Below average — CMS composite of the measures below.
The next survey window likely opens around June 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 Prestige Care Center Of Fairfield during CMS and state inspections, most recent first.
Unsafe food handling and cross-contamination occurred during meal prep and lunch service when a dietary staff member used the same pair of gloves throughout the observation while handling food, utensils, drawers, refrigerator doors, lids, bread, and serving items. The staff member touched food and surfaces repeatedly without changing gloves, including placing food into a blender, serving resident plates, retrieving sauce from a refrigerator, and handling bread and butter patties. The DM stated staff were expected to wash hands and change gloves after touching food or surfaces, and facility policy required safe hygienic practices to prevent contamination.
Mechanical lift slings were not laundered according to manufacturer instructions for 11 residents who used a mechanical lift. The D of Housekeeping stated the facility dried the slings in a dryer on normal heat and had done so since she started at the facility. The sling labels directed staff to air dry or tumble dry at a lower temperature, and the facility policy required laundering mechanical slings per manufacturer instructions.
Missing Vaccine Consent and Declination Documentation: The facility failed to document influenza and pneumococcal vaccine status, education, and informed consent or declination for 5 reviewed residents. Records showed some residents received Prevnar 20 or refused a pneumococcal vaccine, but the EHR lacked documentation that staff provided education on risks and benefits or obtained consent/declination. One resident had no documentation showing whether influenza or pneumococcal vaccines were received or refused, and the DON stated residents should be up to date on immunizations.
Missing COVID-19 Vaccine Education and Consent Documentation: The facility failed to document education, informed consent, or declination for multiple residents reviewed for immunizations, and one resident had no documentation showing whether a COVID-19 vaccine was received or refused. Residents with diagnoses including CHF, dementia, depression, diabetes, and weakness either received boosters or had vaccine refusal noted, but the EHR lacked evidence that staff educated the resident or representative on the risks and benefits or documented consent/declination as required by facility policy.
Failure to notify the resident's family and provider of missed alprazolam doses: A resident with anxiety and intact cognition missed six scheduled doses of alprazolam because the medication was on order, and the resident representative was not informed until after asking. Staff and the DON confirmed that the family and provider should have been notified when the medication was unavailable.
A facility failed to ensure a routine medication was available for a resident with heart failure, obesity, and HTN. The resident had a new order for fluticasone nasal spray, but nursing notes, eMAR entries, and progress notes repeatedly documented that the medication was unavailable, not in the facility, on order, or could not be located. The DON later stated the medication was found in the carts and that extra bottles were in the building.
Medication Administration Error Rate Exceeded: The facility had a 7% medication error rate during observation. An LPN gave a resident sucralfate as a tablet with water instead of as a slurry 1 hour before meals, and an RN administered only one Senna Plus tablet instead of two while lidocaine patches were unavailable and on order. The resident involved in the sucralfate error had anxiety, depression, muscle weakness, and moderate cognitive impairment.
A resident with anxiety disorder and intact cognition missed multiple doses of alprazolam when the medication ran out and was not reordered in time. MAR entries and nursing notes showed the doses were marked as on order or out of medication, and staff interviews confirmed the pharmacy had not received a refill request and emergency stock was not used to bridge the gap.
Dietary Staff Did Not Follow Ordered Therapeutic Diets and Resident Preferences: Two residents with severe cognitive impairment and swallowing-related diet needs were served meals that did not match their ordered diets or stated preferences. One resident ordered pureed meals with small portions and double protein but received divided portions that did not provide the ordered protein amount, while another resident who wanted meat ground into small pieces was served whole meat patties and ate little of the meal.
Failure to Maintain Resident Dignity and Respect: Staff left one cognitively intact resident exposed and uncovered during toileting care, with BM present and the room door open to view, while another cognitively intact resident was reportedly subjected to profane language and disrespectful comments by a Dietary Aide after a meal issue. The DON and Administrator were aware of the incidents described in the record and interviews.
Failure to Obtain Informed Consent for Psychotropic Medications: The facility did not ensure residents and/or representatives were informed of the risks, benefits, and side effects of psychotropic meds before administration for three sampled residents. One resident had severe cognitive impairment and was prescribed multiple antipsychotic and antidepressant meds, another had severe cognitive impairment with numerous psychotropic orders, and a cognitively intact resident stated he never signed consents and had not really been spoken to about his psychotropic meds. The clinical records lacked signed consent forms, despite the facility policy requiring education on psychotropic drug use and alternatives.
Failure to Report Alleged Abuse: Staff members described a Dietary Aide using profane and derogatory language toward a resident with intact cognition after becoming upset over a meal issue, but the incident was not reported to the State Agency or the Administrator. Multiple staff heard about the exchange, yet each believed someone else would report it, and the facility had no incident report on file for the allegation despite policy requiring timely reporting of alleged abuse.
Failure to thoroughly investigate an abuse allegation involving a resident with intact cognition. A CNA overheard a dietary aide use a derogatory term toward the resident and make a rude comment after being upset about remaking a meal tray. The DON/Administrator knew the dietary aide had been loud with the resident, but the incident was not fully reported or investigated as required by facility policy.
The facility failed to provide bed hold notices for two residents reviewed for hospitalizations. One resident with insomnia, muscle weakness, and heart failure fell and was transferred to the hospital, and another resident with heart failure, anxiety disorder, and depression was also hospitalized; both had intact cognition by BIMS. The clinical record lacked documentation that bed hold information was given to the resident or representative at the time of transfer, and the DON stated she could not locate the notices while the facility policy required written notice at transfer.
Failure to identify and assess a skin wound: A resident with intact cognition, hemiplegia/hemiparesis, and dependence for transfers had a right hip wound that was not recognized in weekly skin checks, despite a care plan focused on skin integrity. The resident reported staff noticed the area and said they would get cream, while later observation showed a reddened area with a dark center and peeling edges; an LPN described it as eschar-like, and the NP measured it as 1.5 cm x 2.1 cm and believed it was a shear injury. The DON said the wound should have been reported to the nurse and risk management completed.
A resident with ESRD receiving hemodialysis had multiple missing pre-dialysis assessments and some missing post-dialysis assessments in the EHR. Staff, including an LPN and the DON, confirmed the assessments were expected each time dialysis occurred and should include checking the bruit, thrill, vitals, weight, and fistula access site, consistent with the facility’s hemodialysis policy.
The facility failed to complete annual performance evaluations for 2 CNAs reviewed. The Administrator confirmed the evaluations were missing and said they were missed during a transition of DON personnel. The DON stated HR provides the list of due evaluations and the DON is responsible for completing the reviews. The facility policy requires employee competency evaluations to be completed at the required frequency.
Hand hygiene was not performed during glove changes while an ARNP provided wound care to a resident with a right great toe skin issue and bloody drainage. The ARNP removed and replaced gloves multiple times without cleaning her hands, handled the resident’s bedding area and personal items, and later touched the resident’s dirty breakfast dishes with gloved hands. Staff interviews and the facility hand hygiene policy confirmed that hand hygiene is required before donning gloves and immediately after removing them.
Multiple residents experienced unsafe conditions, including being left unattended in a shower chair, being knocked down by another resident in a wheelchair, and falling from a mechanical lift due to improper equipment use. Staff shortages, inadequate supervision, and lack of appropriate interventions contributed to these incidents. Additionally, oxygen tanks were observed being transported without proper securing, violating facility policy.
The facility did not ensure continuous on-site coverage by CPR-certified staff, as required by policy. Review of staff schedules and certification lists showed multiple shifts, especially overnight and on weekends, without a CPR-certified staff member present. Leadership acknowledged awareness of these coverage gaps, though no residents required CPR during the period reviewed.
Multiple residents did not receive medications as directed by professional standards or manufacturer/pharmacist instructions. For example, a resident with diabetes received insulin without timely access to food, another had medications set up by a CMA but administered by an RN, and a resident prescribed levothyroxine received it with other medications instead of separately. Additionally, morning medications for a resident with a G-tube were given significantly later than scheduled. These deficiencies were confirmed through observation, record review, and staff interviews.
Surveyors found that insufficient staffing led to delayed responses to call lights, with some residents waiting over 30 minutes for assistance with mobility, toileting, and repositioning. Staff interviews confirmed that reduced staffing levels contributed to these delays, and residents with significant care needs were left unattended for extended periods.
Surveyors found unsanitary kitchen conditions, including dirty equipment, food debris, and improper glove use during meal preparation. The Dietary Manager and staff handled multiple surfaces and utensils with the same gloves before serving food to residents, and cleaning schedules were inconsistent and incomplete. Facility policies for hand hygiene and sanitation were not consistently followed.
A resident with moderately impaired cognition had conflicting documentation regarding code status, with both DNR and full code orders present in the medical record and code status book. Staff interviews revealed confusion about the resident's current wishes, and the resident was unable to clearly communicate her preference, requesting staff to consult her family. The facility did not consistently follow its policy on advance directives and CPR documentation.
A resident with severe cognitive impairment and multiple diagnoses developed a deep tissue injury to the right heel. Despite care plan orders and provider instructions to offload pressure using heel protectors, staff repeatedly failed to ensure the resident wore the required devices, leaving the heel in contact with the mattress. Observations confirmed the lack of intervention, and the DON acknowledged staff responsibility to provide heel protectors.
A resident with ESRD who received dialysis did not have post dialysis assessments consistently completed and documented as required by facility policy. Staff interviews confirmed that both pre and post dialysis assessments should have been performed and recorded, but electronic health records showed missing post dialysis assessments on multiple occasions.
The facility did not update its Facility Assessment to reflect the needs of residents receiving hemodialysis and those with G-tubes, despite having several such residents in care. The assessment lacked identification of required specialized staff training and medical supplies, even though the facility's policy and leadership recognized these needs and the importance of updating the assessment with changes in resident care requirements.
A resident with severe cognitive impairment and frequent urinary incontinence was found to have a persistent urine odor in their room, despite daily linen changes and cleaning efforts by staff. Staff interviews and observations confirmed the odor was ongoing, with wet areas noted in the bathroom and incomplete resolution of the issue, contrary to facility policy requiring a sanitary and comfortable environment.
Staff did not provide a meal in a timely manner to a resident with intact cognition, resulting in distress, and failed to use a dignity cover for a catheter bag for another resident with severe cognitive impairment. Nursing staff and the DON confirmed that catheter bag covers were not available, and facility policy required their use to promote dignity.
The facility did not complete required self-medication administration assessments for two residents—one with diabetes and another with severe allergies and an order for an EpiPen at bedside. Both residents were either observed with medications at bedside or had orders to self-administer, but there was no documented interdisciplinary assessment as required by facility policy. Staff were also unaware of one resident's allergies and the location of emergency medication.
A resident with severe cognitive impairment and a G-tube was administered medications and tube feeding by an LPN while the room door remained open, exposing the resident's abdomen and G-tube. Staff interviews and facility policy confirmed that privacy should have been maintained during such procedures.
A resident with severe cognitive impairment was routinely administered risperidone without clear documentation or identification of targeted behaviors justifying its use. Clinical records, care plans, and staff interviews indicated the resident did not exhibit significant behavioral disturbances, and the facility failed to specify or monitor behaviors as required by policy for psychotropic medication administration.
The facility did not report multiple allegations of abuse and resident-to-resident altercations within the required timeframe. Incidents included a resident being knocked down and injured by another resident in a wheelchair, a staff member allegedly handling a resident aggressively, and a resident with a history of inappropriate behavior touching another resident. In each case, reporting to authorities was delayed or not documented as required by policy.
A resident with intact cognition was discharged without an ongoing discharge planning process, as required documentation and care plan updates were missing, and discharge notifications were not properly completed or signed. Facility administrators provided inconsistent accounts of the discharge process, and there was no evidence that the resident was adequately prepared for a safe transfer, as outlined in facility policy.
The facility did not update care plans to address significant weight loss, severe allergies, wheelchair safety, and changes in advanced directive status for several residents. For example, a resident with notable weight loss did not have this addressed in their care plan, another involved in a wheelchair incident lacked additional safety interventions, a resident's change to DNR status was not reflected in the care plan, and a resident with severe allergies had no care plan interventions or documentation for EpiPen use.
Two residents dependent on staff for bathing did not receive the required number of baths, with documentation showing missed or delayed bathing and lack of follow-up when baths were not provided. One resident was cognitively intact and denied refusing care, while the other had moderate cognitive impairment and multiple medical conditions, including pressure ulcers. Staff interviews and documentation confirmed gaps in bathing care, contrary to facility policy.
Two residents with diabetes experienced multiple episodes of hyperglycemia, with blood sugar readings exceeding 399 mg/dl, but staff failed to document provider notifications or follow-up interventions as required by care plans and medication orders. Staff interviews revealed inconsistent practices regarding provider notification, and the DON acknowledged inadequate documentation.
A resident with an indwelling urinary catheter did not receive proper infection control and catheter care, including inconsistent use of Enhanced Barrier Precautions, improper hand hygiene, and failure to use appropriate anchoring devices. Staff used improper cleaning techniques, did not promptly address a leaking catheter bag, and did not follow facility policy for catheter care, resulting in continued discomfort and risk of infection for the resident.
A resident with severe cognitive impairment, hemiplegia, and a feeding tube experienced a significant, rapid weight loss. Facility staff did not clarify discrepancies in weight records, failed to document a required weekly weight, and did not notify the physician or implement interventions in a timely manner, despite care plan and policy requirements. Staff interviews confirmed inconsistent monitoring and lack of follow-up on the resident's weight changes.
A resident with multiple medical conditions and intact cognition requested physical therapy to improve mobility, but the facility did not document any follow-up or provision of therapy services after the initial request, despite policy requiring such services.
Surveyors found that the facility did not post daily nurse staffing and census information in a visible area as required by policy. The Administrator confirmed the absence of the posting, and the Staffing Coordinator reported she was unaware of her responsibility to post this information. Facility policy requires this information to be posted daily and accessible to residents, staff, and visitors.
A resident with atrial fibrillation and a prosthetic heart valve received unnecessary doses of warfarin after staff failed to follow physician orders to hold the medication following elevated INR results. Despite clear orders and facility policy, the resident continued to receive warfarin, resulting in a critically high INR and subsequent hospital admission. Staff interviews revealed confusion and lack of clarity regarding medication hold procedures and documentation.
The facility failed to maintain a clean and sanitary environment, as observed in the rooms of two residents requiring maximal assistance. One resident reported her room was filthy, with gritty floors and debris on the toilet. Another resident's room was found dirty, with unswept and unmopped bathroom floors. Despite cleaning efforts by a housekeeper, issues persisted, and the Housekeeper Director could not provide records of monthly deep cleaning.
The facility failed to follow its policy requiring two licensed nurses to conduct shift change narcotic counts, leading to discrepancies in narcotic counts. A Certified Medication Aide completed a count alone and left keys unsecured, a practice noted as common. A Registered Nurse also counted narcotics alone and passed keys without a proper count, resulting in missing narcotics, including Hydrocodone/APAP and Morphine sulfate, discovered by another aide. The discrepancies were reported to the Administrator and DON.
A facility failed to secure medication cart keys, allowing unauthorized access and resulting in missing narcotics. Staff C, a Certified Medication Aide, left keys in an unlocked drawer, leading to Staff A accessing the cart. The next day, Staff E found missing Hydrocodone/APAP and Morphine sulfate from two residents' supplies, and later, an entire bubble pack of Oxycodone was missing. The facility did not follow its policy requiring two licensed nurses to account for controlled substances and keys at shift changes.
The facility failed to accurately code medications and services in the MDS assessments for four residents. A resident's MDS inaccurately coded insulin use, another's failed to indicate hospice services, and two residents' MDS assessments incorrectly listed anticoagulant medication use instead of antiplatelet medication. These discrepancies highlight the facility's failure to ensure accurate MDS coding, impacting the care and services provided to the residents.
The facility failed to provide comprehensive individualized care plans for four residents, omitting critical aspects such as diabetes management, oxygen therapy, wound care, and hospice services. These omissions were identified through observations, interviews, and record reviews, highlighting a lack of specific interventions and documentation in the care plans.
A long-term care facility failed to provide adequate staffing during lunch, resulting in insufficient assistance for residents with eating and toileting needs. An LPN was the only staff member present, leading to an incontinent episode for a resident with severe cognitive impairment. Other residents reported long wait times for assistance and medication errors, highlighting the staffing issues. Interviews with staff revealed that the facility was short-staffed due to a CNA attending an appointment, impacting the quality of care provided.
The facility did not follow the prescribed pureed diet menu, omitting pureed cornbread from a meal. A cook prepared the meal without pureeing the cornbread, despite it being listed on the Week 4 Wednesday Diet Spreadsheet. The Dietary Manager acknowledged the oversight, noting that the cornbread might have been missed. The facility's guidelines required adherence to written menus and standardized recipes, which were not followed.
The facility failed to maintain kitchen sanitation and proper food safety practices. Observations included unsanitary storage of food items, such as open bags of hamburger and undated sour cream, and inadequate testing of dishwasher temperature and chemical levels. Additionally, dietary staff transported uncovered plates of food to residents' rooms due to a lack of lids, with the Dietary Manager suggesting the use of foil as a temporary measure.
Unsafe Food Handling and Cross-Contamination During Meal Preparation and Service
Penalty
Summary
The facility failed to ensure dietary staff prepared and served food using safe hygienic practices to prevent cross-contamination during meal preparation and meal service. During observation, Staff R and the Dietary Manager prepared meals while wearing gloves, but Staff R repeatedly handled food, utensils, drawers, refrigerator doors, lids, and other surfaces without changing gloves or washing hands. Staff R removed lids with a gloved hand, used tongs to place chicken-fried steak patties into a blender, carried broth across the kitchen in a spoon to add to the blender, and continued handling food and equipment with the same pair of gloves throughout the entire observation. Staff R also used a gloved hand to pull bread slices from a loaf and placed them into a blender with milk to puree them. During lunch meal service, Staff R continued using the same gloves while taking lids on and off food containers, serving food with tongs and spoons, and touching a plastic-coated menu on the steam table while plating each resident meal. Staff R reached into a refrigerator behind the steam table to retrieve barbeque sauce, squirted it onto a resident's plate, and returned it to the refrigerator. Staff R also reached into a loaf of bread with a gloved hand to remove slices for residents and retrieved butter patties from the refrigerator while serving meals. The Dietary Manager stated staff needed to wash hands when going from the dining room to the kitchen, before putting on and after taking off gloves, and to change gloves after touching food, their face or body, or surfaces such as refrigerators and drawers. The facility policy stated staff shall adhere to safe hygienic practices to prevent contamination of foods from hands or physical objects and shall not touch food with bare hands.
Mechanical Lift Slings Not Laundered per Manufacturer Instructions
Penalty
Summary
The facility failed to launder mechanical lift slings according to manufacturer instructions for 11 of 11 residents who utilized a mechanical lift. An undated facility list of Hoyer slings identified 11 residents who used a mechanical lift. During a tour of the laundry, the Director of Housekeeping stated that the facility dried mechanical lift slings in the dryer on a normal heat setting and did not use a lower heat setting, and that this had been the practice since she began at the facility in 2024. After the interview, she provided a mesh mechanical lift sling and a solid material mechanical lift sling, both of which had labels directing staff to air dry or tumble dry at a lower temperature. The facility policy Safe Resident Handling/Transfers, revised 6/2026, directed staff to launder mechanical slings according to manufacturer's instructions.
Missing Vaccine Consent and Declination Documentation
Penalty
Summary
The facility failed to ensure pneumococcal and/or influenza vaccinations were provided, and failed to document informed consent or declination for 5 of 5 residents reviewed for immunizations. Resident #2 had diagnoses of chronic pain, morbid obesity, and diabetes, and was cognitively intact with a BIMS score of 15 out of 15; the EHR showed the resident refused the pneumococcal vaccine, but there was no documentation that staff educated the resident or representative on the risks and benefits of the vaccine or documented the declination. Resident #8 had heart failure, Alzheimer's disease, and non-Alzheimer's dementia, with a BIMS score of 6 out of 15; the EHR showed the resident received Prevnar 20, but there was no documentation of education or consent from the resident or representative. Resident #10 had heart failure, abnormal posture, and muscle weakness, with a BIMS score of 4 out of 15; the EHR lacked documentation showing whether the resident received or refused influenza or pneumococcal vaccine, and there was no documentation of education, consent, or declination. Resident #21 had anxiety, depression, and muscle spasms of the back, with a BIMS score of 15 out of 15; the EHR showed the resident received Prevnar 20, but there was no documentation of education or consent. Resident #23 had non-Alzheimer's dementia, depression, and insomnia, with a BIMS score of 12 out of 15; the EHR showed prior PPSV23 and PCV13 vaccinations, but lacked documentation showing whether the resident received or declined the most current pneumococcal vaccine, and lacked documentation of education, consent, or declination. The DON stated residents should be up to date on immunizations, and the facility policy stated residents were to be offered annual influenza immunization with information provided on benefits and potential side effects before administration.
Missing COVID-19 Vaccine Education and Consent Documentation
Penalty
Summary
The facility failed to ensure the provision of the COVID-19 vaccine for 1 of 5 residents reviewed for immunizations, and failed to obtain documented informed consent or declination for 5 of 5 residents reviewed. Resident #2 had diagnoses of chronic pain, morbid obesity, and diabetes, and a BIMS score of 15 out of 15 indicating intact cognition. The EHR showed that Resident #2 refused a COVID-19 vaccine, but there was no documentation that staff educated the resident or representative on the risks and benefits of the vaccine or documented the declination. Resident #8 had heart failure, Alzheimer's disease, and non-Alzheimer's dementia, with a BIMS score of 6 out of 15 indicating severely impaired cognition, and received a COVID-19 booster without documentation of education or consent from the resident or representative. Resident #10 had heart failure, abnormal posture, and muscle weakness, and the EHR lacked documentation showing whether the resident received or refused a COVID-19 vaccine, as well as any education, consent, or declination. Resident #21 had anxiety, depression, and muscle spasms of the back, with a BIMS score of 15 out of 15, and Resident #23 had non-Alzheimer's dementia, depression, and insomnia, with a BIMS score of 12 out of 15; both received COVID-19 boosters, but the EHR lacked documentation of education on risks and benefits and resident consent. The DON stated residents should be up to date on immunizations, and the facility policy required education and offering of the COVID-19 vaccine, including discussion of risks, benefits, and potential side effects.
Failure to Notify Family and Provider of Missed Anti-Anxiety Medication Doses
Penalty
Summary
The facility failed to notify the resident, the resident's physician, and the resident's family representative when Resident #21 missed six scheduled doses of alprazolam 0.5 mg ordered twice daily for anxiety. The resident had a BIMS score of 15 out of 15, indicating intact cognition, and the diagnosis list included an anxiety disorder. Review of the June 2026 MAR showed the medication was not administered on 6/1/26 for both AM and PM doses, 6/2/26 AM, 6/3/26 AM and PM, and 6/4/26 AM because the medication was on order. During interview, the resident representative stated the resident had been without the anti-anxiety medication for 3 days and reported that when the medication was stopped in the hospital in the past, the resident did not react well and at one point reported seeing bugs crawling on the ceiling. The resident representative stated they were not notified before asking about the medication. Staff interviews confirmed that the family and provider should have been notified when the resident did not receive the prescribed medication, and the NP stated she should have been notified that the resident was out of alprazolam prior to June 4. The DON also confirmed the family and provider should have been notified when the medication did not come in.
Routine Medication Not Available for Resident
Penalty
Summary
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist was not met when the facility failed to ensure a routine medication was available for Resident #9. Resident #9’s MDS dated 4/23/26 listed diagnoses of heart failure, obesity, and high blood pressure, and a BIMS score of 15 out of 15 indicating intact cognition. A 7/11/25 nursing note documented a new order for fluticasone 50 mcg, 2 sprays daily in the morning, but a 7/12/25 nursing note stated the medication was unavailable. Subsequent eMar and progress notes repeatedly documented that the medication was not in the facility, was on order, or could not be located on multiple dates through 6/26/26. On 7/1/26, the DON stated fluticasone was located in the carts and that there were 2 extra bottles in the building. The facility policy on Medication Reordering stated routine medications would be accurately and safely provided and that staff would reorder medications if fewer than 6 doses remained.
Medication Administration Error Rate Exceeded
Penalty
Summary
The facility failed to ensure a medication error rate less than 5 percent when a medication administration observation resulted in a 7 percent error rate. Resident #42’s record showed diagnoses of anxiety, depression, and muscle weakness, with a BIMS score of 8 out of 15 indicating moderate cognitive impairment. The June 2026 MAR listed an order for sucralfate 1 gram by mouth twice daily, to be made into a slurry and given 1 hour prior to meals. During an observation, an LPN administered the sucralfate as a tablet with water instead of making it into a slurry, and the resident’s unit dinner time was listed as 5:45 p.m. while the DON stated the unit did not eat until 6:00 p.m. Resident #21’s physician orders included Senna Plus 8.6-50 mg, two tablets by mouth twice daily, and a lidocaine 4 percent patch to be applied daily at 8:00 a.m. and removed at 8:00 p.m. During a medication pass observation, an RN prepared medications for the resident but placed only one Senna Plus tablet in the pill cup and reported she was looking for lidocaine patches, which were not available because more had to be ordered from the pharmacy. The RN administered the medications without including the ordered two Senna Plus tablets, and the MAR documented a code of 9 for the lidocaine patch, with progress notes stating the patch was on order.
Missed Alprazolam Doses Due to Failure to Reorder Medication
Penalty
Summary
The facility failed to ensure Resident #21 received alprazolam as ordered and did not reorder the medication or use emergency stock to prevent missed doses. Resident #21 had a diagnosis of anxiety disorder, was cognitively intact with a BIMS score of 15 out of 15, and had a care plan addressing use of anti-anxiety medication. The physician order in the EHR was for alprazolam 0.5 mg, 1 tablet by mouth twice daily for anxiety. The June 2026 MAR showed multiple doses marked with a chart code indicating "Other/See Nurses Notes," and nursing notes documented the medication was "on order" on 6/1, 6/2, and 6/4, and "out of medication" on 6/3. During interview, Resident #21 stated there had been an issue with her medications running out and she had to wait 3 or 4 days before receiving it. Staff interviews showed the medication was not reordered in time and the pharmacy had not received a refill request between the prior order and the new order placed on 6/4/26. Staff also stated the resident was out of alprazolam for a couple of days, and the DON stated she believed the medication should have been available in emergency stock and that staff should have checked it and contacted the pharmacy when the medication did not arrive. The facility policy required routine and emergency medications to be obtained in a timely manner and directed nurses to reorder medications when six or fewer doses remained.
Dietary Staff Did Not Follow Ordered Therapeutic Diets and Resident Preferences
Penalty
Summary
The facility failed to ensure dietary staff served meals that met residents’ therapeutic needs and preferences for 2 of 5 residents reviewed for diet orders. Resident #18 had diagnoses including diabetes, aphasia, and morbid obesity, was severely cognitively impaired with a BIMS score of 0, and was dependent on staff for eating. The resident’s physician order called for a regular diet with pureed texture, thin consistency, small portions, and double protein. During observation, dietary staff prepared pureed lunch items by blending three servings of country fried steak with beef broth and dividing the protein between two residents, giving Resident #18 1.5 servings instead of the ordered double protein and also dividing pureed carrots, mashed potatoes, and bread so the resident received 1.5 servings of each item. Resident #49 had diagnoses including stroke, chronic respiratory failure, and malnutrition, with severe cognitive impairment and dependence on staff for eating. The resident’s order was for a general diet with mechanical soft texture and nectar consistency for pleasure per request, and records noted dysphagia following cerebral infarction with speech therapy recommendations for pureed food. During observation, the resident was served a whole barbeque pork rib patty on one meal and a whole chicken fried steak patty on another, and staff had to cut up the meat or the resident refused to eat it. The resident stated she did not ask for meat to be served whole and wanted it ground into small pieces. The dietary manager stated the resident had previously sent back mechanical soft food and requested regular meat instead of ground meat.
Failure to Maintain Resident Dignity and Respect
Penalty
Summary
The facility failed to ensure staff treated residents with dignity and respect for 2 of 18 sampled residents. Resident #13 had intact cognition with a BIMS score of 14 out of 15 and diagnoses including irritable bowel syndrome and morbid obesity. The resident was dependent on staff for toileting, hygiene, and transfers, needed partial assistance to roll in bed, and was always incontinent of urine and frequently incontinent of bowel. During an observation, Staff K responded to Resident #13’s call light and assisted her with toileting. Staff K left the room to look for supplies, and the resident reported she was left on her right side facing away from the room door with her bottom bare while waiting for help. Staff D later entered the room and found the resident facing away from the door with her buttocks uncovered and exposed to the open doorway, with a strong bowel movement odor in the room. Staff D stated the resident did not have a brief on and that was a problem, and he retrieved supplies before returning to the room with Staff L. The resident stated she had been waiting for someone to come in and help her, and Staff K reported she had not been sure whether she left the resident covered when she left the room. Resident #40 also had intact cognition with a BIMS score of 15 out of 15. Staff D reported hearing Staff E, a Dietary Aide, call the resident a profane name and tell her, "You should know what you wanted," after becoming upset about remaking a plate. Staff E acknowledged cussing around the resident but said he was not cussing at her and did not remember what he said. The Administrator stated she knew something about Staff E getting loud in the dining room and had met with the dietary team about appropriate conversations and language.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure residents and their families were informed of the risks, benefits, and side effects of psychotropic medications before those medications were administered for 3 of 3 sampled residents. Review of the facility policy titled Use of Psychotropic Medication stated residents and/or representatives were to be educated on the risks and benefits of psychotropic drug use, as well as alternative treatments and non-pharmacological interventions. However, the clinical records for the sampled residents lacked signed informed consent forms for the prescribed psychotropic medications. Resident #54 had a BIMS score of 2 out of 15, indicating severe cognitive impairment, and a diagnosis of senile degeneration of the brain. The resident’s record showed orders for quetiapine, lorazepam, risperidone, and bupropion, and the care plan directed staff to educate the resident/family/caregivers about the risks, benefits, and side effects of antidepressant and psychotropic medications. The record lacked signed informed consents, and a separate folder contained unsigned and undated consent forms for bupropion, risperidone, and quetiapine. The MDS Coordinator stated she was responsible for completing psychotropic consent forms, was behind on obtaining them, and had difficulty reaching the responsible person for the resident. Resident #11 had a BIMS score of 1 out of 15 and diagnoses including Alzheimer’s disease, anxiety, and depression. The resident was prescribed multiple psychotropic medications, including bupropion, fluoxetine, haloperidol, lorazepam, olanzapine, quetiapine, and risperidone, but the clinical record lacked signed informed consent forms. Resident #7 had intact cognition with a BIMS score of 15 out of 15 and diagnoses including anxiety disorder, depression, schizophrenia, and PTSD. The resident was prescribed trazodone, duloxetine, clozapine, and bupropion, yet the record also lacked signed informed consent forms. During interview, Resident #7 stated he never signed consents for his psychotropic medications and the facility had not really spoken to him about them.
Failure to Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of abuse to the State Agency for 1 of 1 resident reviewed for abuse. Resident #40 had a BIMS score of 15 out of 15, indicating intact cognition. Staff interviews described an incident in which a Dietary Aide became upset while remaking the resident’s plate and used inappropriate and profane language toward the resident, including calling the resident a derogatory name and telling the resident, “You should know what you wanted.” Staff D stated he heard the exchange in early June 2026 but did not report it, believing Staff G would do so. Additional interviews showed the incident was known to multiple staff members but was not reported to the Administrator or State Agency. Staff F, RN, stated she was told the Dietary Aide was rude to the resident and later learned the aide admitted cussing in front of the resident, but she did not report it because she thought another staff member had. Staff G, CMA, stated the Dietary Aide told the resident, “you didn’t have to be such a dick,” continued using profanity, and left only after being told to leave; she also did not report it because she thought the nurses would. The Administrator stated she knew only that the Dietary Aide had gotten loud in the dining room and held a meeting with dietary staff, but said she would have suspended him and reported the incident if she had known what was specifically said. Review of the facility’s incident reports found no report to the State Agency regarding the Dietary Aide and Resident #40, despite the facility policy requiring reporting of alleged abuse within specified timeframes.
Failure to Thoroughly Investigate Allegation of Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation of an allegation of abuse involving one resident who had a BIMS score of 15 out of 15, indicating intact cognition. A CNA stated he overheard a dietary aide call the resident a derogatory name after becoming upset about having to remake the resident’s plate, and also heard the dietary aide tell the resident, "You should know what you wanted." The CNA stated the incident occurred in early June 2026 and that he did not report it, believing another staff member had reported it to the Administrator. During interview, the Administrator stated she knew the dietary aide had been loud in the dining room with the resident and that she had spoken with dietary staff about interactions with residents. She stated that if she had known exactly what was said, she would have reported the incident to the State Agency and started an investigation. Facility policy required an immediate investigation when abuse was suspected or reported, including identifying staff responsible, interviewing all involved persons and witnesses, focusing on whether abuse or mistreatment occurred, and providing complete and thorough documentation of the investigation.
Failure to Provide Bed Hold Notices After Hospital Transfers
Penalty
Summary
The facility failed to provide bed hold notices for 2 of 3 residents reviewed for hospitalizations. Resident #10 had diagnoses including insomnia, muscle weakness, and heart failure, and had a BIMS score of 14 out of 15 indicating intact cognition. After a fall on 6/13/26, the resident was transferred to the hospital and returned on 6/15/26, but the clinical record lacked documentation that bed hold information was relayed to the resident or the resident's representative upon transfer. Resident #60 had diagnoses including heart failure, anxiety disorder, and depression, with a BIMS score of 15 out of 15 indicating intact cognition, and the clinical record also lacked documentation of bed hold information provided to the resident or representative upon hospital transfer. The DON stated she could not locate bed hold notifications for the residents and said the nurse usually verbally explained the bed hold information upon discharge and the social worker obtained a signature the next day, while the facility's Bed Hold Notice policy required written information to be provided at the time of hospital transfer.
Failure to Identify and Assess a Skin Wound
Penalty
Summary
The facility failed to identify and assess a non-pressure skin wound for 1 of 2 residents reviewed for wounds. Resident #1 had a BIMS score of 13 out of 15, indicating intact cognition, and diagnoses that included hemiplegia/hemiparesis. The MDS showed the resident required substantial to maximal assistance with bed mobility and transfers and was at risk for pressure ulcers. The care plan identified a focus on potential impairment to skin integrity, and the resident was admitted with no pre-existing pressure ulcers, venous/arterial ulcers, surgical wounds, or diabetic wounds. Weekly skin reviews documented no skin changes or skin intact, but during interviews the resident stated she had a wound on her right hip that staff noticed and said they would get cream for, though she did not know how it happened. On observation, the resident’s right upper hip had a slightly reddened area with a flat dark brown/black center and peeling skin at the edges. An LPN stated it appeared like eschar tissue and something that had been there awhile, and the NP measured the area as 1.5 cm by 2.1 cm and thought it was a shear injury. The NP confirmed staff should have noticed and reported the wound, and the DON stated it was a communication issue and that the wound should have been reported to the nurse and a risk management report completed.
Missing Dialysis Assessments
Penalty
Summary
The facility failed to complete required pre- and post-dialysis assessments for Resident #5, a cognitively intact resident with end stage renal disease who received hemodialysis while residing in the facility. The resident’s care plan identified risks related to dialysis and included interventions to observe for infection at the shunt site, hypotension, and edema. Review of the electronic health record showed multiple missing pre-dialysis assessments and missing post-dialysis assessments for some dialysis visits. Staff interviews confirmed that the pre- and post-dialysis assessments were expected to be completed each time the resident went to dialysis. An LPN stated the assessments should be done every time and should include checking the bruit, thrill, vitals, and weight. The DON also confirmed that when the resident returned from dialysis, vitals, weights, and the fistula needed to be checked, and before dialysis the fistula needed to be checked. The facility policy stated that the nurse would ensure the dialysis access site was checked before and after dialysis treatments and every shift for patency by auscultating for a bruit and palpating for a thrill.
Failure to Complete Annual CNA Performance Evaluations
Penalty
Summary
The facility failed to complete annual performance evaluations for 2 of 3 certified nursing assistants reviewed. Staff D, a CNA hired on 4/24/25, had no annual evaluation in the employee file, and Staff I, a CNA hired on 4/17/25, also had no annual evaluation in the employee file. The Administrator confirmed during interview that the annual evaluations for Staff D and Staff I had not been completed and stated they were missed during a transition of DON personnel. The DON stated that Human Resources provides a list of staff annual evaluations that are due and that the DON is responsible for completing the reviews. The facility policy titled Competency Evaluation states that it is the policy of the facility to evaluate each employee to assure appropriate competencies and skills for performing his or her job and to meet the needs of facility residents, and that subsequent and/or annual competency is evaluated at a frequency determined by the facility assessment, evaluation of the training program, and/or job performance evaluations.
Hand Hygiene Not Performed During Glove Changes in Wound Care
Penalty
Summary
The facility failed to ensure staff performed hand hygiene during glove changes while providing wound care to a resident with multiple sclerosis, heart failure, and peripheral vascular disease. The resident’s MDS dated 4/24/26 and an IDT note dated 6/25/26 documented a non-pressure skin issue to the right great toe, and the physician ordered Triple Antibiotic Ointment and an Optifoam Gentle 3 dressing to be applied daily. During observation of wound care on 6/30/26, the ARNP and the Infection Preventionist/LPN sanitized their hands and prepared supplies, then donned gloves to begin care on the resident’s right great toe, which had deep red bloody drainage and visible blood at the wound site. During the wound care, the ARNP removed gloves multiple times and failed to perform hand hygiene before donning new gloves. She removed the dressing, cleaned the wound, applied antibiotic ointment, measured the wound, applied foam dressing and Aquaphor to both lower legs, and at one point donned a glove on only one hand before touching her hair and opening and closing the resident’s nightstand drawer to obtain tubigrips. She also handled the resident’s dirty breakfast dishes with gloved hands before leaving the room. Staff interviews confirmed hand hygiene should occur before wound care and with every glove change, and the ARNP stated she knew she had forgotten to perform hand hygiene during glove changes. The DON stated staff should perform hand hygiene with every glove change, and the facility policy stated gloves do not replace hand hygiene and that hand hygiene should be performed before donning gloves and immediately after removing them.
Failure to Prevent Accidents and Ensure Safe Transfers
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents for several residents. One resident with Alzheimer's disease, dementia, and Parkinson's disease, who was severely cognitively impaired and at risk for falls, was left unattended in a shower chair for an extended period. Staff interviews confirmed that the resident required two staff for transfers, but due to short staffing, she remained in the chair for a prolonged time, resulting in red indentations on her leg. Staff and the DON acknowledged that residents should not be left alone in shower chairs. Another incident involved a resident with severe cognitive impairment and gait abnormalities who was knocked down by another resident in a wheelchair, resulting in a large hematoma to the back of her head and a headache. The resident was transferred to the ER and later returned. The resident who caused the incident had a history of unsafe wheelchair use, including propelling himself backwards and running into others. Despite previous behavioral issues and staff concerns, the care plan lacked sufficient interventions to ensure wheelchair safety for this resident and others. Additionally, a resident dependent on staff for transfers fell from a mechanical lift due to the use of an inappropriate sling. Staff involved in the transfer noted that the sling was not the usual type, appeared unsafe, and was not designed for bed-to-chair transfers. Despite concerns raised during the transfer, the process continued, resulting in the resident sliding out of the sling and sustaining a hematoma and abrasion to the head. The facility also failed to ensure oxygen tanks were properly secured during transport, as observed on multiple occasions with staff carrying and setting tanks down without holders, contrary to facility policy.
Failure to Maintain 24/7 CPR-Certified Staff Coverage
Penalty
Summary
The facility failed to ensure that at least one CPR-certified staff member was available on-site 24 hours per day, 7 days per week, as required by facility policy. Review of nursing staff schedules and the list of CPR-certified staff revealed multiple shifts, particularly during third shift and weekends, where no CPR-certified staff were present. Both the Administrator and the DON acknowledged gaps in CPR coverage, with the Administrator specifically noting awareness of shortages during certain shifts and the DON confirming ongoing time gaps in coverage. The facility's policy mandates that CPR-certified staff be available at all times, but this standard was not met on several documented occasions. Interviews with facility leadership confirmed knowledge of the deficiency, and documentation showed that the most updated list of CPR-certified staff had not always been communicated. Despite these lapses, there were no reported incidents during the review period where residents required CPR. The facility census at the time was 59 residents, and the deficiency was identified through review of schedules, staff lists, policy, and staff interviews.
Failure to Administer Medications According to Professional Standards and Prescribed Timeframes
Penalty
Summary
The facility failed to ensure medications were administered according to professional standards and manufacturer or pharmacist directions for several residents. For one resident with diabetes, insulin aspart was administered without ensuring a meal was provided within the recommended 5-10 minutes post-injection, as observed when the resident did not receive food until over 30 minutes after administration. Another resident with multiple medication orders via G-tube had medications set up by a Certified Medication Assistant (CMA) but administered by a Registered Nurse (RN), contrary to professional standards and facility policy that require the same staff member to both set up and administer medications. Additionally, a resident prescribed levothyroxine was not consistently receiving the medication as intended; it was sometimes administered with other medications rather than by itself and not always at the scheduled time, despite pharmacist and facility expectations for it to be given separately and early in the morning. Staff interviews confirmed that the medication was not always administered according to these standards, with both night and day shift nurses involved in the inconsistency. For another resident requiring G-tube medications, multiple morning medications scheduled for 7:00 AM were observed being administered at 9:29 AM, well outside the facility's policy of administering medications within one hour before or after the scheduled time. Staff confirmed that this timing was considered late, and the facility's policy was not followed in this instance. These findings were based on direct observation, record review, and staff interviews, and affected multiple residents with complex medical needs.
Delayed Call Light Response and Insufficient Staffing
Penalty
Summary
Surveyors observed multiple instances where residents' call lights were left unanswered for extended periods, and residents requiring assistance did not receive timely care. On one occasion, two residents' call lights remained activated for over 15 minutes while a CNA attended to another resident, passing by the rooms without responding. Additional residents activated their call lights during this period, and staff were not present in the hallway. When the CNA eventually responded, residents requested assistance with toileting and repositioning, indicating unmet needs during the delay. Facility policy requires all staff to respond promptly to call lights, but this was not followed. A resident with Alzheimer's and Parkinson's disease, who required a mechanical lift and two staff for transfers, was left sitting alone in a shower chair for over 40 minutes due to insufficient staff available to assist with her transfer. Staff interviews confirmed that only two aides were present instead of the usual three, resulting in delays. The resident was eventually transferred to bed, and staff noted red indentations on her leg from prolonged sitting. Staff and the DON acknowledged that residents should not be left in shower chairs and that adequate staffing is necessary to meet residents' needs. Additional interviews with residents and staff revealed frequent delays in call light response, with some residents reporting waits of 30 minutes to over an hour, particularly during shifts with reduced staffing. Residents with significant mobility and cognitive impairments, as well as those dependent on staff for activities of daily living, were affected by these delays. Staff and the DON confirmed that call lights should be answered within 15 minutes, but this standard was not consistently met due to staffing shortages.
Failure to Maintain Sanitary Kitchen Conditions and Prevent Cross Contamination
Penalty
Summary
Surveyors observed multiple unsanitary conditions in the facility's kitchen during two meal preparations. The stove was found with spilled pancake batter, grime, and food crumbs, while the deep fat fryer had baskets coated in grime and dark brown oil. The microwave contained food crumbs and spills, and the dry storage room floor was littered with trash, including plastic spoons, papers, sugar packets, and boxes. An open paper bag of french fries was found in a freezer, with fries spilling onto the bottom. Additional observations revealed dirt and debris on the kitchen floor in several areas, as well as crumbs and debris on the lower shelf with clean sheet pans. During meal preparation, the Dietary Manager (DM) was seen handling multiple objects, such as oven mitts, food thermometers, writing pads, refrigerator doors, and various utensils, with the same pair of gloves, without changing gloves or performing hand hygiene between tasks. The DM then used these gloved hands to handle serving scoops, which were subsequently used to portion food for residents. A similar pattern was observed when the DM prepared mashed potatoes, again touching various surfaces and utensils with the same gloves before using serving scoops to portion food. Additionally, a dietary aide served soup in a bowl that was stacked on a cart with other bowls and plates that had visible dried food residue and crumbs. Interviews with the DM revealed inconsistencies in the cleaning schedule and responsibilities. The DM initially stated that staff followed a daily cleaning schedule, but was only able to provide a blank schedule and later clarified that cleaning tasks were shared among staff. The DM also admitted that the fryer was not included on the cleaning schedule and that the stove top was not cleaned daily. Facility policies required hand washing before food preparation and after contact with unsanitary items, as well as maintaining clean and sanitary food service areas, but these standards were not consistently followed.
Failure to Ensure Consistent Communication and Documentation of Code Status
Penalty
Summary
The facility failed to ensure consistent communication and clarification of a resident's code status, specifically whether to perform cardiopulmonary resuscitation (CPR) or to follow a Do Not Resuscitate (DNR) order. The resident in question had moderately impaired cognition, as indicated by a Brief Interview for Mental Status (BIMS) score of 10 out of 15. Multiple documents in the resident's record, including the care plan, IPOST form, resuscitation designation orders, and physician orders, contained conflicting information regarding the resident's code status. Some records indicated the resident was a full code, while others indicated DNR status. Additionally, staff interviews revealed uncertainty and confusion about the resident's current code status, with staff referencing both full code and DNR in different contexts. Observation of staff interactions with the resident showed that the resident was unable to provide a clear answer regarding her wishes for resuscitation and requested that the nurse follow up with her family. Review of the code status book in the dining room also revealed the presence of both DNR and full code documentation for the same resident. The Director of Nursing acknowledged the mix-up and the need to clarify the correct code status. The facility's policy requires adherence to residents' rights to formulate advance directives and to implement guidelines regarding CPR, but this was not consistently followed in this case.
Failure to Implement Pressure Ulcer Prevention and Treatment Interventions
Penalty
Summary
The facility failed to implement and maintain appropriate interventions to prevent and treat pressure ulcers for a resident identified as being at risk. The resident, who had diagnoses including hemiplegia, dysphagia, and chronic pain syndrome, was assessed as severely cognitively impaired and at risk for pressure ulcers, but had no unhealed ulcers at the time of the initial assessment. Subsequent provider notes documented the development and ongoing presence of a deep tissue injury with eschar on the resident's right heel, with specific orders to offload pressure using heel protectors and to complete wound treatment twice daily. Despite these orders, multiple observations revealed the resident lying in bed without heel protectors, with the right heel in direct contact with the mattress. Staff, including a registered nurse, failed to apply the heel protectors during wound care, and the DON confirmed that staff were expected to ensure residents with pressure ulcers wore boots, locating alternatives if necessary. The facility's policy referenced surveillance for pressure injuries but did not specify interventions for prevention or treatment, and staff did not consistently follow the care plan directives to offload the resident's heel.
Failure to Consistently Complete Post Dialysis Assessments
Penalty
Summary
The facility failed to ensure consistent completion of post dialysis assessments for a resident with End Stage Renal Disease (ESRD) who received dialysis treatments while residing in the facility. Clinical record review showed that although pre-dialysis assessments were completed, post-dialysis assessments were missing on several occasions, specifically on 5/28/25, 6/6/25, and 6/9/25. The resident's care plan identified the risk for complications related to dialysis, and the facility's policy required ongoing assessment and monitoring before and after dialysis treatments. Interviews with staff, including an LPN and the Director of Nursing (DON), confirmed that the expected process was to complete both pre and post dialysis assessments and document them in the electronic health record. However, review of the resident's electronic health record revealed that post dialysis assessments were not completed or documented for the specified dates, contrary to facility policy and professional standards of practice.
Facility Assessment Failed to Address Hemodialysis and G-Tube Resident Needs
Penalty
Summary
The facility failed to ensure its Facility Assessment accurately identified and addressed the specialized staff training and supply needs for residents currently receiving hemodialysis and those receiving nutrition, hydration, and medications via a gastrostomy tube (G-tube). A review of the Resident Matrix showed that three residents were receiving hemodialysis and two residents were receiving care through a G-tube, yet the Facility Assessment did not reflect the presence of any such residents or their associated care requirements. None of these residents were new admissions, as all had been admitted more than 30 days prior to the review. During an interview, the Administrator acknowledged that specialized medical and nursing supplies, as well as staff education and training, would be necessary to care for residents with enteral feeding tubes and those receiving dialysis. The facility's policy and the Administrator both indicated that the Facility Assessment should be updated with changes in census case mix or the addition of new services, but the most recent assessment did not include the current needs of residents requiring hemodialysis or enteral feeding. This omission was identified despite the involvement of department heads, leadership, the Medical Director, and other stakeholders in the assessment process.
Failure to Maintain Sanitary and Comfortable Resident Room Environment
Penalty
Summary
A deficiency was identified when a pervasive urine odor was present in a resident's room, compromising the sanitary and comfortable environment required for residents, staff, and the public. Observations on multiple occasions revealed a strong urine odor upon entering the room, with staff interviews confirming that this was a persistent issue. The resident involved had severely impaired cognition, as indicated by a low BIMS score, and was frequently incontinent of urine. The care plan noted the resident's non-compliance with hygiene needs, specifically a refusal to wear incontinence products despite frequent incontinence. Housekeeping staff reported that the resident's bedding was changed daily and the mattress was sprayed, but acknowledged that the odor remained, particularly due to the resident missing the toilet frequently. Wet areas were observed on the bathroom floor, and staff confirmed that floors were mopped daily, but interventions only partially addressed the odor. Facility policy required prompt disposal of soiled linens and reporting of lingering odors, but the persistent urine smell indicated these measures were insufficient in this case.
Failure to Ensure Resident Dignity During Meal Service and Catheter Care
Penalty
Summary
Staff failed to treat residents with dignity in two separate incidents. In the first case, a resident with diagnoses of anxiety, depression, and morbid obesity, and with intact cognition, did not receive a breakfast tray in a timely manner. The resident reported to the nurse that she did not get her breakfast tray after trays were passed, which made her very upset. Staff interviews revealed that the CNA assigned to pass trays was not permitted in the resident's room, and instead of arranging for another staff member to deliver the meal, the resident was left waiting. The Director of Nursing acknowledged that a check-off system should be in place to prevent missed meal trays. In the second incident, a resident with severe cognitive impairment, Alzheimer's disease, multiple sclerosis, and bipolar disorder, who utilized an indwelling catheter, was observed in the dining room on multiple occasions without a dignity cover on the catheter bag. The catheter bag, containing visible dark yellow urine, was exposed in the presence of other residents. Staff interviews confirmed that catheter bag covers were not available in the facility storage, and both nursing staff and the DON stated that covers should be used to promote resident dignity. Facility policy required the promotion and maintenance of resident dignity, including the use of catheter bag covers.
Failure to Complete Self-Medication Administration Assessments
Penalty
Summary
The facility failed to ensure that self-medication administration assessments were completed for two residents who were permitted or requested to self-administer medications. For one resident with diagnoses including heart failure, diabetes, and anxiety disorder, the care plan noted non-compliance with medication administration, and the resident was observed with a cup of medications at bedside, specifically metformin from the previous night. Staff intervened and removed the medication, and review of the electronic health record revealed no documentation of a self-medication administration assessment for this resident. For another resident with multiple diagnoses including multiple sclerosis, paraplegia, seizure disorder, and severe allergies, there was an order for an EpiPen to be kept at bedside for self-administration in case of hypersensitivity reaction. Despite this, the resident reported not having the EpiPen available in the room and staff were unaware of the resident's allergies or the location of the EpiPen. The facility's records showed no completed self-medication administration assessment for this resident, even after the EpiPen was received. Facility policy required an interdisciplinary team determination before allowing self-administration, but this process was not documented for either resident.
Failure to Provide Privacy During Enteral Tube Feeding
Penalty
Summary
Staff failed to provide privacy during an enteral tube feeding procedure for a resident with severe cognitive impairment, hemiplegia, traumatic brain injury, and dysphagia. During the administration of medications and tube feeding via a gastrostomy tube, the LPN left the resident's room door open, exposing the resident's abdomen and G-tube throughout the procedure. A Certified Nursing Assistant also approached the open doorway and communicated with the LPN during the process, while the door remained open. Interviews with nursing staff and the Director of Nursing confirmed that the expectation is for staff to close resident doors and provide privacy during all care and nursing procedures. Review of the facility's policy on promoting and maintaining resident dignity also directed staff to maintain resident privacy. The failure to close the door and provide privacy during the procedure was observed and confirmed as not meeting facility policy and staff expectations.
Failure to Identify and Document Targeted Behaviors for Antipsychotic Use
Penalty
Summary
The facility failed to ensure that targeted behaviors were identified and documented for the use of antipsychotic medication in a resident with severely impaired cognition. The resident, who had a diagnosis of dementia with and without psychotic disturbance, was routinely administered risperidone, an antipsychotic medication. Clinical assessments, including the Minimum Data Set (MDS) and Preadmission Screening, indicated that the resident did not exhibit hallucinations, delusions, or behavioral disturbances, and had not shown behaviors while hospitalized prior to admission. Despite this, the care plan and physician orders referenced the use of antipsychotic medication for symptoms such as mild depression and psychotic features, but did not specify or describe the targeted behaviors that warranted the medication's use. Review of the resident's care plan and interventions revealed a lack of documentation regarding the specific behaviors or symptoms that justified the ongoing use of risperidone. The care plan noted a gradual dose reduction was declined due to continued symptoms, but did not detail what those symptoms were or how the resident's psychotic features manifested. Behavior monitoring records over the past 30 days showed only minimal episodes, such as two instances of anxious/restless behavior and one episode of elopement/exit seeking, with no consistent or significant behavioral issues documented. Interviews with nursing staff and CNAs further confirmed that the resident generally did not display problematic behaviors, with only occasional confusion, minor irritability, or missed toileting events reported. The facility's policy required that psychotropic medications be used only when appropriate to treat a specific, diagnosed, and documented condition, with ongoing monitoring and documentation of the resident's response. However, the documentation for this resident did not meet these requirements, as there was no clear identification or monitoring of targeted behaviors associated with the antipsychotic use. The deficiency was identified through observation, interview, and clinical record review, highlighting a failure to comply with facility policy and regulatory expectations regarding the use of psychotropic medications.
Failure to Timely Report Alleged Abuse and Resident-to-Resident Incidents
Penalty
Summary
The facility failed to report allegations of abuse, neglect, or theft in a timely manner as required by regulatory guidelines for three separate incidents involving multiple residents and a staff member. In the first incident, a resident with severe cognitive impairment and a history of falls was knocked down by another resident in a wheelchair, resulting in a large hematoma to the back of her head and a complaint of headache. Documentation showed that staff had previously observed the resident in the wheelchair behaving unsafely and nearly injuring others, but the care plan lacked sufficient interventions to address this risk. The incident was not reported to authorities prior to the following day, despite staff witnessing the event and suspecting it may have been intentional. In the second incident, a staff member was alleged to have grabbed a resident with severe cognitive impairment by the wrists and pulled her in an aggressive manner, causing the resident distress. The staff member who witnessed the event reported it to a nurse, but the facility had no documentation of this report or evidence that the allegation was reported to the appropriate authorities as of the time of the survey. Interviews with facility leadership confirmed that such allegations should be reported, but there was no record of timely reporting or investigation. A third incident involved a resident with a history of sexually inappropriate behaviors who was witnessed touching another cognitively impaired resident on the shoulders and chest/breast area. Staff immediately separated the residents and assessed them, and the incident was reported to the state agency the following day. However, facility policy required that such allegations be reported immediately, but not later than two hours after the event if abuse or serious bodily injury was involved. The delay in reporting, as well as the lack of timely documentation and investigation in the other incidents, constituted a failure to follow regulatory requirements for reporting suspected abuse, neglect, or theft.
Failure to Ensure Ongoing Discharge Planning and Safe Transfer
Penalty
Summary
The facility failed to ensure an ongoing discharge planning process for a resident with intact cognition who was reviewed for discharge. The resident's care plan indicated no plans for discharge, and the care conference review form left the discharge potential section blank. Although a Notice of Transfer or Discharge form was prepared, it was not signed by the resident or their representative. Progress notes for the period leading up to the proposed discharge date lacked documentation regarding the resident's discharge plan. The resident was later sent to the emergency room for a psychiatric evaluation and subsequently discharged to an inpatient psychiatric facility, with no evidence of a documented discharge plan in the progress notes during this period. Interviews with facility administrators revealed inconsistencies regarding the discharge process, including whether involuntary discharge paperwork was completed and whether the resident received appropriate notifications. The facility's policy required orientation and preparation for transfer or discharge to ensure safety and minimize anxiety, but there was no documentation that these steps were followed. The resident ultimately did not return to the facility, and administrators were unclear about the resident's final placement or the completion of required discharge procedures.
Failure to Revise Care Plans for Significant Changes and Critical Information
Penalty
Summary
The facility failed to revise and update care plans to reflect significant changes and critical information for several residents. For one resident with hemiplegia, dysphagia, and chronic pain syndrome, there was documented significant weight loss over a short period, but the care plan did not address this weight loss or provide direction for intervention, despite facility policy requiring individualized interventions for nutritional risk. The Director of Nursing confirmed that care plans should address significant weight losses and that staff should notify the physician and complete weights as ordered. Another resident with hemiplegia, morbid obesity, and a history of traumatic brain injury was involved in an incident where they propelled their wheelchair into another resident, causing a fall. The care plan included some interventions for wheelchair mobility and spatial awareness, but lacked additional safety interventions to ensure the safety of the resident and others. The DON acknowledged that if staff believed a resident was unsafe in a wheelchair, appropriate interventions should be included in the care plan. Additional deficiencies included a resident whose care plan did not reflect a change in advanced directive status from full code to DNR, despite documentation in nursing notes and family confirmation. Another resident with severe allergies to food, environmental factors, and medications had no care plan focus area or interventions addressing these allergies, nor documentation of a self-medication assessment or the location of their EpiPen, despite orders allowing self-administration. These omissions were contrary to facility policy and best practices for comprehensive, individualized care planning.
Failure to Provide Adequate Bathing Assistance for Dependent Residents
Penalty
Summary
The facility failed to provide an adequate number of baths for two residents who were dependent on staff for bathing assistance. One resident, with diagnoses including heart failure, depression, and obesity, was cognitively intact and had a care plan specifying showers on Tuesdays and bed baths on Fridays. Documentation showed missed baths, with gaps of up to ten days between bathing, and instances where refusals were recorded without the resident actually refusing. There was also a lack of follow-up documentation or staff response to missed or allegedly refused baths, despite facility policy requiring notification and follow-up by nursing staff. Another resident, with moderate cognitive impairment, diabetes, recent UTI, Parkinson's disease, dementia, and pressure ulcers, was also dependent on staff for bathing and required two-person assistance. The care plan addressed resistance to care and outlined steps for staff to follow if the resident refused. However, documentation revealed a seven-day gap between showers, coinciding with the scheduled bath aide's vacation, and staff interviews confirmed the resident had not refused showers. Facility policy required regular bathing to maintain hygiene and prevent skin issues, but this was not consistently followed.
Failure to Assess and Intervene for High Blood Sugar Episodes
Penalty
Summary
The facility failed to assess and intervene appropriately for two residents with diabetes who experienced multiple episodes of high blood sugar (hyperglycemia). For one resident with a history of diabetes, hemiplegia, and seizure disorder, the care plan directed staff to observe for signs of hyperglycemia, and the medication order required staff to administer insulin and notify the provider for blood sugars over 399 mg/dl. However, the electronic health record showed several blood sugar readings above this threshold without documentation of provider notification or follow-up interventions. Similarly, another resident with diabetes, heart failure, and anxiety had care plan instructions for monitoring medication effectiveness and orders for insulin administration. Despite blood sugar readings above 400 mg/dl, there were no documented provider notifications or follow-up actions. Staff interviews revealed inconsistent understanding of when to notify providers about high blood sugar levels, and the Director of Nursing acknowledged poor documentation practices and agreed that staff should have contacted the provider for abnormal blood sugars.
Failure to Follow Infection Control and Catheter Care Protocols
Penalty
Summary
Staff failed to follow proper infection control and catheter care procedures for a resident with an indwelling urinary catheter. During observed catheter and perineal care, a CNA used the same side of a washcloth multiple times to clean different areas, did not rinse or dry the resident’s skin after cleaning, and did not perform hand hygiene between glove changes. The CNA also did not consistently use the required Enhanced Barrier Precautions (EBP), such as wearing a gown, during high-contact care activities. Interviews with staff confirmed a lack of adherence to hand hygiene protocols and proper use of personal protective equipment as outlined in facility policy. The resident involved had a history of multiple sclerosis, neurogenic bladder, and a recent urinary tract infection, and was dependent on staff for toileting. The care plan specified the need for EBP due to the presence of an indwelling catheter and a history of multidrug-resistant organism colonization. Despite these documented needs, staff did not consistently implement the required precautions or follow the facility’s catheter care policy, which included specific steps for cleaning, drying, and securing the catheter and surrounding area. Additionally, the resident reported being without an anchoring strap for the catheter tubing, resulting in the tubing being taped to the thigh, which caused irritation and pulling. Observations revealed the catheter bag was leaking and covered with a stained pillowcase, and the bag was not promptly changed after the leak was reported. Staff interviews confirmed that the expected practice was to use proper anchoring devices and to change leaking catheter bags immediately, but these actions were not taken in a timely manner.
Failure to Notify Physician and Intervene After Significant Weight Loss
Penalty
Summary
The facility failed to notify the physician and implement timely interventions following a significant weight loss in a resident with multiple medical conditions, including hemiplegia, dysphagia, and chronic pain syndrome. The resident was dependent on staff for eating assistance and had a feeding tube, with severely impaired cognition. Despite care plan directives and physician orders to monitor weights and notify the provider of significant changes, the facility did not clarify discrepancies in recorded weights, did not document a weight during a required week, and did not notify the physician of a substantial weight loss from 166 lbs to 150 lbs over eight days. There was also no documentation of interventions to address the weight loss prior to eventual physician notification. Staff interviews revealed a lack of clarity regarding which weight measurements were accurate and inconsistent monitoring and follow-up on significant weight changes. The Registered Dietician was on leave during the period in question, and the substitute RD did not monitor or document weight changes as required. The facility's policy required physician notification and individualized care plan interventions for significant weight changes, but these actions were not documented or carried out in a timely manner for the resident.
Failure to Provide Requested Therapy Services
Penalty
Summary
The facility failed to provide specialized rehabilitative therapy services for a resident who expressed a desire to become more mobile. The resident, who had diagnoses including heart failure, diabetes, and anxiety disorder, was found to have intact cognition. Documentation showed that the resident requested physical therapy, but there was no evidence in the clinical record of follow-up or provision of therapy services after the initial request. Staff interviews confirmed that the resident's changing payor source was cited as a challenge, but there was no documentation of further efforts to address the resident's request for therapy. Facility policy required the provision of specialized rehabilitative services to meet residents' needs, but this was not followed in this case.
Failure to Post Daily Nurse Staffing and Census Information
Penalty
Summary
The facility failed to post the daily census and nurse staffing information in a visible location as required by facility policy. Multiple observations conducted on several dates revealed that the required information was not posted in the lobby area, where it was supposed to be accessible to residents, staff, and visitors. The absence of this posting was confirmed during interviews with the Administrator and the Staffing Coordinator. The Administrator acknowledged that the information should have been posted above the sign in/out table and confirmed it was not present during the surveyors' visits. The Staffing Coordinator stated she was not aware that posting the daily census and nurse staffing information was her responsibility prior to the day of the interview. Review of the facility's policy indicated that the nurse staffing sheet should be posted daily at the beginning of each shift and be readily available for review.
Failure to Follow Physician Orders for Warfarin Administration
Penalty
Summary
A deficiency occurred when staff failed to follow physician orders for warfarin (Coumadin) administration for a resident with a history of atrial fibrillation, dementia, and a prosthetic heart valve. The resident had a prescribed warfarin dose of 5.5 mg daily, with a therapeutic INR goal of 2.5 to 3.5. Despite an elevated INR result of 6.7, a physician order was given to hold the warfarin dose and decrease the daily dose to 5.0 mg starting the following day. However, the Medication Administration Record (MAR) documented that the resident continued to receive 5.5 mg of warfarin on the day of the elevated INR and for the next three days. The resident's INR continued to rise, reaching 12.4 on a subsequent test. The resident was then admitted to the hospital with pneumonia, urinary tract infection, and a critically high INR of 13, requiring treatment with Vitamin K. Interviews with staff revealed confusion and lack of clarity regarding the process for holding medications, transcribing physician orders, and updating the MAR. Staff members were unsure about how to properly document and communicate hold orders, and there was inconsistency in the understanding of who was responsible for entering and confirming medication changes in the electronic health record system. The facility's policy required clear documentation and adherence to physician orders for anticoagulant use, including holding medications when lab values were outside the therapeutic range. Despite this, the resident received unnecessary doses of warfarin after orders to hold the medication, resulting in a significant medication error and an Immediate Jeopardy situation for the resident's health and safety.
Removal Plan
- Policy/procedure review/revision by the DON/designee.
- Licensed nurse education on facility policies regarding high-risk medication, anticoagulants, transcribing physician's orders, and notifying the physician when lab values not in the therapeutic range, and re-education on putting in appropriate hold orders.
- Licensed nurse education on appropriate transcription of putting medication on hold.
- Corrective action/one to one education with licensed nurse/Certified Medication Aide identified in deficient practice.
Facility Fails to Maintain Clean and Sanitary Environment
Penalty
Summary
The facility failed to maintain a clean and sanitary environment for its residents, as evidenced by observations and interviews with residents and staff. Resident #5, who has an intact cognitive status and requires maximal assistance for daily activities, reported that her room was filthy and not cleaned properly. Observations confirmed that the floor in her room was gritty, the bathroom floor was wet with pooled dark water, and debris was present on the toilet seat and along the backside of the toilet. Staff B, a housekeeper, was observed leaving Resident #5's room without adequately cleaning these areas. Similarly, Resident #3, who has a moderately impaired cognitive status and requires maximal assistance, was found to have a dirty room and unswept, unmopped bathroom floors. Despite Staff B's efforts to clean the room, toilet tissue remained on the floor, indicating incomplete cleaning. Interviews with Staff B and Staff A, the Housekeeper Director, revealed inconsistencies in cleaning practices and a lack of documentation for monthly deep cleaning. Staff A mentioned that each resident's room should be cleaned daily, with beds stripped and sanitized weekly, and deep cleaning performed monthly, but was unable to provide records of these activities.
Failure to Conduct Proper Narcotic Counts and Secure Medication Keys
Penalty
Summary
The facility failed to adhere to its policy requiring two licensed nurses to conduct shift change controlled substance counts, leading to discrepancies in narcotic counts. On one occasion, a Certified Medication Aide, Staff C, completed the narcotic count alone at the end of her shift after being unable to contact the overnight nurse. She then left the medication cart keys in an unlocked drawer at the nurse's station, a practice she stated was common. This lack of adherence to protocol was further evidenced when Staff B, a Certified Nurse Aide, observed another aide, Staff A, with the medication keys and rummaging through the medication cart. Additionally, Staff D, a Registered Nurse, also failed to follow the facility's policy by counting narcotics alone on multiple occasions and passing the medication cart keys without conducting the required count with another nurse. This resulted in missing narcotics, including Hydrocodone/APAP and Morphine sulfate, as discovered by Staff E, a Certified Medication Aide, during her shift. The discrepancies were reported to the Administrator and Director of Nursing, highlighting the facility's failure to maintain accurate narcotic counts and secure medication cart keys as per their policy.
Unauthorized Access to Medication Cart Keys and Missing Narcotics
Penalty
Summary
The facility failed to ensure that medication cart keys were only accessible to authorized personnel, leading to a breach in the security of controlled substances. On the evening of 7/9/24, Staff C, a Certified Medication Aide, was responsible for passing medications and completed the narcotic count with a Registered Nurse, Staff G. However, at the end of her shift, Staff C was unable to find the overnight nurse to complete the narcotic count and instead counted the narcotics on her own, which was a common practice at the facility. She then placed the medication cart keys in an unlocked drawer at the nurse's station, in the presence of two aides, before leaving. This practice was corroborated by Staff B, a Certified Nurse Aide, who witnessed Staff A, another aide, accessing the medication cart with the keys left unsecured. The following morning, Staff E, a Certified Medication Aide, discovered missing narcotics during her shift. She found that two tablets of Hydrocodone/APAP and a dose of Morphine sulfate were missing from the supplies of two residents. Staff E reported these findings to Staff D, the overnight charge nurse, and subsequently to the Administrator and Director of Nursing. Later, during a shift change, Staff E and Staff F, an LPN, discovered an entire bubble pack of 30 doses of Oxycodone was missing from another resident's supply. The report highlights the facility's failure to adhere to its policy requiring two licensed nurses to account for all controlled substances and access keys at the end of each shift, resulting in unauthorized access to medication cart keys and missing narcotics.
Inaccurate MDS Coding for Medications and Services
Penalty
Summary
The facility failed to accurately code medications and services in the Minimum Data Set (MDS) assessments for four residents. Resident #34's MDS inaccurately coded insulin use, as the resident's insulin orders were discontinued, yet the MDS reflected insulin administration. Resident #22's MDS failed to indicate hospice services, despite the resident receiving hospice care and having hospice as the primary payer. The facility's policy on maintaining MDS assessments lacked documentation on ensuring the accuracy of the MDS. Resident #21's MDS inaccurately indicated the use of anticoagulant medication instead of antiplatelet medication, despite physician orders for clopidogrel, an antiplatelet medication. Similarly, Resident #25's MDS incorrectly listed anticoagulant medication use, while the resident was prescribed and administered antiplatelet medications, including clopidogrel and aspirin. These discrepancies highlight the facility's failure to ensure accurate MDS coding, impacting the care and services provided to the residents.
Deficiencies in Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to ensure that each resident had a comprehensive individualized care plan that accurately reflected their plan of care. This deficiency was identified for four residents. One resident, with a diagnosis of type 2 diabetes mellitus, had a care plan that lacked specific interventions or a focus area for diabetes management, despite having physician orders for insulin. The Corporate Nurse acknowledged the absence of a diabetes focus in the care plan, which was expected to include monitoring of blood sugars. Another resident, who used oxygen therapy, had a care plan that did not address the use of oxygen, even though physician orders specified oxygen administration to maintain adequate oxygen saturation levels. The facility's Director of Nursing and Corporate Nurse were initially unaware of the omission, attributing it to the resident's hospice services, but later acknowledged the oversight. A third resident, with a diabetic foot ulcer and other wounds, had a care plan that failed to document current wounds or interventions for wound care and monitoring. The care plan also lacked documentation for the monitoring and care of the resident's PICC line and antibiotic administration. The Director of Nursing confirmed the care plan's deficiencies. Additionally, a fourth resident's care plan inaccurately reflected hospice services, lacking a specific focus and interventions related to hospice care, despite the resident's enrollment in hospice services.
Inadequate Staffing Leads to Resident Care Deficiencies
Penalty
Summary
The facility failed to provide adequate staffing in the dining room during lunch, resulting in insufficient assistance for residents with eating and toileting needs. This deficiency was observed when a Licensed Practical Nurse (LPN) was the only staff member present in the dining room, assisting multiple residents simultaneously. Resident #17, who had severe cognitive impairment and required assistance with toileting, experienced an incontinent episode in the dining room due to the lack of timely help. The LPN attempted to instruct the resident to propel himself to the bathroom, but he was unable to make it in time, leading to the incident. Other residents also reported issues related to insufficient staffing. Resident #33, with moderately impaired cognition, expressed frustration over long wait times for assistance with changing, attributing the delays to a lack of staff. Similarly, Resident #45, who required assistance with various activities, reported receiving incorrect medication and delayed administration of her evening medication, again pointing to inadequate staffing levels. Resident #41, with moderately impaired cognition, noted that it often took a long time for staff to respond to call lights, further highlighting the staffing issues. Interviews with staff members revealed that the facility typically scheduled three Certified Nurse Aides (CNAs) for the hall, but on the day of the incident, only two were available due to one CNA attending an appointment with a resident. Staff members acknowledged that with only two CNAs, they struggled to provide timely care, and residents did not receive the attention they deserved. The Director of Nursing (DON) and the Administrator both commented on the situation, with the DON noting that the facility usually had sufficient staffing and the Administrator attributing the incident to a lack of communication rather than staffing shortages.
Failure to Follow Pureed Diet Menu
Penalty
Summary
The facility failed to adhere to the prescribed dietary menu for residents on a pureed diet. During an observation on June 26, 2026, Staff H, a cook, prepared a meal that omitted pureed cornbread, which was specified in the Week 4 Wednesday Diet Spreadsheet. The menu for the pureed diet included pureed barbecue pork, potato salad, creamy coleslaw, cornbread with margarine, cinnamon applesauce, coffee or hot tea, and milk. However, the cornbread was not pureed as required. The facility had a census of 61 residents, with five residents on a pureed diet and one additional resident who requested it. The Dietary Manager acknowledged the oversight, admitting that the cornbread might have been missed. The facility's Food Preparation Guidelines, revised in January 2023, instructed staff to follow written menus and standardized recipes, which were not followed in this instance.
Sanitation and Food Safety Deficiencies in Kitchen and Food Transport
Penalty
Summary
The facility failed to maintain the kitchen in a sanitary manner, as observed during an inspection. Several issues were noted, including bins of cornstarch and sugar with scoops stored inside the product, which is not a sanitary practice. The chest freezer contained two bags of hamburger with openings, exposing the contents to air, and loose tater tots were found in one of the storage compartments. Additionally, loose debris was observed inside the bread refrigerator, and an open, undated container of cultured sour cream was found in Refrigerator 5. The Dietary Manager acknowledged the oversight regarding the sour cream's date and the lack of testing for the dishwasher's temperature and chemical levels, which are essential for ensuring proper sanitation. Furthermore, the facility did not adequately cover food during transportation to residents' rooms. Dietary staff were observed carrying uncovered plates through the hallway to different resident rooms, as the facility lacked lids for the plates. The Dietary Manager admitted that they recommended using foil to cover the food during transportation, but this practice was not consistently followed. These deficiencies highlight lapses in food safety and sanitation practices within the facility, which could potentially impact the quality of care provided to the residents.
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 30 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
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Nursing homes near Fairfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Parkview Care Center | 0.6 mi | ★★★★★ | 0 | 0 |
| Parkview Home | 17.9 mi | ★★★★★ | 0 | 0 |
| Country Lane Manor | 18.5 mi | ★★★★★ | 1 | 0 |
| Park Place | 20.7 mi | ★★★★★ | 2 | 0 |
| Woodland Health And Rehabilitation | 21.3 mi | ★★★★★ | 6 | 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.