Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Sunset Villa Healthcare during CMS and state inspections, most recent first.
PRN psychotropic medication orders for two residents lacked stop dates. One resident with anxiety, depression, schizophrenia, and cerebral infarction had a hydroxyzine order for anxiety without a stop date, and another resident with depression, anxiety, cerebral infarction, bipolar disorder, and impulse disorder had an Ativan order for agitation and restlessness without a stop date. The DON confirmed both orders were missing stop dates and stated the Ativan order should have had a 14-day renewal date or been discontinued.
The facility failed to ensure MDS assessments accurately reflected the clinical status of two residents. One resident with depression was receiving amitriptyline, but the MDS incorrectly stated no antidepressant use and also noted scheduled pain meds that were not given. Another resident with low back pain had an order for tramadol, but the MDS incorrectly stated no opioid use; the MDS coordinator confirmed both assessments were inaccurate.
A resident with DM2, anticoagulant use, and edema was observed with visible redness and swelling in both lower legs while socializing in the dining room and stated he has daily swelling and takes medication for it. His physician orders did not include edema monitoring, and a pharmacy MRR recommended monitoring for increased edema and notifying the physician if present. The DON confirmed the care plan was not updated to reflect edema management while on a diuretic.
A resident with anxiety, DM2, and cardiac arrhythmia was started on Lorazepam and later Zoloft for anxiety, but the EHR showed no consent was obtained before either medication began. The DON confirmed staff did not obtain the consent forms prior to starting the medications.
Incomplete Care Plans for Diabetes, Anticoagulant Use, and Edema: The facility failed to develop care plans for a resident with DM2 and for another resident with DM2, long-term anticoagulant use, and edema. Records showed insulin orders for the first resident and furosemide for the second, while observation found visible lower-leg redness and swelling in the second resident. The DON confirmed the missing care plan elements.
Failure to monitor a resident's edema. A resident with DM2, anticoagulant use, and edema had a nursing summary note recommending monitoring for increased edema and physician notification if present. He was observed with visible redness and swelling in both lower legs and reported daily swelling while taking a diuretic, yet the physician order for furosemide had no edema monitoring in place. The DON confirmed the resident had edema and that monitoring was not provided.
A resident’s call light was not working during an observation, and the resident stated she needed help but nobody was coming. There was no light outside the room, and the DON later confirmed the call light was not working and said the bulb must have burnt out.
The facility did not report allegations of abuse and neglect to the State Agency within the required timeframe for three residents. Incidents included a CNA pulling a resident by the arm and making inappropriate comments, a resident left in a soiled brief without personal care, and a meal not being offered despite documentation stating it was refused. Required incident reports were not submitted promptly, and one incident was incorrectly dated.
The facility did not submit investigation summaries to the State Survey Agency within the required five working days following an alleged abuse incident involving a CNA and a resident, as well as a physical altercation between two residents. The Administrator confirmed the delays in reporting for both cases.
A CNA verbally abused a resident by making derogatory comments about her financial situation and physically yanked her arm while assisting her, causing the resident to feel rushed and embarrassed. The CNA had previously received training on abuse prevention and resident rights.
Three residents requiring assistance with ADLs, including bathing, did not consistently receive showers or baths as scheduled, with documentation showing multiple gaps of several days without evidence of being offered or assisted with bathing. Interviews confirmed that residents did not receive the expected level of care, and the administrator acknowledged the shower schedule was not followed.
A resident with multiple diagnoses, including Alzheimer's and severe dementia, was left on the floor for approximately three hours after a fall due to staff failing to conduct timely rounds. The resident's daughter, monitoring via a camera, alerted the facility, leading to staff assistance. The facility's policy required rounds every two hours, which were not completed, resulting in neglect.
The facility failed to implement an ongoing infection prevention and control program, as observed by signs of enhanced barrier precautions on several room doorways. The Infection Preventionist (IP) confirmed the lack of documentation for an annual review of infection monitoring, attributing the failure to the previous IP not completing these duties. This deficiency potentially affects all 96 residents in the facility.
The facility failed to implement a comprehensive antibiotic stewardship program, as the Infection Control Committee did not regularly review infections or monitor antibiotic usage patterns. The Infection Preventionist confirmed the absence of documentation for ongoing monitoring and an annual review, attributing the lapse to the previous IP's inaction. This deficiency could potentially affect all 45 residents.
The facility failed to develop comprehensive care plans for three residents, leading to deficiencies in addressing their specific needs. One resident's care plan lacked interventions for a wander guard and dementia care, another's omitted hydration support and hospice services, and a third's catheter care plan was delayed by 38 days. These oversights were confirmed by the DON, highlighting gaps in care planning.
The facility failed to update the care plans for two residents regarding their pain medication management. One resident had an order for oxycodone, and another for a fentanyl patch, but their care plans did not include necessary details such as monitoring for pain, non-pharmacological interventions, or the effectiveness of the medication. The DON confirmed these omissions.
A resident who signed a consent form for the influenza vaccine did not receive the vaccination. The EHR showed the last flu shot was given over a year prior, and despite consenting to a new vaccination, the resident did not receive it. The DON confirmed the oversight but could not explain why the vaccine was not administered.
The facility failed to offer COVID-19 vaccinations to four residents, as their EHRs lacked documentation of vaccine offers or administration. The DON confirmed the absence of evidence, despite the facility's policy to follow CDC guidelines for COVID-19 prevention.
A resident with cognitive impairment and multiple diagnoses was observed dressing in her room in view of the dining area, compromising her privacy. The resident required assistance with dressing, as noted in her care plan, but was left exposed to staff and other residents.
A facility failed to maintain a homelike environment for a resident by not repairing a damaged wall and broken blinds in the resident's room. The resident reported the issue to maintenance but received no response. An observation confirmed the poor condition, and the Maintenance Director acknowledged the need for repairs.
The facility failed to create accurate baseline care plans for two residents, one with a catheter and another with a UTI, leading to potential gaps in immediate care. The Director of Nursing confirmed the omissions, emphasizing the need for accurate care plans to ensure proper resident care.
A resident with multiple diagnoses, including cognitive impairment, was observed struggling to dress herself without staff assistance, despite her care plan indicating the need for supervision and assistance. This incident highlights a deficiency in the facility's adherence to the care plan, potentially affecting the resident's dignity and health.
A resident with severe dementia and other medical conditions did not receive adequate hydration support in a facility. The resident was not consistently offered drinks by staff, and fluid intake was not properly documented or monitored. The care plan indicated total dependence on staff, yet no hydration support or interventions were in place. The Director of Nursing confirmed the lack of necessary supports for the resident's hydration needs.
The facility failed to label medications with a proper open date or expiration date, as observed with three opened bottles of generic throat spray in the Medication Storage room. An LPN confirmed the bottles were opened without a labeled open date and had unreadable expiration dates, making it impossible to determine their expiration. The DON confirmed that opened medications should be labeled correctly.
Two residents at a facility experienced falls due to inadequate supervision and failure to follow safety protocols. One resident, a moderate fall risk, was left unsupervised in the restroom, resulting in a fall and a brain bleed. Another high fall risk resident fell during a therapy session without a gait belt and was not assessed by a nurse immediately after. Both incidents highlight lapses in adhering to fall prevention protocols.
The facility failed to lock a medication cart near the nurse's station, leaving it unattended and accessible to residents. The DON confirmed this did not meet facility expectations, as carts should be locked when not in use.
The facility failed to complete baseline care plans within 48 hours of admission for two residents, leaving critical sections such as Nursing Services, Nutritional Services, and Activities blank. This was confirmed by facility staff, indicating a lapse in ensuring immediate care needs are met.
The facility failed to maintain a current, comprehensive care plan for a resident, as all items in the care plan were canceled. This was confirmed by a Regional Nurse, indicating a lack of an updated care plan to address the resident's needs.
A resident with a complex medical history informed a nurse she thought she was having a stroke, but no immediate action was taken. Later, the resident showed significant weakness during a transfer, which was not adequately assessed. The resident became unresponsive and hypoxic several hours later, leading to a delay in treatment and her eventual death in the hospital.
A facility failed to provide adequate supervision and preventive measures for a resident with dementia at risk of elopement. The resident was found outside the facility, and at the time, there was no operational Wander Guard system. Subsequent evaluations identified the resident as an 'Imminent Risk,' and the resident was later equipped with a functional Wander Guard monitor.
PRN Psychotropic Orders Lacked Required Stop Dates
Penalty
Summary
The facility failed to ensure that psychotropic medications were used only when medically necessary for 2 of 5 residents reviewed for unnecessary medications. For one resident with diagnoses including anxiety, depression, schizophrenia, and cerebral infarction, the physician order dated 02/17/26 included hydroxyzine 50 mg every eight hours as needed for anxiety, but no stop date was listed. During interview on 04/23/26, the DON confirmed that the hydroxyzine order did not have a stop date and should have had one. For another resident with diagnoses including depression, anxiety, cerebral infarction, bipolar disorder, and impulse disorder, the physician order dated 12/24/26 included Ativan 1 mg every four hours as needed for agitation and restlessness, but the order did not contain a stop date. During interview on 04/23/26, the DON confirmed that the Ativan order lacked a stop date and stated the medication should have had a 14-day renewal date or should have been discontinued, but it was not. The report also states that staff failed to ensure monitoring for possible side effects of an antipsychotic medication for the duration of the order for the resident with hydroxyzine.
Inaccurate MDS Assessments
Penalty
Summary
The facility failed to ensure that the MDS accurately reflected the clinical status of 2 residents reviewed for assessments. For one resident with diagnoses including type 2 diabetes mellitus, PTSD, and depression, the physician order showed amitriptyline 100 mg daily at bedtime for depressive symptoms, but the MDS stated that the resident did not take antidepressant medications and also indicated scheduled pain medications were received. During interview, the MDS coordinator confirmed the resident did take antidepressant medications, had not taken any pain medications, and that the MDS was inaccurate. For another resident with diagnoses including spondylolysis, low back pain, hypertension, and anxiety disorder, the physician orders included tramadol for low back pain, but the MDS stated that the resident did not take opioid medication. During interview, the MDS coordinator confirmed the MDS was not accurate because it did not indicate the resident's use of an opioid medication and should have done so.
Failure to Monitor Edema in Resident Receiving Diuretic Therapy
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs by not appropriately monitoring edema in a resident receiving diuretic therapy. Resident #48 was admitted with diagnoses including type 2 diabetes mellitus, long-term use of anticoagulants, and edema. During an observation and interview, the resident was seen socializing in the dining room and had visible redness and swelling in both lower legs, and stated that he has swelling daily and takes medication to help it. The resident's physician orders showed no monitoring in place for edema, and a pharmacy medication review dated 01/07/26 recommended monitoring the resident for increased edema and notifying the physician if present. The DON confirmed that the resident's care plan was not updated to reflect management of his edema while on a diuretic and that it should have been.
Failure to Obtain Consent Before Starting Anxiety Medications
Penalty
Summary
The facility failed to ensure that a resident and/or the resident’s representative were informed in advance of the medications being given and understood the reasons, risks, and benefits of those medications for one resident reviewed for unnecessary medications. The resident was admitted with diagnoses of anxiety, type 2 diabetes mellitus, and cardiac arrhythmia. Physician orders showed Lorazepam 0.5 mg by mouth twice a day for anxiety starting 07/17/25 and Zoloft 25 mg by mouth one time a day for anxiety starting 01/08/26. Review of the resident’s EHR showed no consent was obtained before either medication was started. During interview, the DON confirmed staff did not obtain the consent forms prior to starting Lorazepam and Zoloft and stated this did not meet her expectations because the consent forms are to be obtained before the medications are started.
Incomplete Care Plans for Diabetes, Anticoagulant Use, and Edema
Penalty
Summary
The facility failed to develop and implement accurate, comprehensive care plans for 2 residents reviewed for care planning. One resident was admitted with a diagnosis of type 2 diabetes mellitus and had physician orders for Lantus in the morning, Insulin Aspart before meals and at bedtime, and Insulin Glargine at bedtime, but the care plan last revised on 04/29/26 contained no care plan for diabetes mellitus. During interview, an RN confirmed the resident had diabetes mellitus, and the DON later confirmed the facility should have developed a care plan to address the diagnosis but did not do so. A second resident was admitted with diagnoses of type 2 diabetes mellitus, long-term use of anticoagulant medications, and edema. Observation and interview showed both lower legs had visible redness and swelling, and the resident stated the redness and swelling were present daily and that he took a diuretic medication. The physician orders included furosemide 20 mg in the morning for edema, but the care plan did not address the resident’s anticoagulant use or edema. The DON confirmed the resident had edema and that the facility should have developed a care plan for the anticoagulant medication use and edema but failed to do so.
Failure to Monitor Resident Edema
Penalty
Summary
The facility failed to provide quality of care when staff did not monitor one resident for edema. The resident was admitted with diagnoses including type 2 diabetes mellitus, long-term use of anticoagulants, and edema, and his quarterly MDS showed a BIMS score of 15, indicating he was cognitively intact. His nursing summary report dated 01/07/26 included a new recommendation to monitor him for increased edema and to notify the physician if present. During an interview and observation on 04/20/26, the resident was seen in the dining room with visible redness and swelling in both lower legs, and he stated that he had redness and swelling daily and took a diuretic medication. The physician orders included furosemide 20 mg in the morning for edema, but there was no monitoring in place for edema. The DON later confirmed that the resident did have edema and that the facility should have been monitoring it but failed to do so.
Nonworking Call Light in Resident Room
Penalty
Summary
The facility failed to ensure a working call light system was available in a resident’s bathroom and bathing area for 1 of 3 residents reviewed during random observation. During an observation and interview on 04/20/26 at 9:29 am, Resident #4 stated she needed help and pushed her call light, but nobody was coming, and there was no light outside of her room. Later that morning, at 9:34 am, the DON confirmed the call light was not working and stated the light bulb must have burnt out.
Failure to Timely Report Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to report allegations of abuse and neglect to the State Agency within the required twenty-four-hour timeframe for three out of five residents reviewed. Specifically, one incident involved a CNA pulling a resident by the arm and making derogatory comments about her financial situation while assisting her into a sitting position. Another incident involved a CNA assisting a resident to bed while leaving them in a soiled adult brief and not providing necessary personal care. Additionally, there was an allegation that a CNA falsely reported a resident refused a meal when the meal was never offered. Record reviews and interviews confirmed that the initial incident reports for these events were not submitted to the State Agency within the mandated timeframe, with one incident's date of occurrence also being incorrectly documented.
Failure to Timely Report Investigation Results to State Survey Agency
Penalty
Summary
The facility failed to report the results of all investigations of alleged abuse or neglect to the State Survey Agency within five working days of the incidents, as required. Specifically, an incident occurred in which a Certified Nurse Aide allegedly pulled a resident by the left arm while assisting her into a sitting position, and the investigation summary for this event was submitted six working days after the incident. Additionally, a resident-to-resident altercation involving physical assault was not reported within the required timeframe. The Administrator confirmed that the investigation summaries for both incidents were not submitted to the State Survey Agency within five working days.
Verbal Abuse and Rough Handling by CNA
Penalty
Summary
A certified nurse aide (CNA) was verbally abusive to a resident by making fun of her financial situation and telling her that a driver would take her to another facility because she could not afford her bills. The CNA also yanked the resident by her left arm while assisting her into a sitting position, which made the resident feel rushed and embarrassed. The resident reported that she did not like being rushed and felt embarrassed by the CNA's comments and laughter regarding her finances. Review of the CNA's training file confirmed that the CNA had received training on abuse, neglect, exploitation, and resident rights prior to the incident.
Failure to Provide Scheduled ADL Bathing Assistance
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL), specifically bathing or showering, for three residents who required varying levels of support. Documentation and interviews revealed that these residents did not consistently receive showers or baths according to the facility's established schedule. In several instances, there were gaps of multiple days where no evidence was found that residents were offered or assisted with bathing, and in some cases, residents reported not receiving a shower since admission except for a single occasion. One resident, admitted with fractures and requiring substantial to maximal assistance, was scheduled for showers three times a week but only received one documented shower during the review period. The resident confirmed not being assisted with showers as expected and expressed that even if one shower was provided, it was insufficient. Another resident with heart failure and muscle atrophy, also requiring significant assistance, was scheduled for showers on alternate days but experienced periods of up to seven days without documentation of being offered or assisted with a bath or shower. This resident also reported inconsistencies in receiving scheduled showers. A third resident, with dementia and failure to thrive, required partial to moderate assistance and was scheduled for showers three times a week. Documentation showed only three showers provided in the month, with several refusals noted, but also multiple periods of up to seven days with no documentation of being offered or assisted with bathing. The facility administrator confirmed that the shower schedule was not followed for these residents, as reflected in the facility's records.
Neglect Incident: Resident Left on Floor for Hours After Fall
Penalty
Summary
The facility failed to prevent neglect for a resident who was not checked on timely by the staff, resulting in the resident lying on the floor for approximately three hours after a fall. The resident, who had multiple diagnoses including Alzheimer's disease, bipolar disorder, severe dementia with behavioral disturbance, cognitive communication deficit, and essential hypertension, was admitted to the facility with a care plan indicating a risk for falls due to confusion, deconditioning, and poor safety awareness. On the night of the incident, the resident's daughter, who had installed a camera in the resident's room, observed her father fall at approximately 8:45 pm and remain on the floor until she called the facility at 12:09 am to alert them. The facility's policy required nursing staff to conduct rounds at least every two hours, but this was not adhered to, as evidenced by the video footage and the resident's daughter's account. The Director of Nursing acknowledged that the resident lying on the floor for over three hours did not meet the facility's expectations, as staff should have checked on the resident at least every two hours. The failure to complete rounds timely and ensure the resident's safety led to the neglect incident, as the staff did not enter the room until after being notified by the resident's daughter.
Failure to Implement Ongoing Infection Control Program
Penalty
Summary
The facility failed to develop and implement an ongoing infection prevention and control program, which is essential for preventing, recognizing, and controlling the onset and spread of infections. This deficiency was identified during a survey when signs indicating enhanced barrier precautions were observed on the doorways of several rooms. A review of the facility's Infection Prevention and Control Program Policy revealed that the Infection Preventionist (IP) is responsible for coordinating the development and monitoring of infection control policies and procedures, as well as reporting compliance information to the Administrator and the Infection Control Committee. During an interview, the IP confirmed the absence of ongoing documentation or evidence to support an annual review of infection monitoring. The IP acknowledged that the facility had not continuously implemented an ongoing infection prevention and control program prior to October 2024 due to the previous IP not fulfilling these duties. This failure has the potential to affect all 96 residents living in the facility, as identified by the census provided by the Administrator.
Failure to Implement Comprehensive Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement a comprehensive antibiotic stewardship program, which is essential for optimizing infection treatment and minimizing adverse events related to antibiotic use. The deficiency was identified during a survey, where it was found that the Infection Control Committee (ICC) did not regularly review infections or monitor antibiotic usage patterns as required by the facility's policy. The policy, last revised in June 2020, mandates that the ICC should review microbial culture results, resistant organisms, alerts, and antibiograms for trends of resistance. However, there was no documentation to support that these activities were being conducted regularly. During an interview, the Infection Preventionist (IP) confirmed the absence of ongoing monitoring documentation for antibiotic usage patterns and acknowledged that an annual review of the Antibiotic Stewardship Program had not been completed. The IP attributed this lapse to the previous IP's failure to perform these duties before October 2024. Since taking over, the current IP has only monitored infections for four months, leaving an eight-month gap without continuous implementation or review of the program. This lack of documentation and consistent monitoring could potentially affect all 45 residents in the facility.
Deficient Care Planning for Residents
Penalty
Summary
The facility failed to develop and implement accurate, person-centered comprehensive care plans for three residents, leading to deficiencies in addressing their specific needs. Resident #5's care plan lacked interventions for the use of a wander guard and did not address the care required for his severe dementia diagnosis. This oversight was confirmed by the Director of Nursing (DON) during an interview, highlighting a gap in the care plan that could result in staff being unaware of the resident's needs. Resident #24's care plan was also found to be lacking, as it did not include interventions for hydration support, dementia care, or hospice services. The resident's daughter, who has a camera in the resident's room, reported that staff did not offer fluids as promised, which was not addressed in the care plan. The DON confirmed these omissions, acknowledging that the care plan was not comprehensive and did not meet expectations. For Resident #34, the care plan for catheter care was not developed or implemented until 38 days after admission, despite the resident having a catheter in place upon arrival. This delay in care planning was confirmed by the DON, who stated that the care plan did not meet her expectations. These deficiencies indicate a failure to provide timely and appropriate care planning for residents with specific medical needs.
Failure to Revise Pain Management Care Plans
Penalty
Summary
The facility failed to revise the care plans for two residents regarding their pain medication management. Resident #5 was admitted to the facility and had a physician order for oxycodone to be administered every six hours as needed for pain. However, the comprehensive care plan for Resident #5, last revised on January 31, 2025, did not include the use of pain medications, monitoring for pain, non-pharmacological interventions, or the effectiveness of pain medication use. The Director of Nursing confirmed that the care plan was not updated to include these aspects of pain management. Similarly, Resident #24 had a physician order for a fentanyl transdermal patch to be administered every three days. The comprehensive care plan for Resident #24, last revised on October 23, 2024, did not include the order for the fentanyl patch or interventions for monitoring pain, non-pharmacological interventions, or the effectiveness of pain medication use. The Director of Nursing confirmed that the care plan for Resident #24 was not revised to include pain medication management, which was necessary.
Failure to Administer Influenza Vaccine After Consent
Penalty
Summary
The facility failed to ensure that a resident who had completed and signed a consent form for the influenza vaccine actually received the vaccination. The record review of the resident's Electronic Health Record (EHR) indicated that the last influenza vaccine was administered on 09/21/22, and the resident signed a consent for the influenza vaccine on 11/28/24. However, the EHR did not show that the resident received the vaccination after consenting. During an interview with the Director of Nursing (DON), it was confirmed that the resident had not yet received the influenza vaccination after providing consent, and the DON was unable to confirm why the vaccination had not been administered.
Failure to Offer COVID-19 Vaccinations to Residents
Penalty
Summary
The facility failed to offer COVID-19 vaccinations to four residents, as identified in the report. The Electronic Health Records (EHR) for these residents did not contain any documentation indicating that the COVID-19 vaccine was offered or administered. Specifically, Resident #7 and Resident #10's records lacked any COVID-19 vaccine forms, while Resident #9 and Resident #14 had not been offered the vaccine since their last recorded vaccinations in 2022. Interviews with the Director of Nursing (DON) confirmed the absence of evidence in the EHRs for these residents. The facility's COVID-19 Program Policy, revised in May 2021, aims to prevent the spread of COVID-19 by following CDC recommendations. However, the facility did not adhere to these guidelines, as evidenced by the lack of documentation and offering of the COVID-19 vaccine to the residents. The CDC recommends that individuals in long-term care settings receive the COVID-19 vaccine, yet the facility's failure to offer the vaccine to these residents represents a significant oversight in their infection control and prevention efforts.
Failure to Ensure Resident Privacy During Dressing
Penalty
Summary
The facility failed to ensure personal privacy for a resident while dressing in her room, leading to a deficiency in maintaining confidentiality and dignity. The resident, who was admitted with multiple diagnoses including Type 2 Diabetes Mellitus, a degenerative disease of the nervous system, and altered mental status, was observed standing in her room wearing only a disposable adult brief and a t-shirt while pulling up her pants. This occurred in full view of the main dining area, where staff and other residents could see her. The resident's care plan indicated she required supervision and assistance with dressing, highlighting a lapse in providing the necessary support to maintain her privacy.
Failure to Maintain a Homelike Environment
Penalty
Summary
The facility failed to provide a comfortable and homelike environment for a resident by not repairing the wall and the blinds in his room. During an interview, the resident pointed out the sliding glass door in his room, which had several broken and missing blinds, and mentioned that he had requested maintenance to fix them but had not received any response. The resident indicated that the blinds had been in disrepair for months, although he could not recall the exact duration. An observation of the resident's room revealed a section of the wall by the bed, measuring approximately six feet by three feet, with paint that was scraped and peeling. Additionally, the sliding glass door had several broken and missing blinds. The Maintenance Director confirmed the room's poor condition and acknowledged the need for repairs, stating that he would look into ordering new blinds.
Inaccurate Baseline Care Plans for Two Residents
Penalty
Summary
The facility failed to create accurate baseline care plans for two residents, leading to potential gaps in their immediate care needs. One resident was admitted with multiple diagnoses, including acute respiratory failure with hypoxia, a urinary tract infection (UTI), bladder-neck obstruction, and benign prostatic hyperplasia. Despite being admitted with a catheter, the baseline care plan did not document the presence of the catheter or any necessary interventions. This oversight was confirmed by the Director of Nursing (DON), who acknowledged the omission and stated that the expectation is for all baseline care plans to contain accurate information to ensure residents receive the care they need. Another resident was admitted with a UTI, type 2 diabetes, and acute kidney failure. The resident reported frequent UTIs and confirmed being admitted with one. However, the baseline care plan lacked any interventions for the UTI. This deficiency was also confirmed by the DON, who reiterated the expectation for baseline care plans to accurately reflect residents' needs. The absence of these critical details in the care plans could lead to inadequate care and potential adverse events for the residents.
Failure to Assist Resident with ADLs
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL) for a resident who required help with dressing. The resident, who was admitted with multiple diagnoses including Type 2 Diabetes Mellitus, a degenerative disease of the nervous system, and altered mental status, was observed struggling to dress herself without staff assistance. Despite having a care plan indicating the need for supervision and assistance with dressing, the resident was left to dress herself in full view of the dining area, highlighting a lapse in the facility's adherence to the care plan. During a dining observation, the resident was seen attempting to put on her pants without success, indicating a need for assistance as outlined in her care plan. The resident's Minimum Data Set (MDS) assessment showed a Brief Interview for Mental Status (BIMS) score of 08, indicating moderate cognitive impairment, which further underscores the necessity for staff support. The lack of assistance in this instance is a clear deficiency in the facility's provision of care, potentially affecting the resident's dignity and health.
Failure to Maintain Adequate Hydration for a Dependent Resident
Penalty
Summary
The facility failed to maintain adequate hydration for a resident, identified as R #24, who was dependent on staff for all self-care activities. The resident, who had severe dementia with behavioral disturbances and other medical conditions, was not offered drinks consistently when staff entered his room, as reported by his daughter and Power of Attorney. The facility's records showed that the resident's fluid intake was not documented or monitored daily, and there were no recommendations or orders for the amount of fluid the resident should have daily. The care plan indicated total dependence on staff, yet the facility did not have any hydration support or interventions in place. The documentation survey report for January 2025 revealed that on 22 out of 31 days, the resident did not receive the minimum amount of fluids recommended by CMS. Specific instances of inadequate fluid intake were documented, with some days showing no fluid intake recorded at all. The Director of Nursing confirmed that the resident did not have any supports or interventions to assist with hydration needs, acknowledging that such supports were necessary given the resident's state of dependence.
Medication Labeling Deficiency
Penalty
Summary
The facility failed to ensure that medications were labeled with a proper open date or expiration date, which is a deficiency likely to negatively impact the health of all residents. During an observation of the Medication Storage room, three opened bottles of generic throat spray were found without a labeled open date and with unreadable expiration dates. An LPN confirmed that the bottles were opened, the expiration dates were unreadable, and no open date was written on them, making it impossible to determine when they were opened or their expiration. The Director of Nursing also confirmed that opened medications should be labeled correctly with a readable open date and expiration date.
Failure to Prevent Falls and Provide Adequate Supervision
Penalty
Summary
The facility failed to prevent accidents for two residents, both of whom were at risk for falls. The first resident, who had a history of repeated falls and was considered a moderate fall risk, was left unsupervised in the restroom. Despite being aware of the resident's fall risk, the staff did not provide the necessary supervision, resulting in the resident falling and sustaining a head injury that led to a brain bleed. Interviews with the resident's family and hospice nurse confirmed that the resident was left alone, contrary to the family's instructions and the facility's protocol. The second resident, who was identified as a high fall risk, experienced a fall during a therapy session. The Occupational Therapy Aide did not use a gait belt, as required by the facility's protocol, and failed to notify a nurse for an assessment after the fall. Instead, the resident was assisted off the ground and taken to lunch without a proper evaluation. The resident later required medical attention for symptoms that developed after the fall, including a headache and emesis. Both incidents highlight a failure to adhere to established protocols for fall prevention and post-fall assessment. The staff interviews revealed a lack of consistent application of safety measures, such as the use of gait belts and immediate nurse assessments following falls. These deficiencies contributed to the residents' injuries and subsequent hospital treatments.
Medication Cart Security Lapse
Penalty
Summary
The facility failed to ensure that all medication carts were locked while not in use, which had the potential to affect all 19 residents residing in rooms 100-111. During a random observation, a medication cart located near the nurse's station was found unlocked, with no staff present in the area. Residents were observed in the vicinity of the unlocked cart. In an interview, the Director of Nursing confirmed the cart was unlocked and unattended, which did not meet the facility's expectations, as medication carts should be locked when not actively being used by a nurse.
Incomplete Baseline Care Plans for Two Residents
Penalty
Summary
The facility failed to create accurate baseline care plans within 48 hours of admission for two residents, which is a necessary step to ensure proper care. For the first resident, the baseline care plan was incomplete, with only the Social Services section filled out, while Nursing Services, Rehabilitative Services, Nutritional Services, and Activities sections were left blank. This was confirmed by both the Regional Clinical Consultant and the Minimum Data Set Coordinator. Similarly, the second resident's baseline care plan was missing entries in the Nursing Services, Nutritional Services, and Activities sections, as confirmed by the Regional Nurse. These omissions could likely result in a decline in the residents' conditions due to staff not being aware of the care residents need.
Failure to Implement Comprehensive Care Plan
Penalty
Summary
The facility failed to update and implement a comprehensive person-centered care plan for a resident, identified as R #2, who was admitted to the facility on an unspecified date. A review of R #2's care plan, dated 04/24/24, revealed that all items were listed as canceled, indicating the absence of a current care plan. This deficiency was confirmed during an interview with the Regional Nurse on 06/06/24, who acknowledged that there was no current, updated care plan for R #2 due to the cancellation of all items in the existing care plan.
Failure to Identify and Respond to Change in Condition
Penalty
Summary
The facility failed to ensure that a resident received timely treatment and care in accordance with professional standards of practice. The resident, who had a complex medical history including acute and chronic respiratory failure, Type 2 Diabetes Mellitus, morbid obesity, and other conditions, informed a nurse that she thought she was having a stroke. Despite this, the nurse did not contact the physician or take further immediate action. Later, the resident demonstrated significant unexplained weakness during a transfer, which was not adequately assessed as a change in condition by the staff. Several hours later, the resident became unresponsive and hypoxic, leading to a delay in treatment and her eventual death in the hospital emergency room. The nursing progress notes revealed that the resident had reported feeling like she was having a stroke, but the nurse did not observe any immediate signs of a stroke and did not contact the physician. Later in the day, the resident was unable to assist in her transfer from a wheelchair to bed, and staff had to use a hoyer lift to complete the transfer. Despite the resident's significant weakness, the nurse did not check her vital signs or consider it a change in condition. The resident was later found unresponsive by her husband, with an oxygen saturation level of 65%, and was subsequently transferred to the hospital where she was intubated and later expired. Interviews with staff, including the CNA and LPN involved in the resident's care, confirmed that the resident had shown signs of significant weakness and fatigue, but these were not adequately assessed or reported as changes in condition. The Director of Nursing and Assistant Director of Nursing both acknowledged that the staff should have recognized these signs as changes in condition and taken appropriate actions, including notifying the physician and possibly sending the resident to the hospital earlier. The failure to do so likely contributed to the delay in treatment and the resident's subsequent death.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to ensure adequate supervision and preventive measures for a resident at risk of elopement. The resident, diagnosed with dementia, exhibited wandering behavior and was identified as an elopement risk. Despite this, the resident's Elopement Risk Evaluation scored them as 'No Risk.' On one occasion, the resident was found outside the facility in the parking lot, indicating a lapse in supervision. At the time of the incident, the facility did not have an operational Wander Guard system in place to prevent such occurrences. Subsequent evaluations of the resident indicated an 'Imminent Risk' for elopement, and the resident was later equipped with a Wander Guard monitor. Observations confirmed that the Wander Guard system was functional and that the resident wore the device. Interviews with staff corroborated the resident's elopement risk and the use of the Wander Guard system as a preventive measure.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 25 citations issued within 25 miles in the last 12 months — including the 1 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.
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A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Roswell
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Casa Maria Healthcare | 1.2 mi | ★★★★★ | 18 | 0 |
| Spring River Rehabilitation And Care Center | 4.5 mi | ★★★★★ | 7 | 1 |
| Artesia Healthcare & Rehabilitation Center, Llc | 36.8 mi | ★★★★★ | 20 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.