Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Fair Oaks Rehab & Healthcare during CMS and state inspections, most recent first.
A resident who had been the roommate of a known salmonella-positive resident developed nausea and loose stools, with documentation of ongoing loose stool, poor appetite, and poor oral intake over several days. Despite prior salmonella cases in the facility, staff and the NP did not consider or communicate that the symptoms could represent salmonella, and the resident was treated with IV fluids without being promptly evaluated for infection. The resident’s condition worsened until an RN sent the resident to the hospital, where stool testing was positive for salmonella and the resident was treated for sepsis; later analysis showed all positive salmonella samples from the facility were identical organisms.
A cognitively impaired, non-verbal resident with hemiplegia and severe decision-making impairment was not protected from sexual abuse by a male resident with a documented history of sexually inappropriate behavior toward female residents. Staff had prior knowledge of this male resident’s pattern of touching, kissing, and following cognitively impaired female residents, and his care plan included an intervention not to leave him unsupervised with female residents. Despite this, he was observed with his hand on the female resident’s thigh moving toward her genital area in a common area, and later both residents were seen holding hands in the same area while multiple staff did not intervene. Behavior monitoring tools failed to capture his ongoing behaviors, and the facility’s abuse policy and care plan interventions were not effectively implemented to prevent his access to vulnerable female residents.
Surveyors found that two residents on isolation-level precautions did not have isolation signs posted on their room doors, despite physician orders and care plans for Enhanced Barrier Precautions (EBP) and strict isolation. Both residents were cognitively intact and required assistance with ADLs, and had diagnoses including Parkinson’s disease, surgical aftercare, pressure ulcers, type 2 DM, wound infections, and UTI. The DON confirmed that both residents had EBP orders and that signs should have been on their doors to alert staff to use appropriate PPE, and acknowledged that the signs were not moved when the residents changed rooms, contrary to the facility’s infection prevention and control manual describing EBP use of gown and gloves during high-contact care.
A resident with severe cognitive impairment and incontinence was not provided timely incontinence care, resulting in prolonged exposure to urine and soiled clothing. Staff and family confirmed the resident had not been checked or changed for several hours, despite care plan and facility policy requiring frequent checks and cleaning. The incident was confirmed through observation, interviews, and record review.
A facility-wide removal of bed siderails occurred before assessing whether individual residents needed them for bed mobility or positioning. Several residents reported that the rails were taken away without their input, and records showed they had varying levels of assistance needs for rolling in bed; one resident had a signed consent for bed rails, and the DON acknowledged that therapy assessments had not yet been completed.
A cook prepared a pureed cheeseburger by processing too much food at one time, and the dietary manager and surveyor observed that the finished product was thick, lumpy, pasty, and contained bits rather than a smooth puree. The dietary manager stated it was not smooth as pudding, while the facility’s recipe and pureed food policy required a completely pureed consistency for residents on a puree diet.
Failure to assess a resident for self-administration of medication. A resident with COPD was observed using an inhaler and storing it in a lock box on the nightstand, but the chart had no assessment, care plan, or physician order authorizing self-administration of the inhaler. The DON stated residents need to be assessed, care planned, and have a physician order to self-administer medications.
A resident had a recurrent Stage III pressure ulcer on the right posterior thigh, but the wound care nurse did not complete an assessment or document measurements after a new open area was identified. The resident said the area was not caused by an accident and that her skin splits there sometimes, and the wound was documented on the weekly skin check as a new open area. The facility could not provide a wound care assessment with measurements for the wound.
Failure to implement an approved nutritional intervention for a resident with malnutrition and severe underweight status. The RD recommended MedPass 60 mL TID for varied PO intake and low BMI, and the provider signed off, but the order was not entered into the system and the MAR did not show it was given. During observation, the resident appeared very thin, ate only a cookie at one meal, and was asleep during another meal despite staff attempts to wake her.
A resident with chronic pain and multiple left foot/ankle diagnoses did not receive oxycodone as ordered for pain control. The MAR ordered 1 to 2 tablets q4h PRN based on pain level, but the controlled substance record showed the supply was running low, and staff told the resident she would receive only 1 tablet plus Tylenol instead of the ordered 2 tablets. The resident reported severe pain rated 9/10 and said the facility frequently ran out of her pain medication while waiting on a refill.
A resident was observed lying in bed with two pills on his bed covers during med pass. An RN stated that nurses should always watch to make sure a patient swallows medications, then removed the pills from the linens. The facility policy states staff must ensure residents have swallowed or otherwise received medications properly.
Pharmacy recommendations were not addressed for a resident receiving Trelegy Ellipta. An LPN administered the inhaled corticosteroid without instructing the resident to rinse and spit afterward, even though the pharmacy review recommended adding that instruction to the MAR. The DON stated pharmacy recommendations are typically routed to the NP and handled within a couple of days, while the facility policy required immediate reporting and documentation if a recommendation was declined.
Medication administration errors exceeded the allowed rate, with 7 errors in 47 opportunities. An RN omitted scheduled AM meds for one resident with osteoarthritis, DM, and HTN, delayed insulin and oral meds, and applied a lidocaine patch to the wrong elbow; an LPN omitted three scheduled AM meds for another resident because they were unavailable. The DON stated meds should follow the five rights, be given within the ordered time window, pain patches should be applied at the ordered site, and insulin should be given with or right before meals.
Failure to use PPE for residents on contact isolation and EBP. A CNA entered a resident’s room on contact isolation without PPE and carried unbagged soiled linens out of the room. In a separate event, an LPN entered a resident’s room without a gown even though the resident had a catheter and was ordered for EBP; the room also lacked an EBP sign, and the LPN provided direct care and insulin administration.
Two residents experienced significant medication errors when one did not receive insulin according to updated physician orders due to outdated instructions in the MAR, and another missed scheduled doses of an antibiotic because the medication was not reordered in time. Nursing staff and facility policies were not followed, resulting in these errors.
A resident with a Full Code status was found unresponsive and without vital signs, but the facility staff failed to initiate CPR immediately. Despite instructions from the DON and MOD to start resuscitation, the nurse on duty delayed action, leading to a 42-minute gap before CPR was performed by emergency personnel. This delay resulted in the resident's death and was identified as an Immediate Jeopardy situation.
A resident with a history of cognitive and physical impairments sustained a new spiral fracture to the left distal humerus due to the facility's failure to adequately assess and monitor her post-surgical condition. Despite reports of increased pain and swelling from therapy staff, the nursing staff did not document or act on these changes, leading to a torsional injury that required further surgical intervention.
The facility failed to properly reconcile and secure a delivery of hydrocodone/Norco, affecting 14 residents with current orders for the narcotic. The medication was left unsecured on top of the stat safe over a weekend due to a lack of access by the staff present, resulting in its disappearance.
A resident dependent on staff for daily living activities was found with saturated clothing and a heavily soiled incontinence brief, indicating inadequate care. The resident expressed pain, and her skin showed signs of a Moisture Associated Skin Disorder. Multiple CNAs were unable to confirm when the resident was last changed, and the facility lacked a specific policy for dependent residents' care, relying on standard nursing practice.
A resident's dietary care plan was not followed, as their meal included pea salad despite their documented dislike for peas. The resident did not eat the pea salad and confirmed their dislike when asked.
A resident reported to a CNA that a man twisted her arm, resulting in swelling and redness. The CNA informed an RN, but the RN did not investigate further or report the allegation to the Administrator immediately. The facility's policy requires immediate reporting of abuse allegations, but the incident was not reported until the next day.
The facility failed to test residents for COVID-19 after exposure to a positive Occupational Therapist Aide. Despite the facility's policy requiring testing after exposure, residents who had close contact with the aide were not tested, and their medical records showed no mention of exposure or testing. This breach in infection control was acknowledged by the Assistant Director of Nursing.
The facility failed to provide adequate pressure ulcer care and prevention for two residents. A resident with a stage 2 coccyx pressure ulcer and MRSA infection was found without the prescribed dressing, and another resident with hemiplegia was observed with heels resting on the bed, contrary to her care plan. Staff acknowledged the deficiencies, which were against the facility's pressure injury prevention policy.
The facility failed to provide adequate ROM care and restorative interventions for two residents. One resident with hemiplegia was not receiving prescribed ROM exercises, and documentation was incomplete. Another resident with Parkinson's disease lacked necessary palm guards and finger separators, with staff admitting to losing equipment. The absence of a restorative nurse and inadequate documentation contributed to these deficiencies.
A resident with chronic kidney disease and other health issues experienced significant weight loss due to the facility's failure to implement prescribed nutritional interventions. Despite recommendations for extra protein with meals, the resident's diet card did not reflect these changes, and he was not consistently provided with the additional protein portions. The dietitian communicated the need for extra protein, but the dietary manager confirmed inconsistencies in the diet card and meal provisions, leading to continued risk for weight loss.
The facility did not offer pneumococcal vaccinations to three residents, as required by their policy. A review of records showed no documentation of consent or refusal for the PCV20 vaccine for these residents. The facility's administrator confirmed the lack of documentation. The facility's policy states that residents over 65 should receive a dose of PCV20 if they have completed a series of PCV13 and PPSV23 vaccines, or a dose of PCV20 or PCV15 and PPSV23 a year apart if they have no history of pneumonia vaccines.
Failure to Consider Salmonella in Symptomatic Resident During Known Outbreak
Penalty
Summary
The facility failed to ensure that a resident experiencing nausea and loose stools during an ongoing salmonella situation was appropriately considered for possible salmonella infection. One resident, who had been a roommate of another resident previously confirmed positive for salmonella, began having nausea and loose stools on 3/14/26, as documented in progress notes from both the morning and evening shifts. Despite these symptoms and the known prior salmonella cases in the facility, the resident was not promptly evaluated for salmonella. On 3/17/26, a nurse practitioner documented that the resident had poor appetite and loose stool for three days with poor oral intake despite staff encouragement, and ordered IV fluids, but there was still no indication that staff considered salmonella as a possible cause. The resident’s condition continued to worsen until 3/21/26, when an RN sent the resident to the emergency department, where hospital records showed a positive salmonella stool sample and treatment for sepsis. The DON stated that when the resident developed loose stool and nausea, they did not immediately think of salmonella because earlier positive cases had occurred months before, and staff did not treat the new symptoms as a potential salmonella case. The nurse practitioner reported being aware of prior positive salmonella cases in the facility but was unaware that the resident’s roommate had been the original case and stated that, had this been known, the resident would have been sent out sooner for testing. The nurse practitioner also stated that from 3/14/26 until the hospital transfer on 3/21/26, no staff indicated that the resident could possibly have salmonella. A regional infection control coordinator later confirmed that all four positive salmonella samples from the facility were identical organisms.
Failure to Protect Cognitively Impaired Resident From Known Sexually Inappropriate Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively impaired, non-verbal resident (R7) from sexual abuse by another resident (R8) with a known pattern of sexually inappropriate behaviors. R7 had a history of multiple strokes, hemiplegia on the right side, aphasia resulting in no speech and rare understandability, memory impairment, and severely impaired decision-making. She used a wheelchair, self-propelled, and required maximum assistance with activities of daily living. Her care plan did not identify any behaviors, despite her tendency to hold hands with others and wheel herself toward people to grab their hands. On the evening of 3/2/2026, staff observed R8 in the resident common area with his hand on R7’s thigh, moving toward her genital area. An agency LPN (V17) immediately separated the residents, called for R7’s nurse, and directed R8 to leave the area after witnessing his hand on R7’s thigh moving up toward her private area. Prior to this incident, multiple staff were aware that R8 had a history of sexually inappropriate behavior toward female residents. The care plan for R8, initiated in 2025, documented that he might be socially inappropriate with other residents and included an intervention added on 3/20/2025 to not allow him to be unsupervised with female residents, as well as an intervention to remove him from situations to protect the rights and safety of others. Progress notes showed that after Depo-Provera was started in 7/2025 for abnormal sexual behavior, R8 continued to engage in inappropriate conduct, including touching a female resident’s abdomen, kissing another female resident’s hand, following a female resident around while trying to hold her hands and rub her arms, and kissing another cognitively impaired female resident (R6) on the mouth. Staff interviews confirmed that R8 had been caught touching and kissing female residents, engaging in multiple instances of inappropriate touching around breasts, and being sexually inappropriate with another resident in his room. Despite this documented and observed pattern, behavior monitoring tools for R6, R7, and R8 showed no behaviors for the last 30 days. On the day of the incident, an RN (V11) had already taken steps to move R7 to another unit earlier in the shift after R8 called out for staff to bring R7 to him, due to R8’s known history with female residents. However, this information was not communicated to the agency LPN (V17), who stated that if she had known, she would have kept a closer eye on the situation and kept female residents away from R8. The responding police officer’s report documented that the nurse witness stated R8’s hand was on R7’s lap, close to her vaginal area, and that R7 could not speak or move well enough to give consent. A resident witness reported seeing R7 swat away R8’s hand and stated that this was not the first time R8 had touched female residents inappropriately. Despite the incident and R8 being charged with criminal sexual abuse, the surveyor later observed R7 and R8 holding hands in the common area while numerous staff were present and did not intervene until the administrator noticed the surveyor observing the situation. The facility’s abuse policy stated that residents have the right to be free from abuse, defined sexual abuse as behavior without consent or capacity to consent (including kissing and hugging), required monitoring of resident behaviors for abuse triggers, reassessment of care plan interventions, and removal of alleged perpetrators from further resident contact, but these measures were not effectively implemented to prevent or promptly address R8’s access to cognitively impaired female residents such as R7.
Removal Plan
- Place R8 on one-on-one care until discharge.
- Identify female residents that gravitate to him and closely monitor them to ensure staff are following care plans for interventions.
- Educate nursing staff regarding R8's one-on-one status and the need to re-direct females from his vicinity while he remains in the facility.
- Educate all staff on the abuse policy and procedure including how to identify inappropriate sexual behavior with a focus on residents that don't have the cognitive ability to consent.
- Educate nursing staff on where to find the care plan of residents to include any interventions for behaviors.
- Review all behaviors in the morning clinical meeting to ensure proper interventions are put into place and the care plan is updated to reflect such, and ensure any changes are communicated to the staff.
- Hold an Ad Hoc QAPI meeting with QAPI team members and the Medical Director to review the abuse policy and procedure, the state regulation, and the measures being put in place to ensure this deficient practice doesn't happen again.
Failure to Post Isolation Signage for Residents on Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when two residents on isolation-level precautions did not have isolation signage posted on their room doors. One resident was admitted with diagnoses including Parkinson’s disease, surgical site aftercare, and a urinary tract infection, was cognitively intact, and required moderate assistance with ADLs. A physician order dated 12/12/2025 directed the use of Enhanced Barrier Precautions (EBP) for this resident. Another resident was admitted with diagnoses including surgical aftercare, pressure ulcers, type 2 diabetes, and wound infections, was cognitively intact, and required partial assistance with ADLs. This second resident had a physician order dated 11/4/2025 for contact isolation, and a care plan dated 11/6/2025 with a revision on 12/19/2025 indicating a need for strict isolation precautions. On 3/3/2026 at 1:00 PM, surveyors observed that there were no isolation signs on the doors of either resident’s room, despite the existing orders and care plan for EBP and isolation. At 1:30 PM the same day, the Director of Nursing confirmed that both residents had orders for EBP and acknowledged that signs should have been on their doors to alert staff to use appropriate PPE to prevent the spread of infections. The Director of Nursing further explained that one resident’s contact isolation had been changed to EBP after diarrhea resolved, and stated that the signs should have been moved when the residents changed rooms. The facility’s undated infection prevention and control manual for EBP states that EBP is intended to reduce transmission of multi-drug-resistant organisms and involves the use of gown and gloves during high-contact resident care, underscoring that signage was an expected component of implementing these precautions.
Failure to Provide Timely Incontinence Care for Dependent Resident
Penalty
Summary
A dependent resident with severe cognitive impairment, Lennox-Gastaut Syndrome, epilepsy, autistic disorder, and incontinence of urine and bowel was not provided timely incontinence care. The resident's care plan required frequent checks for incontinence and perineal care after each episode. On the day of observation, the resident had not been changed since getting up in the morning, resulting in a saturated incontinence brief, soiled clothing, and a strong urine odor. Staff confirmed that the resident had not been checked or changed for several hours, despite facility policy and care plan directives to check at least every two hours. Interviews with staff and the resident's family member confirmed the lapse in care, with staff acknowledging the resident's high risk for skin breakdown due to incontinence and inability to reposition independently. The facility's policy on pressure injury assessment and treatment also required prompt cleaning of soiled skin, but there was no specific incontinence care policy in place at the time of the incident. The deficiency was identified through direct observation, interviews, and record review.
Failure to assess residents’ need for siderails before removal
Penalty
Summary
The facility failed to assess residents’ need for siderails for positioning and bed mobility before removing them from the beds of 4 of 16 residents reviewed. On 9/8/25, R42 was observed lying in bed without siderails or assist bars. R42’s father said the facility had removed the siderails about a week earlier, even though R42 used them to help turn in bed and as therapy. R42’s rehab data showed diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, and that he required substantial/maximal assistance to roll from left to right in bed. The DON stated that siderails had been removed from everyone in the building because of entrapment risk, and that therapy was supposed to assess each resident’s need for siderails, but that this had not yet been done; she also stated she knew R42 needed siderails for positioning and mobility. R47 was observed in his room without siderails on his bed and stated the rails had been taken off and he was told he could not have them, leaving him with nothing to assist him in turning in bed. His functional assessment showed he required partial/moderate assistance to roll from left to right, and the DON stated he was able to use siderails for bed mobility. R26 also had no bedrails and said she was going to complain because the siderails had been removed and she could no longer use them to roll herself in bed; her assessment showed no ROM limitations and substantial/maximal assistance needed to roll, and her signed bed rail/enabler consent form showed she consented to the use of bed rails for her care. R23 reported that siderails had been removed from her bed and that she was not given the option to keep them, even though she said she needed them to turn or raise up in bed; her assessment showed she required supervision or touching assistance to roll left and right. The facility’s Bed Rails Policy stated that when a bed has a pre-installed rail, the facility must determine whether disabling the rail would pose a risk to the resident.
Pureed Meal Not Prepared to Smooth Consistency
Penalty
Summary
The facility failed to ensure that pureed meals were prepared in a smooth consistency for residents receiving a puree therapeutic diet. During observation, a cook placed seven hamburger patties, thick processed cheese product, hamburger buns, and liquid broth into a food processor and blended the mixture while the processor was full to the brim. The dietary manager and cook sampled the product and noted it needed more blending, but the cook continued processing and then placed the puree in the steam tray. When a sample tray was later observed, the pureed cheeseburger appeared thick and lumpy, and the surveyor sampled it as thick, pasty, and containing bits that had to be removed from the upper palate with the tongue. At 12:30 PM, the dietary manager sampled the puree cheeseburger and stated there were nibbles and that it was not smooth as pudding. The manager also stated the cook was following the recipe but was nervous, and that the amount being pureed was too much at one time. The facility’s list identified six residents, R49, R56, R65, R20, R33, and R42, as receiving a puree therapeutic diet. The facility’s puree cheeseburger recipe directed that products be prepared separately if possible and blended until completely pureed with no lumps or bits, and the undated pureed food policy stated pureed foods should have the consistency of applesauce or smooth mashed potatoes.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a resident was assessed as able to self-administer medications. During observation on 9/8/25 at 9:35 AM, R50 was seen talking with a visitor, used an inhaler, and then placed the inhaler in a lock box on the nightstand. R50 stated that she had been storing it in the box for a while. The resident’s physician orders included Albuterol-Budesonide Inhalation Aerosol 90-80, ordered as 1 puff inhaled orally every 4 hours as needed for shortness of breath related to COPD, but there was no physician order for self-administration of the inhaler. The medical record contained no assessment or care plan related to self-administering medications at the time of survey. The DON stated on 9/10/25 at 8:30 AM that residents need to be assessed, care planned, and have a physician order to self-administer medications.
Failure to Assess and Measure a Recurrent Stage III Pressure Ulcer
Penalty
Summary
The facility failed to ensure a Stage III pressure wound on a resident’s right posterior thigh was assessed and measured after a new area of skin impairment was identified. The resident was observed with a dressing to the right posterior thigh and stated the area was not caused by an accident and that her skin splits there sometimes. The wound care nurse said she was aware of the wound and that when a new skin condition is reported, the CNA notifies the nurse, the nurse assesses it, and she is notified; she also said she would assess it within 24 hours, usually the same day. However, she stated she did not complete an assessment or document wound measurements. A weekly skin check form documented a new open area on the right thigh, but the facility could not provide a wound care assessment with measurements after the area was identified. The wound care nurse also said the resident’s right posterior thigh wound is a pressure ulcer that repeatedly opens and heals and remains a Stage III pressure ulcer each time it reopens.
Failure to Implement Ordered Nutritional Supplement
Penalty
Summary
The facility failed to implement a nutritional intervention for a resident who was underweight. R12 was admitted with diagnoses of moderate protein-calorie malnutrition and dementia, and her weight was documented at 77 pounds with a BMI of 14.1. The dietitian’s 8/19/25 note stated that R12 screened at risk for malnutrition, had varied meal intake of 25-100%, and recommended MedPass 60 mL three times daily between meals for varied oral intake and underweight status. The Nutrition Diagnosis Criteria Form also documented a recommendation for 2 Cal Med Pass 60 mL three times daily, and this recommendation was signed as approved by the provider. Despite the approved recommendation, R12’s Physician’s Order Sheet did not document an order for MedPass three times daily, and the September MAR did not show that MedPass was administered. During observation, R12 appeared very thin, ate only one cookie from her tray before stating she was no longer hungry, and on another occasion was asleep in the dining room with her breakfast tray in front of her. Staff attempted to wake her multiple times, but she would not wake up to eat, and she was taken out of the dining room without eating breakfast. The DON stated the facility received the recommendation form, it was signed by the provider and scanned into the chart, but the order was not entered into the system.
Pain Medication Not Given as Ordered
Penalty
Summary
The facility failed to ensure a resident received pain medication as ordered for adequate pain control. The resident had diagnoses including chronic pain, pain in the left foot, ankle and joints, osteoarthritis of the left foot and ankle, dislocation of the tarsal joint of the left foot, contracture of the left foot, a non-pressure chronic ulcer of the left foot, joint disorder of the left ankle and foot, and aftercare following joint replacement surgery. The care plan identified pain related to status post left Achilles tenotomy, presence of an external fixator, left ankle contracture, and chronic pain, with an intervention to administer analgesia as ordered. The medication order was oxycodone 5 mg, 1 to 2 tablets every 4 hours as needed for pain, with 1 tablet for pain rated 1 to 5 and 2 tablets for pain rated 6 to 10. The resident’s controlled substance record showed regular use of oxycodone from 9/3 through 9/6, and on 9/7 there were only 7 pills left. On 9/8, the resident stated she had severe pain rated 9 out of 10 and reported that staff constantly ran out of her pain medication and were waiting on a prescription from the doctor. She stated she was not due for more medication until 1:00 PM. Later that day, she reported receiving only half of her dose because the medication was running low, and said the nurse told her she would receive one pill and Tylenol instead of the ordered two pills. The RN stated he had heard a refill request had been sent, but he had not received it yet, and he told the resident she only had three pills left and offered one pill with extra Tylenol. The DON stated controlled substances require a new prescription with each refill and that staff should reorder when about 7 pills remain; she also stated the resident should never have to go without pain medication or choose one pill or two because the medication was running low.
Medication Not Ensured to Be Swallowed
Penalty
Summary
The facility failed to ensure that 1 of 16 residents reviewed for pharmacy services, R46, ingested his medications. On 9/8/25 at 10:36 AM, R46 was observed lying in bed on his left side with two pills on his bed covers. At 10:42 AM, the RN stated that the nurse should always watch to make sure a patient swallows their medications, and then approached R46’s bed and removed the two pills from his linens. The facility’s Medication Administration Policy for Senior Living states that staff members must ensure that residents have swallowed or otherwise received the medication properly.
Pharmacy Recommendations Not Addressed for Inhaled Medication
Penalty
Summary
The facility failed to ensure pharmacy recommendations were addressed and/or implemented for 1 of 5 residents reviewed for monthly medication review. During the morning medication pass, an LPN administered Trelegy Ellipta via inhalation to the resident and did not instruct or encourage the resident to rinse her mouth afterward. The resident’s Pharmacy Medication Regimen Review dated 7/20/25 stated that the resident had an order for the inhaled corticosteroid Trelegy Ellipta and recommended that the resident rinse her mouth with water (swish and spit) after each inhalation to prevent oral candidiasis, and asked that this be considered for addition to the MAR. On interview, the DON stated that pharmacy recommendations are received the next day, presented to the NP, addressed within a couple of days, and then processed and implemented by the facility. The facility’s Pharmacist Consultant Policy and Procedure stated that pharmacist recommendations are to be reported immediately that day to the DON, attending physician, and/or nurse on duty, and that any declined recommendation must have the rationale documented.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to administer medications as ordered at the correct time and the correct location, resulting in 7 errors out of 47 opportunities for a 14.89% medication error rate. This involved 2 of 4 residents observed during the medication pass. One resident had diagnoses of generalized osteoarthritis, diabetes mellitus, and hypertension, with orders for a lidocaine external patch to the right elbow at 8:00 AM, Vitamin D3 at 8:00 AM, labetalol 100 mg twice daily at 8:00 AM and 8:00 PM, and insulin lispro with meals. During the morning medication pass, the RN began preparing the resident’s 8:00 AM medications at 8:59 AM, omitted the 8:00 AM labetalol and Vitamin D, and later administered the insulin, oral medications, and applied the lidocaine patch at 9:30 AM. The resident’s breakfast tray was still on the bedside table and uneaten when the blood sugar was checked, and the resident said he was finished with the tray and was not going to eat anything. A second resident’s morning medication pass showed three omitted medications: Biotin 5 mg, pantoprazole sodium delayed release 40 mg, and venlafaxine HCL extended release. The LPN prepared and administered the resident’s medications but stated the three omitted medications were gone and would need to be reordered. The resident’s active orders and MAR showed all three medications were scheduled for 8:00 AM daily. The DON stated nurses should follow the right dose, right medication, right time, right route, and right resident, give ordered medications within one hour before or after the ordered time, check the medication room or convenience box if a medication is unavailable, follow the ordered location for pain patches, and give insulin when the resident gets the meal or right before eating.
Failure to Use PPE for Isolation and EBP Residents
Penalty
Summary
The facility failed to ensure PPE was used when providing care to residents on contact isolation or enhanced barrier precautions. R8’s physician order sheet showed contact isolation for Carbapenem-Resistant Acinetobacter Baumannii (CRAB), and on 9/8/25 a contact isolation sign was posted on the room door. A CNA entered R8’s room without PPE, then exited holding unbagged soiled linens in her hand and arm and disposed of them in a cart in the shower room. The DON stated that staff should wear gloves and a gown when entering a room for contact isolation and should dispose of all linen in the linen container in the room. R63 had a catheter and an order for enhanced barrier precautions related to wounds, with physician orders also showing a urinary catheter started on 7/25/25. The resident’s room was not identified with an EBP sign, and the resident stated staff had only been wearing gloves, not gowns, since having the catheter. An LPN entered the room without an isolation gown, adjusted the resident’s gown and bedding to access the arm, and then administered insulin. The LPN later stated the resident should have been on EBP for having a catheter and that gown and gloves should have been worn for care, and the DON stated PPE for EBP is gown and gloves for direct care.
Failure to Prevent Significant Medication Errors
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by two cases involving medication administration. In the first case, a resident with brittle diabetes did not receive insulin according to the most recent physician orders. The resident's endocrinology summary included a revised sliding scale for Novolog insulin, but the Medication Administration Record (MAR) did not reflect these updated orders, and nursing staff continued to follow the outdated scale. The Assistant Director of Nursing confirmed that the revised orders from the endocrinologist were not implemented, resulting in the resident not receiving the correct insulin doses as prescribed. In the second case, a resident with multiple diagnoses, including hepatic encephalopathy, did not receive both scheduled doses of the antibiotic Rifaximin on a specific day because the facility had run out of the medication. The Assistant Director of Nursing stated that the medication was not available due to a failure to reorder it in advance, as required. The facility's policy requires that all medication orders be accurately documented and administered according to the five rights of medication use, but these procedures were not followed in these instances.
Failure to Initiate CPR for Full Code Resident
Penalty
Summary
The facility failed to immediately provide cardiopulmonary resuscitation (CPR) to a resident, identified as R9, who was found not breathing and pulseless. R9 had a physician's order indicating she was a Full Code, meaning resuscitation efforts should have been initiated immediately. However, the staff did not start CPR until 42 minutes after R9 was found unresponsive, which resulted in her death at the facility. This incident was identified as an Immediate Jeopardy situation. The deficiency occurred when V22, a Registered Nurse, discovered R9 unresponsive and without vital signs. Despite R9's Full Code status, V22 did not initiate CPR immediately. V22 was unsure of the policy for handling a deceased resident and did not verify R9's code status promptly. Instead, V22 called the Director of Nursing (V2) and other staff members, delaying the initiation of CPR. V22 eventually called 911, but CPR was not started until emergency medical personnel arrived. Interviews with other staff members, including V23 (CNA), V25 (RN), and V24 (Manager on Duty), revealed that there was confusion and a lack of urgency in responding to R9's condition. V24 and V2 both instructed V22 to start CPR, but V22 refused, citing R9's mottled appearance and the belief that she was already deceased. The facility's policy required immediate CPR for Full Code residents, but this was not followed, leading to the delay in resuscitation efforts and R9's subsequent death.
Removal Plan
- The Director of Nursing, Assistant Director of Nursing, Post Acute Nurse, MDS Nurses, Wound Care Nurse, Regional Director of Nursing, Charge Nurse or Designee educated clinical staff regarding the CPR policy and procedure and Advanced Directive policy and procedure including identification of when CPR is needed. All additional staff will be educated prior to working their next scheduled shift and new hires will be educated during the orientation process.
- Current resident orders were reviewed by the regional nurse to confirm resident preferences aligned with code status.
- The facility nurse management team started auditing certified and licensed nursing staff on appropriate action if a resident is found unresponsive with no pulse or blood pressure and not breathing. This will be done four times a week for six weeks. A mock code was conducted on all three shifts to ensure understanding of the CPR policy and procedure. The Director of Nursing or designee will conduct a mock code with clinical staff once per month for 6 weeks to verify understanding of CPR policy and procedure, including identification of when CPR is needed. Any noted issues will be addressed and will be discussed during the QAPI (Quality Assurance and Performance Improvement) process.
- An emergency QAPI meeting with the QAPI team members and Medical Director was held to discuss the deficient practice and review the policies. The CPR policy was reviewed, and no changes were needed to the current policy. The Advance Directive policy was reviewed, and no changes were needed to the current policy.
Failure to Monitor Post-Surgical Condition Leads to New Fracture
Penalty
Summary
The facility failed to adequately assess and monitor a resident's change of condition following surgical repair of a left humerus fracture. The resident, who had a history of cognitive communication deficit, aphasia, hemiplegia, and hemiparesis, was admitted to the facility after a fall that resulted in a left humerus fracture. Despite the resident's complex medical history and the need for careful monitoring, the facility did not perform daily assessments on the resident's left upper extremity, as evidenced by missing documentation in the electronic health record for several days. The resident was discharged from the hospital without a physician's order for a sling, yet the facility's occupational therapist provided one for comfort and protection. However, the nursing staff failed to obtain a physician's order for the sling, and there was a lack of communication and documentation regarding the resident's pain and swelling. Multiple therapy staff reported increased pain and edema to the nursing staff, but these reports were not documented or acted upon. The resident's pain levels increased significantly, reaching a severe level, but this was not adequately addressed by the nursing staff. Ultimately, the resident sustained a new spiral fracture to the left distal humerus, which was discovered during an outpatient appointment. The orthopedic surgeon confirmed that this was a new fracture caused by a torsional injury, likely due to inadequate support and monitoring of the resident's arm. The facility's failure to assess the surgical extremity every shift and to report changes in the resident's condition to the physician contributed to the resident's injury and the need for additional surgical intervention.
Failure to Reconcile and Secure Controlled Narcotic Medication
Penalty
Summary
The facility failed to maintain proper reconciliation of a controlled narcotic medication, specifically hydrocodone/Norco, which affected all 14 residents with current orders for the narcotic. The issue arose when a delivery of Norco was made to the facility on a Friday evening. The medication was signed for by an LPN and handed over to an RN to be placed in the stat safe. However, the RN did not have a second nurse with access to the stat safe to assist in placing the medication inside, as required by policy. Consequently, the RN left the Norco on top of the stat safe, intending to address it later. Over the weekend, the medication remained unsecured on top of the stat safe, and multiple staff members noticed it but did not take action to secure it properly. By Monday, the pharmacy contacted the facility to report that the medication had not been logged into the stat safe. An investigation was initiated, but the narcotic was still unaccounted for as of the survey date. The facility's policy required immediate reconciliation and secure storage of narcotics, which was not followed, leading to the medication's disappearance.
Inadequate Incontinence Care for Dependent Resident
Penalty
Summary
The facility failed to provide adequate incontinence care for a resident, identified as R5, who was dependent on staff for activities of daily living. R5's Minimum Data Set indicated that she required maximal assistance for personal hygiene and was dependent for toileting. On the day of the incident, R5 was observed sitting in a reclining wheeled chair, and it was noted that she had been changed by a CNA before lunch. However, later in the afternoon, R5 was found in the same position, moaning and expressing pain between her buttocks. Multiple CNAs were unable to confirm the last time R5 had been changed, indicating a lack of communication and documentation regarding her care. When R5 was eventually assisted from the chair to the bed, her outer clothing was found to be saturated with urine, and her incontinence brief was heavily soiled. The absorbent material in the brief was saturated, and R5's skin showed signs of a Moisture Associated Skin Disorder, causing her pain when wiped. The facility's administrator admitted to not having a specific policy for activities of daily living care for dependent residents, relying instead on standard nursing practice. This lack of a structured policy may have contributed to the oversight in R5's care, resulting in her discomfort and potential skin impairment.
Failure to Honor Resident's Dietary Preferences
Penalty
Summary
The facility failed to adhere to a resident's dietary care plan by not honoring their food preferences. The resident's care plan, dated 10/28/24, specified that their dietary preferences should be respected, and they disliked peas. However, during an observation on the same day at 12:34 PM, the resident was found in their room with a meal that included pea salad, which they did not consume. When asked, the resident indicated they did not like peas, confirming the oversight in following their dietary care plan.
Delayed Reporting of Abuse Allegation
Penalty
Summary
The facility staff failed to immediately notify the Administrator, who is also the Abuse Coordinator, of an allegation of physical abuse involving a resident. On the morning of September 15, a Certified Nursing Assistant (CNA) discovered that a resident's right forearm was swollen and red after the resident reported that a man living in the facility had twisted it. The CNA promptly informed a Registered Nurse (RN) about the resident's condition and the allegation. However, the RN did not inquire further about the cause of the arm pain or the resident's statement regarding the alleged abuse. The Director of Nursing and the Administrator both stated that all allegations of abuse should be reported immediately to the Administrator to initiate an investigation. Despite this policy, the allegation was not reported to the Administrator until the following day, September 16. The facility's State Report form for the allegation was also dated September 16, indicating a delay in reporting. The facility's Abuse Prevention and Prohibition Policy mandates that all alleged violations involving abuse, neglect, exploitation, or mistreatment be reported immediately to the Administrator.
Failure to Test Residents After COVID-19 Exposure
Penalty
Summary
The facility failed to perform COVID-19 testing for residents after exposure to a positive healthcare worker, specifically an Occupational Therapist Aide, identified as V14. On 7/9/24, V14 exhibited symptoms of a runny nose and feeling unwell, leading to a positive COVID-19 test result. Despite being informed of this positive result, the facility did not conduct COVID-19 testing for the residents who had been in close contact with V14 during therapy sessions on 7/8/24 and 7/9/24. These residents, identified as R13, R15, R16, R19, and R33, were not tested for COVID-19, and their electronic medical records did not reflect any mention of exposure or subsequent testing. The facility's COVID-19 policy, dated 3/6/24, mandates testing for residents identified as having exposure to a positive case, regardless of vaccination status. The policy recommends testing immediately after exposure, and if negative, retesting at specified intervals. However, the facility did not adhere to this policy, as confirmed by V2, the Assistant Director of Nursing, who acknowledged that the residents should have been tested following their exposure to V14. The failure to test these residents represents a breach of the facility's infection prevention and control program, as outlined in their policy aligned with CDC guidance.
Failure to Provide Adequate Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to ensure proper treatment and pressure-relieving interventions for two residents at risk for pressure ulcers. Resident 19, who was at high risk for developing pressure ulcers as indicated by her Braden Scale Pressure Score, had a stage 2 coccyx pressure ulcer with MRSA infection. Despite having physician orders for specific wound care, including the application of medihoney and a hydrocolloid dressing, the dressing was observed to be missing during an incontinence care session. The staff, including a CNA and an RN, acknowledged the absence of the dressing and the need for it to be reported if not in place. Resident 12, diagnosed with hemiplegia and hemiparesis following a nontraumatic subarachnoid hemorrhage, was observed lying in bed with her heels resting on the mattress, contrary to her care plan which required her heels to be floated to relieve pressure. The facility's Pressure Injury Prevention policy emphasized minimizing pressure on heels using pillows or other devices, yet this intervention was not implemented during observations. An LPN confirmed the importance of floating heels to relieve pressure, highlighting the facility's failure to adhere to its own policy and care plan for pressure injury prevention.
Deficiencies in Restorative Care and ROM Interventions
Penalty
Summary
The facility failed to provide adequate range of motion (ROM) care and restorative interventions for two residents, leading to deficiencies in their care. One resident, with a history of hemiplegia and hemiparesis following a cerebral infarction, was not receiving the prescribed passive range of motion exercises for the left ankle and hand. Documentation was incomplete, with only two entries over a month-long period, both lacking details on the duration of exercises. Observations revealed the resident's left arm was contracted and not wearing a splint, despite a therapy evaluation recommending one. Interviews with staff confirmed the absence of a restorative nurse and inadequate documentation of ROM exercises. Another resident, diagnosed with Parkinson's disease and muscle weakness, was not provided with the necessary palm guards and finger separators as ordered. Observations showed the resident's hands were clenched without the required devices, and staff admitted to losing the palm guard for the right hand. The Director of Therapy was unaware of the missing equipment, and there was no documentation of restorative services being provided. The facility's failure to ensure proper restorative care and equipment for these residents highlights significant lapses in their care management.
Failure to Implement Nutritional Interventions for Resident with Weight Loss
Penalty
Summary
The facility failed to provide adequate nutritional interventions for a resident, identified as R33, who experienced significant weight loss. R33, a male resident with multiple diagnoses including chronic kidney disease stage 4, hemiplegia, dementia, and hyperkalemia, was observed to have a weight fluctuation and a notable decrease from 141.2 lbs to 133.7 lbs over a month. Despite the dietary recommendations for extra protein with each meal, the resident's diet card did not reflect these changes, and he was not consistently provided with the additional protein portions as prescribed. On one occasion, R33 was observed eating breakfast without the recommended yogurt for extra protein, indicating a lapse in implementing the dietary plan. The dietitian, V10, acknowledged the resident's weight loss and had communicated the need for extra protein to the dietary manager, V11. However, the dietary manager confirmed that the diet card did not list the extra protein for breakfast, and there was a lack of consistency in providing the additional protein portions during meals. The facility's protocol for addressing unplanned weight loss was not effectively implemented, as evidenced by the failure to adjust the resident's diet card and ensure the prescribed nutritional interventions were followed. This oversight contributed to the resident's continued risk for weight loss, despite the identified need for increased protein intake.
Failure to Offer Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure that pneumococcal vaccinations were offered to three residents, as required by their own policy. The deficiency was identified during a review of the records for five residents, where it was found that three residents had no documentation of being offered the PCV20 pneumonia vaccine. Specifically, the electronic records for these residents showed no documentation of consent or refusal for the vaccine. The facility's administrator confirmed the absence of documentation for these residents. According to the facility's pneumonia policy, residents over the age of 65 should receive a dose of PCV20 if they have completed a series of PCV13 and PPSV23 vaccines, or a dose of PCV20 or PCV15 and PPSV23 a year apart if they have no history of pneumonia vaccines.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 255 citations issued within 25 miles in the last 12 months — including the 7 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 South Beloit
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Autumn Lake Healthcare At Beloit | 3.8 mi | ★★★★★ | 16 | 0 |
| Beloit Health And Rehabilitation Center | 5 mi | ★★★★★ | 19 | 0 |
| Alden Meadow Park Hcc | 10.8 mi | ★★★★★ | 11 | 0 |
| River Bluff Nursing Home | 10.9 mi | ★★★★★ | 6 | 0 |
| East Bank Center, Llc | 11.2 mi | ★★★★★ | 1 | 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.