Average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Northgate Unit Of Lakeview Christian Home during CMS and state inspections, most recent first.
Incomplete daily nurse staffing postings were observed, with no visible staffing sheet in a common area, repeated missing census documentation in record review, and a posted sheet that only showed morning shift staffing and did not include the resident census.
Expired medications and supplies were found in multiple medication storage rooms, including lancets, blood collection tubes, hypodermic needles, Bluetooth glucose monitoring strips, IV catheters, and an IV start kit. Surveyors also found a multi-use vial of regular insulin in the refrigerator without an open date or required dating. An LPN and a CMA confirmed the items were expired or improperly labeled, and the DON stated medications should be labeled and dated according to policy.
Expired yogurt, milk, and salad dressing were found in the refrigerator, along with unlabeled produce and frozen meat in the freezer. Kitchen equipment was heavily soiled, sanitizer testing was inconclusive, refrigerator temp logs were incomplete, and pitchers of beverages were not labeled or dated. During meal service, an NAIT assisted two residents with feeding without performing hand hygiene.
The facility failed to maintain a routine process to inspect bed frames, mattresses, and bed rails for possible entrapment. Record review showed the bed inspection form addressed bed height and wheelchair cushion securement, but did not include checks of frames, mattresses, or rails. The ADMIN and MAINT both confirmed there was no checklist or routine maintenance program for these inspections unless a work order was submitted.
A corridor handrail in the west hall just past the main entrance was observed to be loose and easily pulled away from the wall. A PTA and the DON confirmed the rail was unsecured, and the deficiency was identified as affecting all residents who use handrails.
Failure to Obtain Consent for Antidepressant Medications: The facility did not ensure that a resident or their representative was informed about the risks and benefits of antidepressant medications before use. Three residents had orders for Sertraline, Lexapro dose increase, or Bupropion, but no consent was present in the EHR. The DON confirmed the consents had not been obtained prior to use.
The facility failed to ensure residents with personal funds accounts could access their money on evenings and weekends. Multiple residents stated they could not get money when the front office was closed and had to request it in advance. The ADM stated residents are expected to request money ahead of time, and if an emergency occurs after hours, staff must call the ADM or BOM to come in and check money out.
A facility failed to develop and implement baseline care plans within 48 hours of admission for 3 residents. One resident had a blank baseline care plan despite diagnoses including RA, A-fib, chronic pain, and a history of falls; two other residents had no baseline care plan in the EHR. The DON confirmed the missing or blank care plans for all 3 residents.
Infection control precautions were not consistently followed for residents on contact precautions and EBP. A CNA entered a resident’s room without PPE and later handled food and a drink cup in the dining area without hand hygiene, a RN entered another resident’s room without PPE while taking vital signs, and a third resident with an open wound did not have EBP signage or PPE posted outside the room. The DON confirmed the expected PPE use for these situations.
A resident with dementia, schizoaffective bipolar type, depression, and bipolar II disorder had a physician order for a secure alarm bracelet to reduce elopement risk and was observed wearing the bracelet, but the care plan only addressed wandering behavior and did not include the bracelet. The MDS showed severe cognitive impairment and a need for a wander/elopement alarm, and the DON confirmed the bracelet was not included in the care plan.
A resident was unable to activate his tap-style call light during an observation, and a CNA later confirmed the cord was pinched between the bed and preventing it from working until the bed was raised. The issue was identified for 1 of 4 residents reviewed for call lights.
A paper listing residents' names and vital sign readings was left face up on the nurses station countertop, exposing personal health information to unauthorized individuals. This was confirmed by a staff member and the DON, and had the potential to affect all residents on two halls.
A resident with a history of dizziness, dementia, and osteoporosis experienced an unwitnessed fall, which was documented in progress notes and led to new physician orders for fall prevention and monitoring. However, the annual MDS assessment failed to record the fall, and the MDS Coordinator confirmed the inaccuracy during an interview.
Two dietary aides were observed working in the kitchen without wearing hairnets, as required by facility policy. The Assistant Dietary Manager confirmed that all staff should have been wearing hairnets while in the kitchen. This lapse in food safety protocol had the potential to affect all residents in the facility.
Two residents did not have accurate or complete care plans regarding their need for supplemental oxygen. One resident's care plan incorrectly listed oxygen therapy despite no current order or use, while another resident who depended on supplemental oxygen had no care plan addressing this therapy. The DON confirmed these discrepancies during interviews.
Staff did not update care plans for two residents after significant changes in their care needs. One resident using assist bars for bed mobility did not have this intervention reflected in the care plan, and another resident admitted to hospice care did not have hospice services addressed in the care plan. The DON confirmed both omissions.
A deficiency was identified when staff failed to accurately document a resident's diagnosis of major depressive disorder on the PASRR Level 1 Identification Screen. Although the resident's records listed major depressive disorder, staff marked on the PASRR that there was no mental illness, a mistake later confirmed by the DON.
A treatment cart was observed unlocked and unattended in a hallway, with no staff present in the area. Both a case manager and an RN confirmed the cart was not secured, potentially allowing unauthorized access to medical supplies and personal health information for residents in nearby rooms.
The facility failed to maintain sanitary food service conditions by not ensuring staff performed hand hygiene when distributing food trays and assisting multiple residents with eating and drinking. This deficiency was observed in the dining room and confirmed through staff interviews, potentially affecting all 76 residents.
The facility failed to implement a comprehensive antibiotic stewardship program, leading to improper monitoring and administration of antibiotics. A resident recovering from a UTI was prescribed ceftriaxone, but discrepancies in administration and discontinuation dates were found. The facility did not perform required antibiotic timeouts or involve the physician in daily discussions about antibiotic use.
The facility failed to ensure that two residents' bedside tables with frequently used items were within their reach, leaving them unable to access necessary items. Both residents were unable to get up on their own, and staff confirmed that the tables should have been positioned within reach.
The facility failed to provide written transfer notices to residents, their representatives, and the Ombudsman for six residents transferred to the hospital for various medical reasons. The Administrator confirmed the absence of a written transfer notice form, and the Ombudsman only received a monthly faxed list of transferred residents' names.
The facility failed to provide written notices of the bed hold policy to residents and their representatives during hospital transfers. The deficiency was identified for six residents, and the facility did not keep copies or document the notices in the medical records.
The facility failed to ensure care plan revision and care plan meeting requirements for multiple residents, leading to outdated care plans and lack of appropriate interventions. Notifications for care plan meetings were not effectively communicated, and hospice staff were often absent without documentation.
The facility failed to administer antibiotics in a timely manner for a resident with a positive urine culture and did not apply compression stockings as ordered for another resident with localized edema. The delay in starting antibiotics and the lack of adherence to the physician's order for compression stockings were confirmed through interviews and observations.
The facility failed to keep treatment carts locked when not supervised by staff and did not ensure a fall mat was placed next to a high fall-risk resident's bed as specified in the care plan. Multiple observations and staff interviews confirmed these deficiencies.
The facility failed to ensure that the physician provided a rationale for not following the pharmacist's recommendations for two residents reviewed for unnecessary medications. For one resident, the pharmacist recommended increasing the dosage of Metformin, which was denied without rationale. For another resident, the pharmacist recommended a reduction of either divalproex or Seroquel, but the provider marked the reduction as contraindicated without providing a rationale. This lack of documentation was confirmed by the DON.
The facility failed to initiate a GDR of medication as recommended by the pharmacist and ordered by the provider for two residents. One resident continued to receive the same dose of gabapentin despite a recommendation to reduce it, and another resident's provider did not document a rationale for not reducing divalproex or seroquel. The DON confirmed these deficiencies.
The facility failed to properly store medications and ensure medication carts were locked, affecting all 53 residents in the East and H Units. Unlocked medication carts and loose medications were observed, and insulin was improperly stored against manufacturer's instructions. These issues were confirmed by staff and the DON.
The facility failed to follow proper infection control practices by not labeling nasal cannulas with the date they were changed for three residents. This deficiency was confirmed through observations and staff interviews, indicating a lapse in the facility's protocol to change and date nasal cannulas weekly.
The facility failed to ensure call lights were functional and accessible in residents' bathrooms and bathing areas. Pull cords were not within reach from the floor for ten residents, and the alarm sound for call lights in two rooms was not working. Additionally, call lights were not within reach for two other residents. These issues were confirmed through observations and staff interviews.
The facility failed to provide required training on abuse, neglect, and exploitation (ANE) and Dementia Management to several staff members. The facility relies on face-to-face training sessions conducted monthly, but if a staff member misses a session, they may miss mandatory training. This was confirmed during interviews with the Administrator and the DON.
The facility failed to ensure the MDS was accurate for a resident who had a documented UTI. Despite the resident's symptoms and subsequent diagnosis, the quarterly MDS assessment did not reflect the UTI. The MDS Coordinator confirmed the inaccuracy during an interview.
The facility failed to provide a homelike environment for all 76 residents by not repairing broken roof tiles in the activity room. Observations revealed multiple broken and cracked tiles, and the Maintenance Director and Administrator confirmed the issues without specifying details of repairs.
Incomplete Daily Nurse Staffing Postings
Penalty
Summary
The facility failed to post nurse staffing information daily at the beginning of the shift with the required details, including the facility name, current date, total number and actual hours worked by RN, LPN, CNA staff directly responsible for resident care per shift, and resident census. On 05/17/26 at 9:30 a.m., surveyors observed that no staffing data posting sheet was visible in a conspicuous, accessible area. Record review of 18 months of staff postings showed that January 2026 had 31 of 31 days without census documentation, and February 2026 had 24 of 28 days without census documentation. On 05/21/26 at 8:27 a.m., surveyors observed a staffing data posting sheet dated 05/20/26 that was incomplete, and at 8:35 a.m. a CNA confirmed that the posted sheet only included the morning shift staffing and did not document the resident census.
Expired Medications and Supplies Found in Medication Storage Rooms
Penalty
Summary
The facility failed to properly store medications and medical supplies in the medication storage rooms, including failure to ensure insulin multidose vials were dated when first used and dated 28 days after first use. During observations, surveyors found multiple expired items in stock, including lancets, blood collection tubes, hypodermic needles, Bluetooth glucose monitoring strips, IV catheters, and IV start kits in the 200 hall, east medical storage room, and 400 hall medical storage room. One multi-use vial of regular insulin was found in the refrigerator opened without an open date on the box or vial. During interviews, an LPN confirmed the expired items were still present and should have been removed from stock. A CMA also confirmed that the insulin vial lacked the required open date and expiration date and that the expired medical supplies should have been removed from stock. The DON stated that allowing medical supplies to remain in working stock did not meet her expectation and that medications of any type should be labeled and dated according to policy.
Expired and Unlabeled Food, Incomplete Refrigerator Logs, and Poor Hand Hygiene During Meal Service
Penalty
Summary
Food was not stored and served under sanitary conditions when kitchen and dining area staff failed to dispose of expired food, label and date food items, maintain complete refrigerator temperature logs, and perform hand hygiene during meal service. During kitchen observation, expired yogurt cups, lactose free milk, and Italian salad dressing were found in the refrigerator, along with bags of shredded lettuce or cabbage and sliced red onion that were not properly labeled or dated. In the freezer, bags of frozen chicken and unidentified frozen meat were also found without labels or dates. Dietary staff confirmed the expired and unlabeled items should have been discarded or labeled appropriately. The kitchen stove and oven were observed with dried, burnt-on food particles, splashes, and grease buildup, and a sanitizer bucket tested inconclusive because the water did not contain the required chemicals needed to sanitize. Refrigerator logs in two dining areas were missing temperature entries on multiple dates, and staff confirmed the logs were incomplete. In one dining area, pitchers of different colored liquids were not labeled or dated, and a pitcher labeled as apple juice had a date of 05/15/26. A dietary aide also confirmed a brown liquid appearing to be tea was being served from a pitcher that was not labeled or dated. During meal service, a nurse aide in training touched her chair, applied protective coverings to two residents, returned to her chair, and then assisted the residents with feeding without performing hand hygiene.
Lack of Routine Bed Entrapment Inspections
Penalty
Summary
The facility failed to conduct regular inspections of bed frames, mattresses, and bed rails, if any, as part of a maintenance program to identify possible entrapment areas. Record review of the occupational therapy bed inspection form showed inspection of bed height, securement of a wheelchair cushion, and issues identified with bed height and seat cushion, but it did not include inspection of frames, mattresses, or rails for possible entrapment. During interview, the Administrator confirmed the facility did not have a checklist or routine maintenance process to inspect bed frames, bed mattresses, and bed rails, and stated that if there was an issue with bedrails, a work order was placed and repaired at that time. The Maintenance Director also confirmed there was no routine maintenance program in place to inspect bed frames, bed mattresses, and bed rails unless a work order was submitted.
Loose Corridor Handrail
Penalty
Summary
The facility failed to maintain corridor handrails at one identified location, with a rail along the west hall corridor just past the main entrance observed to be loose and easily pulled away from the wall. During the observation, the handrail was found to be unsecured, and a PTA later confirmed that the rail was loose and could be easily pulled away from the wall. The Director of Maintenance also confirmed that the rail was loose and needed to be repaired. The deficiency was identified as affecting all 77 residents in the census who use handrails.
Failure to Obtain Consent for Antidepressant Medications
Penalty
Summary
The facility failed to ensure that residents or their representatives were informed about medications they were receiving, including the risks and benefits associated with those medications. Record review showed that three residents had medication orders for antidepressants, but no consent was present in the electronic health record for the medications or for dose increases when applicable. The deficiency involved a resident admitted with diagnoses including a lumbar compression fracture, acute pain, CHF, chronic A-fib, major depressive disorder, and insomnia; another resident admitted with encephalopathy, pneumonia, dementia, chronic A-fib, major depressive disorder, and generalized anxiety disorder; and a third resident admitted with major depressive disorder, insomnia, dementia with mood disturbance, bipolar disorder, and Parkinson's disease. For the first resident, an order was entered for Sertraline 50 mg daily for depression, and the DON confirmed that consent for the increased dose had not been obtained. For the second resident, orders showed Lexapro 10 mg daily with a later increase to 20 mg daily for depression, and no consent was present for the increased dose. For the third resident, an order was entered for Bupropion 150 mg daily, and the EHR showed no consent for its use. During interview, the DON confirmed that consent had not been obtained prior to the use of these medications and stated this did not meet expectations.
Resident Funds Not Accessible After Hours
Penalty
Summary
The facility failed to ensure that residents with personal funds accounts could access their money on evenings and weekends. During an interview with Resident Council members, multiple residents stated they were not allowed to get money when the front office was closed and that the only way to request money was in advance. Review of the facility’s Resident Accounts policy showed that the receptionist is responsible for the resident accounting system, the facility keeps about $100 in cash on hand for residents, and the remainder of resident funds is kept in a checking account at a local bank. The Administrator stated that residents are to request money in advance and that if an emergency occurs when the office is closed, staff will call her or the Business Office Manager and one of them will come to the facility to check money out.
Failure to Complete Baseline Care Plans for Newly Admitted Residents
Penalty
Summary
The facility failed to develop and implement an adequate baseline care plan within 48 hours of admission for 3 of 6 residents reviewed. For Resident #12, the face sheet showed admission with diagnoses including rheumatoid arthritis, history of falling, longstanding persistent atrial fibrillation, chronic pain syndrome, calculus of the lower urinary tract, and a disorder of the urinary system, but the baseline care plan dated 03/25/26 was blank and contained no information. During interview on 05/21/26, the DON confirmed that Resident #12's baseline care plan did not meet expectations because it contained no information. For Resident #20, the face sheet showed admission with CHF, dementia, osteoarthritis, type 2 diabetes mellitus, CKD, major depressive disorder, generalized anxiety disorder, and a history of falling, but the EHR contained no baseline care plan. The DON confirmed on 05/21/26 that the facility failed to develop a baseline care plan for Resident #20 when admitted. For Resident #58, the face sheet showed admission with hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, dementia with behavioral disturbance, depression, an unspecified open wound on the right foot, chronic pain syndrome, neuromuscular dysfunction of the bladder, and atrial fibrillation, but the EHR also contained no baseline care plan. The DON confirmed on 05/21/26 that the facility failed to develop a baseline care plan for Resident #58 when admitted.
Infection Control Precautions Not Followed for Residents With Contact Precautions and EBP
Penalty
Summary
The facility failed to maintain an ongoing infection prevention and control program for 3 residents by not following the required precautions for residents with contact precautions and enhanced barrier precautions (EBP), and by not placing EBP signage and PPE outside one resident’s room. R #2 had diagnoses including quadriplegia, neuromuscular dysfunction of the bladder, multiple pressure ulcers, MRSA, and type 2 diabetes mellitus. Although a contact precaution sign and PPE cart were observed outside R #2’s room, a CNA entered the room without PPE, then left the room and handled a drink cup and food in the dining area without washing or sanitizing her hands. The resident stated he understood the reason for contact precautions but did not mind staff entering without gowns, and the DON confirmed staff are expected to don PPE before entering and doff it when exiting, with the trash can for used PPE near the room entrance/exit. R #17 had diagnoses including a non-pressure chronic ulcer with necrosis of bone and an open wound of the lower leg. A RN entered R #17’s room and pulled a vital sign machine without wearing PPE, and later stated PPE was not required because she was only taking vital signs and did not touch the wound. The DON confirmed PPE is required for all care, including taking vital signs, for residents on EBP. R #58 had a stage 3 pressure ulcer on the foot and an unspecified open wound of the right foot; her care plan identified her as at risk for pain and infection due to the open wound. However, no EBP signage was observed outside her room, and the DON confirmed she should have been on EBP due to the open wound but was not.
Care Plan Not Updated for Security Alarm Bracelet
Penalty
Summary
The facility failed to revise the care plan for one resident to include a security alarm bracelet. The resident had diagnoses of dementia, schizoaffective bipolar type, depression, and bipolar II disorder. Record review showed a physician order for a secure alarm bracelet to minimize the risk of elopement, and the order was discontinued and renewed. The resident’s quarterly MDS indicated severe cognitive impairment with a BIMS score of six and that a wander/elopement alarm was required. An observation on 05/18/26 showed the resident wearing a security alarm bracelet on the left ankle. However, the resident’s care plan, revised on 04/16/26, documented behavioral problems including wandering but did not include the security alarm bracelet. During interview, a nurse aide in training confirmed the resident had worn the bracelet for a while and that staff checked its placement every shift. The DON confirmed the bracelet had not been included in the resident’s care plan and should have been.
Call Light Not Working for a Resident
Penalty
Summary
The facility failed to ensure that call lights in residents' rooms were within residents' reach for 1 of 4 residents reviewed for call lights, specifically Resident #2. During an observation and interview on 05/17/26 at 12:51 pm, Resident #2 was attempting to activate his call light but could not get it to work. Resident #2 stated that he likes the tap-activated call light because it is easier for him to use. Later that day, during an interview with CNA #4 at 12:55 pm, the CNA was unable to activate the call light until she raised the position of Resident #2's bed. CNA #4 confirmed that the cord to Resident #2's call light was pinched between the bed and was stopping the call light from working.
Resident Health Information Left Unsecured at Nurses Station
Penalty
Summary
A deficiency occurred when a paper document containing residents' names and their vital sign readings was left face up on the nurses station countertop, making personal health information visible to unauthorized individuals. This was observed during a random facility check, and the presence of the document was confirmed by a staff member. The Director of Nursing also acknowledged that such information should be safeguarded and not left in plain view. The incident had the potential to affect all 38 residents residing on the East 1 and East 2 halls.
Inaccurate MDS Assessment Following Resident Fall
Penalty
Summary
Facility staff failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for one resident. The resident's admission record included diagnoses of dizziness, senile dementia, and osteoporosis. On 03/18/25, the resident experienced an unwitnessed fall, which was documented in progress notes and resulted in new physician orders for fall prevention, monitoring for injuries, and neurological checks. Despite this incident, the resident's annual MDS assessment indicated that no falls had occurred since admission or the prior assessment. During an interview, the MDS Coordinator confirmed that the MDS was inaccurate because it did not reflect the documented fall.
Failure to Ensure Dietary Staff Wore Hairnets in Kitchen
Penalty
Summary
During an observation of the kitchen, it was noted that two dietary aides were not wearing hairnets while present in the kitchen area. This was confirmed during an interview with the Assistant Dietary Manager, who acknowledged that all staff are required to wear hairnets while in the kitchen. The failure to follow this protocol was observed during a random inspection and is likely to affect all 79 residents listed on the facility's census at the time.
Failure to Develop and Implement Accurate Care Plans for Oxygen Therapy
Penalty
Summary
The facility failed to develop and implement accurate, person-centered comprehensive care plans for two of four residents reviewed. For one resident, the care plan indicated a need for oxygen therapy, but current medical orders did not include supplemental oxygen, and the DON confirmed that the resident does not use oxygen, making the care plan inaccurate. For another resident, who was diagnosed with atherosclerotic heart disease, dementia, and dependence on supplemental oxygen, the care plan did not address the use of oxygen at all, despite the resident's ongoing need for it. The DON confirmed that this resident uses supplemental oxygen and should have a care plan in place for its use, but none was present.
Failure to Revise Care Plans for Assist Bar Use and Hospice Admission
Penalty
Summary
Staff failed to revise and update care plans for two residents following significant changes in their care needs. For one resident with multiple diagnoses including Parkinson's disease, abnormalities of gait, and polyosteoarthritis, an evaluation documented the use of bilateral assist bars for bed mobility and transfers, with the resident's consent. Despite the presence of assist bars on the bed and the resident's use of them for repositioning and mobility, the care plan did not include any reference to assist bar use. The Director of Nursing confirmed that the care plan was not updated to reflect this intervention. For another resident with a history of atherosclerotic heart disease, dementia, and hypertensive heart disease with heart failure, a medical order was issued to admit the resident to hospice care. However, the care plan, last updated several months after the hospice order, did not address hospice care or services. The Director of Nursing acknowledged that the resident was on hospice and that the care plan should have included this information, but it had not been updated accordingly.
Inaccurate PASRR Assessment for Resident with Major Depressive Disorder
Penalty
Summary
A deficiency occurred when the facility failed to ensure the accuracy of the Pre-Admission Screening and Resident Review (PASRR) assessment for a resident with a documented diagnosis of major depressive disorder. Record review showed that the resident was admitted with multiple diagnoses, including major depressive disorder, which is considered a mental illness. However, the PASRR Level 1 Identification Screen completed by staff indicated that the resident did not have a diagnosis or suspected mental illness. During an interview, the DON confirmed that the resident does have a diagnosis of major depressive disorder and acknowledged that the PASRR documentation was incorrect. This inaccuracy in the PASRR assessment was identified through both record review and staff interview, highlighting a failure to properly document the resident's mental health status as required.
Unattended Unlocked Treatment Cart Found in Facility Hallway
Penalty
Summary
Facility staff failed to ensure that all treatment carts were locked while unattended, as required for the secure storage of drugs and biologicals. During a random observation, a treatment cart located in the hallway of the 200 rooms was found unlocked with no facility employees present in the area. This was confirmed by both a case manager and a registered nurse, who acknowledged the cart was unlocked and subsequently secured it. The unlocked cart had the potential to allow unauthorized access to medical supplies and personal health information for all 18 individuals residing in rooms 200 through 216. No specific details about the medical history or condition of the affected residents were provided in the report.
Failure to Maintain Sanitary Food Service Conditions
Penalty
Summary
The facility failed to serve food under sanitary conditions by professional standards of food service safety, potentially affecting all 76 residents who eat food prepared in the kitchen. During an observation of the dining room of the H Unit, it was noted that a CNA did not wash or sanitize her hands with hand sanitizer in between meal passes. Additionally, in the main dining room, two staff members, a CNA and a Nurse Aide, assisted multiple residents with eating and drinking without performing hand hygiene between residents. This was confirmed by the staff members during interviews, where they admitted to not typically performing hand hygiene between feeding different residents. The Director of Nursing (DON) stated that staff do not need to perform hand hygiene when alternating between feeding two different residents unless a resident touches the item the staff member is using to feed the residents. This practice contradicts professional standards of food service safety and proper hand hygiene protocols, increasing the risk of foodborne illnesses among residents. The failure to adhere to these standards was observed and confirmed through staff interviews, highlighting a significant deficiency in the facility's food handling and hygiene practices.
Failure to Implement Comprehensive Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement a comprehensive antibiotic stewardship program, which is designed to optimize the treatment of infections while reducing adverse events associated with antibiotic use. The facility's policy required nursing staff to conduct an antibiotic timeout within 48-72 hours of antibiotic therapy to monitor response and review laboratory results. However, it was found that the facility did not follow this protocol. Specifically, the Director of Nursing (DON) confirmed that they do not perform 48-hour timeouts for antibiotics, and the Infection Preventionist (IP) stated that the physician is not involved in daily meetings discussing residents' antibiotic use and reactions. This lack of adherence to the policy has the potential to affect all 76 residents in the facility, as it could lead to inappropriate antibiotic use and resistance to multi-drug resistant organisms. The report highlighted the case of a resident recovering from a urinary tract infection (UTI). The resident was prescribed ceftriaxone, an antibiotic, which was administered as ordered. However, there were discrepancies in the administration and discontinuation dates of the antibiotic, indicating a lack of proper monitoring and communication. The resident's Medication Administration Record (MAR) showed that ceftriaxone was administered through specific dates, but there was no evidence of the required antibiotic timeout or consultation with the practitioner to determine if the antibiotic should continue or be adjusted. This failure to follow the antibiotic stewardship program's protocol underscores the facility's deficiency in managing antibiotic use effectively.
Failure to Provide Reasonable Accommodation of Resident Needs
Penalty
Summary
The facility failed to provide reasonable accommodation of resident needs for two residents, resulting in their bedside tables with frequently used items being out of reach. Resident #37 was observed sitting in a chair next to his bed with his call bell placed behind him on the bed, out of his sight and reach. Additionally, his bedside table with drinks was positioned approximately four feet away at the foot of his bed. Resident #37 confirmed that he was unable to get up on his own and could not access his drinks. This was corroborated by CNA #22, who acknowledged that the drinks should have been within the resident's reach. Similarly, Resident #41 was observed lying in bed with her bedside table, containing drinks and a box of tissues, placed about three feet away from her bed. Resident #41 stated that she was unable to get out of bed on her own and could not reach her drinks. CNA #23 and LPN #23 both confirmed that the bedside table with drinks and other frequently needed items should have been within Resident #41's reach. The Director of Nursing also confirmed that residents' bedside tables with frequently used items should be within their reach.
Failure to Provide Written Transfer Notices
Penalty
Summary
The facility failed to ensure that residents, their representatives, and the Ombudsman received a written notice of transfer as soon as practicable for six residents reviewed for hospitalization. Specifically, residents were transferred to the hospital for various medical reasons, including falls, blood in stool, pain, MRSA, lethargy, and shortness of breath. In each case, the staff did not provide a written transfer notice to the residents or their representatives, nor did they send a copy of the written transfer notice to the Office of the State Ombudsman. This deficiency was confirmed through record reviews and interviews with the facility's Administrator and the Ombudsman. The Administrator confirmed that the facility does not have a written transfer notice form, and the Ombudsman confirmed that she only received a faxed list of resident names who were transferred to the hospital from the facility monthly, rather than copies of the written notices. This lack of proper documentation and notification could likely result in the residents and/or their representatives not knowing the reason or location of the resident's discharge, as well as the Ombudsman not being adequately informed to advocate for the residents effectively.
Failure to Provide Written Bed Hold Notices
Penalty
Summary
The facility failed to ensure that residents and their representatives received a written notice of the bed hold policy, which indicates the duration the bed would be held in cases of transfer to a hospital or therapeutic leave. This deficiency was identified for six residents who were transferred to the hospital for various medical reasons, including falls, blood in stool, pain, MRSA, lethargy, and shortness of breath. The medical records of these residents did not contain any written notice of the bed hold policy for their respective hospital transfers. During interviews, the Administrator and Receptionist confirmed that the facility's process involved sending bed hold notices by mail to the resident's representative the next business day. However, the facility did not provide the bed hold notice to the residents themselves, did not keep a copy of the notice, and did not document in the medical record that the notice was sent. This lack of documentation and direct communication with the residents led to the deficiency, as there was no evidence that the bed hold policy was communicated effectively to the residents or their representatives.
Care Plan Revision and Meeting Deficiencies
Penalty
Summary
The facility failed to ensure care plan revision and care plan meeting requirements for multiple residents. Specifically, the facility did not have the required Interdisciplinary Team (IDT) members and resident representatives participate in care plan meetings for two residents. Additionally, care plan meetings were not held within seven days after the completion of the MDS assessment for one resident. This led to the care plans not being updated with the most current resident conditions and appropriate interventions. The facility also failed to revise care plans with the most current resident information for several residents. For instance, one resident's care plan was not updated to reflect their fluctuating abilities, another resident's care plan did not include a recent urinary tract infection (UTI) diagnosis, and another resident's care plan did not account for a recent hospitalization due to a gastrointestinal bleed. Furthermore, the care plans for some residents did not include necessary medical interventions such as compression stockings and oxygen therapy. Interviews with family members and staff revealed that notifications for care plan meetings were not effectively communicated, leading to family members missing these important meetings. Additionally, hospice staff were often not present at care plan meetings, and there was a lack of documentation regarding their absence. These deficiencies could result in staff being unaware of changes in care provided and residents not receiving the care related to changes in their health status or healthcare decisions.
Failure to Administer Timely Antibiotics and Apply Compression Stockings
Penalty
Summary
The facility failed to ensure residents received treatment and care in accordance with professional standards of practice for two residents. For one resident, antibiotics were not started until five days after a positive urine culture for Escherichia Coli was received. The urine culture results were sent to the facility provider on the same day they were received, but the facility did not attempt to contact the provider until four days later. The antibiotics were subsequently ordered and started five days after the culture results were received. This delay was confirmed during an interview with the MDS coordinator and the DON. For another resident, the facility failed to apply compression stockings as ordered by the physician. The resident, who had a diagnosis of localized edema, was observed without compression stockings on multiple occasions. The physician's order to apply knee-high compression stockings in the morning and remove them at night was not included in the resident's care plan. Interviews with a CNA and an LPN revealed that they were unaware of the order for compression stockings, and the resident was not wearing them at the time of the interviews. The DON confirmed that CNAs are expected to apply and remove compression stockings as per the physician's order.
Failure to Lock Treatment Carts and Ensure Fall Mat Placement
Penalty
Summary
The facility failed to keep treatment carts locked when not supervised by staff, affecting all 53 residents in the East Unit and H Unit. Multiple observations over several days revealed that treatment carts were left unlocked and unattended. Staff members, including RNs, CMAs, and LPNs, confirmed during interviews that the treatment carts should be locked when not in use. The Director of Nursing (DON) also confirmed that treatment carts should be locked when staff are not present. Additionally, the facility failed to ensure that a fall mat was placed next to a high fall-risk resident's bed as specified in the care plan. The resident, who had a history of falls and was unable to get out of bed independently, was observed without a fall mat next to her bed. The fall mat was found folded up behind a recliner in the resident's room. Staff members, including a CNA and an LPN, confirmed that the fall mat should be placed next to the resident's bed to prevent injury. The DON also confirmed that the fall mat should be in place as per the care plan.
Failure to Document Rationale for Not Following Pharmacist's Recommendations
Penalty
Summary
The facility failed to ensure that the physician provided a rationale for not following the pharmacist's recommendations for two residents reviewed for unnecessary medications. For Resident #36, the pharmacist recommended increasing the dosage of Metformin from 500 mg twice daily to 500 mg three times daily. The provider denied this recommendation but did not provide a rationale for the decision. This was confirmed by the Director of Nursing (DON) during an interview. The physician's orders for Resident #36 continued to reflect the original dosage without any documented rationale for the denial of the pharmacist's recommendation. For Resident #41, the pharmacist recommended considering a reduction of either divalproex or Seroquel. The provider marked the gradual dose reduction (GDR) as contraindicated but did not document a rationale for this decision. The physician's orders for Resident #41 continued to include divalproex 125 mg twice a day and Seroquel 25 mg at bedtime without any changes or documented rationale for not following the pharmacist's recommendation. This lack of documentation was also confirmed by the DON during an interview.
Failure to Implement Gradual Dose Reduction and Document Rationale
Penalty
Summary
The facility failed to initiate a gradual dose reduction (GDR) of medication as recommended by the pharmacist and ordered by the facility provider for two residents. For one resident, the pharmacist recommended a GDR of Depakote and gabapentin due to frequent falls, daytime drowsiness, and irritability. The facility provider marked the GDR for Depakote as contraindicated and agreed to reduce gabapentin to 100 mg three times daily. However, the resident's medical record did not show a new order for the reduced gabapentin dose, and the resident continued to receive the same dose. The DON and MDS coordinator confirmed that the GDR had not been completed as agreed upon by the provider. For another resident, the pharmacist recommended a further reduction of divalproex or seroquel due to the resident not exhibiting behaviors. The provider marked the GDR as contraindicated but did not document a rationale for this decision. The resident's medical record did not contain information that the physician ordered a GDR for divalproex or seroquel after the pharmacist's recommendation. The DON confirmed that the provider did not document a rationale for not acting upon the pharmacist's recommendations and had not ordered a dose reduction for the medications.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to store medications properly and ensure medication carts were locked for all 53 residents in the East Unit and the H Unit. During an observation, a medication cart on the H Unit was found unlocked without staff present. This was confirmed by an RN and the DON, who both acknowledged that medication carts should be locked when unattended. Additionally, loose medications were found in the medication carts on both units, including a half of a white round tablet and a white round tablet with the imprint HH 223. These observations indicate a failure to maintain proper medication storage protocols, which could lead to residents obtaining or being administered incorrect medications. Furthermore, the facility did not store insulin according to the manufacturer's instructions. An Admelog SoloStar insulin pen was found in the refrigerator with an open date of 03/01/24, despite the manufacturer's guidelines stating that the pen should be kept at room temperature and not refrigerated after opening. The DON confirmed that she was unaware of the proper storage requirements for Admelog. These deficiencies highlight significant lapses in medication management and storage practices within the facility.
Failure to Label Nasal Cannulas
Penalty
Summary
The facility failed to follow proper infection control practices for three residents who were observed using nasal cannulas without proper labeling. During observations, it was noted that the nasal cannulas for these residents were not labeled with the date they were changed, which is against the facility's practice of changing nasal cannulas weekly and dating them for tracking purposes. Specifically, Resident #14 was seen in the dining area with an unlabeled nasal cannula, and this was confirmed by RN #11. Resident #65 had an oxygen concentrator and a portable oxygen tank, both with nasal cannulas that were either illegibly labeled or not labeled at all, as confirmed by CNA #22 and RN #21. Resident #179, who had a physician's order to change the nasal cannula on the first Sunday of the month, was also observed with an unlabeled nasal cannula, confirmed by RN #11 and the DON. These observations indicate a failure in the facility's infection control practices, as staff did not adhere to the protocol of labeling nasal cannulas with the date they were changed. This deficiency was confirmed through multiple interviews with staff members, including RNs and CNAs, who acknowledged that nasal cannulas should be changed weekly and labeled accordingly. The lack of proper labeling could potentially lead to the spread of contagious and resistant illnesses among residents.
Deficient Call Light Accessibility and Functionality
Penalty
Summary
The facility failed to ensure that call lights were functional and accessible in residents' bathrooms and bathing areas. Specifically, the pull cords for the call light system in the bathrooms were not within reach from the floor for ten residents. Additionally, the alarm sound for the call lights in two residents' rooms was not working, and the call lights were not within reach for two other residents. These deficiencies were confirmed through observations and interviews with residents and staff, including Licensed Practical Nurses (LPNs) and Certified Nursing Assistants (CNAs). The Director of Nursing (DON) and the Administrator also confirmed that the call lights should be within reach and audible to alert staff when activated. For instance, one resident reported that her call light lit up but did not make an audible sound, and the pull cords in her bathroom were coiled up and not accessible. Another resident was found sitting in a chair with the call light placed on the bed behind him, making it impossible for him to reach it. Similarly, another resident lying in bed could not reach her call light, which was hung on the bed rail out of her reach. These observations were corroborated by staff interviews and care plan reviews, which indicated that the call lights should be kept within reach of the residents to ensure they can call for assistance when needed.
Failure to Provide Mandatory Training
Penalty
Summary
The facility failed to provide required training on abuse, neglect, and exploitation (ANE) and Dementia Management to several staff members. Specifically, CNA #26, LPN #21, LPN #22, and RN #21 did not complete the necessary training within the specified date range. The facility relies on face-to-face training sessions conducted monthly, covering different subjects each month. However, if a staff member misses a monthly session, they may miss mandatory training. This was confirmed during interviews with the Administrator and the Director of Nursing (DON). The lack of completed training could result in staff not knowing how to identify and report instances of abuse, neglect, and exploitation.
Inaccurate MDS Assessment for UTI Diagnosis
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) was accurate for one resident reviewed for MDS accuracy. Specifically, the resident complained of burning pain upon urination, and a McGreer's Criteria form indicated acute dysuria and a significant bacterial count in a urine sample. The resident was subsequently diagnosed with a urinary tract infection (UTI) and prescribed gentamicin. However, the quarterly MDS assessment did not document the UTI diagnosis. The MDS Coordinator confirmed the omission during an interview, acknowledging that the MDS assessment was not accurate for the resident.
Failure to Maintain Homelike Environment
Penalty
Summary
The facility failed to provide a homelike environment for all 76 residents by not repairing broken roof tiles in the activity room. During an observation, it was noted that one ceiling tile had a corner piece broken off, a second tile had a corner piece broken off and was missing the corner of the tile, and a third tile had a crack on the corner. The Maintenance Director confirmed that roofing tiles were replaced but did not specify where and when. The Administrator confirmed that one tile in the activity room was cracked but did not see any other broken tiles, despite maintenance confirming replacements without specific details.
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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.
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Nursing homes near Carlsbad
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Artesia Healthcare & Rehabilitation Center, Llc | 30.2 mi | ★★★★★ | 19 | 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 August 2026) and official state health department websites.