Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at California Terrace during CMS and state inspections, most recent first.
A facility failed to maintain an effective roach control program and sanitary waste management, as evidenced by staff reports of frequent roach sightings, a resident’s report of daily roaches in his room and on his bed and wheelchair, and direct observation of multiple roaches in that resident’s room. Housekeeping and maintenance leaders acknowledged that roach sightings are often reported but admitted they do not review pest sighting logs on the units and sometimes do not request as-needed pest control visits after sightings. The dumpster area was found with open, overflowing containers and scattered food waste, in direct conflict with facility policies requiring sealed trash bags, closed and clean dumpsters, and environmental conditions that prevent insect harborage.
The facility failed to maintain a clean, safe, and homelike environment as required by its housekeeping policy, affecting all residents. Multiple residents, including individuals with moderate cognitive impairment and others with intact cognition and significant medical conditions, reported dirty rooms, overflowing trash, and filthy dining chairs. Surveyors observed dirty bathroom floors, brownish stains on walls and floors, dried food and spills on floors and tables, stained and caked-on food in chair crevices, dust and old food on heating units, and black or brown dust on ceilings and vents across several floors. Broken tables and seats were left in resident-accessible dining areas, and shower and privacy curtains were missing in some areas. Housekeeping and supervisory staff acknowledged that floors were not being mopped daily, chairs were not being cleaned, day rooms were not consistently cleaned after meals, trash was not always emptied daily, and that staffing and workload sometimes prevented daily room cleaning, contrary to the written housekeeping guidelines.
A resident with schizoaffective disorder, bipolar type, muscle wasting, and rheumatoid arthritis, and moderate cognitive impairment was found with clothing in a closet that was not folded and included stained pants and shirts, making it unclear which items were clean or dirty. An LPN reported that CNAs are responsible for separating clean and dirty clothes after laundry but that this was not done, and both the LPN and a CNA acknowledged that mixing clean and dirty clothes is not acceptable and can leave the resident in smelly, uncomfortable clothing. This situation conflicted with the facility's Resident Rights policy requiring a safe, clean, comfortable, homelike environment and care that promotes dignity and quality of life.
A resident with epilepsy, unsteadiness, and muscle wasting was pushed and knocked down by another cognitively intact resident with serious mental illness and documented behavior problems, after a verbal altercation involving a third resident escalated despite staff presence and attempted separation. The injured resident sustained a scalp hematoma requiring hospital evaluation. Interviews showed that while a CNA attempted to intervene, the push occurred as staff turned away, and the Administrator later characterized the event as an accident. The Social Service Director acknowledged not reviewing PASRR Level I/II documents for the involved residents, contrary to facility policy requiring PASRR review to identify behavioral needs and guide care planning, contributing to the failure to prevent resident‑to‑resident physical abuse.
The facility failed to maintain an adequate supply of clean linen, including towels and washcloths, resulting in two residents not receiving timely hygiene care and showers. One resident with severe cognitive impairment and extensive medical comorbidities required incontinence care after a BM but remained in bed waiting to be changed while a CNA reported having no towels or washcloths and resorted to using pieces of a cut-up sheet. Another cognitively intact resident reported that when he wanted to shower in the morning, towels were sometimes unavailable. Surveyors observed empty linen rooms and carts on upper floors, staff confirming delayed or missing linen deliveries, and very limited stock in the central linen room, while laundry logs documented minimal or no towels delivered to certain floors, demonstrating a systemic linen shortage affecting resident cleanliness and comfort.
The facility failed to prevent and control a roach infestation, resulting in live roaches being found in resident rooms and beds. Multiple residents with intact cognitive status, as well as family members and staff, reported or observed roaches in mattresses, personal items, and throughout living areas. Maintenance logs and staff interviews confirmed the ongoing presence of pests despite regular extermination efforts, and the facility did not effectively implement its pest control policy.
Several residents with significant mobility and self-care deficits experienced prolonged delays in staff response to call lights, with some waiting up to an hour or more for assistance. Additionally, multiple residents reported that broken furnishings, such as bedside tables and bathroom grab bars, were not repaired for weeks or months, despite maintenance policies and care plan interventions requiring prompt attention. Staff interviews and record reviews confirmed that maintenance issues were not consistently reported or addressed in a timely manner.
Surveyors found persistent stains, debris, and unaddressed maintenance issues throughout the facility, including dirty dining rooms with leftover food and trash, stained and damaged ceiling panels, and chipped paint. Multiple residents reported slow maintenance response and inadequate housekeeping, while staff interviews confirmed lapses in daily cleaning and environmental checks, resulting in unsanitary and unhomelike conditions.
A resident with left-sided weakness and a history of falls was repeatedly observed without a required wheelchair leg strap, despite care plan directives. The resident and others encountered hazards due to multiple cracks and uneven surfaces on the patio ramp, causing mobility devices to get stuck and nearly resulting in a fall. Staff were aware of the missing leg strap and the ramp hazard, but neither issue was addressed, contrary to facility policy.
Food Storage, Hygiene, and Utensil Sanitation Deficiencies: Boxes of food were stored on the floor in the walk-in refrigerator, freezer, and dry storage area, including items placed on wet flooring from a ceiling leak. A dietary aide was observed preparing and serving food without both beard and mustache covered, serving spoons were stored dirty with grime and black specks, and sliced bread crates were left unlabeled.
Dumpster Area Not Kept Clean or Covered: Surveyors observed dietary trash scattered around the dumpster grounds, including milk cartons, paper plates, foam cups, and napkins, with one dumpster lid left open. The Dietary Manager and Maintenance Director both acknowledged that trash should be secured in the dumpsters, and the Administrator stated the lid should be closed and the surrounding area kept clean.
Failure to maintain a facility-wide antibiotic stewardship monitoring system. The IP stated antibiotic monitoring had been delegated to the DON, but the DON was not keeping up with the antibiotic stewardship log and the IP could not provide prior months' monitoring of residents receiving antibiotics. The facility policy requires the IP-led ASP to track antibiotic use and review antibiotic prescriptions for appropriateness of dose, duration, and indication.
Pest control program failed to keep the facility free of insects. A resident with DM2, muscle wasting/atrophy, difficulty walking, abnormal posture, HTN, and intact cognition reported roaches and gnats in her room and said she was scared to sleep; surveyors also observed a roach behind a calendar on her wall and a live bug near the elevator. The DON and Maintenance Director described a notification process for insect or mouse sightings, and a service inspection report documented dead roaches in a resident room and a healthcare maintenance area.
Failure to obtain orders for self-administration of medications: Two residents had medication left at the bedside without physician orders allowing self-administration. One resident with dementia and moderately impaired cognition had a nighttime pill found in a cup on a light fixture, and staff stated it should not have been left there. Another resident had a labeled cup with Nystatin powder on the nightstand, and staff stated bedside medication should not be present. Neither resident had a self-administration order or care plan.
A razor was found at a resident’s bedside in Unit 3A, and the RN stated razors should never be left there because anyone entering the room could grab it and harm themselves or the resident. The DON later stated the razor should be disposed of in the sharps container and noted that another resident in the unit could pick it up and harm himself or others. The resident had HTN, hemiplegia/hemiparesis, and candidiasis of the skin and nail, and a BIMS score of 15 indicating cognitive intactness.
Loose pills of different sizes, shapes, and colors were observed at the bottom of a medication cart used for 33 residents. An RN stated the 11:00pm-7:00am shift was supposed to clean the cart, and the DON stated nurses working the carts were responsible for keeping them free of loose pills and spills. The facility policy required medications and biologicals to be stored safely, securely, and properly, with contaminated medications removed and disposed of.
Staff failed to follow infection control practices during resident care, tray delivery, and medication administration. An RN and CNAs were observed entering and exiting an EBP room without hand hygiene, passing trays without cleaning hands between residents, touching oral meds with a bare finger, and using shared BP equipment on multiple residents without disinfecting it. The report also noted missing EBP signage and PPE bin outside a resident’s room with a suprapubic catheter, and a CNA placing soiled linen on a clean linen cart.
The facility failed to ensure code status physician orders were documented in the EMR for two residents reviewed for advance directives. One resident had diagnoses including COPD and venous insufficiency, with a POLST showing full treatment and a care plan noting DNR/Full code, but no code status order appeared on the Physician Order Sheet. Another resident with intact cognition had no code status displayed on the PCC profile or order screens. Staff stated code status should be documented in the resident record and orders.
A resident with a new diagnosis of schizoaffective disorder was not referred for a new PASRR screening after the diagnosis changed. The record contained only an older screening form, while the MDS showed moderately impaired cognition and delirium-related findings. Staff interviews confirmed that a new PASRR should have been completed when the new diagnosis was identified.
Failure to provide ADL grooming and shaving for two residents. One resident with a self-care deficit and care plan for assistance with dressing and hygiene was observed wearing the same clothes over multiple days, reported not having clothes returned, and had a last documented shower several days earlier after refusing ADL care due to fear clothes would be stolen. Another resident with dementia and cognitive impairment was observed ungroomed with facial hair and stated not knowing the last time he had been shaved; the DON stated shaving is part of ADL care and should be provided daily or as needed.
Low Air Loss Mattress Set Incorrectly: A resident with HTN, muscle weakness, and dementia was found lying on a low air loss mattress set to Firm with the Static button on. An LPN confirmed the settings, and the wound care nurse later stated the mattress should be set according to the resident’s weight; the resident weighed 167.2 lbs, but the dial had been set to 350 lbs. The resident’s MDS noted pressure ulcer risk and use of a pressure-reducing bed device.
Oxygen equipment was left uncovered for three residents receiving respiratory care. A nebulizer mask and nasal cannula tubing were observed out in the open instead of being bagged or otherwise contained after use, and staff including an LPN, RN, and DON stated the equipment should be covered to prevent contamination.
Incorrect Insulin Dose Prepared: An LPN prepared an insulin syringe with 6 units for a resident whose sliding scale order required 7 units based on a blood sugar of 258. The error was identified before administration when the surveyor stopped the nurse and the order was rechecked. The resident had Type 2 DM and severely impaired cognition, and facility leadership stated insulin administration requires verifying the five rights and the correct dose before giving the medication.
The facility failed to monitor personal refrigerator temperature logs and failed to ensure that residents' personal refrigerators had thermometers. Staff gave conflicting statements about responsibility for monitoring, and one resident's refrigerator was observed without a thermometer, with the gauge sitting on the nightstand after being broken for about 3 days. The issue affected two residents, including one with protein-calorie malnutrition and another who was cognitively intact.
A resident with depression, HTN, syncope, collapse, and moderate cognitive impairment was observed in a room without privacy curtains. The resident stated they had been there for 2 months and had not had any privacy curtains. The DON said privacy curtains provide privacy during care and are a dignity issue, and the Administrator and Housekeeping Supervisor stated residents in shared rooms should have privacy curtains when available.
Two cognitively intact residents engaged in a verbal and physical altercation after a dispute over TV and radio volume, resulting in one resident being struck on the head with a dumbbell and sustaining a laceration that required staples. Staff responded after being alerted by another resident, and documentation confirmed the incident as physical abuse. Staff were aware of abuse prevention protocols and had received relevant in-service training.
A resident with multiple medical and psychiatric diagnoses was subjected to verbal and emotional abuse by another resident, who became aggressive and attempted to strike him during an altercation over personal belongings. Staff and LPNs confirmed the incident, which was not prevented despite facility policies on abuse prevention and resident safety.
A deficiency was cited when a facility area was found to contain accident hazards and lacked adequate supervision to prevent accidents. The environment did not meet required safety standards, resulting in insufficient oversight.
The facility failed to ensure timely responses to nurse call systems, affecting seven residents. Observations showed that calls were often ignored or delayed, with one resident found in need of care and another having to use a personal phone for assistance. Staff were unaware of calls due to a covered call system screen, despite a policy requiring prompt responses.
The facility failed to maintain a functional call light system, affecting residents on the third and fourth floors. Observations revealed unplugged or malfunctioning call light phones, leading to delayed staff responses. Residents reported long wait times for assistance, with one experiencing a medical emergency. Staff acknowledged the risks of a non-functional system, and maintenance issues were noted.
A resident with severe cognitive impairment was physically abused by another resident in the dining room, resulting in a laceration and hospitalization. The aggressive resident, who was mildly cognitively impaired, was difficult to redirect and verbally aggressive. The facility failed to prevent the altercation, leading to a deficiency in care standards.
The facility failed to ensure cleanliness in the third and fourth floor shower rooms, affecting residents' use of these areas. Surveyors found feces and a soiled diaper on the floors, and residents reported similar observations. Housekeeping and nursing staff had unclear responsibilities for cleaning, leading to unsanitary conditions. The facility's policies require maintaining a clean and safe environment, which was not met.
The facility failed to post accurate and timely daily nursing staffing information, affecting all 230 residents. The staffing information was not posted on time on one day and was posted with an incorrect year and missing census on another. The Staffing Coordinator admitted to these oversights, while the DON and Administrator confirmed the requirement for accurate postings at the start of each shift.
The facility failed to ensure cleanliness in the residents' common shower room on the second floor, affecting 66 residents. A surveyor observed debris and dirt, including plastic bottles and towels, on the floor. The Nurse Manager and Housekeeping staff acknowledged the unsanitary conditions and the infection control concern. The DON confirmed the expectation for cleaning between uses to prevent infection spread.
The facility failed to maintain a pest-free environment, with cockroaches observed in resident rooms on the 2nd floor. Multiple residents reported frequent sightings of roaches, and the nurse manager confirmed the issue. Facility inspection reports highlighted cleanliness problems and food left around, attracting pests. The administrator had no comment on pest control measures.
A resident with a history of cellulitis and an amputated leg developed maggots in a foot wound due to inadequate wound care. Despite hospital recommendations for daily betadine and gauze dressing, the facility's records show inconsistent treatment. The resident reported a painful ingrown toenail, but the Nurse Supervisor did not assess the foot, and the Wound Care Nurse refused a bandage change. The Nurse Practitioner confirmed maggots in the wound, attributing it to moisture attracting flies.
A facility failed to implement and supervise a care plan for a resident with self-harm and suicidal behaviors, resulting in multiple incidents of self-injury. The resident accessed dangerous objects like a shaving blade and a spoon to cut himself and punched a glass-framed picture, requiring hospitalization. The care plan was not updated, and no interventions were in place to prevent further harm, despite the resident's known history and triggers related to smoking restrictions.
A resident with schizophrenia and bipolar disorder exhibited aggressive behavior, leading to altercations with two other residents. Despite staff intervention, the situation escalated, resulting in physical harm to one resident. The facility's failure to provide adequate supervision and address the risk of abuse in care plans contributed to these incidents.
The facility failed to report two incidents involving a resident and other residents, where physical and verbal altercations occurred. Despite staff presence, including the Administrator and Assistant Director of Nursing, these incidents were not reported to the State Agency as required by the facility's policy. The Director of Nursing, working remotely, was not informed, highlighting a breakdown in communication and policy adherence.
The facility failed to maintain food safety standards, including daily temperature checks for coolers and freezers, proper storage of scoops, and use of beard guards by dietary staff. Additionally, expired test strips were used for sanitizing utensils, potentially compromising food safety. These deficiencies were acknowledged by staff and highlighted by the consultant dietary manager.
The facility failed to maintain an effective pest control program, as dumpsters were observed overflowing with trash and lids left open, allowing potential pest entry. Additionally, a gap between the loading dock doors was noted, further compromising pest control efforts. Staff acknowledged these issues, which contradict the facility's policies on sanitation and pest prevention.
A resident with cognitive impairments and chronic respiratory issues was found with a portable oxygen tank improperly stored on the floor, contrary to facility policy. Staff acknowledged the risk of combustion from the free-standing tank, which should have been secured in a holder or designated area.
The facility failed to properly label, date, and contain oxygen equipment for several residents requiring respiratory care. Observations showed outdated and improperly stored nebulizer masks and humidifier bottles, contrary to facility policy requiring weekly changes. Staff acknowledged the oversight and the importance of proper equipment maintenance for infection control.
The facility failed to accurately account for controlled substances and did not dispose of expired medications, affecting four residents. Discrepancies in drug counts and expired insulin were found during a survey. LPNs admitted to not following procedures for narcotic accountability and medication storage, leading to these deficiencies.
A facility failed to implement Enhanced Barrier Precautions (EBP) for residents with conditions requiring such measures, and a CNA did not follow proper glove and washcloth changing protocols during ADL care. The Infection Preventionist and nursing staff showed inconsistent understanding of EBP requirements, and there were no EBP orders in residents' records, risking infection spread.
The facility failed to maintain cleanliness in the fourth floor resident pantry, affecting 65 residents. Observations revealed substances on the microwave, overflowing garbage, and dried substances on walls and floors. Staff interviews confirmed that housekeeping is responsible for cleaning, but the schedule was not followed, resulting in unsanitary conditions.
The facility failed to provide a homelike environment due to insufficient linens and towels, leading to residents using dirty pillowcases and sheets. Privacy and cleanliness were compromised as some residents lacked privacy curtains, and several rooms were missing window curtains, affecting residents' comfort and privacy.
A resident with severe cognitive impairment and multiple diagnoses was found with dirty fingernails, indicating a failure in providing adequate nail care. The resident expressed a desire for nail cleaning, and staff acknowledged that nail care should be part of daily activities and showers. Facility policies require maintaining residents' nails short, smooth, and clean.
The facility failed to monitor personal refrigerator temperatures for two residents, leading to a deficiency in food safety. Despite policies requiring daily checks, inconsistencies were found in the monitoring process, with staff providing conflicting information about responsibilities. This oversight affected a cognitively intact resident and another with cognitive impairments, potentially exposing them to spoiled or expired food.
A resident's call device was found non-functional, affecting their ability to request assistance. The issue was confirmed by the Social Service Director, and another resident noted the device had been broken for months. The affected resident's care plan emphasized the need for a working call light due to fall risks.
Failure to Maintain Effective Roach Control and Sanitary Waste Management
Penalty
Summary
The facility failed to maintain an effective pest control program to eliminate roaches, affecting one of three residents reviewed and potentially all 247 residents. A housekeeping aide reported seeing roaches during routine cleaning, most recently about one week prior on the fourth floor, and stated she uses roach spray in resident rooms when she sees many roaches and reports sightings continuously to the Administrator. Another housekeeping aide reported last seeing roaches about two months earlier in resident rooms and stated that after he reports sightings to the Administrator, the pest control company typically comes the following week. During observation of a resident in his room, the resident reported seeing roaches daily, especially at night, and stated he could not eat food in his room without roaches crawling into it and that roaches were on his bed and chair at night and felt as if they were biting him. At that time, the surveyor observed multiple roaches crawling under and on the resident’s motorized wheelchair and on the wall near the bathroom. When this was brought to the housekeeping aide’s attention, he acknowledged they were roaches and commented that they appeared because there was “company,” indicating awareness of an ongoing roach presence in the environment. The Housekeeping Director stated that staff and residents frequently report roach sightings to him and the Maintenance Supervisor, that pest control visits occur bimonthly and as needed, and that there is a pest control sighting book on each unit. However, he admitted that he and the Maintenance Supervisor do not check these books and that only the pest control company reviews them during bimonthly visits, meaning there could be unaddressed sightings. He also acknowledged seeing a roach in the pantry one week earlier and killing it without contacting pest control for an as-needed visit. The Maintenance Supervisor confirmed that staff and residents report sightings to him and the Housekeeping Director, denied knowledge of the pest control books, and reported seeing a roach in a shower room about a month earlier without notifying pest control until their next scheduled visit. Additionally, inspection of the dumpster area revealed open and overflowing dumpsters with trash and old food scattered from the ramp to the dumpster, contrary to the facility’s policies requiring sealed trash bags, closed and clean dumpsters, and grounds free of debris, as well as the pest control policy assigning responsibility for coordinating pest control and maintaining conditions that prevent insect harborage.
Failure to Maintain Clean, Safe, and Homelike Environment Throughout Facility
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, clean, comfortable, and homelike environment in accordance with its housekeeping policy, affecting all 244 residents. Multiple residents with varying cognitive and physical conditions reported and were observed living in unclean conditions. One resident with intact cognition and a history of diabetes, frostbite, gangrene, and partial toe amputation refused to sit on dining room chairs, describing them as “nasty and filthy” and stating he had never seen them cleaned. Another resident reported that floors were usually swept but not mopped, garbage was not taken out daily, and that overflowing trash in the room made him feel bad; his bathroom and toilet floors were observed to be dirty with brownish material on the toilet bowl and floor, and his garbage can was overflowing. Surveyors observed widespread environmental uncleanliness and disrepair throughout the facility’s common areas and resident rooms. On multiple floors, dining rooms and day rooms had dried food particles on floors and tables, chairs with brownish stains and caked-on food in crevices, spills on floors, dust and old food particles on heating units, and black or brown dust on ceilings and vents. Broken tables and seats were present in resident-accessible dining areas, including two broken tables on one floor and broken seats in another dining room. On one unit, there were no shower curtains on the large end of the shower room separating two showers, and in one resident’s room, large brownish stains were observed on the walls and floors, with food particles around the baseboards and no privacy curtains present. Facility staff interviews corroborated the observations of inadequate cleaning and environmental maintenance. A housekeeper stated that floors on one floor were not clean, with used paper towels, food particles, and cups on the floor, and that dining room seats were very dirty with brownish stains and caked-on food and dirt; she reported she had not cleaned chairs since starting work and had not seen anyone else clean them, and that floors that were supposed to be mopped daily had not been mopped. The housekeeping supervisor reported having ten full-time housekeepers and two floor technicians and stated that day rooms and parlors were supposed to be cleaned after every meal, that seats with urine and food grease stains should be cleaned daily, that garbage cans were supposed to be emptied every day, that shower curtains should always be present for privacy, and that broken furniture should not be left in resident areas. Another housekeeping staff member stated she was assigned 30 rooms per day and sometimes could not clean all of them, even though rooms were supposed to be cleaned daily. The facility’s housekeeping policy required daily trash removal, cleaning of surfaces when dust or soiling was visible, and adherence to daily cleaning assignments to maintain a clean and orderly environment, which was not followed as evidenced by the observed conditions.
Failure to Maintain Clean and Organized Clothing for a Resident
Penalty
Summary
The facility failed to honor a resident's rights to dignity and a clean, homelike environment by not managing the resident's clothing in a clean and organized manner. The resident had diagnoses including schizoaffective disorder, bipolar type, muscle wasting and atrophy at multiple sites, and rheumatoid arthritis, and an MDS BIMS score of 9/15 indicating moderate cognitive impairment. During an observation, the resident was lying in bed, was teary eyed, and difficult to understand. When the first-floor supervisor LPN opened the resident's closet, the resident's clothes were found not folded, with whitish pants showing a large brownish stain in the crotch area and other pants and shirts observed with stains. The LPN stated it was difficult to know which clothes were clean or dirty. The LPN explained that CNAs are responsible for maintaining resident clothing after it is returned from laundry and are supposed to store clean clothes separately from dirty clothes, and that it is not acceptable to mix clean and dirty clothes because staff or residents would not know which items are clean. The LPN also stated that if the resident wears dirty clothes, he can smell and that the resident needs supervision choosing which clothes to wear, although he dresses himself. A CNA similarly stated that it is not acceptable to mix the resident's clean and dirty clothes because everything will smell and the resident will not be comfortable wearing smelly clothes, which can make him feel horrible. The facility's Resident Rights policy dated 11/18 documents that the facility must be safe, clean, comfortable, and homelike, and that the facility must treat residents with dignity and respect and care for them in a manner that promotes their quality of life.
Failure to Prevent Resident-to-Resident Physical Abuse and Inadequate PASRR Utilization
Penalty
Summary
The deficiency involves the facility’s failure to prevent and protect a resident from resident‑to‑resident physical abuse. On the date of the incident, one resident (R9), who had a PASRR Level II indicating serious mental illness and a care plan noting risk for potential abuse due to behavior problems, poor impulse control, and poor boundaries, became involved in a verbal interaction with another resident (R13). A third resident (R8) exited his room and became involved in the exchange. According to the facility’s reported incident document, R8 became disrespectful in his choice of words and stepped in front of R9 as R9 turned to go back to his room. Staff were present and attempted to separate the two residents, but R9 reached around staff and pushed R8, causing R8 to stumble and fall. R8’s medical history included generalized epilepsy with status epilepticus, unsteadiness on feet, muscle wasting and atrophy at multiple sites, and other lack of coordination, placing him at higher risk for injury from a fall. Following the push, R8 was sent to the hospital, where records documented a small left posterior parietal scalp hematoma with scalp swelling. R9’s behavior note documented that he admitted shoving R8 after R8 threatened him. During a later interview, R9 stated that R8 “went crazy and touched” him, threatened to beat and kill him, and that he pushed R8 in response. Another resident (R13) recalled arguing with R9 and that R8 became involved, and reported that R9 later told him he had pushed R8, though R13 did not witness the actual push. Staff interviews revealed gaps in the facility’s processes related to abuse prevention and PASRR follow‑up. A CNA (V6) described that, when witnessing residents arguing or being triggered, he would separate them, notify the nurse and supervisors, redirect them, move them to a different location, and monitor them. The Administrator (V1), who witnessed the event, stated that she saw staff (a CNA) go over and separate the residents, and then saw R9 push R8 as the CNA turned away, characterizing the incident as an accident and stating she did not think it could have been prevented. The Social Service Director (V16), responsible for PASRR Level II follow‑up, stated he had not reviewed the PASRR Level I or II documents for either R8 or R9, despite the facility’s PASRR policy requiring review of PASRR documents to determine problems, needs, and issues to be addressed in care planning. The facility’s Abuse and Retaliation Prevention policy defined physical abuse as the infliction of injury on a resident by non‑accidental means requiring medical attention, including controlling behavior through corporal punishment, underscoring that the push and resulting injury met the facility’s own definition of physical abuse.
Failure to Maintain Adequate Linen Supply for Resident Hygiene and Comfort
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, clean, comfortable, and homelike environment by not ensuring adequate clean linen, including towels and washcloths, for residents on the 3rd and 4th floors. One resident, a [AGE]-year-old with hemiplegia, cerebrovascular disease affecting the left dominant side, aphasia, cerebral infarction, type 2 diabetes with retinopathy, constipation, hypertension, GERD, hyperlipidemia, unspecified dementia, psychotic disturbance, mood disturbance, and anxiety, had a Brief Interview for Mental Status score indicating severe cognitive impairment and care plan goals to remain clean, dry, and odor free with appropriate cleansing and peri-care after each incontinent episode. On one survey day, a CNA reported that this resident needed incontinence care after a bowel movement but there were no towels or washcloths available, and the CNA was observed holding pieces of a cut-up sheet, stating she would have to use this to clean residents and that she had not been able to change residents all day due to lack of linen. The resident was observed lying in bed waiting to be changed while the CNA apologized and explained the absence of linen and towels. Another resident, a [AGE]-year-old with bipolar disorder, schizoaffective disorder, asthma, cocaine dependence with cocaine-induced mood disorder, and hypertension, was cognitively intact per a recent Brief Interview for Mental Status. This resident reported that sometimes when he wanted to shower in the morning, there were no towels available on the floor. During the survey, a CNA on the 4th floor showed the clean linen room, which had no fresh linen, including towels, and stated that linen had not been delivered yet for her 7:00 a.m. to 3:00 p.m. shift and that residents complain when they want to shower and there are no towels. Laundry staff confirmed that the 4th floor had not yet received its linen delivery and that deliveries to other floors had occurred earlier in the morning, with the 4th floor typically receiving linen around 10:00 a.m. Multiple staff interviews and observations documented ongoing linen shortages affecting both floors. On one day, the 3rd floor linen room had no towels, washcloths, or linens to make beds, and linen carts were empty, with CNAs stating they had not received linen/towels yet and were using a small amount left from the previous shift, causing some residents to wait for care until linen arrived. The housekeeping/laundry supervisor acknowledged that the 3rd floor linen cart should have been delivered earlier, that linen supplies were low at the end of the month while awaiting a new order, and that complaints about needing linen, towels, and washcloths were common. The facility’s extra linen room was observed to contain only limited remaining stock, and laundry logs showed minimal or no towels delivered to certain floors on specific dates, supporting the finding that the facility failed to maintain adequate linen supplies necessary to honor residents’ rights to a safe, clean, comfortable, and homelike environment.
Failure to Prevent and Control Roach Infestation in Resident Rooms
Penalty
Summary
The facility failed to prevent and control a live roach infestation in resident rooms, resulting in roaches being observed in beds and throughout resident living areas. Multiple residents, all with cognitive capacity as indicated by their BIMS scores, reported or were observed to have roaches in their rooms, on their mattresses, and in personal spaces such as wheelchairs. Family members and staff confirmed the presence of roaches, with one family member describing roaches running throughout a resident's mattress and emerging from clean sheets. Staff, including CNAs and housekeeping, reported that roaches were prevalent on multiple floors and were especially noticeable when food was present or beds were moved for cleaning. Maintenance logs documented repeated reports of roaches and bed bugs in resident rooms over several months. Interviews with facility leadership, including the administrator, DON, and housekeeping director, confirmed awareness of the ongoing roach problem. Staff stated that they were instructed to report pest sightings on maintenance logs, but the issue persisted despite regular extermination efforts. The facility's pest control policy, which requires prevention and control of insects, was not effectively implemented, as evidenced by continued reports and direct observations of live roaches in resident areas. The administrator attributed the infestation in part to resident behaviors and external factors but acknowledged the ongoing problem.
Delayed Call Light Response and Untimely Furnishing Repairs
Penalty
Summary
Surveyors identified that the facility failed to answer call lights in a timely manner for four residents and did not accommodate timely repairs for furnishings for three residents, as observed through interviews, record reviews, and direct observation. One resident, who is cognitively intact but has quadriplegia and requires substantial assistance with daily activities, reported that staff often took up to an hour to respond to call lights, sometimes turning off the light and leaving without providing assistance. During the survey, the resident's call light was activated and not answered for 46 minutes, despite visible indicators at the nurses' station and in the hallway. Other residents also reported similar delays, with one stating that staff response could take up to an hour and a half, and another noting that staff would turn off the call light and not return for hours. In addition to delayed call light responses, the facility failed to address maintenance issues in a timely manner. One resident had a broken bedside table with peeling plastic that had not been fixed since July, while another had a missing wheel on a bedside table that had been broken for two to three weeks. A third resident reported a missing grab bar in the bathroom, which had not been repaired for months. Maintenance staff stated they rely on nursing staff to report broken items, but no work orders were found for these issues, and the maintenance supervisor was unaware of the problems. Facility policies require prompt response to call lights and timely reporting and repair of maintenance issues. Care plans for the affected residents included interventions for staff to respond promptly to requests for assistance and to ensure the use of appropriate assistive devices. Despite these documented expectations, staff failed to meet the required standards, resulting in prolonged wait times for assistance and unresolved maintenance concerns that impacted residents' ability to safely and independently perform daily activities.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, safe, and homelike environment for multiple residents, as evidenced by persistent stains, debris, and unaddressed maintenance issues across several floors. Observations revealed brown and dark tan splatter stains on central walls, stained and bubbled ceiling panels in resident rooms, and chipped paint and peeling floor trimming. Dining rooms on multiple floors were found with food particles, debris, dirty trays from previous meals, and other items such as paper towels, plastic bags, and bath towels left on the floor during meal times, even as residents were present and eating. Residents reported that maintenance was slow to address repairs and that housekeeping did not adequately clean, particularly with sweeping. Staff interviews confirmed that maintenance relies on staff to report environmental issues and does not conduct daily checks in resident rooms. The Maintenance Supervisor was unaware of the stained and bubbled ceiling panels in several rooms, despite the potential for ceiling panels to fall if leaks were present. Housekeeping staff were expected to clean dining rooms after each meal and maintain cleanliness in hallways and resident rooms daily, but these tasks were not consistently performed as observed during the survey. Facility policies required daily cleaning assignments, prompt removal of trash, and regular environmental tours or safety audits to identify and address concerns such as watermarks, peeling paint, and damaged wall coverings. However, visual quality control and adherence to these guidelines were lacking, resulting in unsanitary and unhomelike conditions that affected multiple residents throughout the facility.
Failure to Maintain Safe Environment and Follow Care Plan for Fall Risk Residents
Penalty
Summary
The facility failed to follow a resident's plan of care and did not recognize or address accident hazards in the patio area. One resident with significant musculoskeletal impairments, including left hemiplegia, muscle weakness, and a history of repeated falls, was dependent on staff for wheelchair mobility and required a leg strap to prevent the left leg from falling off the wheelchair footrest. Despite care plan interventions specifying the use of a leg strap, the resident was observed multiple times without the strap, and both nursing and aide staff were unaware of its whereabouts. The resident reported previous incidents of the left leg falling out of the footrest, particularly when traversing the ramp in the patio area, which was described as uneven and cracked. Observations and interviews revealed that the patio ramp had multiple cracks and uneven surfaces, with height differences of up to 0.75 inches, causing difficulties for several residents using wheelchairs and rollators. Multiple residents, all identified as fall risks, experienced their mobility devices getting caught on the cracks, and one resident nearly tipped over as a result. Staff and residents reported that the ramp had been a known hazard for an extended period, with loose pieces of cement present. The facility's own policies required regular environmental safety audits and removal of hazards, but these were not effectively implemented, resulting in ongoing risks to residents' safety.
Food Storage, Hygiene, and Utensil Sanitation Deficiencies
Penalty
Summary
Foods were not stored under sanitary conditions in the walk-in refrigerator, walk-in freezer, and dry storage area. During the initial tour, boxes of cheese, pork loins, and deli turkey were observed placed on the floor of the walk-in refrigerator, and the entire floor was covered with water from a ceiling leak. Cartons of milk in thin plastic crates were set on top of the puddle of water, including four crates directly on the floor and additional crates stacked above them. In the walk-in freezer, a box of zucchini, a box of tater tots, and a box of roast beef were observed on the floor. In the storage room, several boxes of food, including canned sweet potatoes, canned sliced apples, Ready Care Shakes, chocolate chip cookies, corn flakes, and rice crispies, were observed on a dirty, sticky floor. The Dietary Manager stated that frozen meat, dairy products, and dry storage goods should be six inches above the ground to prevent cross contamination, and the Administrator stated that delivered boxes and food should be placed on a pallet to raise them off the ground. Food preparation and equipment sanitation practices were also not maintained. A dietary aide was observed plating brownies while his beard was covered but his mustache was not, and he was later observed placing food on resident trays and re-entering the kitchen without both beard and mustache covered. The Dietary Manager stated that beard covers were distributed when aides entered the kitchen because they were not available at the kitchen door entrance, and the aide stated he was not aware both beard and mustache needed to be covered until that day. In addition, serving and mixing spoons were displayed on a dusty rack with grime, grease buildup, and black specks, and one spoon used during puree preparation came from that display. Crates of sliced whole bread were also observed unlabeled on two separate observations, despite the Dietary Manager stating bread should be dated upon entering storage and again upon opening.
Dumpster Area Not Kept Clean or Covered
Penalty
Summary
The facility failed to ensure that the dumpster grounds were free from food-related trash and that the dumpster lid was closed. During an outside inspection of the dumpster area, surveyors observed dietary trash covering the grounds and one dumpster lid open. The trash items around the dumpster included open individual-sized milk cartons, used paper plates, foam drinking cups, dietary napkins, and other dietary-related trash. The Dietary Manager stated that all garbage and refuse should be disposed of properly by kitchen staff and referred the surveyor to the Maintenance Director for further guidance. The Maintenance Director also observed the open dumpster lid and trash on the ground and stated that trash is supposed to be placed securely into the dumpsters and not on the ground. The Administrator later stated that the dumpster lid should be closed and the area around it should be clean. The facility's undated Safe Food Handling - Dumpster document stated that dietary trash will be disposed of in a sealed plastic trash bag, the dumpster will be securely covered, and the ground surrounding the dumpster will be free of trash and debris.
Failure to Monitor Antibiotic Use
Penalty
Summary
The facility failed to implement a facility-wide system to monitor antibiotic use. On 08/11/25 at 3:07 pm, the Infection Preventionist (IP) provided surveyors a list showing three residents in the facility were currently receiving antibiotics. At that time, the IP stated the list had just been typed for the surveyor and said he had delegated antibiotic stewardship monitoring to the DON. The IP also stated the DON had not been keeping up with monitoring residents on antibiotics because she had a lot of personal things going on, and he was unable to provide previous months' monitoring of residents who received antibiotics. On 08/13/25 at 9:49 am, the DON stated she assists the IP nurse with some infection prevention duties and was not up to date with the antibiotic stewardship monitoring log. She stated it is important to keep up with the log to track residents and keep up with the antibiotics so they can keep up with what is going on in the facility. The facility policy titled Policy and Procedure Antimicrobial Stewardship Policy, dated 01/2022, states the antimicrobial stewardship program is established under the leadership of the IP and is responsible for developing and maintaining a system to monitor antibiotic use, including tracking measures of antibiotic use and reviewing a subset of antibiotic prescriptions for appropriateness of dose, duration, and indication.
Pest Control Program Failed to Keep Facility Free of Insects
Penalty
Summary
The facility failed to maintain an effective pest control program to keep the facility free of insects. During observation, a surveyor saw a brown bug, identified as a roach, crawl from behind the activities calendar taped to a resident’s wall. The resident had diagnoses including Type 2 Diabetes Mellitus, muscle wasting and atrophy, difficulty in walking, abnormal posture, and hypertension, and had a BIMS score of 15 indicating intact cognition. The resident stated that roaches and gnats were frightening at night and said she did not know how many gnats she had swallowed because she sleeps with her mouth open. Additional observations and interviews documented ongoing insect activity in the facility. Surveyors saw a live black bug, identified as a roly poly, in front of the elevator, and the resident later stated she had seen about five more roaches crawling down the window screen and did not know whether they were coming from other rooms or upstairs. The DON stated that when insects or mice are seen, staff notify the Administrator, who contacts the pest control company. The Maintenance Director stated staff are to notify him of bug or mouse sightings, he notifies the Administrator, and the pest control company comes about every two weeks and more often if necessary. A service inspection report also documented dead roaches at the time of service in a resident room and in a healthcare combined preventative maintenance area, and the facility’s pest control policy stated the facility shall be kept in a condition and cleaning procedures used to prevent harborage or feeding of insects or rodents.
Failure to Obtain Orders for Self-Administration of Medications
Penalty
Summary
The facility failed to obtain an order for two residents to self-administer medications. One resident had diagnoses including dementia, paranoid personality disorder, delusional disorders, and alcohol abuse, and a BIMS score of 8 indicating moderately impaired cognition. During observation, a large pill was found in a medication cup on top of that resident’s light fixture, and the LPN stated it was a nighttime medication that should not be left at the bedside because anyone could take it. The DON later stated medication should not be left at the bedside, and the resident’s physician orders and care plans contained no order or plan for medication self-administration. For the second resident, a labeled medication cup containing whitish powder was observed on the nightstand. The RN stated the powder appeared to be Nystatin powder and that there should be no treatment or medication at bedside because someone could walk in, grab it, and swallow it. The resident stated he did not remember who placed the cup there and pointed to his left arm as the area being treated. The resident’s orders included Nystatin external powder for skin conditions, but there was no order allowing self-administration, and the care plan did not include self-administration of medication. The facility’s self-administration procedure and medication policy both required assessment and a physician order before residents could self-administer medications.
Razor Left at Resident Bedside
Penalty
Summary
The facility failed to ensure a resident’s environment was free from hazard when a razor was found at the resident’s nightstand in Unit 3A. During the initial tour, the RN stated Unit 3 had more psyche residents than dementia residents, and when the razor blade was pointed out, the RN stated that razors should never be at bedside because anyone who walks into the room may grab it and harm themselves or the resident. The DON later stated the razor should be disposed of in the sharps container and noted that another resident in the unit could pick up the razor and harm himself or other residents. The resident involved, R138, had diagnoses including hypertension, hemiplegia and hemiparesis, and candidiasis of skin and nail, and the MDS documented a BIMS score of 15 indicating cognitive intactness.
Loose Pills Found in Medication Cart
Penalty
Summary
Drugs and biologicals were not stored in accordance with accepted professional principles when surveyors observed 18 loose pills of different sizes, shapes, and colors at the bottom of the medication cart for Team 2 on the second floor. The observation was made on 8/11/2025, and the cart was identified as serving 33 residents receiving medications from that cart. An RN stated that the 11:00pm-7:00am shift was supposed to clean the medication cart, and the DON later stated that nurses working the carts were responsible for cleaning them, that the cart was expected to be free of loose pills and spills, and that the 3rd shift was responsible for making sure medication carts were kept clean. The facility policy on Storage of Medication states that medications and biologicals are to be stored safely, securely, and properly, and contaminated medications without secure closures are to be immediately removed from inventory and disposed of according to medication disposal procedures.
Infection Control Failures During Resident Care and Medication Pass
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. Survey observations and interviews showed staff did not perform hand hygiene after contact with residents during tray pass, before entering and after exiting rooms on Enhanced Barrier Precautions (EBP), and between residents during medication pass. Staff were also observed touching a resident’s oral medications with a bare finger, failing to sanitize shared medical equipment between resident uses, and storing soiled linen on a clean linen cart. On the second-floor unit, a CNA and an LPN were observed entering and exiting an EBP room occupied by a resident without performing hand hygiene, and no gloves, gown, or handwashing were observed when the CNA exited the room. During lunch tray delivery, CNAs passed multiple trays without hand hygiene between residents, and one CNA adjusted scrub pants and then carried a liquid vitamin supplement bottle to a resident’s room without hand hygiene. During medication pass, an RN administered medications to three residents in the same room without hand hygiene between residents, used a wrist blood pressure machine on one resident and then on another without wiping it with anti-infective wipes, and touched tablets in a medication cup with a bare finger while counting them. The report also identified that a resident with an indwelling suprapubic catheter had an active order for catheter monitoring, a care plan noting higher infection risk and EBP during care, and a BIMS score indicating cognitive intactness. Despite this, there was no EBP sign posted and no PPE bin available outside the resident’s room when observed, although staff stated the resident should have been on EBP. In another observation, a CNA placed soiled linen on a clean linen cart and stated dirty linen should not have been placed there. The facility’s policies cited in the report required hand hygiene, EBP gown and glove use during high-contact care, cleaning of equipment between residents, and keeping dirty linen separate from clean linen.
Missing Code Status Orders in EMR
Penalty
Summary
The facility failed to ensure that a code status physician’s order was present in the EMR for two residents reviewed for advance directives. For one resident, the face sheet listed diagnoses including bacterial infection, venous insufficiency, and COPD, and the Physician Order Sheet showed an active order dated 08/11/25 but no code status order. The resident’s POLST dated 04/03/20 indicated full treatment, and the care plan documented that the resident wished to be DNR/Full code. The Director of Social Services stated that the social service department was responsible for ensuring residents had a code status on the Physician Order Sheet, and the DON stated the nurse was responsible for placing the resident’s code status order on the physician order sheet. For the second resident, the record listed diagnoses including Type 2 DM, muscle wasting and atrophy, difficulty walking, abnormal posture, and hypertension, and the Brief Interview of Mental Status score of 15 indicated intact cognition. The resident’s profile screen and order screens in PCC did not display a code status, and an LPN stated that a resident’s code status should be included on the profile screen and in the orders. The facility policy on Advanced Directives stated that a written physician’s order is required in response to the resident’s advance directive(s), and that the physician’s order shall be specific and address each advance directive(s).
Failure to Complete New PASRR Screening After New Psychiatric Diagnosis
Penalty
Summary
The facility failed to ensure a resident with a new diagnosis of schizoaffective disorder was referred to the appropriate state-designated agency for a new PASRR. R9 was originally admitted on 10/05/2020 and later readmitted to the facility. The record showed a diagnosis of schizoaffective disorder with an onset date of 05/08/2023, while the only screening in the record was a State Department on Aging Care Coordination Unit - Choices for Care Screening Verification Form dated 10/02/2020. R9's 06/10/2025 MDS documented a BIMS score of 11, indicating moderately impaired mental status, and also documented delirium-related findings including inattention and disorganized thinking. During interviews, the Social Services Director stated that PASRR Level I should be completed upon admission and when there is a new diagnosis, and the Business Office Manager stated that a new PASRR should be completed when a resident has a new diagnosis. The Administrator's email correspondence stated that if there is a new diagnosis that would trigger a Level II, a post screen should be requested in a timely manner, no more than 5 business days after the new diagnosis. The 08/2024 PASRR Preadmission Screening Resource stated that a current NF resident experiencing a significant change requires a Level I PASRR screen upon discovery of the significant change.
Failure to Provide ADL Grooming and Shaving
Penalty
Summary
The facility failed to ensure that residents who depended on staff assistance for ADL care received grooming and shaving. For one resident with a self-care deficit and a care plan calling for one assist with dressing and hygiene tasks, the resident reported that clothes were not being washed or returned and stated having no clothes. Surveyor observations over multiple days showed the resident wearing the same clothing, and a CNA stated the resident dressed herself in the mornings while another CNA stated the resident had been showered and dressed in the same clothes because she refused changing clothes or ADL care due to fear that someone would steal her clothes. The last documented shower noted in the record was several days earlier, and the DON stated ADLs were expected daily and refusals should be reported immediately to the floor nurse. For another resident with dementia, lack of coordination, altered mental status, and abnormal posture, the record showed a BIMS score indicating cognitive impairment and an MDS indicating the resident required supervision or touching assistance for personal hygiene. Surveyor observation found the resident in the hallway ungroomed with facial hair and a beard, and the resident stated not knowing the last time he had been shaved and that the nurse had to do it. The DON stated shaving is part of ADL and grooming, that residents who cannot shave themselves are to be shaved by CNA staff during ADL care, and that shaving should be offered daily and as needed.
Low Air Loss Mattress Set Incorrectly
Penalty
Summary
The facility failed to ensure that a resident’s low air loss mattress was set at the recommended setting. On 08/11/2025, R238 was observed lying on a low air loss mattress that was set at firm, and the Static button was turned on. When this was pointed out to an LPN, she stated the mattress was set at firm and the Static button was on, and she said she was a new nurse. The resident had diagnoses including hypertension, muscle weakness, and dementia, and the record showed an active order for a pressure reduction mattress in place. The wound care nurse later stated that the mattress setting should be based on the resident’s weight so the air flows evenly and that the setting should not be higher than the resident’s weight because that defeats the purpose of the low air loss mattress. She checked the mattress and found the weight setting at Firm, then moved the dial to 350 lbs. The resident’s documented weight was 167.2 lbs. The wound care nurse also stated the Static button is used when staff are transferring the resident and should not be left on because it makes the mattress provide a firm surface. The resident’s MDS documented that he was at risk for pressure ulcers and had a pressure-reducing device for bed.
Oxygen Equipment Not Contained After Use
Penalty
Summary
The facility failed to contain oxygen equipment, including nebulizer masks and nasal cannula tubing, for three residents who were receiving respiratory care. For one resident with asthma and COPD-related shortness of breath, a nebulizer mask was observed hanging from the nightstand drawer while the resident stated the mask was used every day. An LPN stated the mask should be contained when not in use to avoid dust, bacteria, and germs, and the DON stated the nurse is responsible for covering the nebulizer mask and/or tubing with a bag and storing it appropriately after treatment so it does not come into contact with environmental contaminants. The facility policy titled Oxygen Equipment states that oxygen tubing/nebulizer masks will be covered when not in use. For another resident with diagnoses including heart failure, dilated cardiomyopathy, and a prosthetic heart valve, nasal cannula tubing was observed laying on the portable oxygen machine and not contained. An LPN stated the nasal cannula should be in a bag when not in use for sanitation and contamination reasons. For a third resident with COPD, chronic respiratory failure, and a BIMS score of 12 indicating moderately impaired mental status, a nebulizer mask was observed lying on top of the nightstand and not contained. An RN stated the mask should be placed in a plastic bag after treatment because it was out in the open and anything could go inside it, and the DON stated the nebulizer mask should be bagged or contained after use so no organism gets in contact with it and so it will not be contaminated from environmental factors.
Incorrect Insulin Dose Prepared
Penalty
Summary
The facility failed to prepare an insulin syringe dosage according to the prescribed sliding scale order for one resident receiving insulin. During observation, an LPN checked the resident’s blood sugar at the room entrance and stated the blood sugar was 258. Based on the active sliding scale order, the resident should have received 7 units of insulin subcutaneously. The LPN was then observed preparing the insulin injection and withdrew 6 units into the syringe. Before entering the resident’s room to administer the medication, the surveyor stopped the LPN and asked for the order to be rechecked. After logging into the electronic record and reviewing the insulin order, the LPN stated the correct dose was 7 units, acknowledged that 6 units had been prepared in error, and discarded the syringe before redrawing the correct dose. The LPN stated the wrong dose could have interfered with the resident’s blood sugar levels and that the incorrect dose would not sufficiently decrease the blood sugar to the desired therapeutic range. The resident had diagnoses including Type 2 Diabetes Mellitus, Hyperlipidemia, deficiency of other vitamins, and glaucoma. The MDS documented a BIMS score of 2, indicating severely impaired cognitive function. Facility leadership stated that insulin administration requires hand hygiene, checking the insulin order, and verifying the five rights, including the right dose, and that the nurse should triple check the medication and dosage against the physician’s order before administration. The facility’s policy also required checking the five rights when the medication is selected, again as the dose is prepared, and again after the dose is prepared and before the injection is administered.
Personal Refrigerator Temperature Monitoring and Thermometer Deficiency
Penalty
Summary
The facility failed to monitor personal refrigerator temperature logs and failed to ensure that a resident's personal refrigerator had a thermometer. The facility policy titled "Food Brought into the Facility by Friends/Family/Others (Outside Sources) for Residents Policy" states that staff will monitor residents' rooms, resident personal refrigerators, unit pantries, and facility refrigerators and freezers for food and beverage disposal needs, and that all refrigerators in use in the facility have an internal thermometer with temperatures recorded daily. The Administrator stated that personal refrigerators should be monitored every day, with housekeeping responsible for cleaning them and nursing responsible for recording temperatures, and that nursing should alert the Administrator if thermometers are missing. The deficiency affected two residents, including one resident with diagnoses of unspecified protein-calorie malnutrition and muscle wasting and atrophy at multiple sites, and another resident with a BIMS score of 15 who was cognitively intact. Staff gave conflicting statements about which department was responsible for monitoring personal refrigerators. One resident's personal refrigerator was observed without a thermometer, with the thermometer gauge sitting on the nightstand and the resident stating it had been there for about 3 days because it was broken and had not been replaced. An LPN stated there should be a thermometer in all residents' refrigerators for food safety and that night shift was supposed to check refrigerator temperatures.
Missing Privacy Curtain in Shared Room
Penalty
Summary
The facility failed to ensure that a resident had a privacy curtain that extended around the bed. The deficiency affected one resident out of 54 in the sample. The resident’s face sheet documented diagnoses including depression, hypertension, syncope, and collapse, and the Brief Interview for Mental Status dated 6/13/25 documented a BIMS score of 12 with moderate cognitive impairment. On 8/11/25 at 11:00 AM, the resident’s room was observed without privacy curtains. The resident stated they had been in the room for 2 months and had not had any privacy curtains, and said they knew they should have the curtains whether they used them or not. On 8/13/25, the DON stated privacy curtains should be with every resident because they provide privacy while rendering service and are a dignity issue. The Administrator stated every resident should have privacy curtains in their rooms to ensure privacy during care and as needed, and the Housekeeping Supervisor stated every resident should have a privacy curtain if they are in a room with another resident, if available. Facility documents included Residents Rights for People in Long-Term care Facilities, which states residents have a right to privacy and confidentiality, and a facility policy titled Safe, Clean, Comfortable and Homelike Environment stating that having a privacy curtain is clean and in good condition.
Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Injury
Penalty
Summary
The facility failed to prevent a resident-to-resident physical assault involving two cognitively intact residents. One resident was watching television and listening to the radio when he got up to assist his roommate with a lunch tray and accidentally fell on him. This led to a verbal altercation over the volume of the TV/radio, during which both residents exchanged profanities. The situation escalated when one resident attempted to hit the other with a food tray, prompting the roommate, who was bed bound, to strike the first resident on the back/side of the head with a dumbbell. Staff were alerted to the commotion by another resident and responded immediately, finding one resident bleeding from a head injury. The injured resident was transported to the hospital by paramedics and received two staples for a laceration to the head before returning to the facility the same day. Documentation reviewed included hospital emergency department records, witness statements, and assessments for aggressive behaviors. The incident was reported as an assault, and the dumbbell used in the altercation was confiscated. Staff interviews confirmed knowledge that hitting constitutes resident-to-resident physical abuse, and records indicated that in-service training on abuse prevention had been conducted prior to the incident.
Failure to Protect Resident from Verbal and Emotional Abuse
Penalty
Summary
A deficiency occurred when a resident (R5) was not protected from verbal and emotional abuse by another resident (R1). R1, who has diagnoses including Chronic Obstructive Pulmonary Disease, Primary Insomnia, Major Depressive Disorder, and Paranoid Schizophrenia, became verbally aggressive towards R5, who also has multiple diagnoses such as Chronic Obstructive Pulmonary Disease, Undifferentiated Schizophrenia, Type 2 Diabetes Mellitus, Anxiety Disorder, and Hypertension. The incident took place in the dining room, where R1 was observed yelling at R5, accusing him of taking his cigarettes. Multiple staff members, including LPNs and a CNA, confirmed that R1 was shouting, screaming, and moving aggressively towards R5, and at one point attempted to strike him. Staff were made aware of the situation and intervened to redirect R1. Despite the facility's policies on resident safety, supervision, and abuse prevention, the incident demonstrates a failure to prevent verbal and emotional abuse. The facility's own staff, including the Assistant Director of Nursing and the Administrator, acknowledged that no form of abuse should occur within the facility. Documentation and interviews confirm that the altercation was not prevented or adequately managed to protect R5 from abuse, as required by facility policy and regulatory standards.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which resulted in the presence of accident hazards and insufficient oversight to prevent potential incidents. No additional details regarding the specific hazards, the individuals involved, or their medical conditions at the time of the deficiency are provided in the report.
Failure to Respond to Nurse Call Systems
Penalty
Summary
The facility failed to ensure reasonable accommodations for residents' needs by not providing accessible and timely responses to nurse call systems for seven residents out of a sample of twenty. Observations and interviews revealed that residents experienced significant delays in receiving assistance after activating their nurse call systems. In one instance, a resident was found with a strong urine odor and stated that the nurse call was not answered promptly, resulting in a delay in receiving necessary care. Another resident activated the nurse call during an interview, and despite the call light being visible, it went unanswered for ten minutes as the nurses at the station were unaware due to the call system screen being covered by a sheet of paper. Further interviews with residents indicated a pattern of neglect, with reports of calls being ignored or turned off by staff. One resident mentioned having to use a personal cell phone to contact the front desk for assistance. The facility's policy requires that all call lights be answered promptly by any staff within their scope of practice, yet this was not adhered to, as evidenced by the staff's lack of awareness and response to activated calls. The administrator was unaware of the issue with the covered call system screen and the staff's failure to respond to calls, despite the facility having a policy in place to ensure timely responses to residents' needs.
Call Light System Malfunction and Monitoring Failure
Penalty
Summary
The facility failed to ensure that the call light system was functional and adequately monitored, affecting the residents on the third and fourth floors. During observations, it was noted that a resident's call light was illuminated without an audible alert at the nurse's station, and the call light system phone was found unplugged. This issue was observed on both the third and fourth floors, where the call light phones were either unplugged or not functioning properly, leading to a lack of awareness among staff about residents' needs. Interviews with staff revealed that the call light system was supposed to alert them with an audible sound and display the resident's room number when activated. However, due to the phones being unplugged or malfunctioning, these alerts were not being received. Staff members acknowledged the potential risks of a non-functional call light system, including delayed responses to emergencies. Maintenance issues were reported, such as a broken cord that frequently disconnected the phone, and a call light that continuously illuminated without being pressed. Residents reported significant delays in response times, with one resident waiting 45 minutes for assistance while experiencing a medical emergency, and another often waiting up to two hours. The facility's policy emphasized the importance of responding to call lights promptly, yet the system's failures and the staff's lack of awareness of these issues contributed to the deficiency. The resident council meeting minutes also documented complaints about delayed responses to call lights, indicating ongoing concerns about the system's reliability.
Resident-to-Resident Physical Abuse Incident
Penalty
Summary
The facility failed to prevent and protect a resident from resident-to-resident physical abuse, affecting one resident out of three reviewed for abuse. On the day of the incident, a resident with severe cognitive impairment was involved in an altercation with another resident who was mildly cognitively impaired. The altercation occurred in the dining room, where the aggressive resident struck the other resident in the face, resulting in a laceration near the eyebrow. The aggressive resident was reported to have been verbally aggressive and difficult to redirect by staff. The incident was witnessed by another resident and staff members, who reported that the aggressive resident punched the other resident hard enough to cause a loud impact. The staff responded by separating the residents and assessing their conditions. The injured resident was found to have a laceration and was sent to the hospital for further evaluation, where additional medical issues were identified, including signs of multiple infarctions and possible stroke. The aggressive resident was also sent to the hospital for psychiatric evaluation due to their behavior. The facility's administrator was informed of the incident and initiated a report to the state agency. The facility's policy on abuse prevention emphasizes the residents' right to be free from abuse, neglect, and mistreatment. Despite this policy, the facility's failure to prevent the altercation and protect the resident from harm constitutes a deficiency in their care standards.
Failure to Maintain Cleanliness in Shower Rooms
Penalty
Summary
The facility failed to maintain cleanliness and sanitation in the third and fourth floor shower rooms, potentially affecting all 33 residents on the third floor and 60 residents on the fourth floor. During a survey, a brown colored substance, identified as feces, was observed on the floor of the fourth-floor east side shower room. Additionally, a blue soiled diaper was found on the floor of the third-floor east side shower room. Interviews with residents revealed that feces were occasionally observed on the shower room floors, leading to at least one resident avoiding the use of the shower facilities. Housekeeping staff and nursing personnel provided conflicting accounts of responsibility for cleaning the shower rooms. The fourth-floor housekeeper indicated that either the floor tech or housekeeper could clean the shower rooms, while the third-floor RN stated that housekeeping staff were mainly responsible. The Housekeeping Director confirmed that shower rooms should be cleaned two to three times a day and as needed, and it was unacceptable for feces and soiled diapers to be present. The facility's policy and job descriptions emphasize maintaining a clean, safe, and comfortable environment, which was not upheld in this instance.
Failure to Post Accurate Daily Nursing Staffing Information
Penalty
Summary
The facility failed to post the daily nursing staffing information accurately and in a timely manner, affecting all 230 residents. On the morning of January 6th, the surveyor observed that the daily nursing staffing information was not posted upon entrance to the facility. It was later posted near the receptionist area, but not at the required time. On the following day, the staffing information was posted with an incorrect year and lacked the resident census. The Staffing Coordinator, responsible for posting the information, admitted to missing the census and posting the information late. The Director of Nursing and the Administrator both confirmed that the daily staffing should be posted at the beginning of the shift, around 7 a.m., and should be complete and accurate. The facility's job descriptions for the Staffing Coordinator, Director of Nursing, and Administrator outline their responsibilities in ensuring appropriate staffing levels and accurate postings. However, the failure to adhere to these responsibilities resulted in incomplete and inaccurate staffing information being posted, which is a deficiency in meeting the regulatory requirements for nursing facilities.
Failure to Maintain Cleanliness in Shower Room
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in the residents' common shower room on the second floor, which has the potential to affect all 66 residents residing there. During an investigation, a surveyor observed debris and dirt on the floor of the shower room, including plastic bottles, gloves, paper, plastic bags, clothes, and towels. The Nurse Manager acknowledged the unkempt condition of the shower room and identified it as an infection control concern. The Housekeeping staff stated that the shower room should be disinfected after each use for sanitary purposes. The Director of Nursing confirmed that the expectation is for the shower room to be cleaned between uses to prevent the spread of infection. The facility's housekeeping guidelines emphasize maintaining a safe and sanitary environment for residents, staff, and visitors.
Cockroach Infestation in Resident Rooms
Penalty
Summary
The facility failed to ensure that residents' rooms were free of cockroaches, affecting all 66 residents on the 2nd floor. During an investigation, a surveyor observed a cockroach crawling near a resident's bed, and multiple residents reported seeing roaches frequently in their rooms. The nurse manager acknowledged the roach problem, and the facility administrator had no comment regarding pest control measures. Facility service inspection reports from October 2024 documented issues with cleanliness and food being left around, which attracted pests. These reports also noted the presence of roaches in residents' rooms, the 2nd floor nurses' station, and the front lobby. The facility's pest control policy aims to prevent or control insects and rodents from spreading disease, but the reports indicate that these measures were not effectively implemented.
Inadequate Wound Care Leads to Maggot Infestation
Penalty
Summary
The facility failed to provide appropriate wound care for a resident, leading to the development of maggots in a foot wound. The resident, who is cognitively intact and has a history of cellulitis, spinal stenosis, and an amputated left leg, reported a painful ingrown toenail to the Nurse Supervisor, who did not assess the foot. The resident also requested a bandage change from the Wound Care Nurse, which was refused. The resident expressed distress over the presence of maggots in the wound prior to a leg amputation. The Nurse Practitioner confirmed seeing maggots in the wound and noted that moisture could attract flies, leading to maggot infestation. The facility's records indicate inconsistent wound care treatment. Hospital records recommended daily betadine and gauze dressing, but the facility's Medication Administration Records show limited administration of these treatments. The Wound Care Nurse and Nurse Practitioner documented the presence of infection and necrosis in the resident's toe, with hospital records noting a necrotic toe and possible osteomyelitis. Despite these issues, the facility's wound care policy aimed to promote healing, but the lack of adherence to recommended wound care practices contributed to the deficiency.
Failure to Implement Care Plan for Resident with Self-Harm Behaviors
Penalty
Summary
The facility failed to follow its care plan policy to develop, implement, and supervise a newly admitted resident with self-injurious and suicidal behavioral concerns. This resulted in multiple incidents where the resident gained access to dangerous objects and harmed himself. The resident, who has a history of self-harm and various psychiatric diagnoses, was able to access a shaving blade and a spoon, which he used to cut his arm. Additionally, the resident punched a glass-framed picture, causing an injury that required hospitalization and sutures. The resident's care plan was not updated to address these incidents, and no interventions were put in place to prevent further self-harm. Despite the resident's known history of self-harm and suicidal ideations, the facility did not conduct adequate risk assessments or implement necessary safety measures. The care plan lacked specific interventions to manage the resident's behavior, and staff failed to provide the necessary supervision to prevent access to harmful objects. Interviews with staff revealed that the resident's behavior was often triggered by the inability to smoke, leading to agitation and self-harm. Staff members expressed concerns about the appropriateness of the facility for the resident, given his behavioral issues and the lack of effective interventions. The facility's environment, including the presence of glass-framed pictures, posed additional risks for the resident, which were not adequately addressed in the care plan.
Failure to Prevent Resident Abuse and Ensure Adequate Supervision
Penalty
Summary
The facility failed to protect residents from verbal and physical abuse by another resident, leading to multiple altercations involving residents with cognitive impairments and aggressive behaviors. Resident 1, diagnosed with schizophrenia and bipolar disorder, exhibited aggressive and noncompliant behaviors, including verbal threats and physical aggression towards other residents. Despite being sent for a psychiatric evaluation, Resident 1 returned to the facility and continued to display aggressive behavior, resulting in altercations with Residents 11 and 12. Resident 12, who also has a history of cognitive impairment and confrontational behavior, engaged in a verbal altercation with Resident 1, which escalated to a near-physical confrontation. Staff intervened to separate the residents, but the situation was not adequately de-escalated, leading to further incidents. Resident 11, who has a history of aggressive behavior, was involved in a physical struggle with Resident 1 over a cane, which required staff intervention to prevent harm. The facility's failure to provide adequate supervision and intervention allowed Resident 1 to strike Resident 2 in the face, causing physical harm. Despite the presence of staff, the incidents were not effectively managed, and the care plans for the involved residents did not adequately address the risk of abuse. The facility's policies on supervision and abuse prevention were not effectively implemented, contributing to the occurrence of these incidents.
Failure to Report Allegations of Abuse
Penalty
Summary
The facility failed to adhere to its policy of reporting allegations of abuse to the administrator and the State Agency, as evidenced by two incidents involving a resident, R1, which were not reported. The first incident involved R1 and another resident, R11, who were seen tussling over a cane, resulting in R11 striking R1 twice in the face. Despite the presence of several staff members, including the Administrator, Assistant Director of Nursing, and CNAs, the incident was not reported to the State Agency. The second incident involved a verbal altercation between R1 and another resident, R12, which escalated to a physical confrontation invitation outside the facility. Again, this incident was not reported to the State Agency, and the facility's records showed no reportables for these incidents. Interviews with staff revealed that the Director of Nursing was working remotely and was not informed of the incidents, while the Assistant Director of Nursing was onsite and in charge. The facility's policy mandates that any suspicion or allegation of abuse must be reported immediately to the administrator and documented, with a thorough investigation to follow. However, the Administrator and Director of Nursing confirmed that no reports were made for the incidents involving R1, R11, and R12, indicating a failure in communication and adherence to the facility's abuse prevention policy.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to several food safety and sanitation protocols, which could potentially affect all residents. During an inspection, it was observed that the walk-in cooler and freezer temperature logs had missing entries, indicating that temperatures were not checked daily. This lapse was acknowledged by a dietary aide, who confirmed the absence of temperature records for an entire day. Additionally, a scoop used for dry food was found improperly stored on the lid of a bin, which could lead to cross-contamination. The dietary aide admitted that the scoop should have been stored in a designated area to prevent such risks. Further observations revealed that dietary staff were not wearing appropriate beard guards, which is necessary to prevent hair from contaminating food. One dietary aide admitted to removing the beard guard, while another incorrectly believed it was unnecessary in the dish machine area. Moreover, the facility was using expired test strips to check the concentration of sanitizing chemicals, which could compromise the effectiveness of utensil sanitation. The dietary aide was unaware of the expiration and could not locate new test strips. The consultant dietary manager confirmed the importance of these protocols, emphasizing the need for daily temperature checks, proper storage of scoops, use of beard guards, and unexpired test strips to ensure food safety.
Pest Control Deficiency Due to Improper Dumpster Management
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by several observations and interviews. On October 6, 2024, during an initial tour of the dumpster area, it was noted that each of the two large dumpsters had one open lid. A dietary aide confirmed that the lids should not be open to prevent animals from accessing the dumpsters. Additionally, a gap was observed between the two doors leading to the loading dock, which was acknowledged by the assistant maintenance staff. The gap in the doors and the open dumpster lids were identified as potential entry points for pests such as mice and cockroaches. On October 7, 2024, further observations revealed that the dumpsters were overflowing with trash and the lids remained open. The assistant maintenance staff indicated that housekeeping or other staff responsible for disposing of trash were expected to close the dumpster lids to prevent animal access. The facility's policies on food and nutrition services sanitation and pest control emphasize the importance of securely covering dumpsters and ensuring that all building openings are tight-fitting to prevent pest entry. These failures in adhering to the facility's policies have the potential to affect all residents by allowing pests to enter the facility.
Improper Storage of Oxygen Tank Poses Hazard
Penalty
Summary
The facility failed to ensure a safe environment free from hazards for a resident, identified as R189, who was observed with a portable oxygen tank on the floor in their room. R189, who has chronic obstructive pulmonary disease and acute respiratory failure with hypoxia, requires continuous oxygen therapy. The resident's cognitive impairments, indicated by a BIMS score of 7, further necessitate careful supervision and adherence to safety protocols. Despite these needs, the oxygen tank was not stored in a holder, posing a potential risk of falling and causing a hazardous situation. The Director of Nursing and a Registered Nurse acknowledged the improper storage of the oxygen tank, emphasizing the potential dangers of a free-standing tank, including the risk of combustion. The facility's policy on oxygen administration and storage clearly states that oxygen cylinders must be stored in designated areas and not left free-standing in residents' rooms. This oversight in following established safety guidelines and regulations for oxygen storage could potentially affect all 64 residents on the third-floor unit.
Failure to Properly Label, Date, and Contain Oxygen Equipment
Penalty
Summary
The facility failed to properly label, date, and contain oxygen equipment, affecting four residents who required respiratory care. Observations revealed that a resident with asthma, heart disease, and epilepsy had a nebulizer mask dated from August and a humidifier bottle from June, both not properly contained. Despite the resident's cognitive intactness, the equipment was not changed as per facility policy, which mandates weekly changes. A registered nurse confirmed the oversight and acknowledged the need for equipment to be covered to prevent dust and bacteria accumulation. Another resident with COPD, heart failure, and cerebrovascular disease was observed with an undated humidifier bottle attached to an oxygen concentrator. The resident's cognitive impairment was noted, and the facility's Director of Nursing stated that the humidifier bottle should be changed weekly and dated, contrary to a nurse's claim of monthly changes. The lack of proper dating and changing of the equipment was highlighted as a potential infection risk. A third resident with COPD and acute respiratory failure was found with an oxygen nebulizer mask dated from June and not contained. The resident, who was cognitively intact, used the oxygen when experiencing breathing difficulties. A licensed practical nurse acknowledged the outdated equipment and the importance of changing and containing it for sanitation purposes. The facility's policy requires weekly changes and proper storage of oxygen equipment to maintain infection control, which was not adhered to in these cases.
Controlled Substance and Medication Storage Deficiencies
Penalty
Summary
The facility failed to maintain an accurate account of controlled substances and did not dispose of expired medications, affecting four residents. During a survey, discrepancies were found in the controlled drug records for three residents. For one resident, the Lorazepam count was off by one tablet, while another resident's Lacosamide count was also short by one tablet. Similarly, a third resident's Hydromorphone count was incorrect by one tablet. Additionally, a bottle of Lantus Insulin for another resident was found to be expired, yet still stored in the medication cart. Interviews with the facility's LPNs revealed lapses in following the facility's policies for narcotic accountability and medication storage. One LPN admitted to not signing out medications immediately after administration due to being rushed, while another confirmed that expired medications should be returned to the pharmacy or discarded. The facility's policies require narcotics to be signed out when administered and counted by two nurses at shift changes, and expired medications to be removed and destroyed. These procedures were not consistently followed, leading to the deficiencies observed.
Inadequate Infection Control and EBP Implementation
Penalty
Summary
The facility failed to implement proper infection prevention and control measures, specifically Enhanced Barrier Precautions (EBP), for several residents. Four residents, identified as having conditions such as obstructive and reflux uropathy, pressure ulcers, and end-stage renal disease, were not placed on EBP despite having medical conditions that warranted such precautions. During a survey, it was observed that there were no Personal Protective Equipment (PPE) bins or EBP signs near or on the doors of these residents' rooms, indicating a lack of adherence to the facility's policy on EBP. Additionally, a Certified Nursing Assistant (CNA) failed to follow proper glove and washcloth changing protocols during Activities of Daily Living (ADL) care for a resident. The CNA used only one pair of gloves and two washcloths to wash and dry the resident's entire body, which is against the facility's policy that requires changing gloves and washcloths between different body sites to prevent cross-contamination. The Director of Nursing confirmed the expectation for staff to change gloves and use different washcloths for different body parts to avoid spreading bacteria or germs. The Infection Preventionist and other nursing staff demonstrated a lack of understanding of EBP requirements, as evidenced by inconsistent statements regarding the necessity of gowns and gloves during high-contact resident care activities. The facility's policy clearly outlines the need for gowns and gloves during such activities, especially for residents with wounds or indwelling medical devices. The absence of EBP orders in the residents' records further highlights the facility's failure to ensure compliance with infection control protocols, potentially putting all residents at risk of infection spread.
Unsanitary Conditions in Fourth Floor Resident Pantry
Penalty
Summary
The facility failed to maintain cleanliness and sanitation in the fourth floor resident pantry, which has the potential to affect the 65 residents residing on that floor. During an observation on October 6, 2024, the surveyor noted multiple areas of brown, green, and white substances on the microwave, both inside and outside. Additionally, the garbage was overflowing, with trash observed on the floor surrounding the garbage can. The walls and floor of the pantry also had dried brown substances, indicating a lack of regular cleaning and maintenance. Interviews with facility staff revealed that the pantry is used by both residents and employees, and it is the responsibility of the housekeeping department to ensure its cleanliness. The Nursing Supervisor acknowledged the unclean state of the pantry and indicated that housekeeping should address it. The Housekeeping/Laundry Director confirmed that the housekeeping team is responsible for the upkeep of the pantry, which is supposed to be cleaned a few times a day. However, the observed conditions suggest that the cleaning schedule was not adequately followed, leading to the unsanitary state of the pantry.
Inadequate Linens and Privacy Measures in Facility
Penalty
Summary
The facility failed to provide a homelike environment for several residents due to inadequate supply of linens and towels. Residents reported not having enough towels to dry themselves after showers and having to use dirty pillowcases and sheets because clean ones were not available. Observations confirmed that some residents had discolored and dirty pillowcases, and staff acknowledged the shortage of linens. The laundry department's records showed insufficient distribution of linens across the facility's floors, and staff admitted that the supplies were not enough to meet the residents' needs. Additionally, the facility did not maintain privacy and cleanliness standards in residents' rooms. One resident's privacy curtain was stained, and another resident did not have a privacy curtain at all. The housekeeping director was unaware of these issues, despite policies requiring regular room inspections. Staff confirmed that they often had to wait for linens to be available before providing care, further indicating a lack of adequate supplies. Furthermore, several residents' rooms lacked window curtains, affecting their privacy and comfort. Residents expressed dissatisfaction with the lack of curtains, which allowed excessive light into their rooms and compromised their privacy. The maintenance director acknowledged that all rooms should have curtains but was unaware of the missing ones. The facility's administrator also confirmed that rooms should have curtains to ensure residents' privacy and dignity, but could not explain why some rooms were missing them.
Failure to Provide Adequate Nail Care
Penalty
Summary
The facility failed to provide adequate nail care for a resident diagnosed with Chronic Obstructive Pulmonary Disease, Vascular Dementia, Major Depressive Disorder, Metabolic Encephalopathy, and Lack of Coordination. The resident, who has a severe cognitive impairment with a Brief Interview of Mental Status score of 03, was observed by a surveyor to have a greyish black substance under the fingernails on both hands. The resident expressed a desire to have his fingernails cleaned. A Licensed Practical Nurse acknowledged that nail care should be performed daily, while the Director of Nursing stated that nursing staff are responsible for providing nail care during activities of daily living and showers, which occur twice a week. A Certified Nursing Assistant confirmed that nail care is provided as needed, especially if the fingernails are dirty or need trimming. The facility's policy and job description for Certified Nursing Assistants include maintaining residents' nails short, smooth, and clean.
Failure to Monitor Personal Refrigerator Temperatures
Penalty
Summary
The facility failed to adequately monitor the temperature logs of personal refrigerators for two residents, leading to a deficiency in ensuring food safety. Resident 98, who is cognitively intact with a BIMS score of 15, and Resident 174, who has some cognitive impairments with a BIMS score of 8, were both affected by this oversight. The surveyor observed that the temperature logs for these residents' personal refrigerators were not consistently checked as required. Resident 174 was unable to confirm how often the refrigerator was checked, and Resident 98 indicated that their refrigerator was checked only once a week, contrary to the facility's policy. The facility's policy mandates that nursing staff monitor personal refrigerators for spoilage, contamination, and safety, with temperatures recorded daily. However, interviews with staff revealed inconsistencies in the monitoring process. A Registered Nurse stated that floor nurses are responsible for checking refrigerator temperatures every shift, while a Licensed Practical Nurse indicated that night shift nurses are responsible for this task. The Director of Nursing confirmed that personal refrigerators should be checked daily to prevent exposure to spoiled or expired food, which could harm residents. Despite these protocols, the temperature logs for the residents' refrigerators were not maintained as required, leading to a potential risk of foodborne illness.
Non-Functioning Call Device in Resident's Room
Penalty
Summary
The facility failed to ensure that a resident's call device was functioning, which affected one resident in a sample of 67. On October 6, 2024, a surveyor requested the resident to activate his call device, to which the resident responded that it did not work. The Social Service Director confirmed that the call device was not working, as no light was observed on the call device box or the overhead indicator outside the resident's room. Another resident, who was the roommate, stated that the call light had been broken since they moved into the room four months prior. The resident affected by the non-functioning call device was admitted in early September and had a cognitive status indicating they were cognitively intact, as documented in their Minimum Data Set. The resident's care plan highlighted the risk for falls related to co-morbidities and emphasized the importance of having the call light within reach for assistance. The facility's call light policy and procedure underscored the necessity of a functioning nurse call system to respond to residents' needs in a timely manner.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 1,841 citations issued within 25 miles in the last 12 months — including the 27 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Chicago
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Little Village Nrsg & Rhb Ctr | 1.3 mi | ★★★★★ | 6 | 0 |
| Aperion Care International | 2.4 mi | ★★★★★ | 3 | 0 |
| Archer Heights Healthcare | 3.5 mi | ★★★★★ | 5 | 0 |
| Southview Manor | 3.7 mi | — | 0 | 0 |
| Kensington Place Nrsg & Rehab | 3.7 mi | ★★★★★ | 4 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.