Below average — CMS composite of the measures below.
The next survey window likely opens around May 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 Alta Skilled Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident admitted with bilateral primary osteoarthritis of the knee received Hydrocodone-Acetaminophen for pain management after a physician order was entered and the medication was administered on multiple days. The President of Clinical Services could not locate a signed consent, and the DON confirmed informed consent had not been obtained before administration of the opioid and that it should have been obtained so the resident was aware of the risks and benefits.
A resident with polyneuropathy, ankylosing spondylitis, osteoarthritis, and spinal stenosis had a physician order for daily chair time and required a 2-person Hoyer Lift for transfers. Staff did not consistently honor the resident’s request to get out of bed, citing short staffing, and the resident was often only assisted out of bed for showers or a few times per week instead of daily.
A resident with chronic respiratory failure, COPD, pulmonary hypertension, and oxygen dependence repeatedly asked to have an ID wrist band removed, but it remained on the resident’s wrist during multiple observations. The resident said the LPN insisted the band be worn at all times, while the LPN confirmed the resident had requested removal for months. Staff stated the wrist bands were used as a double check for med admin, and the DON and Administrator were unaware the resident’s request had not been communicated to staff.
Failure to protect a resident from peer physical abuse: a resident punched another resident in the face in the activity room, causing a superficial abrasion and minimal bleeding. The aggressor had a documented hx of prior aggressive behaviors toward staff and others, but the care plan did not address those behaviors before the incident. The injured resident later avoided the activity room and stated the other resident was dangerous.
Care plan not implemented for aggression and wound care: A resident with a history of physical and verbal aggression had a care plan that called for staff to analyze triggers and document de-escalation methods, but the DON stated the record and treatment plan did not include methods staff would use to de-escalate the behaviors, and a later aggressive episode was not accurately captured on the behavior task. Separately, a resident with a right heel wound had ordered wound care documented as completed on the TAR, but the floor nurse and wound care LPN confirmed the dressing was not in place and the wound care had not actually been performed by the assigned nurse.
Unattended Medications and Improper Pain Medication Handling: Staff left medications at a resident’s bedside for self-administration without an order or care plan allowing it, and another resident was found with a cup of pills left in the room by an RN. A third resident with chronic pain and neurologic impairment was reported to have oxycodone and morphine left in the room, which the resident hoarded; the record lacked evidence of self-administration ability. The DON and other staff confirmed medications were to be administered and observed until swallowed, but that did not occur in these cases.
Wound care was documented as completed for a resident with a right heel wound, but the dressing was not in place and the care had not actually been performed. The resident had an open wound with bleeding from the heel, and the floor LPN and Wound Care LPN each indicated the other was responsible for the treatment, while the DON stated the treatment should not have been charted complete unless it was done.
A resident with hemiplegia, major depressive disorder, and a history of intentional self-harm was found to have hoarded oxycodone and morphine pills that an RN had reportedly left with the resident. The resident said the pills were kept so they could self-administer them if pain occurred and staff could not be reached. A Unit Manager LPN found unsecured pain pills in the room, estimated about 15 pills, and confirmed the meds were accessible to residents and staff; the DON stated nurses were expected to verify swallowing before leaving the room.
Pain management was not carried out as ordered for two residents. One resident with a recent BKA and phantom pain received acetaminophen and oxycodone outside the ordered pain ranges, while the DON and an LPN confirmed the meds were not given per the prescribed pain scales. Another resident with stroke-related deficits and chronic pain syndrome was found hoarding unsecured oxycodone and morphine in the room after staff reportedly left pills with the resident and did not ensure ingestion, despite the facility’s expectation that meds be observed until swallowed.
A RN left a cup of unknown pills unattended on a resident’s bedside table instead of watching the resident take them. Surveyors observed the unsecured medications with no nurse in sight, and the RN later acknowledged leaving them with the resident. The DON stated meds should be administered by confirming the right resident, right med, and right dose, and by ensuring the resident swallows them before the nurse leaves the room.
Staff personal drink containers were observed in the 500 and 600 hall satellite resident pantry, including refillable water bottles, open soda, Red Bull, Gatorade, and a Starbucks drink on the countertop in the resident food service area. The Kitchen Manager and a CNA confirmed the pantry was for resident food and drink items only and that staff drinks in the room posed a cross contamination risk; staff drinks were supposed to be stored in the employee break room. The facility did not provide a policy for where staff personal belongings were to be stored.
Inaccurate wound care documentation: A resident with a right heel wound and diagnoses including an open foot wound and osteomyelitis had treatment documented as completed on the TAR, but the assigned floor nurse said she did not perform the wound care and the Wound Care LPN said the wound care was not being done by her. When the Wound Care LPN assessed the heel, there was no dressing in place, yet the record showed the treatment as completed.
An LPN and RN failed to perform hand hygiene between multiple glove changes while providing wound care to a resident with open thigh wounds and a pressure ulcer. The staff removed and replaced gloves repeatedly during dressing removal, wound cleansing, application of wound products, and brief care without HH in between, and the LPN stated HH was only needed before and after wound care.
A resident receiving hospice services for a large, tunneling breast mass did not have a care plan in the facility's records addressing wound care, despite hospice providing this care. Facility staff confirmed the absence of a wound care order and care plan, which was not in accordance with facility policy requiring comprehensive, integrated care planning.
The facility did not update care plans for two residents: one with Parkinson's disease who required a neurology appointment for increased tremors, and another with ongoing nicotine use who stored smoking paraphernalia in their room. Staff were unaware of the status of the neurology appointment and the location of smoking materials, and care plans lacked necessary revisions to address these issues.
A resident with Parkinson's disease and multiple sclerosis experienced increased tremors, prompting repeated requests and physician orders for a neurology referral. Despite these, staff only sent referrals to the resident's previous neurologist, who could not accept the patient due to insurance issues, and did not attempt referrals to other neurologists. The care plan was not updated to reflect the resident's symptoms or referral needs, and clinical leadership did not monitor the referral process, resulting in a delay in care.
Two residents did not receive care in accordance with physician orders and facility policy: one experienced increased tremors without timely neurology referral due to repeated attempts only with a non-contracted provider, and another had a non-healing wound managed by hospice without a facility order or care plan documenting wound care responsibilities.
A resident at risk for pressure injuries developed a Stage III coccyx ulcer, and wound care was not consistently provided as ordered by the physician. Documentation showed multiple missed wound care treatments over several weeks, and both the DON and Wound Care Nurse confirmed that care was not completed as required. Facility policies for skin inspection and wound management were not followed, resulting in a deficiency.
A resident with a G-tube and orders to check gastric residuals before administering medications did not have their residual volume checked by an LPN prior to receiving medication. The LPN and DON confirmed that this step was missed, which was not in accordance with physician orders and facility policy.
A resident had a prescribed bottle of lorazepam present in the medication storage room, but there was no corresponding order in the electronic health record or entry on the MAR. Additionally, an ordered C-PDR cream for nausea or vomiting was not available for the resident. The DON confirmed that all ordered medications should be available, and facility policy required accurate medication order documentation.
A medication cart was found unattended, unlocked, and with the keys left on top in a hallway, making medications accessible to unauthorized individuals. An RN confirmed the cart was left unsecured and out of sight, which was not in accordance with facility policy requiring medication carts to be locked and keys kept with nursing staff.
A resident receiving hospice care did not have coordinated care between the facility and the hospice agency, resulting in discrepancies in medication orders, missing wound care plans, and unavailable prescribed medications. Facility staff and hospice personnel confirmed that medication reconciliation and care plan updates were not completed as required, and the facility lacked a designated hospice coordinator.
A CNA entered a room under Enhanced Barrier Precautions (EBP) to assist a resident with an ESBL urinary tract infection without performing required hand hygiene, despite clear signage and available alcohol-based hand rub. This action was observed by an RN and confirmed by facility leadership as a violation of policy.
A wound cart and a medication cart containing resident medications were left unlocked and unattended in two separate hall entrances, with residents present nearby. An LPN and an RN confirmed the carts were unsecured, and the DON stated that floor nurses are responsible for ensuring carts are locked according to facility policy.
The facility failed to properly screen and offer pneumococcal vaccinations to 28 residents based on medical conditions, only considering age in their screening process. This oversight led to eligible residents not receiving the vaccine as per CDC guidelines.
A resident with multiple diagnoses exhibited significant decline, including bluish discoloration and severe pain in the lower extremity. Despite a physician's order for an ultrasound, the facility's contracted diagnostics company lacked an ultrasound technician, and the family and physician were not informed of the ongoing decline. The resident was eventually sent to the hospital after a week of worsening symptoms.
A facility failed to provide a comfortable, homelike environment for a resident when the AC unit in their room was broken and not promptly repaired. Despite the resident's spouse informing staff, the issue persisted for three days without alternative accommodations. The facility's policy on maintaining a homelike environment was not followed, leading to the deficiency.
The facility failed to provide necessary care for a resident with DVT, leading to severe gangrene and hospitalization, and did not protect residents from physical abuse by another resident. Despite worsening symptoms, the resident with DVT did not receive timely medical intervention, and the facility's documentation lacked consistent assessment of pedal pulses. Additionally, the facility did not implement new interventions for a resident with disruptive behaviors, resulting in an incident of physical abuse.
A resident reported $20 missing from their wallet shortly after admission, but the facility failed to follow its policy for investigating the report. The CNA who received the report did not document it, and the DON was unaware of the issue until the survey team brought it to attention. No follow-up was conducted by Social Services, and the facility's policy on investigating misappropriation was not followed.
A resident with a urinary catheter repeatedly pulled out the catheter, resulting in hospital visits for reinsertion and treatment for hematuria. Despite these incidents, the care plan did not include interventions to prevent this behavior. Both the LPN and DON acknowledged the need for documented interventions, which were not in place at the time of the incidents.
The facility failed to implement interventions for a resident with a urinary catheter who repeatedly pulled it out, did not provide timely care for a resident with a suspected DVT, and did not communicate a hospice physician's order, resulting in the resident not receiving the ordered medication.
The facility failed to ensure that two residents were weighed according to the facility's policy, leading to significant gaps in weight monitoring and documentation. One resident was not weighed for over six months despite significant weight fluctuations, and another resident experienced a drastic weight loss without proper follow-up.
The facility failed to ensure a CNA had an annual performance evaluation completed timely. A CNA hired over a year ago had their last evaluation documented late, missing the required annual review date. The Human Resources Manager confirmed the delay, violating the facility's policy for annual reviews.
A resident with chronic pancreatitis and muscle spasms missed several doses of prescribed medications due to the facility's failure to reorder them in a timely manner. The facility's policy required medications to be reordered at least three days before running out, but this was not followed, leading to missed doses and increased pain for the resident.
The facility failed to ensure timely ultrasounds for residents due to the contracted diagnostics company not having an ultrasound technician available for onsite visits. The Administrator was unsure when first notified about the issue and could not provide documented evidence that the lack of an ultrasound technician was addressed or that any direction was given to the nursing staff. The DON was aware of the issue and had instructed to send residents to the hospital for ultrasounds but was not aware if the nursing staff had been informed of this need prior to their tenure as DON.
The facility failed to ensure complete medical records for two residents. One resident missed several required weekly weight measurements, and another resident's G-Tube flushes were not documented as per physician orders. The DON confirmed these deficiencies.
The QAPI committee failed to identify that the contracted diagnostics company lacked an ultrasound technician, leading to a delay for a resident with a physician's order for an ultrasound. The Administrator was unsure when notified and could not provide documented evidence of addressing the issue. The DON knew about the lack of a technician and instructed to send residents to the hospital but was unaware if nursing staff had been informed.
A facility failed to ensure Enhanced Barrier Precautions (EBP) were implemented for a resident with a jejunostomy tube (J-tube). An LPN did not wear a gown or gloves while disconnecting the tube feeding, despite the requirement indicated by a sign outside the resident's room and the resident's care plan. The Director of Nursing confirmed the necessity of gown and gloves to prevent infections, as outlined in the facility's Infection Prevention and Control Program (IPCP) policy.
A resident with a history of wandering and wearing a Wanderguard device followed a CNA out of an alarmed exit door, but the alarm failed to activate, allowing the resident to wander into the parking lot. The facility's policy required staff to prevent such incidents, but the alarm system malfunctioned, and maintenance did not detect the issue during weekly checks.
A resident with hydrocephalus and difficulty walking experienced a loss of dignity when a PT verbally confronted them for walking in the facility. The resident felt disrespected and embarrassed, leading to emotional distress. An RN witnessed the incident and reported it to the Administrator and DON. The resident expressed a desire to leave against medical advice rather than work with the PT again.
A resident was verbally abused by an RN at the nurse's station, witnessed by a CNA and a family member. The RN was suspended and later terminated, but the investigation was incomplete as not all witnesses were interviewed, and documentation was lacking. The resident did not report psychosocial harm, but the facility's investigation did not meet its own standards.
A resident with chronic health conditions reported being roughly handled and slapped by a CNA. Despite the facility's policy requiring prompt investigation and reporting of abuse allegations, the Administrator and DON did not investigate or report the incident, citing the resident's history of unfounded allegations. The CNA continued to work with the resident, contrary to policy requirements.
A resident with chronic health conditions reported being roughly handled and slapped by a CNA. The facility's Administrator and DON failed to report or investigate the allegation, citing the resident's history of unfounded claims, despite policy requirements for prompt reporting and investigation.
A facility failed to investigate and report abuse allegations involving a CNA and an RN. A resident alleged a CNA slapped and handled them roughly, but the facility did not suspend the CNA or report the incident. Another incident involved an RN verbally abusing a resident, witnessed by a CNA and a family member. The facility's investigation was incomplete, lacking interviews with all involved parties and proper documentation.
An LPN at the facility was observed leaving premixed doses of MiraLAX unattended on a medication cart, posing a risk of ingestion by others. The DON confirmed that medications should not be left unattended and should be prepared individually. The facility lacked competency checklists for new nurses, contributing to the deficiency.
A resident's medications were left unsupervised at the bedside, resulting in a 100% medication error rate. The medications, documented as administered, were not taken by the resident. An LPN confirmed the error, and the physician highlighted the risk of drug interactions. The facility's policy on medication administration was not adhered to.
The facility failed to properly store and supervise medications, with an LPN leaving premixed MiraLAX unattended on a medication cart, posing a risk of ingestion by others. Additionally, medication carts were left unlocked and unattended, allowing access by staff, residents, and visitors, contrary to facility policy.
Failure to Obtain Consent for Opioid Pain Medication
Penalty
Summary
The facility failed to ensure informed consent was obtained for an opioid pain medication for Resident #137, who was admitted with bilateral primary osteoarthritis of the knee. A physician ordered Hydrocodone-Acetaminophen 10-325 mg, one tablet by mouth every four hours as needed for pain management, and the medication was administered on multiple days in June 2026. During interview, the President of Clinical Services stated that a signed consent for the Hydrocodone-Acetaminophen could not be located, and the DON later confirmed that consent had not been obtained before the medication was administered. The DON also confirmed that consent should have been obtained so the resident was aware of the risks and benefits of the medication.
Failure to Accommodate Resident’s Daily Transfer Preference
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of Resident #26 when the resident requested to get out of bed. Resident #26 was admitted and readmitted with diagnoses including polyneuropathy, ankylosing spondylitis, osteoarthritis, and spinal stenosis. A physician’s order dated 04/24/2026 directed that the resident get up in a chair every day per resident and doctor, and the care plan identified altered physical mobility related to impaired balance, weakness, pain, and decreased activity tolerance. The care plan also specified use of a Hoyer Lift and two staff for transfers. Documentation reviewed showed that bed-to-chair transfers did not occur on multiple dates in May and June 2026. During interview, Resident #26 stated the resident wanted to get out of bed once or more per day but was often unable to because staff said the facility was short staffed. The resident reported being assisted out of bed twice weekly for showers and said the resident complained to the physician, which led to the daily wheelchair order. A CNA, LPN, and the DON confirmed the resident required two-person Hoyer Lift assistance and that daily transfers were not always accommodated, with the resident instead being assisted out of bed approximately two to three times per week.
Resident Was Not Given Choice to Remove Identification Wrist Band
Penalty
Summary
The facility failed to ensure Resident #23 was afforded the choice of wearing an identification wrist band. Resident #23 was admitted with diagnoses including chronic respiratory failure with hypoxia, COPD, pulmonary hypertension, and dependence on supplemental oxygen. On 06/22/2026, the resident was observed sitting on the side of the bed with a plastic wrist band on the left wrist that identified the resident’s name, room number, and allergies. At that time, the resident stated the wrist band was not wanted and reported having asked the facility to remove it several times. The resident also stated the Unit Manager LPN would ensure the wrist band was worn at all times and would have a fit if the resident was found without it. On 06/23/2026, the Unit Manager LPN confirmed the resident had been requesting removal of the wrist band since February 2025 and stated monthly audits were completed to ensure residents were wearing wrist bands and that the information was correct. The LPN also stated that during a staff meeting that morning, staff were told that if a resident did not want to wear the wrist band, it was to be removed and the removal documented in the care plan. Despite this, the wrist band remained on the resident’s wrist during later observations on 06/24/2026 and 06/25/2026. The RN stated the wrist bands were used as a double check for accurate medication administration, and the DON confirmed residents were asked to wear wrist bands for verification during medication administration. The DON and Administrator both stated they were not aware of the resident’s request or that the instruction to remove the wrist band had not yet been disseminated to nursing staff or Unit Managers.
Failure to Protect Resident from Peer Physical Abuse
Penalty
Summary
The facility failed to ensure a resident was protected from abuse when Resident #43 punched Resident #49 on the left side of the face in the activity room. Nursing staff heard an altercation in the activity room, and Resident #49 reported that Resident #43 had punched the resident. A physical exam found a superficial abrasion to the left posterior ear with minimal bleeding. Resident #49 was admitted and readmitted with diagnoses including acquired absence of the right leg above knee and major depressive disorder, recurrent, unspecified. Resident #43 had a documented history of aggressive behavior before the incident, including throwing a water pitcher at a Physical Therapist, screaming, cursing, and swinging fists at a CNA, being verbally abusive and aggressive toward staff, and slapping a CNA's hand. A progress note on the day of the incident documented that Resident #43 physically hit another resident in the activity room and stated, "I don't care that I did that." The care plan for Resident #43 did not include interventions to address physically aggressive behaviors before the incident, and the DON confirmed this omission. Resident #49 later stated the resident avoided the activity room after the incident and believed Resident #43 was dangerous.
Care plan not implemented for aggression and wound care
Penalty
Summary
The facility failed to ensure a comprehensive care plan was implemented for a resident with a history of physical and verbal aggression toward other residents. Resident #43 was admitted with diagnoses including major depressive disorder, recurrent, moderate, and essential hypertension. After a facility-reported incident in which nursing staff heard an altercation in the activity room and a nurse found the resident had punched another resident on the left side of the face, the resident stated, "I don't care that I did that." A later progress note documented the resident yelling and using foul language in the hallway after becoming upset that another resident was wheeling nearby. The care plan initiated for the resident addressed physical aggression related to anger and poor impulse control and included staff analyzing and documenting the times, places, circumstances, and triggers for aggressive behaviors, as well as what de-escalated the behaviors. During review, the DON stated the care planned interventions would be documented under the task for regressive behavior, and that the data entered would be used to analyze behavior patterns and determine triggers. The DON also stated the resident's clinical record and treatment plan did not include methods staff would use to de-escalate the resident's aggressive behaviors. The regressive behavior task dated for the resident documented that the resident had not exhibited regressive behavior on the date of the later incident, even though the DON confirmed the resident had been verbally aggressive toward another resident and staff. The DON stated it was important to accurately document the care planned interventions to ensure the resident's behaviors could be analyzed to determine triggers and methods to de-escalate in order to update the resident's treatment plan. The facility also failed to implement wound care as ordered for Resident #56, who was admitted with diagnoses including an unspecified open wound of the right foot and other acute osteomyelitis of the right ankle and foot. A nursing narrative note documented a CNA noticed bright red blood on the floor of the resident's room from the heel of the right foot. An order directed staff to cleanse the open area to the right heel, apply xeroform, then an ABD pad, wrap with Kerlix, and secure with an ACE wrap. The care plan identified an actual alteration in skin related to the right heel wound and included administering treatments as ordered and monitoring for effectiveness. The treatment record documented the wound care as completed on a date when the floor nurse later stated the wound care had not been performed by that nurse, and the wound care LPN confirmed the dressing was not in place when the heel was assessed. The DON stated the wound care should not have been documented as complete unless it had actually been completed and that staff were responsible for reviewing and implementing the care plan.
Unattended Medications and Improper Pain Medication Handling
Penalty
Summary
The facility failed to maintain professional standards of quality when medications were left at residents’ bedsides and when pain management practices did not follow professional standards for three sampled residents. The report states that medications were left unattended for residents to take on their own, despite the facility’s policy and staff statements that medications were to be administered safely and observed until swallowed. The deficiency involved Residents #137, #133, and #6, and the report states this practice had the potential to result in unverified and unsupervised medication administration, medication misuse or diversion, adverse medication outcomes, and inadequate pain management. Resident #137 was admitted with multiple chronic conditions including chronic respiratory failure with hypoxia, pulmonary hypertension, bilateral knee osteoarthritis, diabetes with neuropathy, anxiety, depression, hypertension, hypothyroidism, and diastolic heart failure. During observation, two cups of pills and one cup of liquid medication were found on the tray table next to the resident’s bed while the resident was in bed and alone in the room. The resident stated the nurse had left the medications there for self-administration and said medications were often left on the tray table, sometimes overnight. The resident’s care plan directed that medications be administered as ordered by the physician, and there was no physician order or care plan documentation allowing self-administration. The LPN confirmed leaving the medications on the tray table and stated the nurse should have watched the resident consume them. Resident #133, who had diagnoses including progressive multiple sclerosis, severe protein-calorie malnutrition, and a healing right femur fracture, was observed with a cup of unknown pills on a table next to the bed while no nurse was in the room or within line of sight. The resident stated the RN had left the pills there. The RN later confirmed leaving the medications with the resident because there were no controlled medications in the cup and said the nurse should watch the resident take the medications. The DON stated nurses must ensure the right resident, right medication, and right dosage, and must remain until the resident swallows the medications. The facility policy and nursing text cited in the report both stated medications were to be administered safely and per physician orders. Resident #6, who had diagnoses including hemiplegia and hemiparesis following intracerebral hemorrhage, major depressive disorder, and intentional self-harm, was reported to have been given oxycodone and morphine pills that were left with the resident and then hoarded. The resident stated an RN would leave the pain medications and leave the room, and the resident kept the pills so pain could be self-managed if staff were unavailable. A psychiatric follow-up note documented partially decomposed narcotic pills that the resident said were being saved for transfer, and a nursing note documented continued hoarding of pain pills. The clinical record lacked evidence that the resident was able to self-administer medications. Staff later found unsecured pain medications in the room, and the Unit Manager LPN stated approximately 15 pain pills were present and that staff did not know how the resident obtained and hoarded them. The DON stated pain assessments were done routinely and that pain was subjective and must be respected, but also confirmed the resident had not been administered pain pills according to the physician order.
Wound care was documented as complete but not performed
Penalty
Summary
The facility failed to ensure wound care was completed as ordered for a resident with an open wound to the right heel. The resident was admitted with diagnoses including unspecified open wound of the right foot and other acute osteomyelitis of the right ankle and foot. A nursing narrative note documented that a CNA observed bright red blood on the floor of the resident’s room, with the bleeding coming from the heel of the right foot. An order was entered to cleanse the open area to the right heel, apply xeroform, cover with an ABD pad, wrap with Kerlix, and secure with an ACE wrap, and the care plan identified the resident’s actual alteration in skin related to the right heel wound. The June 2026 TAR documented the treatment as completed on a Monday, but on the following day the Wound Care LPN stated that wound care for the traumatic heel wound was the responsibility of the floor nurse. The assigned floor nurse stated the resident had been assigned to her the prior day, but she had not seen the wound and had not performed the wound care because she believed the Wound Care LPN was managing it. The Wound Care LPN then confirmed she was not performing the resident’s wound care and found the resident did not have a dressing on the heel. The DON stated the wound care should not have been documented as complete unless it had actually been completed.
Unsecured Pain Medications Left at Resident Bedside
Penalty
Summary
The facility failed to ensure medications were not left unsecured at a resident’s bedside for one sampled resident who had diagnoses including hemiplegia and hemiparesis following a nontraumatic intracerebral hemorrhage, major depressive disorder, recurrent, unspecified, and intentional self-harm by other specified means. A Psychiatric Follow Up Progress Note documented that the resident had concerning medication hoarding behavior and was found with bags of partially decomposed narcotic pills that the resident said were being saved for transfer to another facility. A Nursing Progress Note also documented issues with hoarding pain pills related to frustration about not having a pain pump. The resident stated that an RN would leave oxycodone and morphine pills with the resident, and that the resident was able to hoard the pain pills without staff knowledge so the resident could self-administer them if pain occurred and staff could not be reached. A Unit Manager LPN reported that unsecured medications were discovered in the resident’s room and estimated there were about 15 pain pills. The DON and Unit Manager LPN stated that nurses were expected to administer medications in the resident’s room, verify the correct resident, inform the resident of the medications, watch the resident swallow them, and not leave until the medications were swallowed; however, the Unit Manager LPN confirmed the resident’s oxycodone and morphine pills were unsecured in the facility and accessible to all residents and staff. The DON also stated that nurses were not administering or checking the resident’s medications any differently after the incident.
Pain medications not administered or monitored as ordered
Penalty
Summary
The facility failed to ensure safe, appropriate pain management for two residents by not following care planned interventions, not evaluating pain per physician orders, and not administering pain medication according to the ordered pain levels. For one resident with a recent left below-knee amputation and phantom pain, the record showed orders for acetaminophen for mild to moderate pain and oxycodone for severe pain, yet acetaminophen was given for pain levels of 6 and 7 and oxycodone was given for pain levels below the ordered range, including pain levels of 2 and 6. The care plan required pain assessment before opioid administration and documentation of effectiveness, and the resident stated that staff did not always understand the phantom pain and that the medications did not always help. The Director of Nursing confirmed the medications were not administered appropriately for the pain levels written in the physician orders. The DON stated oxycodone should not have been given for a pain level of 2 and that acetaminophen was not ordered for moderate to severe pain. A LPN also stated that mild to moderate pain was 1 to 5 and moderate to severe pain was 5 to 10, and that staff were expected to follow the orders as written. The facility policy required pain to be assessed consistently, pain medication to be given as ordered, and medication administration to be carefully documented. For the second resident, who had hemiplegia and hemiparesis following intracerebral hemorrhage, major depressive disorder, and chronic pain syndrome, staff found unsecured pain pills in the resident’s room after the resident had been hoarding oxycodone and morphine. Prior notes documented that the resident had been saving partially decomposed narcotic pills and continued hoarding pain pills due to frustration about not receiving a pain pump. The resident reported that an RN would leave oxycodone and morphine pills in the room and leave, and staff described that the resident had been cheeking pills and spitting them out after nurses left. The DON and Unit Manager LPN confirmed that medications were supposed to be brought in, identified, explained, observed until swallowed, and not left unattended, and they acknowledged that the resident’s pain medications were unsecured and accessible in the room.
Unattended Medications Left at Resident Bedside
Penalty
Summary
Medication administration was not completed in a safe manner for Resident #133, who was admitted and later readmitted with diagnoses including active primary progressive multiple sclerosis, unspecified severe protein-calorie malnutrition, and a fracture of the neck of the right femur with routine healing. On 06/25/2026 at 8:56 AM, surveyors observed a cup containing unknown pills on a table next to the resident’s bed. The medications were left unattended, there was no nurse within line of sight, and the resident stated the RN had left the pills with them. At 9:01 AM, the RN was observed entering another resident’s room to administer medications and waited with that resident until all medications were swallowed. At 9:04 AM, the RN stated medications were to be given by confirming the right resident, right medication, and right dosage, and that the nurse should watch the resident take the medications. The RN acknowledged leaving the medications unattended with Resident #133 and confirmed the cup of medications was unsecured on the resident’s side table. The DON stated the nurse was expected to ensure the resident swallowed medications before leaving the room, and the facility policy required medications to be administered in a safe manner.
Staff Drinks Found in Resident Pantry
Penalty
Summary
The facility failed to ensure that the 500 and 600 hall satellite resident pantry and refrigerator food and drink items were protected from cross contamination. During observation on 06/22/2026 at 9:15 AM, three refillable water bottles, one open soda can, one open Red Bull, one open Gatorade, and one Starbucks drink belonging to staff were found on the countertop in the 500 and 600 satellite pantry, which is part of the resident food service area. The Kitchen Manager confirmed that the pantry was meant only for resident food and drink items and stated it could be much cleaner. On 06/23/2026 at 2:13 PM, a CNA confirmed the pantry was for resident food and drink items and that staff personal drink containers in the pantry room posed a risk of cross contamination, and that staff personal drinks were to be stored in the employee break room. On 06/24/2026 at 12:15 PM, the Kitchen Manager again confirmed the pantry was for resident food and drink items and that staff personal drink containers in the pantry room posed a risk of cross contamination. The facility did not provide a policy related to where staff personal belongings were to be stored.
Inaccurate wound care documentation
Penalty
Summary
The facility failed to ensure that Resident #56’s record contained accurate documentation of wound care for a right heel wound. Resident #56 was admitted with diagnoses including an unspecified open wound of the right foot and other acute osteomyelitis of the right ankle and foot. The resident reported that the foot had recently been injured and had started bleeding, and a nursing narrative note documented that a CNA found bright red blood on the floor of the resident’s room coming from the heel of the right foot. An order was entered to cleanse the open area to the right heel and apply xeroform, an ABD pad, Kerlix, and an ACE wrap, and the care plan identified an actual alteration in skin related to the right heel wound with interventions to administer treatments as ordered and monitor effectiveness. The June 2026 TAR documented the right heel treatment as completed on Monday 06/22/2026, but on 06/23/2026 the Wound Care LPN stated that wound care for the traumatic heel wound was the responsibility of the floor nurse, while the assigned floor nurse stated she had not seen the wound and had not performed wound care because the Wound Care LPN was managing it. The Wound Care LPN then assessed the resident’s right heel and confirmed there was no dressing in place, yet the treatment had been documented as completed by the floor nurse. The DON stated the wound care should not have been documented as complete unless it had actually been performed, and that accurate documentation was important to ensure the resident did not develop an infection and the wound did not worsen.
Hand Hygiene Not Performed Between Glove Changes During Wound Care
Penalty
Summary
The facility failed to ensure staff performed hand hygiene between glove changes during wound care for Resident #9, who was admitted and later readmitted with diagnoses including unspecified open wounds of the right and left thighs and a pressure ulcer of the sacral region. The resident had wound care orders for the right buttock pressure injury to be cleansed with normal saline, patted dry, treated with Medihoney and collagen particles, covered with calcium alginate, and protected with barrier cream and a silicone dressing daily. During observed wound care on 06/24/2026, the Wound Care LPN and an RN performed hand hygiene with alcohol-based hand rub and donned gloves at the start, but repeatedly removed gloves and put on new gloves without performing hand hygiene in between. This occurred when the LPN removed the old dressing, placed a barrier cloth, cleansed the wound, patted the wound bed dry, applied wound products and dressings, cleansed the resident's thigh, applied collagen particles and barrier cream, and assisted with applying a clean brief. The RN also removed gloves, retrieved a box of gloves from the bathroom, and donned new gloves without hand hygiene in between. The LPN stated hand hygiene did not need to be performed between glove changes and that performing hand hygiene before starting wound care and after completing wound care was acceptable, while the RN stated hand hygiene should have been performed between glove changes. The Infection Preventionist stated hand hygiene should have been performed anytime gloves were removed to stop the spread of infection because the soiled dressing could carry microorganisms.
Failure to Integrate Hospice Wound Care into Resident Care Plan
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident's care plan was integrated with the hospice plan of care and did not include a care plan addressing the resident's wound care needs. The resident, who was admitted with diagnoses including palliative care and abnormal diagnostic findings, developed a large, tunneling breast mass that required wound care. The resident's representative stated that hospice was providing wound care, and hospice documentation confirmed ongoing wound management. However, there was no corresponding order for wound care or a care plan in the facility's electronic health record. Interviews with facility staff, including an RN, the Unit Manager, and the DON, confirmed that the resident did not have a care plan for wound care provided by hospice, and that such care should have been documented and integrated into the facility's care planning process. The facility's policy required comprehensive, person-centered care plans that incorporate all identified problem areas and professional services, but this was not followed in the resident's case.
Failure to Update Care Plans for Neurology Needs and Smoking Safety
Penalty
Summary
The facility failed to update and revise care plans for two residents, resulting in deficiencies related to the management of a resident's neurological needs and another resident's smoking habits. For one resident with Parkinson's disease and multiple sclerosis, the care plan did not reflect the resident's increased tremors or the need for a neurology appointment, despite repeated requests from the resident's representative and a physician's order indicating the necessity for such an appointment. Staff communicated verbally about the appointment status, but no appointment had been scheduled, and the care plan was not updated to address the resident's changing condition. For another resident with a history of tobacco use and hemiplegia, the care plan failed to address the resident's ongoing nicotine use and did not include interventions for the safe storage and use of smoking paraphernalia. The resident was observed smoking outside the facility and storing cigarettes and a lighter in the bedside table, but staff were unaware of the location of these items. The care plan only referenced a reminder of the facility's no smoking policy and had not been revised to address the resident's current smoking behaviors or associated safety concerns.
Failure to Timely Act on Neurology Referral for Resident with Parkinson's Disease
Penalty
Summary
The facility failed to ensure that a physician's order for a neurology referral was acted upon in a timely manner and monitored for completion for a resident with Parkinson's disease and multiple sclerosis. Despite repeated requests from the resident's representative at care conferences over several months, and documentation in care conference notes and progress notes indicating the need for a neurology appointment due to increased tremors, the facility did not schedule an appointment. The care plan was not revised to address the resident's increased symptoms or the need for a neurology referral. Referrals were sent twice to the resident's previous neurologist, but both times the neurologist's office responded that they could not see the patient due to insurance issues and lack of recent visits. No referrals were sent to other neurologists in the area. The Transportation Coordinator, responsible for coordinating referrals, only sent referrals to the previous neurologist as directed by information from nursing staff, and this process was not monitored by clinical leadership. The Director of Nursing and Unit Manager confirmed that the resident did not have an appointment scheduled and that the referral process was not adequately overseen or documented.
Failure to Coordinate Timely Specialist Referral and Wound Care Documentation
Penalty
Summary
The facility failed to ensure timely management of a resident's increased tremors as ordered by the physician. Despite repeated requests from the resident's representative and documentation in care conference notes and physician orders, the facility did not secure a neurology appointment for the resident experiencing worsening tremors related to Parkinson's disease. Referrals were only sent to the resident's previous neurologist, who no longer accepted the resident's insurance, and no attempts were made to contact other neurologists in the area. Communication between nursing staff and the transportation coordinator was limited to a spreadsheet, and there was no oversight to ensure the referral process was completed as ordered. The resident's care plan was not updated to reflect the need for neurology follow-up or the increased symptoms. Additionally, the facility did not monitor or document wound care for another resident who was on hospice and had a non-healing breast wound. The resident's representative reported that hospice was providing wound care, but there was no physician order or care plan in the facility's records addressing the wound or the facility's role in the care process. The facility's own policy required care planning and documentation for wound management, but this was not followed. The care plan was not integrated with the hospice plan of care, and facility staff did not have clear documentation of their responsibilities regarding the resident's wound care. These deficiencies were identified through observation, interviews with staff and resident representatives, and review of clinical records and facility policies. The lack of timely specialist referral and absence of wound care documentation and planning demonstrated a failure to provide care and services in accordance with physician orders, resident needs, and facility protocols.
Failure to Provide Ordered Pressure Ulcer Care and Prevention
Penalty
Summary
A resident with multiple diagnoses, including adult failure to thrive, chronic kidney disease, and sequelae of cerebral infarction, was admitted to the facility and assessed as being at risk for pressure-related skin impairment due to factors such as shear friction and bed confinement. The care plan included interventions like keeping the resident clean and dry, providing peri care after incontinence, and weekly skin checks by a licensed nurse. Despite these measures, a Stage III pressure injury was identified on the resident's coccyx during a post-shower skin check, which had not been previously observed. Following the identification of the pressure injury, physician orders were written for specific wound care treatments, including cleansing with normal saline, applying skin prep or medi-honey and zinc oxide, and covering or leaving the wound open to air as directed. These orders specified the frequency of care, including every shift and as needed for soiling or dressing dislodgement. However, review of the Wound Care Treatment Administration Records (TAR) for April and May revealed multiple dates and shifts where there was no documented evidence that wound care was provided as ordered. The DON and Wound Care Nurse confirmed that the blanks in the TAR indicated the wound care was not completed on those dates and that the care was not provided according to the physician's orders. Facility policies required daily skin inspections during personal care, prompt identification and documentation of skin changes, and adherence to prescribed wound care treatments. The failure to provide wound care as ordered and to follow the facility's own policies for prevention and monitoring of pressure injuries resulted in a deficiency, as the resident did not receive the necessary care to prevent the development and progression of a pressure injury.
Failure to Check Gastric Residual Prior to G-Tube Medication Administration
Penalty
Summary
A deficiency was identified when a resident with a history of dysphagia, gastroparesis, and gastrostomy status did not have their gastric residual volume checked prior to the administration of medication via a gastrostomy tube (G-tube). The resident had a physician's order specifying that residuals should be checked before administering water, medications, or formula through the G-tube. Despite this order, an LPN administered levetiracetam solution through the G-tube without performing the required residual check. The LPN confirmed that the residual was not checked prior to medication administration, and the Director of Nursing also acknowledged that residuals should be checked before administering anything through a G-tube, in accordance with facility policy. The facility's policy on enteral feedings and safety precautions also documented the requirement to check tube placement and gastric residual volume prior to medication administration. This lapse was observed and confirmed through interviews and record reviews.
Medication Documentation and Availability Discrepancies
Penalty
Summary
The facility failed to ensure that there were no discrepancies between a resident's available medications, the resident's medication orders, and the medication administration record (MAR). During a review of a resident's medications, a bottle of lorazepam was found in the medication storage room with a label indicating it was prescribed for the resident, with specific administration instructions. However, the facility's electronic health record did not include an order for lorazepam, and the medication was not listed on the resident's MAR. The RN confirmed that the medication had been delivered by the hospice agency's pharmacy, but it was not properly documented in the facility's records. Additionally, the resident had an order for C-PDR cream to be applied as needed for nausea or vomiting, which was part of the hospice comfort package. The RN stated that the facility did not have the C-PDR cream available for the resident. The Director of Nursing confirmed that all medications ordered for a resident should be available in the facility. Facility policy required that a current list of orders be maintained in the clinical record for each resident, and the pharmacy services contract required regular medication regimen reviews by a consultant pharmacist.
Unattended and Unlocked Medication Cart with Keys Left Accessible
Penalty
Summary
A medication cart was observed unattended and unlocked in the 300 hall, with the keys left on top of the cart and no staff members in sight. The drawers of the cart, which contained drugs and biologicals, were facing the hallway, making the medications accessible to unauthorized individuals. This was directly observed by surveyors at 7:22 AM, and shortly after, a Registered Nurse confirmed that the cart had been left in this unsecured state while unattended and out of sight. The Director of Nursing later confirmed that the facility's policy requires medication carts to be locked when not in use and that the keys should always remain with the nurse. The facility's written policy, adopted in 2019, also specifies that only authorized personnel should have access to medication storage and that carts should not be left unattended if open or accessible. The observed incident was not in compliance with these established procedures.
Failure to Coordinate Hospice Care and Medication Orders
Penalty
Summary
The facility failed to coordinate care and services with a hospice agency for a resident who was receiving hospice care, resulting in discrepancies between the facility's records and the hospice agency's plan of care. The resident, admitted with diagnoses including palliative care and anxiety disorder, had a significant wound on the right breast that was being managed by hospice staff. However, the facility's electronic health record (EHR) did not include an order for wound care, nor did it have a care plan addressing the resident's wound or the use of certain medications prescribed by hospice. There were notable inconsistencies between the facility's medication orders and those from the hospice agency. The facility's EHR listed a different dosage of metronidazole than the hospice agency, included pravastatin which was not on the hospice list, and omitted lorazepam, which was prescribed by hospice for symptom management. Additionally, the facility did not have PDR cream available, despite it being ordered by both the facility and hospice. Interviews with facility staff and hospice personnel confirmed these discrepancies and revealed a lack of medication reconciliation and care plan updates. The facility's policy required coordination with hospice, including reconciling medication orders and care plans, but this was not followed. The Director of Nursing acknowledged that staff should have reconciled medications and care plans with hospice, and the facility did not have a designated hospice coordinator. The process for receiving and communicating new hospice orders was not effectively implemented, resulting in the resident not having appropriate care plans or access to all prescribed medications and therapies.
Failure to Perform Hand Hygiene Before Entering EBP Room
Penalty
Summary
A Certified Nursing Assistant (CNA) entered a room designated for Enhanced Barrier Precautions (EBP) without performing required hand hygiene, either by using alcohol-based hand rub (ABHR) or washing hands. The room was clearly marked as being on EBP, and an ABHR dispenser was available outside the room. The CNA entered to assist a resident with their meal tray and later acknowledged forgetting to use ABHR before entering, despite the resident being on EBP due to an extended-spectrum beta-lactamase (ESBL) urinary tract infection. A Registered Nurse (RN) observed the CNA's failure to perform hand hygiene and confirmed the resident's EBP status due to ESBL in the urine. The facility's policy, updated in March 2024, requires all individuals to clean their hands with ABHR before entering any room on EBP. The Administrator also confirmed that the CNA should have performed hand hygiene prior to entry. The incident was identified through observation, interview, and document review, and the deficiency was noted as having the potential to affect the resident population.
Unsecured Medication and Wound Carts Left Unattended
Penalty
Summary
A wound cart containing resident medications was observed left unlocked in the 200 hall entrance, with four residents sitting nearby. An LPN later confirmed the cart was unsecured and acknowledged that residents could have accessed the medications. Additionally, a medication cart was found unlocked and unattended in the 100 hall entrance, which was confirmed by an RN. The Director of Nursing stated that floor nurses are responsible for ensuring carts are locked and not left unattended. Facility policy requires all compartments containing drugs and biologicals to be locked when not in use and not left unattended if open or accessible.
Failure to Properly Screen and Offer Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure that residents were properly screened for eligibility to receive a pneumococcal vaccination, provided with education regarding the vaccine, and offered the vaccine for administration or declination. Specifically, 28 residents were not screened for eligibility based on criteria other than age, despite having medical conditions that could make them eligible for the vaccine. The facility's policy and flowchart used for screening only considered age, leading to the exclusion of residents under 65 who had conditions such as diabetes or were immunocompromised, which should have made them eligible for the vaccine according to CDC guidelines. For instance, Resident #104, who had type two diabetes mellitus, was not offered the pneumococcal vaccine because the screening process only considered age. The Infection Control Preventionist (ICP) and the Vice President of Clinical Services (VPCS) confirmed that the resident should have been offered the vaccine based on their medical condition. This oversight was consistent across the other 27 residents, who were also not screened for additional eligibility criteria beyond age. The facility's policy, adopted in 2019, stated that all residents should be offered pneumococcal vaccines to prevent pneumonia/pneumococcal infections. However, the policy was not followed correctly, as the screening process did not align with CDC guidelines, which recommend the vaccine for individuals with certain medical conditions regardless of age. This failure to properly screen and offer the vaccine to eligible residents represents a significant deficiency in the facility's vaccination protocol.
Failure to Notify Physician and Family of Resident's Decline
Penalty
Summary
The facility failed to ensure that a resident's representative and physician were notified of a significant change in the resident's condition. Resident #305, who had multiple diagnoses including pulmonary embolism and peripheral vascular diseases, exhibited bluish discoloration and cold, clammy skin on the right lower extremity. Despite the physician ordering a bilateral leg arterial ultrasound, the facility's contracted diagnostics company did not have an ultrasound technician available. The resident's condition worsened over several days, with increased pain and continued discoloration, but the family and physician were not informed of the ongoing decline and the inability to perform the ultrasound in-house. The resident's condition continued to deteriorate, leading to severe pain and behavioral changes. It was only on 05/07/2024 that the physician was notified, and the resident was subsequently sent to the hospital. Interviews with the Unit Manager and Director of Nursing confirmed that there was no documentation of the physician being informed about the lack of an ultrasound technician or the resident's declining condition. The facility's policy required prompt notification of changes in a resident's condition to the healthcare provider and resident representative, which was not adhered to in this case.
Failure to Provide Comfortable Environment Due to Broken AC Unit
Penalty
Summary
The facility failed to provide a comfortable, homelike environment for Resident #257 when the air conditioning (AC) unit in the resident's room was broken and not promptly repaired. Despite the resident's spouse informing the Administrator and staff about the issue, the AC unit remained unfixed for three days. During this period, the room was reported to be uncomfortably warm, and no alternative accommodations, such as moving the resident to another room or providing a fan, were offered. The Licensed Practical Nurse (LPN) and Certified Nursing Assistant (CNA) were unaware of any restrictions on using fans in the room, and the Head Operations Manager (HOM) confirmed that there were no such restrictions. The HOM acknowledged the broken AC unit and stated that a replacement unit had to be ordered from the home office, which arrived and was installed on the third day. The facility's policy on providing a homelike environment was not adhered to, as the staff failed to ensure a comfortable and safe temperature in the resident's room. The Administrator admitted that the resident was not experiencing a comfortable environment due to the broken AC unit and high temperatures. A work order for the AC repair was not created until the third day, and the HOM confirmed that no prior work order had been made. The facility's delay in addressing the broken AC unit and lack of immediate accommodations for the resident led to the deficiency in providing a homelike environment as required by their policy.
Failure to Provide Necessary Care and Protect Residents from Abuse
Penalty
Summary
The facility failed to ensure a resident with a deep vein thrombosis (DVT) received the necessary care to prevent the resident from developing gangrene in a lower extremity and requiring hospitalization. Resident #305 was admitted with multiple diagnoses, including other pulmonary embolism and peripheral vascular diseases. On 04/30/2024, a nurse noticed bluish discoloration and cold, clammy skin on the resident's right lower extremity and informed the physician, who ordered a bilateral leg arterial ultrasound. However, the facility's contracted diagnostics company did not have an ultrasound technician available, leading to a delay in the ultrasound. Despite the resident's worsening condition, including increased pain and further discoloration, the resident was not sent to the hospital until 05/07/2024, resulting in severe gangrene and the need for an above-the-knee amputation or end-of-life care. The facility's documentation lacked consistent assessment of pedal pulses, and the physician was not informed of the resident's clinical decline in a timely manner, contributing to the delay in appropriate care and treatment for the resident's condition. The facility also failed to protect residents from physical abuse by another resident. Resident #83, who had a history of schizophrenia and anxiety disorder, was involved in an incident on 04/09/2024, where the resident spit on and threw a cup of water at their roommate, Resident #122, while the roommate was asleep. Despite Resident #83's documented potential for disruptive behaviors and the need for monitoring and intervention, the facility did not implement new interventions to address the resident's increased behaviors. Resident #83 was eventually transferred to a behavioral health center for additional services, and Resident #122 was moved to another room. The facility's policy on abuse prevention was not effectively implemented to protect residents from abuse by other residents. The Director of Nursing (DON) and the Unit Manager (UM) acknowledged the deficiencies in care and communication. The DON confirmed that the resident should have been sent to the hospital earlier and that the facility failed to notify the physician about the lack of an ultrasound technician and the resident's declining condition. The UM admitted that the facility should have monitored pedal pulses daily for a suspected DVT and that the resident's increasing pain and discoloration were indicative of loss of blood flow. The facility's failure to provide timely and appropriate care resulted in significant harm to Resident #305 and inadequate protection for Resident #122 from abuse by another resident.
Failure to Investigate Missing Money Report
Penalty
Summary
The facility failed to investigate a resident's report of missing money according to its policy. Resident #149, who was admitted with diagnoses including anxiety disorder and homelessness, reported to a CNA that $20 was missing from their wallet shortly after admission. Despite this report, no follow-up was conducted by the facility staff. The resident's clinical record noted the missing money, but the Review and Inventory of Valuable Items was completed seven days after the report and did not include any money in the wallet. The CNA who received the report did not document it and only verbally informed the DON, who was unaware of the issue until the survey team brought it to attention. The DON stated that the correct process would involve documenting the concern as a grievance and having Social Services follow up, which did not occur in this case. The Director of Social Services confirmed that no follow-up had been conducted with the resident or the CNA who received the initial report. The facility's policy on Abuse Investigation and Reporting requires thorough investigation of all reports of misappropriation, including reviewing documentation and interviewing all relevant parties. This process was not followed, leading to the deficiency noted by the surveyors.
Failure to Update Care Plan for Resident with Urinary Catheter
Penalty
Summary
The facility failed to ensure that a resident with a urinary catheter and a behavior of pulling out the catheter had an updated care plan to include interventions to prevent this behavior. Resident #98, who was admitted with diagnoses including benign prostatic hyperplasia and urinary retention, had pulled out the catheter multiple times since admission, resulting in hospital visits for reinsertion and treatment for hematuria. Despite these incidents, the care plan initiated on 06/03/2024 did not document any interventions to address the resident's behavior of pulling out the catheter. On 06/12/2024, both the LPN and the DON confirmed that the resident had pulled out the catheter for the third time that day and acknowledged the need for documented interventions to prevent this behavior. The LPN noted that the resident previously had a leg strap to secure the catheter, but it was not in place during the incidents. The facility's policy on comprehensive person-centered care plans emphasized the need for ongoing assessments and revisions as the resident's condition changed, which was not adhered to in this case.
Failure to Implement Interventions and Provide Timely Care
Penalty
Summary
The facility failed to implement interventions for a resident with a urinary catheter who had a history of pulling out the catheter, resulting in repeated physical trauma. Despite the resident pulling out the catheter multiple times, the care plan lacked documentation of measures to prevent this behavior. Observations and interviews revealed that the resident did not have a leg strap or a StatLock in place, which were previously used to secure the catheter. The Director of Nursing confirmed the need for documented interventions to prevent the resident from pulling out the catheter again. The facility also failed to provide timely care for a resident with a suspected deep vein thrombosis (DVT). The resident exhibited symptoms such as bluish discoloration and cold, clammy skin on the right lower extremity. Although an ultrasound was ordered, it was not performed due to the unavailability of an ultrasound technician. The resident's condition worsened, but the facility did not send the resident to the hospital promptly. The Director of Nursing and the Unit Manager acknowledged that the resident should have been sent to the hospital earlier and that pedal pulses should have been monitored daily. Additionally, the facility did not communicate a hospice physician's order for a resident to the facility's physician, resulting in the resident not receiving the ordered medication. The hospice order for Potassium Chloride ER was scanned into the resident's clinical record but was not entered into the electronic medical record (EMR) or the Medication Administration Record (MAR). The Director of Nursing confirmed that the order was not communicated to the facility's physician and was not administered as required. The facility lacked a designated hospice coordinator, leading to communication gaps between hospice and facility staff.
Failure to Adhere to Weight Monitoring Policy
Penalty
Summary
The facility failed to ensure that two residents were weighed according to the facility's policy. Resident #37, who had diagnoses including type II diabetes mellitus, unspecified dementia, and adult failure to thrive, was not weighed monthly as required. The resident's weight records showed significant fluctuations, and there was no documented weight for August 2023. The clinical record lacked evidence of any weight measurements between November 2023 and June 2024. Despite a significant weight gain noted in October 2023, no follow-up weights were documented, and the resident was not weighed for over six months. The facility's staff, including an LPN, RN, RD, and the DON, confirmed the failure to adhere to the monthly weighing policy and the absence of documented reasons for not weighing the resident, such as resident refusal. Resident #143, who had diagnoses including acute duodenal ulcer with hemorrhage and age-related cognitive decline, also experienced a failure in weight monitoring. The resident was supposed to have weekly weights for four weeks and then monthly if stable, as per physician's orders. However, the resident's weight records showed only one weight measurement since admission, which indicated a drastic and questionable weight loss of 71 lbs. The RD used a hospital weight as a baseline instead of obtaining a new admission weight, and despite the significant weight loss, weekly weights were not performed as ordered. The DON and RD confirmed the failure to follow the weight monitoring orders and the lack of follow-up on the weight monitoring. The facility's policy on Weight Assessment and Intervention required residents to be weighed upon admission, the following day, and weekly for two weeks, with monthly weights thereafter if no concerns were identified. Any weight change of 5% or more required re-weighing the following day for confirmation. The policy also mandated immediate notification of the RD for significant weight changes. The facility staff failed to adhere to these policies for both residents, leading to deficiencies in weight monitoring and documentation.
Late Annual Performance Evaluation for CNA
Penalty
Summary
The facility failed to ensure a Certified Nursing Assistant (CNA) had an annual performance evaluation completed timely for one of the two CNAs employed for more than one year. Employee #8, who was hired on 05/18/2022, had their last performance evaluation documented on 07/11/2023. However, the annual performance evaluation was due by 05/18/2023. During an interview on 06/11/2024, the Human Resources Manager and Regional Human Resources confirmed that the annual performance evaluation for Employee #8 was completed late, failing to adhere to the facility's policy that mandates annual reviews from the date of employment.
Failure to Ensure Availability and Administration of Medications
Penalty
Summary
The facility failed to ensure that ordered medications were available and administered for a resident with chronic pancreatitis, chronic pain, and muscle spasms. The resident reported running out of medication for muscle spasms and pancreatitis, which exacerbated their chronic pain. The physician had ordered Cyclobenzaprine for muscle spasms and Creon for chronic pancreatitis, but the resident missed several doses of both medications in May 2024 due to the facility's failure to reorder them in a timely manner. A Registered Nurse confirmed that the resident missed multiple administrations of both medications and that the medications had to be reordered from the pharmacy. The facility's policy required medications to be reordered at least three days before running out, but there was no evidence that this was done. The Director of Nursing confirmed the missed doses and acknowledged that the medications were not reordered within the required timeframe, as per the facility's policy.
Failure to Ensure Timely Ultrasounds Due to Lack of Technician
Penalty
Summary
The facility failed to ensure timely ultrasounds for residents due to the contracted diagnostics company not having an ultrasound technician available for onsite visits. The Administrator was unsure when first notified about the issue, possibly at the end of April 2024, and could not provide documented evidence that the lack of an ultrasound technician was addressed or that any direction was given to the nursing staff. The Director of Nursing (DON) was aware of the issue and had instructed to send residents to the hospital for ultrasounds when working in the Rehabilitation Department before becoming the DON. However, the DON was not aware if the nursing staff had been informed of this need prior to their tenure as DON. The facility's Quality Assurance and Performance Improvement (QAPI) Program policy indicated that the committee would oversee the implementation of the QAPI Plan and identify and correct quality deficiencies, but this was not effectively demonstrated in this instance.
Incomplete Medical Records for Two Residents
Penalty
Summary
The facility failed to ensure that the medical records for two residents were complete and in accordance with physician orders. Resident #143, who was admitted with diagnoses including acute duodenal ulcer with hemorrhage and age-related cognitive decline, had physician orders for weekly weight measurements. However, the clinical record showed only one weight measurement for April and May 2024, missing several required weekly weights. The Director of Nursing (DON) confirmed that the resident should have been weighed weekly for four weeks and then monthly if stable, but this was not done. The Registered Dietician (RD) also confirmed that the weekly weights had not occurred as ordered. Resident #205, admitted with diagnoses including unspecified protein-calorie malnutrition and dysphagia following cerebral infarction, had physician orders for gastrostomy tube (G-Tube) flushes. The Treatment Administration Record (TAR) and Medication Administration Record (MAR) lacked documented evidence that the G-Tube was flushed per the physician orders on multiple occasions. The DON confirmed the absence of documentation for the G-Tube flushes as required by the physician orders. The facility's policy on Charting and Documentation required that medications administered and treatments performed be documented in the resident's clinical record, which was not adhered to in these cases.
Failure to Address Lack of Ultrasound Technician
Penalty
Summary
The facility's Quality Assessment and Performance Improvement (QAPI) committee failed to identify that the contracted diagnostics company lacked an ultrasound technician, resulting in a delay for a resident with a physician's order for an ultrasound. The Administrator was unsure when they were first notified about the lack of an ultrasound technician but believed it was possibly at the end of April 2024. The Administrator could not provide documented evidence that the issue was addressed or that any direction or instruction was given to the nursing staff. The Director of Nursing (DON) was aware of the lack of an ultrasound technician and had instructed to send residents to the hospital for ultrasounds if needed. However, the DON was not aware if the nursing staff had been informed of this need prior to becoming the DON. The facility's policy stated that the QAPI committee would oversee the implementation of the QAPI Plan and identify and correct quality deficiencies, which was not done in this case.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure Enhanced Barrier Precautions (EBP) were implemented when providing care to a resident's jejunostomy tube (J-tube). Specifically, a Licensed Practical Nurse (LPN) did not wear a gown or gloves while disconnecting the tube feeding from the resident's J-tube, despite a sign outside the resident's room indicating the need for EBP. The LPN confirmed the requirement for gown and gloves and acknowledged the failure to adhere to the precautions. The resident's care plan also documented the need for EBP due to the presence of the J-tube, with interventions including EBP per facility policy. The Director of Nursing (DON) explained that gown and gloves were required for residents with feeding tubes to prevent the introduction of bacteria and potential infections. The facility's Infection Prevention and Control Program (IPCP) policy stated that EBP served to reduce the transmission of multidrug-resistant organisms (MDRO) and applied to residents with indwelling medical devices. The policy required staff to wear a gown and gloves when performing high-contact resident care activities, including indwelling medical device care.
Failure to Prevent Resident Elopement Due to Alarm Malfunction
Penalty
Summary
The facility failed to provide protective supervision for a resident who was at risk of elopement. The resident, who had a history of wandering and was wearing a Wanderguard device, followed a Certified Nursing Assistant out of an alarmed exit door. The alarm system failed to activate, allowing the resident to wander into the parking lot. This incident was discovered when the resident's significant other found them outside and brought them back into the facility. The resident's care plan had identified them as an elopement risk and included interventions such as one-on-one supervision and the use of a Wanderguard device to alert staff of any attempts to exit the building. The Director of Nursing (DON) confirmed that the elopement was preventable and explained that all staff were trained annually on elopement prevention. The facility's policy required staff to prevent residents from leaving the premises and to report any such attempts to a nurse. However, the investigation revealed that the alarm system had malfunctioned at all exits, and the maintenance team had not detected this issue during their weekly checks. The Administrator confirmed that the alarm system was replaced following the incident.
Resident Dignity Compromised by PT's Verbal Confrontation
Penalty
Summary
The facility failed to maintain the dignity of a resident, identified as Resident #9, who was admitted with diagnoses including hydrocephalus and difficulty walking. An incident occurred where a Physical Therapist (PT) was reported to have verbally berated the resident at the nurse's station. The resident expressed that the interaction was a misunderstanding but noted that the PT's demeanor needed to be gentler. The resident's comprehensive care plan highlighted the risk for loss of dignity due to stern instructions from staff and included measures to maintain dignity, such as notifying the physician and next of kin if instructions were perceived as harsh. During a subsequent interview, the resident recounted being confronted and yelled at by the PT for walking around the facility, which led to the resident breaking down into tears and feeling disrespected and embarrassed in front of others. A Registered Nurse (RN) corroborated the resident's account, stating that the PT forcefully escorted the resident back to their room, preventing them from picking out a book. The RN reported the incident to the Administrator and Director of Nursing (DON), and the resident expressed a desire to leave against medical advice rather than work with the PT again.
Verbal Abuse Incident Involving RN and Resident
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a staff member, specifically a Registered Nurse (RN), who was witnessed verbally berating a resident at the nurse's station. The incident involved Resident #7, who was admitted with diagnoses including unspecified chronic bronchitis, severe protein-calorie malnutrition, and depression. The verbal abuse was reported by a Certified Nursing Assistant (CNA) and a family member of another resident, who observed the RN cursing and throwing medication bottles around the nurse's station, with comments directed at Resident #7. The Director of Nursing (DON) was notified of the incident and initiated an investigation. The RN was immediately suspended and later terminated due to misconduct. Despite the trauma screening conducted on Resident #7, which did not indicate psychosocial harm, the investigation was deemed incomplete. The Administrator acknowledged that the investigation lacked interviews with all involved parties, including Resident #19 and another resident mentioned by the CNA, and the statement from Resident #19's family member was not included in the Facility Reported Incident (FRI) documentation. The facility's policy on abuse investigation and reporting requires thorough investigation and documentation of all reports of resident abuse, including interviews with witnesses. However, the investigation into this incident did not meet these standards, as not all witnesses were interviewed, and the documentation was incomplete. The RN had a history of disciplinary action for verbal misconduct, which was not adequately addressed prior to this incident.
Failure to Investigate and Report Abuse Allegation
Penalty
Summary
The facility failed to implement its policy on abuse investigations and reporting, as evidenced by an uninvestigated and unreported allegation of abuse involving a resident. The resident, who had been admitted with chronic congestive heart failure, type 2 diabetes mellitus with diabetic neuropathy, and anxiety disorder, reported to an Adult Protective Services (APS) Social Worker that a Certified Nursing Assistant (CNA) had handled them roughly and slapped them on the cheek. Despite being informed of this allegation by the APS Social Worker, the facility's Administrator and Director of Nursing (DON) did not investigate the claim or report it to the State agency or law enforcement, citing the resident's history of unfounded allegations as the reason for inaction. The facility's policy, adopted in 2019, mandates that all reports of resident abuse be promptly reported and thoroughly investigated, with any accused employee being suspended pending the investigation's outcome. However, the Administrator and DON admitted that the abuse allegation was not investigated, and the CNA continued to work directly with the resident after the allegation was made. This failure to act according to the established policy placed the resident at continued risk of physical abuse by the staff member.
Failure to Report and Investigate Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of physical abuse against a resident by a staff member within the required two-hour time frame. The incident involved a resident who had been admitted with chronic congestive heart failure, type 2 diabetes mellitus with diabetic neuropathy, and anxiety disorder. The resident reported to an Adult Protective Services (APS) Social Worker that a Certified Nursing Assistant (CNA) had handled them roughly and slapped them on the cheek. This information was communicated to the facility's Administrator by the APS Social Worker. Despite being informed of the allegation, the Administrator and the Director of Nursing (DON) did not report the incident to the State agency or law enforcement, nor did they conduct an investigation. The Administrator justified the inaction by citing the resident's history of unfounded allegations. However, the facility's policy required all new allegations of abuse to be investigated and reported promptly. The failure to adhere to this policy resulted in a deficiency, as the facility did not ensure the allegation was reported and investigated as mandated.
Failure to Investigate and Report Abuse Allegations
Penalty
Summary
The facility failed to investigate and report an allegation of abuse involving a resident who claimed a CNA slapped and handled them roughly. Despite being informed of the allegation by an APS Social Worker, the facility did not suspend the CNA or report the incident to the State Survey Agency or law enforcement. The CNA continued to work with the resident and others in the facility, which posed a risk of further abuse. The facility's policy required immediate suspension of any employee accused of abuse and a thorough investigation, which was not followed in this case. Another incident involved a Registered Nurse allegedly verbally abusing a resident at the nurse's station. The incident was witnessed by a CNA and a family member of another resident. The RN was reportedly cursing and throwing medication bottles, which was overheard by a family member who expressed concern. The facility's investigation into this incident was incomplete, as not all involved parties were interviewed, and the family member's statement was not included in the investigation documentation. The Administrator and DON shared responsibility for abuse investigations but failed to conduct thorough investigations in both cases. The lack of complete documentation and interviews with all involved parties led to an incomplete investigation, which was acknowledged by the Administrator. The facility's failure to adhere to its own policies and procedures for handling abuse allegations resulted in deficiencies in protecting residents from potential harm.
LPN Medication Administration Competency Deficiency
Penalty
Summary
The facility failed to ensure that an LPN had the necessary competencies to safely perform medication administration. During an observation, the LPN was found to have premixed doses of Polyethylene Glycol 3350 (MiraLAX) in clear plastic cups and left them on top of the medication cart. These cups, containing a clear liquid, were indistinguishable from plain water and were left unattended in the hallway, posing a risk of being ingested by other residents or visitors. The LPN continued to leave the cups on the cart while attending to residents in their rooms, indicating a lack of proper medication administration practices. The Director of Nursing (DON) confirmed that medications should not be left on top of the medication cart and should be prepared for one resident at a time, not premixed. Furthermore, the facility did not have competency checklists for new nurses, nor did it have a medication administration competency checklist for the LPN involved. This lack of oversight and training contributed to the deficiency observed during the survey.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure that a resident's medications were administered as ordered, resulting in a medication error rate of 100%. A resident was found with two medication cups at their bedside, containing a total of ten medications that were supposed to be administered at specific times. These medications were documented as administered in the Medication Administration Record (MAR), despite the resident not having taken them. The medications included Baclofen, Buspirone HCl, Melatonin, Senokot S, Simvastatin, Lisinopril, and Venlafaxine, which were left unsupervised at the resident's bedside. The Licensed Practical Nurse (LPN) confirmed that the medications should not have been documented as administered if the resident had not taken them and acknowledged that leaving medications at the bedside was against protocol. The physician emphasized that medications should be given at the ordered time to avoid high-risk practices and potential drug interactions. The facility's policy on medication administration, which aligns with the National Institute of Health's five rights of medication administration, was not followed, leading to this deficiency.
Medication Storage and Security Lapses
Penalty
Summary
The facility failed to ensure proper storage and supervision of medications, specifically a laxative powder dissolved in water, which was left unattended on top of a medication cart. An LPN was observed administering medications on the 400 hall, where three cups containing a clear liquid, identified as MiraLAX, were left on the cart. The LPN admitted to premixing the doses and acknowledged that the cups could be mistaken for plain water, posing a risk of ingestion by other residents or visitors. The cups remained unattended on the cart while the LPN entered various rooms, contrary to the facility's policy that medications should be prepared for one resident at a time and not premixed. Additionally, the facility did not secure medication carts, leaving them unlocked and unattended in the 300/400 hall. This was observed when a medication cart was left unlocked, allowing staff, residents, and visitors to pass by it. An RN later noticed the unlocked cart and confirmed that it should have been secured, especially given the presence of residents with dementia who could access the medications. Another instance involved a different LPN who also left a medication cart unlocked, acknowledging their responsibility for securing it. These actions violated the facility's policy on medication storage and security.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 260 citations issued within 25 miles in the last 12 months — 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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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Reno
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Alpine Skilled Nursing And Rehabilitation Center | 1.8 mi | ★★★★★ | 16 | 0 |
| Life Care Center Of Reno | 2 mi | ★★★★★ | 0 | 0 |
| Advanced Health Care Of Reno | 3.9 mi | ★★★★★ | 12 | 0 |
| Caremeridian Llc, Dba Neurorestorative | 4.5 mi | ★★★★★ | 28 | 0 |
| Rosewood Rehabilitation Center | 5.3 mi | ★★★★★ | 30 | 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.