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 Rancho Rehab And Healthcare Center during CMS and state inspections, most recent first.
A facility failed to ensure safe water temperatures for resident consumption, resulting in a resident with significant neurological and sensory impairments sustaining a second-degree burn after spilling hot water provided for making coffee. Staff did not monitor or regulate the temperature of water from a new coffee system, which was found to be excessively hot, and there was a lack of clear procedures and documentation related to the incident.
The facility failed to store food according to professional standards, with numerous items found opened, exposed to air, and without proper labeling or dating. An expired gallon of milk was not discarded, and kitchen equipment and floors were not kept clean. Additionally, the facility did not maintain dishwashing temperature logs or chloride testing logs, as confirmed by staff interviews.
The facility failed to track the required 12 hours of annual education for CNAs and CMTs, with no documentation of training duration. The DON confirmed the absence of a tracking system, leading to some staff not meeting the education requirement.
The facility failed to conduct CNA registry checks for five out of eight sampled new hires, as required by their policy. The Human Resources employee responsible for background checks was unaware of this requirement, leading to a deficiency in ensuring employees did not have disqualifying histories.
The facility did not meet the requirement of having RN coverage for at least eight hours a day on 18 out of 30 days reviewed, potentially leading to unmet health needs for residents. The staffing schedule showed multiple days without RN coverage, attributed to the unavailability of RNs. The facility had only the DON and one regular RN, with occasional assistance from a QA nurse, and was actively hiring to resolve the issue.
The facility failed to follow its policy for monthly Drug Regimen Reviews, affecting five residents. Despite the pharmacist identifying irregularities, there was no documentation of recommendations or follow-up actions in the residents' medical records. The facility lacked a tracking system for pharmacy reviews, contributing to the oversight.
The facility failed to properly label and store medications, with issues such as expired IV fluids, undated insulin vials and pens, and expired medications found in medication carts. Refrigerators had thick ice build-up, preventing proper closure, and non-medical items were improperly stored. Staff interviews confirmed non-compliance with storage and labeling policies.
The facility failed to ensure timely completion and receipt of physician-ordered lab tests for four residents, leading to a deficiency in meeting healthcare needs. A resident on Clozapine did not have required monthly lab tests since September 2024. Another resident with heart failure and diabetes had several lab tests not documented as completed by March 2025. A third resident had multiple lab tests not documented as completed, and a fourth resident did not have a Depakote level drawn despite a documented plan. Staff interviews revealed inconsistencies in the process of entering and following up on lab orders.
The facility failed to implement Enhanced Barrier Precautions (EBP) as required, leading to multiple infection control breaches. Staff did not wear gowns during perineal care for a resident with wounds and a gastrostomy tube, and a CNA wore the same gown between different residents' rooms. Additionally, an LPN did not change gloves between dirty and clean tasks during wound care. These actions violated the facility's infection control policies and CDC guidelines.
The facility failed to document dialysis treatments in the MDS for two residents, despite physician orders and care plans indicating regular dialysis sessions. Both residents had specific interventions related to dialysis, but these were not reflected in the MDS. The responsibility for completing the MDS fell to the Administrator and regional corporate staff, as the facility lacked an MDS Coordinator.
The facility failed to accurately record and update physician orders for three residents, leading to issues such as a resident not receiving double meal portions, another with undated oxygen tubing and missing cardiology documentation, and incomplete neurological checks for a resident at high fall risk. The DON and Regional Corporate Consultant acknowledged these deficiencies.
A facility failed to provide adequate ADL care for three residents, resulting in deficiencies related to personal hygiene and cleanliness. A resident did not receive scheduled showers due to a reported towel shortage, while another was observed with a soiled brief and strong odor. A third resident was repeatedly noted with a strong odor and a soiled bed mat. Despite staff assertions of regular care, observations and resident complaints indicated otherwise.
A resident's motorized wheelchair was not repaired despite being reported as broken, with issues including a damaged armrest, wheel, and battery. The resident, who relies on the wheelchair due to paraplegia, reported the problem to staff, but no effective action was taken. The CNA, therapy, and Social Services were involved but failed to resolve the issue, and the Maintenance Director was unaware of the need for repairs.
The facility failed to maintain proper communication with the dialysis center for two residents receiving dialysis services. Despite policies requiring written communication, the medical records lacked consistent documentation of dialysis communication sheets. Interviews with staff confirmed the responsibility for completing these sheets, highlighting a failure to adhere to the facility's policy.
A resident in a long-term care facility did not receive their prescribed PRN pain medication, Percocet, for several days due to the facility's failure to request timely refills. Despite the resident's reports of severe pain, staff did not document communication with the physician or pharmacy, and the Director of Nursing was unaware of the issue. The pharmacy confirmed that the facility delayed requesting a refill, resulting in the resident's prolonged discomfort.
A facility failed to maintain a medication error rate below 5%, resulting in a 10% error rate for a resident with heart failure and other conditions. The resident's medications, including Aldactone and Jardiance, were unavailable, and the CMT did not inform the resident or resolve the discrepancies before administration. Staff interviews revealed that medications should be refilled before running out, but this was not done, leading to errors in medication administration and documentation.
A resident with a seizure disorder did not have their anti-seizure medication dosage adjusted for 46 days due to a failure in transcribing the treatment plan onto the physician order sheet. Despite the resident's care plan indicating a risk for adverse side effects and a history of seizures, the order to increase Keppra to 1000 mg twice daily was not entered into the EHR or MAR. Interviews revealed inconsistencies in the process of entering physician orders, contributing to this significant medication error.
A resident missed two heart valve surgery appointments due to the facility's failure to hold blood thinners and arrange transportation. Another resident was sent to dialysis without pants and a Hoyer pad, despite needing mechanical lift transfers. The facility lacked staff education and monitoring systems to ensure compliance with care instructions.
A resident with dementia eloped from the facility and was missing for at least 30 minutes before being returned by the police. The facility staff failed to document the resident's activity preferences in the care plan, which could have distracted the resident from wandering. The facility's policies on abuse prevention and wandering were not adequately followed, and there was a lack of immediate notification to administration or state agencies. Staff interviews revealed a lack of awareness of elopement procedures and communication gaps regarding safety protocols.
Failure to Maintain Safe Water Temperatures Results in Resident Burn
Penalty
Summary
The facility failed to maintain an environment free from accident hazards by not ensuring that water temperatures provided to residents for consumption were within a safe range. Staff provided a cup of hot water to a resident, who then delivered it to another resident for the purpose of making instant coffee in their room. The water, obtained from a new coffee system, was measured at temperatures between 179 and 189 degrees Fahrenheit, significantly higher than the recommended safe serving temperature. There was no system in place to monitor or regulate the temperature of water dispensed from the new coffee system, and staff were unaware of the actual temperature being provided to residents. A resident with significant medical conditions, including left-sided hemiplegia, polyneuropathy, stroke, diabetes, and decreased pain sensation due to medication, received the hot water and subsequently spilled it on themselves. The incident resulted in a second-degree burn extending from the right flank to the right mid-thigh. The burn was described as a large, irregular area with the top layer of skin missing, and the resident did not report pain due to their medical condition and medication regimen. The event was not immediately or thoroughly documented in the resident's care plan or incident reports, and there was a lack of timely and complete assessment and documentation of the injury, including measurements and detailed descriptions. Interviews with staff revealed that the dietary aide who provided the hot water did not check the temperature before giving it to the resident and was unaware that the water was intended for another resident. The staff member allowed the water to cool for approximately 15 minutes but did not verify its safety. The new coffee system had only recently been installed, and staff had not been trained or made aware of the increased water temperature. There was confusion among staff regarding the facility's policy on acceptable serving temperatures, and no maximum temperature was specified in the policy. The lack of clear procedures and oversight contributed to the incident and the resulting injury.
Deficiencies in Food Storage and Kitchen Sanitation
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by multiple observations of improperly stored food items. Numerous items in the dry storage room, freezer, walk-in cooler, and stand-alone cooler were found opened, exposed to air, and without proper labeling or dating. Additionally, an expired gallon of milk was not discarded, and several opened food items lacked dates, which is a violation of food safety protocols. These practices were observed over several days, indicating a systemic issue in food storage and handling. Furthermore, the facility's kitchen equipment and floors were not maintained in a clean condition. Observations revealed heavy caked-on stains on the stove and oven, as well as debris and food particles on the floor. The facility also failed to maintain records of dishwashing temperature logs and chloride testing logs, as confirmed by interviews with the Dish Service Worker and Dietary Manager. The Dietary Manager admitted to not having a cleaning schedule for February and March and acknowledged the lack of up-to-date temperature log sheets, which are essential for ensuring food safety and sanitation.
Deficiency in Tracking CNA and CMT Training Hours
Penalty
Summary
The facility failed to ensure a system was in place to track the required 12 hours of annual education for Certified Nurse Aides (CNAs) and Certified Medication Technicians (CMTs). The report identifies that out of ten CNAs and two CMTs sampled, none had documentation showing the length of time their training sessions lasted. This lack of documentation made it impossible to verify if the CNAs and CMTs received the mandated 12 hours of education. The Director of Nursing (DON) confirmed during an interview that the facility did not track the duration of in-service training, and some staff did not meet the 12-hour requirement. The report provides specific examples of employee files reviewed, showing inconsistencies in the number of in-services completed and the absence of recorded training duration. For instance, CNA U had only one in-service completed, while CNA V had twelve, yet neither had documentation of the training length. Similarly, CMT L completed thirteen in-services without recorded duration. This pattern was consistent across all sampled staff, indicating a systemic issue in tracking and documenting the required training hours.
Failure to Conduct CNA Registry Checks for New Hires
Penalty
Summary
The facility failed to ensure that newly hired employees were properly screened to rule out the presence of a Federal Indicator, specifically by not checking the Certified Nurse Aide (CNA) Registry for five out of eight sampled staff members. The facility's policy, dated 10/22/24, mandates that prior to employment, the facility must verify and document various background checks, including the CNA registry. However, upon review, it was found that employees hired on 9/4/24, 10/3/24, 12/23/24, 1/12/25, and 1/22/25 did not have the required CNA registry checks performed. Interviews conducted during the survey revealed a lack of awareness and execution of the policy. The Human Resources employee responsible for completing background checks admitted to being unaware of the requirement to check the CNA registry. The Administrator confirmed that Human Resources is tasked with completing background checks and expected the CNA registry to be checked upon hire. This oversight in the hiring process led to a deficiency in ensuring that employees did not have a history of abuse, neglect, or other disqualifying factors.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide the required eight hours of Registered Nurse (RN) coverage on 18 out of 30 days reviewed, which could potentially lead to unmet health needs for all residents. The facility's policy, revised on 10/24/22, mandates RN services for at least 8 consecutive hours a day, 7 days a week, unless a waiver applies. However, the daily staffing schedule from 2/10/25 to 3/11/24 showed no RN coverage on multiple specified dates. Interviews revealed that the lack of RN coverage was due to unavailability of RNs to work, with only the Director of Nursing (DON) and one regular RN, along with occasional work by a Quality Assurance (QA) nurse, being available. The facility was actively hiring to address this shortage.
Failure to Act on Pharmacist's Recommendations in Medication Regimen Review
Penalty
Summary
The facility failed to adhere to its policy regarding the monthly Drug Regimen Review (DRR) conducted by a licensed pharmacist. The policy mandates that the pharmacist must review each resident's medication regimen monthly, identify any irregularities, and report these to the attending physician, Medical Director, and Director of Nursing (DON). However, the facility did not act on the irregularities noted by the pharmacist, affecting five residents sampled for unnecessary medication review. The pharmacist's recommendations were not documented in the residents' medical records, and there was no evidence of follow-up actions taken by the attending physicians or facility staff. Resident #53, diagnosed with a psychotic disorder, was prescribed Aripiprazole and Sertraline. Despite the pharmacist's notes indicating a review, there was no documentation of pharmacy recommendations in the resident's medical record. Similarly, Resident #42, with diagnoses including schizophrenia and major depressive disorder, was on multiple medications with black box warnings. The care plan required monitoring for adverse reactions, but the pharmacy consultant's notes were not followed up with documented recommendations. Other residents, such as Resident #6, #38, and #51, also had incomplete documentation of pharmacy recommendations despite being on complex medication regimens for conditions like major depressive disorder, bipolar disorder, and anxiety. The facility lacked a tracking system for pharmacy reviews, as confirmed by the Regional Nurse Consultant, which contributed to the oversight in addressing the pharmacist's recommendations and ensuring proper documentation and follow-up actions.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored according to acceptable standards of practice. During observations, it was found that the medication room on the west side contained expired intravenous fluids and a refrigerator with a thick ice build-up, preventing proper closure. Additionally, a bottle of soda was improperly stored in the freezer. Medication carts were found with unlabeled and expired medications, including sodium chloride, aspirin, allergy relief, and calcium supplements. Insulin vials and pens were undated, raising concerns about the potential administration of expired insulin. Further observations revealed that the nurse's medication cart on the east side contained an unlabeled medication cup and multiple undated insulin vials and pens. The treatment cart had opened and undated tubes of antibacterial wound gel, some of which were expired. The medication room refrigerator on the east side also had a thick ice build-up, with a pint-size ice cream stuck in the freezer. Interviews with staff, including the Director of Nursing, confirmed that medications should be dated when opened and stored according to manufacturer guidelines, which was not adhered to in these instances.
Failure to Ensure Timely Laboratory Services for Residents
Penalty
Summary
The facility failed to ensure timely completion and receipt of physician-ordered laboratory tests for four residents, leading to a deficiency in meeting the residents' healthcare needs. Resident #42, who has multiple diagnoses including schizophrenia and is on Clozapine, did not have the required monthly Clozapine lab tests completed since September 2024. This oversight is critical as Clozapine requires regular monitoring to detect life-threatening conditions like agranulocytosis or neutropenia. Resident #18, who is cognitively intact and has several health conditions including heart failure and diabetes, had orders for various lab tests such as CBC, CMP, and vitamin D levels that were not documented as completed by March 2025. This lack of documentation indicates a failure in the facility's process to ensure necessary lab tests are conducted and results are received in a timely manner. Resident #46, also cognitively intact, had orders for multiple lab tests including TSH, A1C, and vitamin D levels, which were not documented as completed. Additionally, Resident #11, who has dementia and a seizure disorder, did not have a Depakote level drawn in December despite a documented plan for it. Interviews with facility staff revealed inconsistencies in the process of entering and following up on lab orders, contributing to the deficiency in providing timely laboratory services.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to infection control standards by not implementing Enhanced Barrier Precautions (EBP) as recommended by the CDC and required by CMS. This deficiency was observed in the care of a resident with wounds and a gastrostomy tube, where staff performed perineal care without wearing gowns, despite the presence of an EBP sign on the resident's door. Additionally, staff failed to change gowns between caring for different residents, as observed when a CNA wore the same gown from one resident's room to another, violating the facility's infection control policy. Another instance of non-compliance involved a resident who was dependent on staff for toileting hygiene and lower body dressing. A CNA was observed performing perineal care on this resident and then entering another resident's room wearing the same gown, which is against the facility's policy and infection control standards. The CNA also used double gloves, which is not recommended, and failed to change gloves between dirty and clean tasks. Furthermore, a Licensed Practical Nurse (LPN) was observed assisting with wound care for a resident with multiple wounds. The LPN did not change gloves between touching dirty and clean areas, such as the resident's wounds and clean linens, which is a breach of infection control practices. Interviews with staff, including the Director of Nursing, confirmed that the facility's expectations were not met, as staff should change gloves and gowns between tasks and residents to prevent the spread of infections.
Failure to Document Dialysis in MDS for Two Residents
Penalty
Summary
The facility failed to ensure accurate assessments for two residents, specifically by not documenting their dialysis treatments in the Minimum Data Set (MDS). Resident #53, diagnosed with acute renal failure, had a quarterly MDS that did not document dialysis as a special treatment, despite having physician orders and a care plan indicating regular dialysis sessions. The resident's care plan included interventions related to dialysis, such as dietary consultations and monitoring for complications, but these were not reflected in the MDS. Similarly, Resident #62, who was admitted with diagnoses including end-stage renal disease and heart failure, also had an MDS that left the dialysis section blank. The resident's physician orders and care plan clearly indicated the need for dialysis three times a week, with specific interventions to monitor and manage potential complications. Interviews with the Director of Nursing and the Administrator revealed that the facility lacked an MDS Coordinator, and the responsibility for completing the MDS fell to the Administrator and regional corporate staff, who were expected to ensure accuracy.
Deficiencies in Physician Orders and Documentation
Penalty
Summary
The facility failed to ensure that physician orders were accurately recorded and updated for three residents. Resident #46, who was diagnosed with severe protein-calorie malnutrition, did not receive the physician-ordered double portions at meals. Observations showed that the resident's meal ticket did not reflect the double portion order, and staff confirmed that the resident received regular portions instead. This discrepancy was acknowledged by the Director of Nursing and the Regional Corporate Consultant, who expected the dietary orders to be accurately communicated and implemented. Resident #18, who had multiple diagnoses including coronary artery disease and respiratory failure, did not have their oxygen tubing dated, and their C-Pap mask was left uncovered, contrary to infection control standards. Additionally, there was no documentation of the resident's cardiology appointment or the instructions for a blood pressure machine received during that appointment. The lack of documentation was noted by the Director of Nursing and the Regional Corporate Consultant, who emphasized the importance of maintaining accurate medical records to ensure continuity of care. Resident #6, who had severe cognitive impairment and was at high risk for falls, did not have complete neurological checks documented following an unwitnessed fall. The resident had a history of falls and was placed on neuro checks, but several opportunities to document these checks were missed. Licensed Practical Nurse A confirmed the protocol for neuro checks following falls, indicating that the facility did not adhere to its own procedures for monitoring residents after such incidents.
Failure to Provide Adequate ADL Care and Hygiene
Penalty
Summary
The facility failed to provide adequate activities of daily living (ADL) care for three residents, resulting in deficiencies related to personal hygiene and cleanliness. Resident #38, who is cognitively intact and requires substantial assistance with bathing, did not receive scheduled showers on two occasions due to a reported towel shortage. The resident expressed that this was an ongoing issue, and records confirmed the absence of shower documentation for the missed dates. Despite the CNA's assertion that no showers were missed due to linen shortages, the resident's complaints and observations of strong body odor indicated otherwise. Resident #2, who is severely impaired and dependent on staff for personal hygiene, was observed with a heavily soiled and shredded disposable brief, emitting a strong urine and body odor. The CNA assigned to the resident acknowledged the issue, noting that the resident's Hoyer pad had a strong urine smell the previous day. The resident's care plan indicated a need for dependent assistance with hygiene, yet the observations suggested a failure to maintain cleanliness and odor control. Resident #6, also severely impaired and requiring substantial assistance, was repeatedly observed with a strong urine and body odor over several days. The resident's room contained a heavily soiled bed mat, which contributed to the odor. Although the CNA mentioned that the resident often refused showers, the persistent odor and condition of the bed mat indicated a lack of adequate hygiene care. Interviews with LPNs and the DON confirmed that residents were expected to receive showers twice a week and be kept clean and odor-free, yet these expectations were not met for the residents involved.
Failure to Repair Resident's Motorized Wheelchair
Penalty
Summary
The facility failed to ensure that a motorized wheelchair used by a resident was in working order, despite being informed of broken or missing parts. The resident, who is cognitively intact and has impairments in both lower and upper extremities, relies on a motorized wheelchair due to conditions such as paraplegia and neurogenic bladder. The resident reported issues with the wheelchair, including a broken left armrest, a damaged right wheel, and a battery that does not hold a charge, making the wheelchair unreliable and uncomfortable to use. The resident had informed staff about the wheelchair issues over the past two months, but no effective action was taken. A CNA reported the problem to therapy and attempted to contact the manufacturer, who only provided parts but did not offer repair services. The Physical Therapist Assistant acknowledged the issue but was unsure of the appropriate contact for repairs, as the resident did not have insurance with therapy and lacked information about the wheelchair's origin. The Social Services Director received the manufacturer's book from the resident but did not recall the extent of the damage. The Maintenance Director was unaware of the repair needs, as the issue was not reported to him. The Director of Nursing stated that the resident never mentioned the wheelchair issues during visits to her office and expected staff to assist in resolving such problems. Despite these expectations, the resident continued to use a malfunctioning wheelchair, indicating a lapse in communication and follow-up among the facility's staff and departments.
Failure in Dialysis Communication for Two Residents
Penalty
Summary
The facility failed to ensure proper communication between the nursing home and the dialysis center for two residents receiving dialysis services. The facility's policy required written communication between the nursing staff and the dialysis provider, including updates on medication changes, condition changes, and the resident's tolerance of dialysis procedures. However, the facility did not maintain consistent written communication records for the two residents, as evidenced by missing dialysis communication sheets in their medical records. Resident #62, who was admitted with diagnoses including end-stage renal disease and required dialysis three times a week, had incomplete documentation of dialysis communication. The resident's care plan and physician's orders outlined specific monitoring and reporting requirements, but the medical record lacked consistent written communication with the dialysis center, with only a few communication sheets available for review. Similarly, Resident #53, diagnosed with renal failure and also receiving dialysis three times a week, had no documented dialysis communication sheets for several appointments, despite orders to complete and collect these forms. Interviews with facility staff, including the Regional Nurse Consultant and the Director of Nursing, confirmed that the nursing staff was responsible for ensuring the completion of dialysis communication sheets. The absence of these sheets in the medical records indicated a failure to adhere to the facility's policy, which was crucial for monitoring the residents' conditions and ensuring their safety during and after dialysis treatments.
Failure to Provide Prescribed Pain Medication
Penalty
Summary
The facility failed to provide a prescribed as-needed (PRN) controlled pain medication, Percocet, to a resident experiencing severe pain. The resident, who was cognitively intact and required assistance with daily activities, had a history of chronic pain due to conditions such as heart disease, high blood pressure, and traumatic brain injury. Despite having a physician's order for Percocet to be administered every six hours as needed, the medication was unavailable for several days, leaving the resident in significant discomfort. Interviews revealed that the resident repeatedly informed staff about the unavailability of Percocet, but the medication was not delivered due to a lack of timely refill requests. The Licensed Practical Nurse (LPN) and other staff members were aware of the situation but failed to document any communication with the physician or pharmacy regarding the need for a refill. The Director of Nursing (DON) and Regional Nurse Consultant (RNC) were unaware of the issue until it was brought to their attention during the survey. The pharmacy confirmed that the facility did not request a refill until much later, despite having a prescription for 100 tablets. The facility's failure to ensure the availability of the prescribed medication and to document necessary communications with the pharmacy and physician contributed to the resident's prolonged period without adequate pain management. The lack of documentation and follow-up by the facility staff highlighted a significant lapse in the provision of pharmaceutical services to meet the resident's needs.
Medication Error Rate Exceeds 5% Due to Unavailable Medications
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in a 10% error rate during medication administration for a resident. Out of 30 observed opportunities, three errors were identified. The errors involved the administration of medications to a resident with diagnoses including heart failure, high blood pressure, and stroke. The resident's medication orders included Aldactone, Jardiance, and senna, but during an observation, it was found that the blister packs for Aldactone and Jardiance were empty, and the senna was not obtained from the cart. The Certified Medication Technician (CMT) did not inform the resident about the unavailability of Aldactone and Jardiance and marked the MAR with a code indicating other reasons. The resident was not aware of any missed doses and believed they had taken all their medications except for inhalers. The facility's policy required that any discrepancies be resolved before administration, but this was not adhered to, leading to the errors. Interviews with staff revealed that medications should be refilled before running out, and if unavailable, the physician and pharmacy should be notified. However, the medications were not administered as scheduled, and the MAR was not accurately documented. The Director of Nursing expected a medication error rate of less than 5% and for medications to be administered timely and per physician orders, which was not achieved in this instance.
Failure to Adjust Anti-Seizure Medication Dosage
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically in the case of a resident with a seizure disorder. The resident's treatment plan was not properly transcribed onto the physician order sheet, resulting in a failure to adjust the dosage of an anti-seizure medication, Keppra, for 46 days. This oversight occurred despite the resident's care plan indicating a risk for adverse side effects from medication use and a history of seizures. The resident, who was cognitively intact and diagnosed with dementia and a seizure disorder, experienced seizure activity on multiple occasions. On one occasion, the resident was observed having a seizure and refused to go to the hospital. The nurse practitioner planned to increase the Keppra dosage to 1000 mg twice daily, but this order was not entered into the electronic health record (EHR) or the medication administration record (MAR) until much later. The resident reported that staff sometimes omitted medications or administered incorrect doses, which could lead to seizures. Interviews with facility staff revealed inconsistencies in the process of entering physician orders into the EHR. Some nurse practitioners entered their own orders, while others relied on facility staff to do so. The Director of Nursing (DON) expected staff to follow facility policies and procedures, which were not adhered to in this case. The failure to properly document and implement the medication order led to a significant medication error, as the resident did not receive the necessary dosage adjustment for an extended period.
Deficiencies in Pre-Surgical and Dialysis Preparation
Penalty
Summary
The facility failed to ensure that a resident arrived for heart valve surgery with blood thinners placed on hold as per the surgical instructions. The resident missed two surgery appointments due to this oversight. The first surgery was scheduled, but the resident arrived without having the blood thinner medication held, which was a requirement for the procedure. The surgical orders had been faxed to the facility in advance, but the facility did not follow the instructions. The surgery was rescheduled, but the resident missed the second appointment because the facility failed to arrange transportation. Another deficiency involved a resident who was sent to dialysis without being properly dressed. The resident, who required extensive assistance due to being a double amputee, was sent without pants and without a Hoyer pad, despite physician orders for transfers via mechanical lift. The LPN responsible for preparing the resident was unaware of the appropriate attire and did not use the Hoyer pad, leading to the resident being sent to dialysis inadequately dressed. The facility lacked documentation of in-servicing or education for staff regarding the importance of following appointment instructions and ensuring residents are properly dressed for outside appointments. There was no monitoring system in place to ensure compliance with these requirements, contributing to the deficiencies observed in the care of the residents.
Resident Elopement Due to Inadequate Supervision and Documentation
Penalty
Summary
The facility staff failed to provide protective oversight for a resident who eloped from the facility and was missing for at least 30 minutes without staff's knowledge. The resident was returned to the facility by the police, who found the resident walking down the sidewalk. The staff did not document the resident's activity preferences in the care plan, which could have been used to distract the resident from wandering. This oversight had the potential to affect all residents who wander or seek to exit the facility. The facility's policies on abuse prevention and wandering and elopement were not adequately followed. The resident's risk for elopement was not properly documented or addressed in the care plan, and there was no immediate notification to the facility administration, physician, or state agencies about the elopement. Additionally, there was no documentation of an investigation being started immediately after the incident. The resident's wandering risk assessment indicated a high risk for wandering, yet the care plan lacked specific interventions to prevent elopement. Interviews with staff revealed a lack of awareness and understanding of the facility's elopement procedures. Some staff members were unaware of the location of the elopement book or how to access resident care information. The resident involved in the incident was not informed that they were not supposed to exit the building alone, indicating a communication gap between the staff and residents regarding safety protocols. This deficiency highlights a failure in the facility's systems to ensure resident safety and prevent elopement.
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What surveyors actually found near you
We read the 916 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
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Nursing homes near Florissant
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St Sophia Health & Rehabilitation Center | 1.9 mi | ★★★★★ | 27 | 0 |
| Bentwood Nursing & Rehab | 2 mi | ★★★★★ | 29 | 0 |
| Willowcreek Wellness & Rehabilitation | 2.4 mi | ★★★★★ | 12 | 0 |
| Pillars Of North County Health & Rehab Center, The | 2.5 mi | ★★★★★ | 2 | 0 |
| Lakeview Post Acute | 2.9 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.