Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Pillars Of North County Health & Rehab Center, The during CMS and state inspections, most recent first.
Staff did not immediately report a resident's sexual abuse allegation against a CNA to administration, as required by facility policy. Instead, the incident was only disclosed to the DON and the resident's family after police were called for an unrelated wellness check. The resident, who had dementia and other conditions, later denied the allegation, but the delay in reporting constituted a deficiency in abuse prevention procedures.
A resident with a history of stroke, malnutrition, and a g-tube did not receive prescribed tube feedings and water flushes as ordered, and staff failed to follow standard practices for enteral nutrition management, including verifying tube placement, checking residuals, and accurately monitoring intake and weight. The feeding pump frequently malfunctioned, and incomplete feedings were not documented or reported to the physician. Facility leadership and the Medical Director were unaware of these issues, and family concerns about weight loss and inadequate care were not fully investigated.
Four residents with conditions requiring pureed diets, including those with dysphagia and neurological impairments, were served pureed chicken that was not prepared to the correct texture because dietary staff failed to follow the recipe and omitted the required thickener, resulting in an improper meal consistency.
Surveyors found that the facility did not keep the walk-in refrigerator at or below 41°F as required, with temperature logs missing for two days and thermometer readings above the standard. Additionally, three residents had water containers with visible brown substances, and staff confirmed that daily cleaning and proper supply of water pitchers were not consistently maintained.
Surveyors identified multiple deficiencies in environmental cleanliness and safety, including unclean bathroom vents with dust and cobwebs, plungers stored directly on the floor, urinals improperly stored on handrails, a missing bathroom light cover, and a broken bed footboard with exposed nails and screws. The Maintenance Director confirmed these issues during follow-up observations and stated that maintenance requests had not been received for these problems.
Two residents with significant medical conditions and fall risks were repeatedly observed with their call lights out of reach, despite staff acknowledging responsibility for ensuring accessibility. One resident's call light was clipped to a privacy curtain, while another's was draped over a wall fixture, leaving both unable to summon assistance as needed.
A resident with quadriplegia and intact cognition was not provided with his preferred shower and instead received bed baths, despite staff being aware of his preference. The care plan did not address his bathing choice, and staff cited a broken shower bed and an unsuitable shower chair as reasons for not accommodating his request.
A resident with multiple diagnoses and intact cognition reported being verbally abused by a CNA, but the allegation was not promptly reported or investigated according to facility policy. The Activity Director received the report but did not initiate an investigation or notify the Administrator, resulting in a delay in reporting the incident to the appropriate authorities.
A resident was admitted with psychiatric diagnoses including schizoaffective disorder, anxiety disorder, and major depressive disorder, but the facility did not complete a required Level Two PASARR assessment. The resident exhibited moderate cognitive impairment and behavioral issues, and staff interviews confirmed that the necessary assessment was not performed due to lack of notification and awareness.
Two residents did not have comprehensive care plans addressing their specific needs: one resident with pain and multiple pain medications lacked a care plan for pain management, while another resident with severe cognitive impairment and total dependence on staff for ADLs had no care plan for ADL assistance. These omissions were confirmed by the MDS Coordinator.
A resident who was fully dependent on staff for care and had moderate cognitive impairment was observed with excessively long fingernails on multiple occasions, despite a care plan requiring grooming. The resident stated a preference for trimmed nails, but staff interviews revealed confusion about responsibility for nail care, especially for hospice patients, resulting in the resident's needs not being met.
A resident with quadriplegia and other medical conditions was not properly notified of a scheduled physician appointment, resulting in the resident being unable to prepare in time and subsequently missing the appointment. Documentation of the appointment existed, but unclear staff responsibilities and communication breakdowns led to the deficiency.
A resident with ESRD missed a dialysis appointment due to transportation issues, and staff failed to administer the ordered as-needed Lokelma, document the missed appointment, or notify the physician. The LPN on duty was unaware of the as-needed order, and the DON was not informed of the incident.
A resident with a mouth infection and dental issues did not receive a dentist visit as ordered by the physician. Although antibiotics and pain relief were prescribed, there was no record of a dental appointment being scheduled or completed. Staff interviews revealed that the order for a dental visit was not communicated to the Social Services Director or receptionist, and the DON confirmed the resident was not seen by a dentist due to this lapse.
The facility did not ensure physician orders in the EMR were accurate and current for three residents, resulting in outdated orders for hospice, dialysis, and restorative services. In each case, orders remained active despite changes in the residents' care needs or service locations, and staff confirmed the inaccuracies and lack of timely updates.
Staff did not consistently wear required PPE, such as gowns and gloves, during high-contact care activities for three residents on Enhanced Barrier Precautions, including wound care and incontinence care. Observations showed that a wound physician, a wound LPN, and two CNAs provided care without donning gowns, despite facility policy and posted signage requiring this protection for residents with open wounds or other qualifying conditions.
Two residents who had consented to receive influenza or pneumococcal vaccines were not administered the vaccines as required. Documentation in the EMR confirmed the lack of administration, and the Infection Preventionist acknowledged that these vaccinations were missed despite proper consent.
The facility failed to follow its pressure ulcer and wound care policies, resulting in deficiencies for two residents. One resident's wound care orders and dietician recommendations were not promptly implemented, and pressure ulcers on the feet were not identified or reported. Another resident was admitted with a pressure ulcer but lacked a treatment order for several days, and dietician recommendations were delayed. The facility's lack of communication and documentation led to inadequate care.
The facility failed to monitor a resident diagnosed with COVID-19 according to their policy. Despite changes in the resident's condition being reported, vital signs and assessments were not documented. The resident was found unresponsive and later pronounced dead, with the cause of death determined to be COVID-19. The Director of Nursing confirmed that the facility's policies were not followed.
Failure to Immediately Report Abuse Allegation to Administration
Penalty
Summary
Facility staff failed to follow the established Abuse Prevention Program policy, which requires immediate reporting of any incident, allegation, or suspicion of abuse to the administrator. In this case, a resident with diagnoses including dementia, heart failure, mood disturbance, anxiety, and psychotic disturbance accused a CNA of sexual assault while being assisted to bed. The CNA immediately informed two other CNAs of the allegation, but none of the staff reported the incident to administration as required. Instead, they dismissed the allegation, believing it to be untrue, and considered the matter resolved among themselves. The deficiency was discovered when the resident's family member, unaware of the abuse allegation, called the police for a wellness check due to concerns about the resident being soiled and not changed by staff. Upon the police's arrival, a CNA informed the family member about the previous day's abuse allegation, which was the first time the family and administrative staff became aware of the incident. The DON was then notified and initiated an investigation. The resident later denied the abuse allegation and stated a preference against care from staff of the opposite sex. The failure to report the allegation immediately to administration constituted noncompliance with the facility's abuse reporting policy.
Failure to Follow Physician Orders and Provide Adequate G-Tube Management
Penalty
Summary
The facility failed to provide services that meet professional standards by not following physician orders and not ensuring adequate management of a resident's enteral gastrostomy tube (g-tube). The resident, who had a history of cerebral infarction, hemiplegia, aphasia, myocardial infarction, severe protein-calorie malnutrition, and was admitted with a g-tube, was supposed to receive continuous tube feeding and regular g-tube flushes as ordered by the physician. However, documentation showed that the prescribed tube feedings and water flushes were not consistently administered, and there were no orders or documentation for essential aspects of g-tube care such as residual checks, placement verification, or monitoring intake and output. The facility also lacked clear policies and procedures for these standard practices. Observations and interviews revealed that the resident's feeding pump frequently malfunctioned, resulting in incomplete delivery of nutrition, and staff did not consistently document the amount of feeding received or notify the physician when feedings were missed or incomplete. The resident was observed lying flat in bed while receiving tube feeding, contrary to the requirement for head-of-bed elevation to reduce aspiration risk. Staff interviews indicated a lack of awareness and adherence to standard practices, such as checking tube placement and residuals, and there was confusion about proper documentation and communication with the physician regarding feeding issues. Additionally, the facility failed to accurately monitor the resident's weight, as weights were recorded without accounting for the weight of the wheelchair cushion, leading to inaccurate assessments of the resident's nutritional status. Family members reported concerns about the resident's weight loss, lack of nutrition, and inadequate care, which were not thoroughly investigated by facility leadership. The Medical Director and facility administration were unaware of the ongoing issues with the resident's enteral feeding and weight loss, and there was no evidence that standard practices for enteral nutrition management were being followed or that staff were properly trained in these procedures.
Failure to Prepare Pureed Chicken to Proper Consistency for Residents on Modified Diets
Penalty
Summary
The facility failed to ensure that pureed chicken lunch entrees were prepared to the proper texture for four residents who required a pureed diet. Review of the dietary recipe for Maple Glazed Puree Chicken specified the use of a food thickener to achieve the correct consistency, but observation in the kitchen revealed that the pureed chicken contained water surrounding the chicken, indicating improper preparation. The Dietary Aide admitted to forgetting to add the thickener due to being busy, and the Dietary Manager acknowledged that the thickener gel could have been mixed in to correct the issue. The Dietary [NAME] confirmed that the thickener was not used for the puree chicken. The residents affected included individuals with significant medical needs such as quadriplegia, traumatic brain injury, cerebral palsy, malnutrition, and dysphagia, all of whom required a mechanically altered or pureed diet as documented in their medical records. The failure to follow the prescribed recipe and dietary orders resulted in the pureed chicken being served in an improper texture, which could make the meal unpalatable and difficult to swallow for these residents.
Failure to Maintain Safe Food Storage and Sanitary Water Containers
Penalty
Summary
The facility failed to maintain the walk-in refrigerator at or below 41 degrees Fahrenheit as required by professional standards and facility policy. Observations revealed that the refrigerator temperature was not recorded for two days, and when checked, the thermometer read 46 degrees Fahrenheit in the morning and 42 degrees Fahrenheit in the evening. The Dietary Manager confirmed that temperatures were supposed to be checked and recorded daily, and that staff should have reported any temperature deviations for service. The Administrator also stated that staff were expected to monitor refrigerator temperatures daily. Additionally, the facility did not ensure that bedside water containers were cleaned and sanitized daily as per policy. Three residents were observed with water containers that had an unknown brown substance on the sides or handles, and one container was found in a bathroom on the back of a toilet tank. The Dietary Manager admitted that water pitchers were supposed to be cleaned every morning but was not fully up to date with all policies and acknowledged that the facility did not have two complete water container sets for each resident as required. The Activities Director confirmed that both nursing and dietary staff were responsible for ensuring the cleanliness of water containers.
Environmental Cleanliness and Safety Deficiencies Identified
Penalty
Summary
The facility failed to maintain a clean, safe, and sanitary environment for residents, staff, and the public, as evidenced by multiple observations of unclean bathroom vents, improper storage of urinals and plungers, and unsafe or broken fixtures and equipment. Surveyors observed thick dust and cobwebs on bathroom vents in several resident rooms, with one instance of a spider hanging from a cobweb near a toilet. In multiple bathrooms, plungers were found in direct contact with the floor, and in one case, dead bugs were present in a light fixture cover. Additionally, urinals were found hanging on handrails without proper labeling or sanitary storage, and a bathroom light was missing its cover, exposing bulbs and mechanisms. Further observations revealed a broken bed footboard with sharp nails and screws exposed on top of a resident's dresser, creating a potential hazard. The Maintenance Director (MD) confirmed these issues during follow-up observations and stated that housekeeping staff were expected to clean vents and that plungers should be stored in plastic tubs to prevent contact with the floor. The MD also acknowledged that urinals should be stored in bags for sanitation and that the broken bed footboard posed a risk of accident. The MD reported that maintenance requests are typically submitted via a mailbox and paperwork slips, but no requests had been received for the observed issues. The facility's policy on routine maintenance assigns responsibility to maintenance staff for ensuring preventative and routine maintenance in compliance with life safety standards. However, a housekeeping policy was requested but not provided before the survey exit. The deficiencies were identified for 11 out of 26 residents observed for environmental conditions, with direct observations and confirmations by the MD, but without evidence of timely maintenance or housekeeping intervention prior to the survey.
Failure to Ensure Call Lights Within Reach for Residents at Risk for Falls
Penalty
Summary
The facility failed to ensure that the call lights were within reach for two residents who were at risk for falls and had significant medical conditions. One resident, who had end stage renal disease and chronic obstructive pulmonary disease, was observed on multiple occasions with her call light clipped to the privacy curtain approximately three feet out of reach. She was unaware of the location of her call light, and her daughter reported that it was usually clipped to the curtain when she visited. This resident had a documented history of multiple falls during her stay, including unwitnessed falls resulting in a bruise to the face. Another resident, with a history of a right femur fracture and epilepsy, was also observed on several occasions with his call light draped over a wall light fixture, out of his reach and sight. This resident was moderately cognitively impaired and had a recent history of falls. Staff interviews confirmed that call lights should be within reach of residents and that all staff were responsible for ensuring this, but observations showed that this was not consistently done for these residents.
Failure to Honor Resident Bathing Preference Due to Equipment Issues
Penalty
Summary
A deficiency occurred when the facility failed to honor a resident's preference for bathing type, specifically not providing the resident with a shower as requested. The resident, who was cognitively intact with a BIMS score of 14 and had quadriplegia (C5-C7 incomplete), depression, and hypertension, had indicated that having a bath of his choice was very important. Despite this, the resident's care plan did not address his bath or shower preferences, and records showed he consistently received bed baths on scheduled days. Multiple staff interviews confirmed awareness of the resident's preference for showers over bed baths. However, staff reported that the shower bed was broken, and the resident was unable to use the available shower chair due to lack of leg rests, which was problematic given his lack of leg control. Maintenance records indicated the shower bed was out of service for a period due to missing wheels, but there was no documentation of concerns prior to the incident. As a result, the resident's right to make choices and have preferences honored was not supported.
Failure to Timely Report and Investigate Alleged Verbal Abuse
Penalty
Summary
The facility failed to implement its policies and procedures for reporting an allegation of abuse involving one resident. According to the facility's policy, any incident of alleged abuse, neglect, exploitation, or mistreatment must be reported to the State Survey Agency (SSA) and the facility Administrator immediately, or within specified timeframes depending on the severity. A resident with diagnoses including COPD, vascular dementia, fibromyalgia, depression, and anxiety, who was cognitively intact, reported that a night shift CNA had verbally abused her by cursing at her. The resident stated she reported this incident to the Activity Director (AD) but could not recall the CNA's name or the exact date of the incident. The AD confirmed that the resident had reported the allegation during a Resident Council meeting but did not take further action to investigate or report the incident, instead sharing the information with the Social Services Director (SSD) for follow-up. The SSD did not learn of the allegation until several days later and only then informed the Administrator, who was unaware of the incident until that point. The Administrator stated that her expectation was for such allegations to be reported to her immediately for appropriate follow-up and notification to the SSA. The delay in reporting and investigating the allegation resulted in noncompliance with the facility's abuse reporting policy.
Failure to Obtain Level Two PASARR Assessment for Resident with Psychiatric Diagnoses
Penalty
Summary
The facility failed to obtain a Level Two Pre-Admission Screening and Resident Review (PASARR) assessment for a resident who was admitted with psychiatric diagnoses, including schizoaffective disorder, anxiety disorder, and major depressive disorder. Documentation in the electronic medical record showed that the resident's Level One PASARR, completed prior to admission, did not reflect these psychiatric diagnoses. The resident was later noted to have moderate cognitive impairment and exhibited behaviors such as wandering, paranoia, exit seeking, and combativeness, which resulted in a transfer to a psychiatric hospital for evaluation. Interviews with facility staff revealed that the Social Service Director was not notified to redo the PASARR for the resident, despite suspecting that the psychiatric diagnoses were present before admission. The Administrator was unaware that the resident had been admitted with diagnoses that would have required a Level Two PASARR assessment. The lack of coordination and communication led to the failure to complete the required assessment, as identified through record review and staff interviews.
Failure to Develop Comprehensive Care Plans for Pain and ADL Needs
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, as required by policy. One resident, who had diagnoses including arthritis, pain in the left hip and right hand, muscle weakness, and general pain, was receiving both morphine and acetaminophen for pain management. Despite an increase in pain reported by the resident and the presence of physician orders for pain medications, there was no care plan in place addressing pain management, non-pharmacological interventions, or the use of pain medications. The MDS Coordinator confirmed that a pain care plan should have been developed but was omitted. Another resident, admitted with diagnoses such as congestive heart failure, anxiety, glaucoma, and adult failure to thrive, was found to have severely impaired cognition and was dependent on staff for all activities of daily living (ADLs), including oral hygiene, toileting, showering, dressing, personal hygiene, eating, bed mobility, transfers, and mobility. However, there was no care plan addressing the resident's need for assistance with ADLs. The MDS Coordinator acknowledged that the resident's total dependence on staff for ADLs should have been included in the care plan.
Failure to Provide Nail Care for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident, who was totally dependent on nursing staff for all aspects of care and had moderate cognitive impairment, was observed to have fingernails extending more than half an inch beyond the fingertips. The resident, who had a history of a right femur fracture, chronic obstructive pulmonary disease, and epilepsy, was admitted to the facility and had a care plan stating the resident would be kept well-groomed. Despite this, observations on two consecutive days confirmed that the resident's nails remained untrimmed, and the resident expressed a preference for having them trimmed. Interviews with staff revealed confusion regarding responsibility for nail care, particularly for residents on hospice. One LPN initially stated that the hospice aide should have trimmed the nails, but acknowledged that facility staff were responsible if hospice did not perform the task. CNAs and another LPN confirmed that facility staff were responsible for nail care unless the resident was diabetic, in which case a nurse would perform the task. The failure to provide nail care resulted in the resident having unmet care needs.
Failure to Notify Resident of Scheduled Physician Appointment
Penalty
Summary
A deficiency occurred when a resident with quadriplegia, depression, and hypertension was not properly notified of a scheduled physician's appointment. The resident, who was cognitively intact, was informed of the appointment at the last minute, leaving insufficient time to prepare. The resident subsequently refused to attend the appointment due to not being ready. The appointment had been rescheduled weeks prior, and the information was documented in both the master notebook at the reception desk and the appointment book at the nurses' station. Interviews revealed that the process for notifying residents of appointments was unclear, with no specific staff member assigned to this responsibility. The assigned RN was unaware of the appointment due to a contract nurse working the previous night and not being familiar with the appointment notification process. The lack of a clear notification protocol led to the resident missing the scheduled medical appointment.
Failure to Provide Ordered As-Needed Medication and Notify Physician After Missed Dialysis Appointment
Penalty
Summary
A resident with end-stage renal disease (ESRD) who required regular dialysis missed a scheduled dialysis appointment due to transportation issues. The facility's policy for care of residents with ESRD did not address procedures for missed dialysis appointments. The resident had a physician's order for Lokelma, to be administered as needed on missed dialysis days, but this medication was not given when the appointment was missed. There was also no documentation in the electronic medical record (EMR) regarding the missed appointment, and the physician was not notified of the incident. Interviews with facility staff revealed that the LPN responsible for the resident on the day of the missed appointment was unaware of the as-needed order for Lokelma and did not check for such orders, as they were not scheduled medications. The Director of Nursing stated that she was not aware of the missed appointment and would have expected documentation, physician notification, and administration of Lokelma as ordered. The resident's care plan included instructions to inform a family member if transportation had not arrived by the scheduled time, but there was no evidence this was done.
Failure to Arrange Dental Visit Following Physician Order
Penalty
Summary
The facility failed to ensure that a resident received a dental visit as ordered by the physician to address a mouth infection. The resident, who had diagnoses including ulcerative oral mucositis and cirrhosis, was observed to have several missing teeth and a broken tooth, and reported pain and difficulty eating. The physician had prescribed antibiotics and ordered a dental appointment as soon as possible due to a tooth and gum infection. However, there was no documentation of a dental visit in the resident's medical record or hard chart. Interviews with facility staff revealed a breakdown in communication regarding the dental appointment order. The Social Services Director was unaware of the physician's order, and the receptionist had not received any request to schedule a dental appointment. The DON confirmed that the nurse responsible for reviewing the physician's order did not communicate the need for a dental appointment to the appropriate staff for follow-up, resulting in the resident not being seen by a dentist.
Failure to Maintain Accurate Physician Orders in Resident Medical Records
Penalty
Summary
The facility failed to maintain accurate and up-to-date physician orders for three residents, resulting in discrepancies in the provision of hospice, dialysis, and restorative services. For one resident with chronic obstructive pulmonary disease and moderate cognitive impairment, hospice orders remained active in the electronic medical record (EMR) even after services were discontinued, as confirmed by the administrator. Another resident with end-stage renal disease and other comorbidities continued to have an active physician order for dialysis at a clinic that had closed, despite receiving dialysis at a different center for several months. The administrator acknowledged the inaccuracy and the need to update the EMR. A third resident, who had a history of cerebral infarction and required substantial assistance for self-care, had outdated orders in the EMR for restorative therapy and splint use, even though the resident no longer used splints and the facility no longer had a restorative therapy program. The administrator confirmed that the range of motion exercises were not being performed as ordered and that the order should have been discontinued. These findings were based on interviews, record reviews, and policy review, and were corroborated by staff and external providers.
Failure to Ensure Staff Use of PPE During Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that staff donned appropriate personal protective equipment (PPE) as required under Enhanced Barrier Precautions (EBP) for three of five residents reviewed. According to the facility's policy, EBP requires staff to wear gowns and gloves during high-contact care activities for residents with certain conditions, such as open wounds or indwelling medical devices. Observations revealed that staff did not consistently follow these requirements during care activities for residents with pressure ulcers and other qualifying conditions. For one resident with stage three pressure ulcers, a wound physician and a wound LPN entered the resident's room, which had EBP signage, and performed wound care using only gloves and not gowns. Both staff members confirmed in interviews that they did not wear gowns, with the physician stating that gowns were not available at the time. The infection preventionist later confirmed that these staff members had not received EBP training and that gowns should have been worn during such care. In another instance, a CNA from an agency provided incontinence care and changed bed linens for a resident with a pressure ulcer, wearing only gloves and not a gown. The CNA stated it was her first day at the facility and that gowns were not available in the room. The infection preventionist confirmed that the resident required EBP and that the CNA should have worn a gown. Additionally, another CNA was observed attempting to dress a resident with EBP signage on the door without donning any PPE. These failures were observed despite the facility's policy and posted signage indicating the need for EBP.
Failure to Administer Consented Flu and Pneumonia Vaccines
Penalty
Summary
The facility failed to ensure that two of five residents reviewed for vaccinations, who had provided consent, were administered the appropriate flu or pneumonia vaccines. One resident, admitted with dementia and a right lower leg fracture, had signed a consent form to receive the pneumococcal vaccine, but there was no documentation in the electronic medical record (EMR) that the vaccine was administered. The Infection Preventionist confirmed during an interview that the resident had consented and the vaccine should have been given, but it was missed. Similarly, another resident admitted with a left heel pressure ulcer had consented to receive the influenza vaccine, as documented in the consent form. However, the EMR contained no record of the vaccine being administered. The Infection Preventionist acknowledged that the resident had been missed and that the vaccine should have been given in a timely manner after consent was obtained. These findings were based on record review, interviews, and policy review.
Deficiencies in Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to adhere to its pressure ulcer and wound care policies, resulting in deficiencies in the care of two residents with pressure ulcers. For one resident, the facility did not initiate the wound care physician's orders or follow the registered dietician's recommendations promptly. The resident had a pressure ulcer on the coccyx, which was not properly documented or treated according to the physician's orders. Additionally, the resident developed pressure ulcers on both feet/heels, which were not identified, assessed, or reported to the physician in a timely manner. The facility's failure to update the resident's care plan to reflect the presence of pressure ulcers further contributed to the deficiency. Another resident was admitted with a pressure ulcer on the coccyx, but the facility did not have a treatment order in place until several days after admission. The resident's pressure ulcer was not treated according to the wound care physician's orders, and the registered dietician's recommendations for nutritional supplements were not implemented promptly. The facility's lack of communication and documentation regarding the resident's treatment orders and care plan updates led to inadequate care for the resident's pressure ulcer. The facility's wound management program policy outlines procedures for assessing and treating pressure ulcers, but these procedures were not followed. The facility failed to ensure that new treatment orders from the wound care physician were implemented promptly and that registered dietician recommendations were acted upon within a reasonable timeframe. The lack of communication and documentation among staff members, including CNAs, LPNs, and RNs, contributed to the deficiencies in pressure ulcer care for the residents.
Failure to Monitor COVID-19 Positive Resident
Penalty
Summary
The facility failed to monitor a resident diagnosed with COVID-19 in accordance with their policy. The resident, who had moderate cognitive impairment and was dependent on activities of daily living, tested positive for COVID-19. Despite the facility's policy requiring increased clinical monitoring, including assessments of symptoms, vital signs, oxygen saturation levels, and respiratory exams every shift, there was no documentation of these assessments in the resident's medical record. The resident's care plan also lacked documentation of the COVID-19 diagnosis. Interviews with staff revealed that the resident exhibited changes in condition, such as being more down and depressed, and not eating breakfast, which were reported to the registered nurse. However, the registered nurse did not document the vital signs in the resident's medical record. Subsequent shifts also failed to document vital signs or monitor the resident's condition as required. The resident was found unresponsive during perineal care, and CPR was initiated but was unsuccessful. The cause of death was determined to be COVID-19. The Director of Nursing confirmed that the facility's COVID-19 and Change in Condition policies were not followed. The expectation was for the charge nurse to obtain and document vital signs each shift to monitor the resident's condition and notify the physician of any changes. The failure to adhere to these policies resulted in a lack of proper monitoring and documentation for the resident diagnosed with COVID-19.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 952 citations issued within 25 miles in the last 12 months — including the 28 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Florissant
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lakeview Post Acute | 0.9 mi | ★★★★★ | 1 | 0 |
| Delmar Gardens North | 1 mi | ★★★★★ | 17 | 0 |
| Crestwood Health Care Center, Llc | 2.1 mi | ★★★★★ | 6 | 1 |
| Stonebridge Florissant | 2.3 mi | ★★★★★ | 14 | 0 |
| Atrium Place Health And Rehabilitation | 2.3 mi | ★★★★★ | 2 | 0 |
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