who was admitted with diagnoses including high blood pressure and generalized muscle weakness, had a BIMS score indicating mild memory impairment. The MDS documented that the resident was not a smoker, and the smoking observation/assessments also indicated the resident denied smoking or using tobacco products. However, during interviews, the resident stated that he smoked cigars and that the facility was aware of his smoking status, which was confirmed by a licensed nurse. Upon review, the MDS Coordinator acknowledged that both the MDS and the smoking observation/assessment inaccurately reflected the resident's tobacco use. This discrepancy demonstrated that the facility did not conduct a comprehensive and accurate assessment of the resident's health status as required.
Failure to Complete Required PASRR Level II Evaluation
Penalty
Summary
The facility failed to follow up with the required Preadmission Screening and Resident Review (PASRR) Level II evaluation for one resident. The resident was initially admitted in February 2023 and readmitted in November 2024 with diagnoses including unspecified psychosis and major depressive disorder. A review of the resident's PASRR Level I Screening Result, dated 11/19/24, indicated that a Level II evaluation was required. However, the Director of Nursing (DON) confirmed during an interview and record review that she was unaware of the need for a PASRR Level II evaluation for this resident, and acknowledged that no follow-up was conducted for the required evaluation. The facility's policy, revised in March 2023, states that all new admissions and readmissions are to be screened for mental disorders, and if the Level I screen indicates possible mental disorder, the individual should be referred for a Level II evaluation. In this case, the lack of follow-up resulted in the resident not receiving the necessary PASRR Level II evaluation as indicated by the screening process.
Failure to Develop and Implement Comprehensive Care Plans for Smoking and Skin Conditions
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for four residents, resulting in unmet physical and psychosocial needs. For one resident with a history of orthopedic aftercare and gas gangrene, there was no care plan addressing his smoking habits, despite documentation and staff interviews confirming his regular, unsupervised smoking in the designated area. The Minimum Data Set Coordinator and Medical Records Director both confirmed the absence of a smoking care plan for this resident, even though the resident was identified as a smoker in the assessment. Another resident with acute on chronic congestive heart failure and documented rashes on her upper arms, chest, and back did not have a care plan addressing her skin condition. Physician orders for topical and oral medications to treat the rashes were present, and the resident reported ongoing itching. The Minimum Data Set Coordinator confirmed that no care plan was created for the rashes, despite the presence of skin observations and medication orders. Additionally, a resident with chronic pulmonary lung disease had a care plan stating that cigarettes and lighters should be stored at the nurse's station, but staff interviews and observations revealed that the resident kept these items on his person, and staff did not follow the care plan. Another resident with high blood pressure and mild memory impairment, who smoked cigars daily, also lacked a care plan for smoking. Staff and the Director of Nursing confirmed the absence of a smoking care plan for this resident, despite facility policy requiring documentation of smoking-related privileges and restrictions in the care plan.
Failure to Assist Resident with Hearing Aid Use Due to Communication and Documentation Gaps
Penalty
Summary
The facility failed to provide necessary assistance with the use of hearing aids for one resident who had a cognitive communication deficit and muscle weakness. The resident was admitted with hearing aids for both ears and required help with their use, as documented in the resident's records and assessments. Despite this, the resident reported not receiving any assistance or education on how to charge or use the hearing aids, which remained unused in their box for two months. Multiple observations and interviews confirmed that the resident continued to experience difficulty hearing and repeatedly requested help from staff. Interviews with facility staff revealed a lack of clear communication and documentation regarding the resident's need for hearing aid assistance. There was no physician order for the hearing aids, and staff were unclear about whose responsibility it was to enter such orders or provide the necessary support. The facility's policies required staff to assist residents with hearing aids and ensure competency in their use, but these procedures were not followed for this resident, resulting in unmet care needs.
Failure to Provide Nail Care for Dependent Resident
Penalty
Summary
A resident with a history of an anoxic brain injury, severe cognitive deficits, and a right hand contracture was found to have long fingernails with a brownish substance underneath the fingernails on her left hand. The resident was non-verbal, dependent on staff for all activities of daily living (ADLs), and unable to make her needs known. Her care plan required staff to provide extensive to total assistance with all personal care, including daily grooming and nail care, as she was unable to participate in her own care. During observation, staff noted the resident's left hand fingernails were dirty and confirmed that nail care should have been performed. Both a licensed nurse and the DON verified that the resident had not refused nail care and that staff were expected to ensure nails were clean as part of routine hygiene and infection control. Facility policy also required staff to provide appropriate grooming for residents unable to perform ADLs independently. The failure to provide nail care resulted in the resident having visibly dirty fingernails, contrary to her care plan and facility policy.
Call Lights Not Within Reach for Residents with Severe Impairments
Penalty
Summary
The facility failed to ensure that call lights were within reach for two residents with severe cognitive and physical impairments. One resident, admitted after an anoxic brain injury and noted to be non-verbal and dependent on others for all mobility and care needs, was observed sitting in a wheelchair next to her bed with her call light left in the bed, out of her reach. Staff confirmed that the call light was not accessible and acknowledged that the expectation was for call lights to always be within reach, especially for non-verbal residents who cannot call out for help. The resident's care plan specifically indicated that the call light should be within reach due to her inability to verbalize needs and poor mobility. Another resident, admitted with dysphagia following a stroke and requiring maximal assistance for mobility, was also found with her call light out of reach on multiple occasions. Staff interviews confirmed that the call light was not positioned appropriately and should have been within the resident's arm reach. The resident's care plan included an intervention to encourage the use of the call light for assistance, and facility policy required call lights to be within easy reach when residents are in bed or confined to a chair. These observations and staff confirmations demonstrate that the facility did not consistently follow care plans or policy regarding call light accessibility for residents with significant care needs.
Failure to Meet Minimum Room Size Requirements
Penalty
Summary
The facility failed to provide the required minimum room size of 80 square feet per resident in multiple occupancy rooms and 100 square feet for single occupancy rooms, as specified by regulations. Specifically, rooms 302, 303, 304, 305, 306, 307, 309, 310, 312, and 314 were identified as not meeting these requirements, with several rooms providing only 65 to 78.12 square feet per resident. This deficiency was identified through document review, which included a letter to the California Department of Public Health, and was confirmed by direct observation of the rooms and interviews with residents and staff. Despite the deficiency in room size, observations noted that the rooms were clutter-free and allowed for the movement of residents using walkers and wheelchairs. Residents and staff interviewed did not report any issues or complaints related to the lack of space, and there were no validated safety concerns or problems with the delivery of care due to room size. The Director of Maintenance confirmed that no alterations had been made to these rooms since the last recertification survey.
Failure to Allow Resident Return After Hospitalization
Penalty
Summary
The facility failed to protect a resident's right to return to the facility following hospitalization, resulting in an unanticipated discharge. The resident, who had long-term kidney disease and breathing problems, was admitted to the facility in the fall of 2024. On December 20, 2024, the resident experienced an acute change in mental status and was sent to the hospital due to extreme lethargy and low blood sugar. Despite the resident having the capacity to make her own decisions, her Power of Attorney (POA), her daughter, was involved in all healthcare and financial decisions. The facility's policy required that residents be allowed to return following hospitalization within the bed-hold period. However, the facility did not permit the resident to return, citing the daughter's interference with care as the reason. The Administrator and Director of Nursing confirmed that the daughter's actions, which included withholding consent and interfering with medical procedures, hindered the facility's ability to provide care. Consequently, the facility discharged the resident on the same day she was sent to the hospital, without taking any bed-hold money, and informed the POA of the discharge after it occurred.
Failure to Follow Prednisone Orders Leads to Resident Complications
Penalty
Summary
The facility failed to adhere to physician orders for a resident who was prescribed Prednisone following a hospital discharge. The resident, who had a history of chronic obstructive pulmonary disease and kidney failure requiring dialysis, was readmitted to the facility with a prescription for Prednisone 60 mg daily for five days. However, the facility continued administering the medication at the same dosage for an additional 17 days beyond the prescribed period. The resident experienced significant side effects due to the prolonged use of Prednisone, including severe oral thrush and fluid retention, which were not addressed by the facility. Despite multiple visits from a Nurse Practitioner, the issue with the Prednisone dosage was not identified or corrected. The resident's family member expressed concern over the facility's failure to follow the physician's orders and provided documentation to the facility's management, which was not acted upon. The facility's Director of Nursing acknowledged the oversight, stating that the stop date for the Prednisone was not entered into the resident's orders upon readmission. Additionally, there was no documented evidence that the Prednisone order was verified with the resident's physician. The facility's policies on medication orders and therapy were not followed, leading to the resident's prolonged exposure to high doses of Prednisone and subsequent health complications.
Resident-to-Resident Altercation Resulting in Injury
Penalty
Summary
The facility failed to protect a resident from abuse during an altercation between two residents. Resident 1, who was cognitively intact and had a history of hemiplegia and hemiparesis, struck Resident 2 on the arm with a wheelchair armrest, resulting in a skin tear. Resident 2, who had moderate cognitive impairment and a history of paraplegia and an unruptured cerebral aneurysm, was engaged in a conversation with Resident 1 when the incident occurred. The altercation was reported by the facility's administrator, and the injury was documented in Resident 2's nurse's notes. Interviews and observations revealed that Resident 1 admitted to hitting Resident 2 after being called a liar and insulted. The Director of Staff Development witnessed the verbal exchange and confirmed that Resident 1 admitted to the physical altercation. Resident 2 expressed feeling both safe and unsafe in the facility due to the incident, indicating a potential emotional impact. The facility's policy on abuse prevention emphasizes the residents' right to be free from abuse, including from other residents, highlighting a failure to adhere to this policy in this instance.
Delay in Providing Medical Records to Resident's Representative
Penalty
Summary
The facility failed to provide a resident's legal representative with timely access to the resident's medical records. Resident 1 was admitted in May 2021, and a family member was designated as the resident's representative. The representative submitted a written request for the resident's complete vaccination records on August 2, 2024, at 2:45 p.m. According to the facility's policy, medical records should be provided within 72 hours of a request, excluding weekends and holidays. However, the facility did not provide the requested records until August 9, 2024, which was beyond the stipulated timeframe. During an interview and documentation review on August 12, 2024, the Medical Record Director confirmed that the facility received the request on August 2, 2024, and acknowledged that the records were provided electronically on August 9, 2024. This delay in providing the medical records was a deviation from the facility's policy, resulting in a deficiency.
Failure to Provide 30-Day Discharge Notice
Penalty
Summary
The facility failed to provide a 30-day discharge notice to a resident, which compromised the resident's ability to appeal the discharge. The resident was admitted with multiple diagnoses, including diverticulitis, gastrointestinal hemorrhage, breast cancer, difficulty in walking, and muscle weakness. On the same day as the discharge, the resident received a physician's order for discharge with home health services, physical and occupational therapy, and an aide. The Social Services Director confirmed that the resident was notified of the discharge on the same day at 3:12 p.m., and the discharge occurred at 5 p.m. The Director of Nursing admitted that the facility does not issue 30-day notices, and there was no documented evidence of a written or verbal notice of intent to discharge provided to the resident.
Failure to Adhere to Resident's Bathing Schedule
Penalty
Summary
The facility failed to ensure the dignity of a resident by not adhering to the resident's bathing schedule, resulting in the resident feeling upset, angry, and dirty. The resident, who was admitted in 2021 with diagnoses including a leg fracture, hypertension, and cancer, reported not receiving a bath for three weeks. The resident expressed dissatisfaction with their appearance and hygiene, stating that their hair was dirty and matted, which made them feel uncomfortable. A review of the resident's bathing task sheet revealed that the resident had only received one partial bath in a 30-day period, with several scheduled bathing days missed. The care plan indicated that the resident was supposed to receive showers at least twice a week. Interviews with facility staff, including a licensed nurse and the assistant director of nursing, confirmed the lack of documentation and adherence to the bathing schedule. The facility's policy required staff to document bathing and notify supervisors if a resident refused a bath, which was not consistently followed in this case.
Pest Control and Sanitation Deficiency in Kitchen
Penalty
Summary
The facility failed to maintain an effective pest control program and sanitary conditions in the kitchen, as evidenced by the presence of several flies and small worm-like creatures in the food preparation area. During an interview, the Dietary Manager (DM) acknowledged the presence of flies, noting that they were more prevalent in the summer. The DM mentioned that a pest control company visited monthly to replace fly trappers and spray outside the facility, and additional visits were arranged if serious issues arose. However, during a kitchen tour, live flies were observed near the stove, sink, and dry storage room. The DM admitted that flies should not be present in the kitchen and hoped they would be caught in traps overnight. Further inspection revealed deteriorating floor tiles under the sink, with a white plastic substance and blackish residue on the tiles. An opening was noted where the sink pipe entered the wall, and the floor was wet and cluttered with food debris and numerous black worm-like creatures. The DM and Kitchen Staff confirmed the presence of these creatures, which were approximately 1 cm long. The DM was unable to identify them but suggested they might be small worms from beneath the tiles. The Infection Control Nurse also observed the creatures and acknowledged their presence, along with a fly on the wet floor. Pest control logs from previous months indicated significant flying insect activity, and the facility's policies emphasized the importance of pest control and sanitation in the kitchen.
Failure to Store Foods According to Professional Standards
Penalty
Summary
The facility failed to store foods according to professional standards for food safety. During an initial kitchen tour, the Dietary Manager (DM) acknowledged several opened and unlabeled food items, including a gallon of milk in the refrigerator, an opened box of cookie dough in the freezer, and three cans of vegetable oil spray in the cooking area. The facility's policy requires all food items to be labeled with an opened date and used by date, which was not followed in these instances. Additionally, a yellow cutting board was found stained with black markings from the rubber stand, which the DM acknowledged. According to the FDA Food Code, cutting surfaces that can no longer be effectively cleaned and sanitized should be resurfaced or discarded, which was not adhered to in this case. Furthermore, the DM acknowledged the presence of brownish puffy substances at the bottom of four metal storage racks in the dry storage room, identified as dust. The facility's policy mandates routine cleaning, which was not followed. The FDA Food Code emphasizes that food contact surfaces must be clean to sight and touch to prevent contamination. These failures had the potential to increase the risk of foodborne illnesses for the 164 residents who received food from the kitchen.
Improper Disposal of Dietary Tray Tickets Compromises Resident Confidentiality
Penalty
Summary
The facility failed to ensure the protection of residents' personal and medical information when dietary tray tickets containing sensitive information were discarded in the general trash. During a kitchen tour, tray tickets with residents' names, ID numbers, room numbers, diet orders, food preferences, and allergies were found in the general trash bin. The Dietary Manager acknowledged the issue and recognized it as a potential HIPAA violation. The Registered Dietitian confirmed that tray tickets should be disposed of in a shred box to maintain confidentiality. Facility policies on confidentiality and residents' rights were reviewed, indicating that access to personal and medical records should be limited to authorized staff and that unauthorized disclosure of resident information is prohibited.
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 254 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Auburn
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Siena Skilled Nursing & Rehabilitation Center | 0.8 mi | ★★★★★ | 2 | 0 |
| Auburn Oaks Care Center | 0.9 mi | ★★★★★ | 9 | 0 |
| Auburn Ravine Healthcare Center | 3.2 mi | ★★★★★ | 2 | 0 |
| Rock Creek Care Center | 4.5 mi | ★★★★★ | 9 | 0 |
| Lincoln Meadows Care Center | 12.1 mi | ★★★★★ | 18 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.