Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Spjst Rest Home 1 during CMS and state inspections, most recent first.
Improper Food Storage, Labeling, Dating, and Thawing: Surveyors observed raw chicken thawing in a sink without running water and found numerous unlabeled, undated, improperly dated, or expired food items in the kitchen, dry pantry, walk-in refrigerator/freezer, and satellite refrigerators. Items included salads, sandwiches, dairy products, sauces, pasta, baked goods, meats, and beverages that lacked required labels, open dates, or discard/use-by dates. Interviews with the cook, DM, ADM, and dietary staff showed inconsistent understanding of food dating and discard practices, and facility policy required food to be stored, labeled, dated, and handled to reduce foodborne illness.
Misappropriation of Controlled Medications: Multiple residents had missing controlled meds, including tramadol, lorazepam, hydrocodone-acetaminophen, acetaminophen-codeine, and oxycodone. Narcotic count sheets and MARs did not match, one narcotic sheet appeared rewritten, and video showed an agency LVN repeatedly handling narcotic binders and cards at med carts, with doses signed out at times that did not align with ordered schedules.
An LVN left a treatment cart unlocked and unattended while entering a resident's room, and staff confirmed carts were expected to be locked when not in use. In a separate observation, unopened Latanoprost bottles were found stored in a medication cart instead of refrigeration, despite manufacturer instructions requiring refrigerated storage until opening. The DON, MA, and RPh all confirmed the storage was not consistent with the medication's instructions.
Pureed meals were prepared with unmeasured broth and did not meet the required pudding-like texture. DM B blended Salisbury steak, beans, and cabbage with added liquid until the items were runny or watery, and the recipe ingredients for the cabbage were not reflected in the finished food. Staff and residents reported the food lacked flavor, and interviews confirmed the expected puree consistency was not being followed.
Staff failed to follow hand hygiene and EBP requirements during resident care and meal assistance. An LPN repeatedly handled food and assisted multiple residents without sanitizing between contacts, and an LPN and CNA provided wound care to a resident with a sacral pressure ulcer without wearing the required gown under EBP. Additional meal observations showed an LPN and CNA feeding residents without hand hygiene, including after handling personal items and between resident contacts.
A resident with dementia and a special utensil care plan and another resident with Alzheimer’s disease who required total feeding assistance were fed at the same time by a CNA during lunch. Both residents waited while the CNA assisted the other resident, and the CNA did not wash hands or use sanitizer between residents. Staff interviews showed awareness that feeding two residents at once was not appropriate and could affect dignity, individualized care, and safe dining.
A resident with COPD and heart disease was exposed to smoke from a malfunctioning air conditioning unit, but the facility failed to conduct a thorough assessment or document vital signs. Despite the resident's complaints of chest pain and discomfort, there was no comprehensive evaluation or monitoring, and staff interviews revealed a lack of communication and documentation. The absence of a social worker further hindered the assessment of emotional distress, placing the resident at risk of not receiving necessary medical care.
The facility failed to maintain food safety and hygiene standards, with issues such as improper food storage, inadequate hand hygiene by staff, and poorly maintained kitchen equipment. Observations included undated food items, improper glove use, and high refrigerator temperatures, posing a risk of food-borne illness to residents.
A long-term care facility failed to maintain an effective infection control program, with staff not sanitizing blood pressure monitors between residents and neglecting hand hygiene protocols. This was observed among several residents with various medical conditions, posing a risk of cross-contamination. The facility's infection preventionist and DON acknowledged the deficiencies, highlighting a lack of consistent training and monitoring.
The facility failed to develop comprehensive care plans for four residents, omitting critical details about ADLs and mental health diagnoses. Two residents' care plans lacked documentation of their dependence on staff for ADLs, while two others did not include their mental health conditions and related medications. Staff interviews confirmed the expectation for such documentation, highlighting the risk of inadequate care due to these omissions.
The facility failed to ensure proper personal hygiene for residents with severe cognitive impairments, leading to unaddressed facial hair and unclean, rough fingernails. Observations revealed systemic failures in providing necessary grooming services, as staff were unaware of or did not address these issues, impacting the residents' dignity and quality of life.
The facility failed to provide scheduled activities for residents on the secure unit, affecting 12 residents. Activities did not occur on specific dates in October 2024, and staff interviews revealed a lack of in-service training on documenting participation and conducting activities. The Activity Director and Memory Care Coordinator acknowledged the absence of proper training and the potential negative impact on residents.
The facility failed to maintain proper respiratory care standards for three residents, leading to potential infection risks. A resident's nasal cannula was repeatedly observed not stored in a bag, while another resident's CPAP machine was on the floor, and their oxygen concentrator filter was dusty. A third resident also had a dusty oxygen concentrator filter. Staff interviews confirmed these practices did not align with facility policies.
The facility failed to properly store and label medications, with expired supplies found in medication storage rooms and a medication cart left unattended. Despite monthly checks by a pharmacist and staff training, expired items were not removed, and medications were not secured, posing risks to residents.
The facility lacked a policy for the use and storage of foods in personal refrigerators, leading to unsanitary conditions in a resident's refrigerator. The resident's refrigerator contained spoiled food and lacked a thermometer for temperature monitoring. Staff interviews revealed confusion about who was responsible for checking these refrigerators, with no clear policy in place.
A hospice nurse in an LTC facility checked a resident's vital signs during meal service in the dining room, violating the resident's right to dignity and privacy. The resident, who had dementia and other conditions, was observed having her blood pressure taken while eating. Staff interviews confirmed that assessments should occur in private, aligning with facility policies on dignity and privacy.
A resident's privacy was compromised during perineal care when a staff member failed to close the door and fully draw the privacy curtain, leaving the resident exposed. The resident, who was cognitively intact and had bowel elimination issues, expressed potential embarrassment if seen by others. Staff interviews confirmed awareness of privacy protocols, and the facility's policy emphasized the importance of maintaining resident dignity.
A resident with severe cognitive impairment and a history of urinary retention was observed multiple times with her foley catheter bag on the floor, contrary to facility protocols. Staff interviews confirmed that catheter bags should be kept off the floor to prevent infection, but this was not adhered to, indicating a deficiency in catheter care practices.
The facility failed to prepare pureed diets correctly, serving watery peas and chicken with chunks, which did not meet the required smooth texture for residents needing pureed food. Observations and staff interviews revealed improper preparation methods and a lack of consistent training, potentially compromising resident safety and nutritional intake.
A facility failed to maintain a safe environment by not properly servicing and documenting the maintenance of in-room HVAC units, leading to a smoking incident in a resident's room. The resident, with a history of COPD and asthma, reported the issue, which was confirmed by a CNA. Maintenance staff relied on memory for cleaning schedules, and there was no documentation or policy guiding the maintenance process.
A resident with a history of cerebral hemorrhage and hemiplegia was injured during a transfer when an unsafe mechanical lift sling was used by unqualified staff. Despite recognizing the sling's frayed condition, Hospitality Aide A and a CNA proceeded with the transfer, resulting in the resident falling and sustaining multiple injuries. The aide was not certified to perform such tasks, and the incident highlighted a lack of proper supervision and reporting within the facility.
A resident with significant medical conditions was injured during a mechanical lift transfer due to the use of an unsafe sling by an unqualified hospitality aide. The aide, who had not passed her clinical certification, used a sling with broken and frayed loops without reporting its condition. This incident revealed a lack of adherence to job descriptions and safety protocols, as well as inadequate supervision and communication among staff.
A resident with impaired mobility was injured during a transfer when an unqualified Hospitality Aide used a mechanical lift with a defective sling. Despite recognizing the sling's poor condition, the aide and a CNA proceeded with the transfer, resulting in the sling breaking and the resident falling. The facility lacked a system to inspect slings, and the aide had been performing CNA tasks without proper certification.
A resident in an LTC facility experienced physical abuse by a CNA during a transfer, resulting in a bruise on her hand. Despite the resident's repeated requests to stop due to pain, the CNA continued the transfer. The resident, who had rheumatoid arthritis and was cognitively intact, felt unsafe and isolated herself after the incident. The facility's investigation confirmed the abuse, and the resident expressed fear and mistrust towards the staff.
A resident with rheumatoid arthritis and cognitive impairment was abused by a CNA during a transfer, resulting in bruising. The facility failed to follow its abuse prevention policy by not immediately relieving the CNA of duty, leading to an Immediate Jeopardy situation. The Director of Nurses and Administrator acknowledged the policy was not followed, as the CNA was not terminated immediately despite confirmed abuse.
Improper Food Storage, Labeling, Dating, and Thawing
Penalty
Summary
The facility failed to properly store, prepare, and distribute food in accordance with professional standards in the kitchen, refrigerators, freezers, dry storage area, and satellite refrigerators. During the initial kitchen tour, surveyors observed raw chicken sitting in a container in the sink and not under running water. The cook later stated that staff had placed the chicken in the sink and that it was not for residents but for staff. The dietary manager stated that staff should thaw food under running cold water, and the administrator stated raw chicken should not be sitting out whether it was for residents or staff. Surveyors also observed multiple food items that were unlabeled, undated, improperly dated, or not assigned discard/use-by dates. In Refrigerator 1, items included potato salad, chef salads, cheese sandwiches, pickles and tomatoes, mixed berries, an opened bag of chocolate chips, expired heavy whipping cream, and an unknown prepared product resembling icing. In the dry pantry, surveyors found hot dog buns, hamburger buns, opened pasta and macaroni, bowtie pasta, cake mixes, baking soda, Asian sauce, and corn meal that were not properly labeled, dated, sealed, or assigned discard dates. In the walk-in freezer, surveyors found unlabeled meat resembling turkey, open pizza crust, open popcorn chicken, and open fish without required dates or labels. In the walk-in refrigerator, surveyors found opened peaches, opened salad dressings, sliced tomatoes, and lettuce without proper labeling or discard dates. Surveyors also observed similar issues in the satellite refrigerators on halls 100/200, 400, and 500/600. These included juices, tea, milk, potato salad, cheese sandwiches, and peaches with cottage cheese that lacked discard dates, and some items lacked names or preparation dates. Interviews with the cook, dietary manager, administrator, dietary manager B, and the dietary aide showed inconsistent understanding of labeling, dating, and discard practices, including differing statements about how long juices, teas, cooked foods, and other items could be kept. The facility policy required foods to be stored, labeled, dated, and handled to minimize foodborne illness, and required refrigerated and frozen foods to be covered, labeled, dated, and stored properly.
Misappropriation of Controlled Medications
Penalty
Summary
The facility failed to protect residents from the wrongful use of their controlled medications, with survey findings identifying missing tramadol, lorazepam, hydrocodone-acetaminophen, acetaminophen-codeine, and oxycodone for multiple residents. The report states that 9 of 20 residents reviewed were affected, including residents with pain, anxiety, cognitive impairment, pressure ulcers, spinal injuries, osteoarthritis, and other chronic conditions. Several of the residents had active orders for scheduled or PRN controlled medications, and their care plans reflected ongoing pain or anxiety management with medication administration as ordered. The investigation found that on multiple medication carts, narcotic count sheets and medication cards did not match the medication administration records. For one resident, 24 tramadol doses were reported missing, and for another resident, two tramadol cards totaling 60 doses were missing. The report also identified discrepancies involving hydrocodone-acetaminophen, lorazepam, oxycodone, and acetaminophen-codeine on different halls. In one instance, a narcotic sheet for hydrocodone-acetaminophen appeared to have been rewritten, with the quantity on the count sheet not matching the quantity on the medication card. The facility documented that the missing medications were discovered during review of narcotic counts and medication records. Video review and staff interviews linked the discrepancies to an agency LVN who worked multiple shifts during the time frame of the missing medications. The DON described video showing the nurse repeatedly standing at medication carts, flipping through narcotic binders, writing on papers, removing and handling narcotic cards, and appearing to place items into a black bag under the nurses’ desk. The report also states that some doses were signed out at times that did not match the ordered administration schedule, and in some cases doses were documented as given when the nurse was not working. Interviews with the ADM, DON, other nurses, and the agency LVN confirmed that the facility was investigating the missing narcotics and had identified the nurse as the suspected perpetrator.
Unlocked Medication and Treatment Carts; Improper Storage of Latanoprost
Penalty
Summary
Drugs and biologicals were not stored in locked compartments under proper temperature controls for 2 of 5 medication carts, including the 200-hall treatment cart and the 500-hall medication cart. During an observation, an LVN was seen pulling supplies from the 200-hall treatment cart, shutting the drawer, and entering a resident's room while leaving the cart unlocked and unattended. In interview, the LVN stated she had been trained to secure medications and treatments and acknowledged she forgot to lock the cart before walking away from it. During another observation, two unopened bottles of Latanoprost were found in the 500-hall medication cart, stored in paper bags in the bottom and top drawers rather than in refrigeration. The bottles were inside boxes that stated unopened bottles must be stored under refrigeration at 2° to 8° C (36° to 46° F), with allowance for up to 8 days at up to 40° C (104° F) during shipment. Staff interviews confirmed the medication should be refrigerated until opened, and the DON stated the medication was not stored according to the manufacturer's instructions. Facility staff, including the ADON, MA, DON, and ADM, stated medication and treatment carts were expected to be locked when unattended and that management monitored cart security during rounds. The RPh stated Latanoprost should be refrigerated until opened and that improper storage prior to opening could decrease the medication's effectiveness. The facility policy also stated compartments containing drugs and biologicals shall be locked when not in use and medications requiring refrigeration must be stored in a secured refrigerator.
Pureed Diets Prepared With Unmeasured Liquid and Incorrect Texture
Penalty
Summary
The facility failed to prepare pureed foods using the prescribed recipe and texture requirements during lunch service. During observation of the pureed diet process, DM B poured unmeasured amounts of chicken broth into sea white beans, sauteed cabbage, and Salisbury steak with gravy while blending the items. The beans appeared runny, the cabbage had a watery consistency, and the meat was not pureed to a pudding consistency. DM B stated she did not know how much liquid she used and said she did not measure, explaining that she puts food in the blender and adds broth. She also stated the facility did not have recipe books, although the surveyor was later provided recipes printed from the computer. The recipe for the meal indicated the meat, beans, and cabbage should be processed in five portions at a time as needed, and the meat should be pureed to a pudding consistency. The cabbage recipe also called for green pepper, onions, garlic cloves, and sliced bacon, with bacon omitted for the puree serving. A test tray showed the puree items had excess liquid and were not pudding-like, while the cornbread was the only item with a pudding-like texture. The regular diet tray was also observed, and the cabbage was bland with no indication that the listed ingredients had been used. During interviews, residents stated lunch had no taste and one resident said the meals were supposed to have colors. The cook stated he had been trained on puree diets by a previous dietary manager and that puree food should be like pudding, not too runny or too thick. DM A stated measuring cups should be used and that failure to follow a recipe could place a resident at risk for choking or weight loss. The ADM stated dietary staff were expected to follow recipes as written, and the DON stated that if a puree diet recipe was not followed, residents could potentially choke, not receive the right amount of nutrients, or lose calories if too much liquid was used.
Hand Hygiene and Enhanced Barrier Precautions Failures
Penalty
Summary
The facility failed to maintain an infection prevention and control program, including hand hygiene and enhanced barrier precautions, for multiple residents during observed care and meal assistance. During the lunch meal on 01/13/2026, LVN C was observed serving and assisting residents in the satellite kitchen and dining area without performing hand hygiene between resident contacts. While preparing a plate for one resident, she scratched her head and later her nose, continued handling the plate, and provided it for transport without hand hygiene. She also donned a glove without hand hygiene before handing a sandwich to another resident, scratched underneath her scrub top while seated with a resident, discarded the glove without hand hygiene, gathered another plate without hand hygiene, wiped one resident’s mouth with the resident’s clothing protector, and handed a drink to another resident without hand hygiene between contacts. On 01/14/2026, Resident #3, who had diagnoses including a sacral pressure ulcer, unspecified pain, and urinary retention, had a quarterly MDS showing a BIMS score of 01 indicating severe cognitive impairment. The resident’s order summary directed staff to wear PPE with all care under Enhanced Barrier Precautions. During observed wound care, LVN C and CNA I washed hands and applied gloves, but neither wore a gown before providing wound care to the resident’s lower back/buttock area. A sign outside the room indicated Enhanced Barrier Precautions were required, and a 3-drawer tote inside the room contained gowns and gloves. Both staff later stated they had been trained on infection prevention and control and acknowledged they did not wear the gown during the wound care. Additional observations showed further hand hygiene failures during meal assistance. On 01/14/2026, LVN C donned a glove without hand hygiene, handed a resident part of a sandwich, sat with the resident, removed the glove, held it balled in her hand, and then wiped the resident’s mouth with the same hand without hand sanitizing. On 01/15/2026, CNA E fed two residents simultaneously without hand hygiene between contacts, and LVN D assumed feeding assistance for one resident without hand hygiene, later removed keys from her pocket and resumed feeding the resident without hand hygiene. Interviews with the ADON, DON, ADM, LVN C, LVN D, and CNA E confirmed staff training on hand hygiene and Enhanced Barrier Precautions, and the ADON and DON stated that residents with open wounds required gowns and gloves for hands-on care. Facility policies reviewed stated that hand hygiene is the primary means to prevent spread of infections and that Enhanced Barrier Precautions require gown and glove use for wound care and other high-contact resident care activities.
Dignity and Feeding Assistance Failure During Lunch
Penalty
Summary
The facility failed to treat two residents with dignity and to provide individualized feeding assistance during the lunch meal. Resident #26 was a female admitted with hypertensive heart disease with heart failure, neurocognitive disorder with Lewy bodies, unspecified dementia, major depressive disorder, and vitamin deficiency. Her MDS indicated severely impaired cognition, and her care plan stated she needed a special utensil and a high-sided plate to assist herself at mealtimes. Resident #41 was a female admitted with Alzheimer’s disease, GERD, anorexia, and unspecified dementia. Her MDS also indicated severely impaired cognition and that she required total assistance with eating, and her care plan stated she needed assistance with meals and fluid intake due to nutritional problems and poor intake. During observation in the dining room, CNA E was feeding Resident #26 and Resident #41 at the same time. Both residents were observed waiting for food while CNA E assisted the other resident, resulting in delayed assistance and individualized care. CNA E did not wash her hands or use hand sanitizer between feeding the two residents. Later, LVN D walked over and asked CNA E to take over feeding Resident #41. The observation showed the two residents being fed concurrently rather than receiving separate, individualized feeding assistance. Interviews confirmed staff awareness of resident rights and dignity expectations during meals. The SLP stated residents have the right to be treated with dignity and respect during meals and noted that feeding two residents at the same time could cause residents to feel confused or left out. LVN D stated staff had been trained on abuse and neglect, resident rights, and dignity, and acknowledged that feeding two residents at the same time could be a problem and could make a resident feel abandoned. CNA E stated it was not appropriate to feed two residents at the same time and acknowledged that she did so while waiting for another staff member to assist. The ADM stated staff should only feed one resident at a time to ensure a safe dining environment, but also stated he was unsure whether the situation was a rights violation.
Failure to Assess and Document Resident's Condition After Smoke Inhalation
Penalty
Summary
The facility failed to ensure that Resident #7 received appropriate treatment and care following an incident involving smoke inhalation from a malfunctioning air conditioning/heating unit in his room. Despite the resident's medical history, which included chronic obstructive pulmonary disease (COPD), asthma, and heart disease, the facility did not conduct a thorough assessment for emotional and physical distress after the incident. The resident experienced chest pain and discomfort, yet there was no documentation of a comprehensive assessment or vital signs monitoring, such as respirations, oxygen saturation, temperature, or pulse, following the smoke exposure. Interviews with staff revealed that there was a lack of communication and documentation regarding the incident. Licensed Vocational Nurses (LVNs) and the Director of Nursing (DON) acknowledged that a head-to-toe assessment and regular monitoring should have been conducted, but these were not documented. The Nurse Practitioner (NP) who evaluated the resident did not perform a full assessment or document vital signs, and there was no follow-up on the resident's complaints of chest pain and cough. The facility's policy required detailed observations and documentation following any incident, but these procedures were not followed. The deficiency was further compounded by the absence of a social worker to assess the resident for emotional or psychosocial distress. The facility's administration was unclear about who was responsible for conducting such assessments. The lack of a comprehensive assessment and documentation after the smoke inhalation incident placed Resident #7 at risk of not receiving necessary medical care, potentially leading to harm or hospitalization.
Food Safety and Hygiene Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by multiple observations of improper food storage and preparation practices. During an inspection, surveyors noted undated and improperly stored food items in the freezer, refrigerator, and dry storage areas. Molded raspberries were found in the freezer, and jalapenos that required refrigeration after opening were improperly stored in the dry storage area. Additionally, a prescription medication, Ozempic, was found in the freezer, which is against facility policy. The kitchen staff did not consistently perform hand hygiene while preparing food, which was observed during the survey. Staff members were seen touching their face masks, using the same gloves after handling different items, and failing to wash their hands between tasks. These actions could lead to cross-contamination and pose a risk of food-borne illness to residents. Furthermore, clean dishes were not stored properly, as they were left uncovered in food preparation areas, increasing the risk of contamination. The facility also failed to maintain kitchen equipment in a clean and functional state. The ice maker in a satellite kitchen had rust and white buildup, and the refrigerator temperatures in satellite kitchens were not maintained at appropriate levels, with one reading as high as 70 degrees. These conditions could contribute to the growth of harmful microorganisms, further endangering the health of residents. Interviews with staff revealed a lack of consistent understanding and adherence to food safety protocols, contributing to the deficiencies observed.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple instances of improper sanitization and hand hygiene practices. Licensed Vocational Nurses (LVNs) and Certified Medication Aides (CMAs) were observed not cleaning and disinfecting blood pressure monitors between resident uses. This occurred with several residents, including those with conditions such as hypertension, congestive heart failure, and cognitive impairments. The lack of sanitization of medical equipment between uses poses a risk of cross-contamination and infection transmission among residents. Additionally, there were instances where staff did not perform hand hygiene before and after resident care or medication preparation. An LVN was observed coughing and handling medical equipment without sanitizing her hands, and another staff member admitted to not performing hand hygiene consistently. These actions contradict the facility's infection control policies, which emphasize the importance of hand hygiene to prevent the spread of infectious agents. The facility's infection preventionist and Director of Nursing (DON) acknowledged the deficiencies in infection control practices. The DON stated that staff were expected to disinfect shared medical equipment and adhere to hand hygiene protocols. However, the report indicates a lack of consistent training and monitoring, as some staff members were unsure of when they last received training on these critical procedures.
Deficiencies in Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for four residents, which resulted in deficiencies in addressing their activities of daily living (ADLs) and mental health diagnoses. Specifically, the care plans for two residents did not include necessary details about their ADLs, despite their dependence on staff for personal hygiene, dressing, bathing, and toileting. This omission was noted in the care plans of residents with severe cognitive impairments, who required significant assistance from staff. Additionally, the care plans for two other residents did not document their diagnoses of mental illnesses, such as delusional disorders and major depressive disorder. These residents were on high-risk medications, including antidepressants and antipsychotics, which were not reflected in their care plans. The absence of these critical details in the care plans could lead to inadequate care, as staff would not be aware of the specific interventions required for these mental health conditions. Interviews with facility staff, including the MDS Coordinator and the ADON, revealed that there was an expectation for care plans to include both ADLs and mental health diagnoses. However, the staff responsible for care plans acknowledged the deficiencies and the potential risks associated with not having comprehensive care plans. The facility's failure to provide a comprehensive care plan policy further highlighted the lack of proper documentation and guidance for staff in managing residents' care needs.
Deficiency in Personal Hygiene Care for Residents
Penalty
Summary
The facility failed to provide necessary services for residents who were unable to perform activities of daily living (ADLs), specifically in maintaining good grooming and personal hygiene. This deficiency was observed in four residents, who were unable to manage their personal hygiene due to severe cognitive impairments and other medical conditions. Resident #31, a 75-year-old female with Alzheimer's disease and other health issues, was observed with facial hair that had not been removed, despite requiring assistance with personal hygiene as per her care plan. Similarly, Resident #38, an 87-year-old female with vascular dementia and Alzheimer's disease, was found with unclean and rough fingernails. Her care plan did not address her ADL needs, and she was dependent on staff for personal hygiene. Observations revealed a blackish substance under her fingernails, indicating a lack of proper nail care. Resident #43, a male with Alzheimer's disease and physical debility, also had unclean and rough fingernails, with a blackish substance underneath, suggesting inadequate attention to his personal hygiene needs. Resident #58, a female with vascular dementia and cerebrovascular disease, was similarly affected, with observations showing unclean and uneven fingernails. Her care plan did not include specific interventions for her ADL needs, despite her severe cognitive impairment. Interviews with staff, including an RN, ADON, and CNA, revealed a lack of awareness and responsibility in addressing these hygiene issues, indicating systemic failures in providing adequate personal care to these residents.
Failure to Provide Scheduled Activities on Secure Unit
Penalty
Summary
The facility failed to provide an ongoing program of activities to support residents' choices and needs on the secure unit, affecting 12 out of 12 residents. Scheduled activities on specific dates in October 2024 did not occur, as evidenced by the absence of documentation in the resident participation records. Interviews with staff revealed a lack of in-service training on documenting participation and conducting activities, particularly on weekends. CNA C mentioned the difficulty of conducting activities due to the workload and lack of instruction on documentation, while the Activity Director and Memory Care Coordinator acknowledged the absence of proper in-service training for staff on the secure unit. The Activity Director and Memory Care Coordinator admitted that if activities were not documented, they were considered not to have occurred. The Activity Director, who had been in the role for over five years, and the Memory Care Coordinator, an employee for approximately one year, both recognized the potential negative impact on residents if routine activities were not provided. The facility's policies on documentation and group programs emphasized the importance of maintaining accurate records and updating the activities calendar to reflect any changes, which was not adhered to in this case.
Failure to Maintain Proper Respiratory Care Standards
Penalty
Summary
The facility failed to adhere to professional standards of practice for respiratory care, as evidenced by observations and interviews. Resident #34, a female with Alzheimer's disease, venous insufficiency, and congestive heart failure, was observed multiple times with a nasal cannula not stored in a bag when not in use. This practice was noted on several occasions, indicating a lack of adherence to infection control protocols. Resident #32, who has chronic respiratory failure, congestive heart failure, and obstructive sleep apnea, was observed with a CPAP machine on the floor and an oxygen concentrator filter covered in dust. The CPAP machine was not stored on the bedside table as required, and the dusty filter suggested neglect in maintaining clean equipment, which could lead to unclean air being filtered. Resident #24, diagnosed with vascular dementia, COPD, and congestive heart failure, also had an oxygen concentrator filter covered in dust. Interviews with staff, including a CNA, LVN, and the DON, confirmed that the facility's practices did not align with their policies, which require nasal cannulas to be stored in bags and concentrator filters to be cleaned regularly. The failure to follow these protocols could increase the risk of infection and respiratory complications for the residents.
Deficiency in Medication Storage and Labeling
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored and labeled according to accepted professional principles in two medication storage rooms and one medication cart. Observations revealed expired supplies in the medication storage rooms for Halls 100, 200, 300, and 400, including colostomy supplies, bisacodyl suppositories, chlorhexidine wipes, a foley catheter insertion tray, and Normal Saline IV flush. Additionally, a medication cart was left unattended with medication cards on top, posing a risk of unauthorized access. Interviews with the Director of Nursing (DON) and the Administrator (ADM) indicated that a pharmacist checks medication rooms and carts monthly, and nurses are trained to check expiration dates. However, expired supplies were not removed as required, and medications were not secured properly. The facility's policy mandates that expired or contaminated medications be stored separately until destruction or return to the pharmacy, but this was not adhered to, leading to potential risks for residents.
Lack of Policy for Personal Refrigerator Use and Storage
Penalty
Summary
The facility failed to have a policy regarding the use and storage of foods brought to residents by family and other visitors, which is necessary to ensure safe and sanitary storage, handling, and consumption. This deficiency was observed in the case of a resident who had a personal refrigerator containing several uncovered drinks, shriveled tomatoes with large black spots, dried food, spilled brown and yellow liquid, halves of a banana, and a bottle of mayonnaise past its best-by date. Additionally, there was no thermometer in the refrigerator to monitor its temperature. The resident, who had no cognitive impairment, was unaware of who, if anyone, checked his personal refrigerator. Interviews with facility staff revealed a lack of clarity and responsibility regarding the monitoring of personal refrigerators. A CNA mentioned that dietary staff should check the refrigerators, while an LVN was unsure of who was responsible. The Administrator stated that housekeeping was supposed to check for spoiled food but was uncertain about the frequency, and the DON confirmed there was no policy for personal refrigerators. The DON also mentioned that housekeeping was supposed to clean and check temperatures daily for residents with low BIMS scores, but this was not being done, leading to potential food spoilage and health risks.
Violation of Resident Dignity During Meal Service
Penalty
Summary
The facility failed to uphold the resident's right to dignity and privacy by allowing a contracted hospice nurse to check vital signs during meal service in the dining room. This incident involved a female resident with a history of depression, dementia, dysphagia, and anxiety, who was observed having her blood pressure taken while attempting to eat. The resident's Quarterly MDS indicated that she could not understand or make herself understood, highlighting her vulnerability in this situation. Interviews with facility staff, including an LVN, RN, ADM, and DON, confirmed that all assessments, including vital sign checks, should be conducted in the resident's room to maintain dignity and privacy. The RN involved admitted to the mistake, acknowledging that the action could affect the resident's dignity. The facility's policy on Quality of Life-Dignity and the Resident's Rights document both emphasize the importance of privacy during medical treatment and personal care, which was not adhered to in this instance.
Privacy Breach During Resident Care
Penalty
Summary
The facility failed to ensure the privacy of a resident during personal care, specifically during perineal care. The incident involved a male resident who was cognitively intact and had a history of bowel elimination issues, including constipation and occasional incontinence. During an observation, it was noted that the staff member providing care did not close the door or fully draw the privacy curtain, leaving the resident exposed to anyone passing by in the hallway. Interviews with the resident and staff confirmed the breach of privacy. The resident expressed that it would be embarrassing if someone saw him during the care process. The staff member acknowledged the lapse in maintaining privacy and stated awareness of the resident's rights to privacy, having received training on the matter. The Director of Nursing and the Administrator both emphasized the importance of maintaining privacy during care, as outlined in the facility's policy on dignity and quality of life.
Improper Catheter Care Observed in Resident
Penalty
Summary
The facility failed to maintain proper care practices related to catheterization for a resident, as evidenced by multiple observations of the resident's foley catheter bag being placed on the floor. The resident, a female with severe cognitive impairment and a history of urinary retention, was observed on several occasions with her catheter bag on the floor, which is against the facility's protocol. The resident's care plan indicated she was at risk for impaired urinary elimination and had a foley catheter due to her medical condition. Interviews with facility staff, including a CNA, LVN, and the DON, revealed that the expectation was for foley catheter bags to be anchored below the bladder level but not touching the floor to prevent infection and other risks. Despite this, the catheter bag was repeatedly observed on the floor, indicating a lapse in adherence to proper catheter care protocols. The staff acknowledged that a catheter bag on the floor could lead to contamination and infection, highlighting the deficiency in maintaining appropriate catheter care for the resident.
Improper Preparation of Pureed Diets
Penalty
Summary
The facility failed to ensure that food was prepared in a form designed to meet the individual needs of residents on pureed diets. Observations revealed that pureed peas served to residents had a watery consistency, which was not appropriate for a pureed diet. Additionally, the preparation of pureed chicken was found to contain small pieces of unblended chicken, indicating that the food was not properly pureed to the required smooth texture. Interviews with staff, including Cook K and the Dietary Manager (DM), confirmed that the texture of the pureed food was not consistent with the standards required for residents on pureed diets. The report highlights that Cook K did not follow proper procedures when preparing pureed food, as evidenced by the improper consistency of the pureed peas and chicken. Cook K was observed adding water to the chicken base without measuring, which resulted in a separation of the chicken base from the water. This improper preparation method led to the pureed chicken containing chunks, which is not suitable for residents who require a smooth, pureed diet to prevent choking and ensure adequate nutritional intake. Interviews with various staff members, including the Registered Dietitian (RD) and the Dietary Manager, revealed a lack of consistent training and understanding of the proper preparation of pureed diets. The RD admitted to infrequent quality checks on pureed food preparation, and the DM was unsure of the last in-service training on pureed food. This lack of oversight and training contributed to the facility's failure to provide food in the appropriate form for residents on pureed diets, potentially compromising their safety and nutritional needs.
Failure to Maintain Safe Environment Due to Inadequate Maintenance of HVAC Units
Penalty
Summary
The facility failed to maintain a safe and functional environment by not properly servicing and documenting the maintenance of in-room air-conditioning and heating units. This resulted in an incident where a unit in a resident's room began to smoke, creating an unsafe and unpleasant environment. The resident, who had a history of chronic obstructive pulmonary disease (COPD) and asthma, reported the smoking incident, which was corroborated by a Certified Nursing Assistant (CNA) who smelled smoke and observed smoke emanating from the unit. Interviews with maintenance staff and the administrator revealed that while the units were reportedly cleaned, there was no documentation to confirm this. The maintenance staff relied on memory to determine when units were cleaned, and there was no facility policy in place to guide the maintenance of these units. The lack of documentation and policy contributed to the oversight, leading to the smoking incident in the resident's room.
Unsafe Sling Use Leads to Resident Injury
Penalty
Summary
The facility failed to ensure adequate supervision and the use of safe assistance devices, leading to an accident involving a resident. Hospitality Aide A and CNA C used a mechanical lift sling that was visibly unsafe, with frayed and torn loops, to transfer a resident. Despite recognizing the sling's condition, they proceeded with the transfer, resulting in the sling breaking and the resident falling to the floor, sustaining multiple injuries including a brain bleed, facial contusion, and a clavicle fracture. The resident involved was a female with a history of nontraumatic intracerebral hemorrhage, hemiplegia, hemiparesis, and diabetes with neuropathy. She required extensive assistance with activities of daily living and was assessed to be at risk for falls. The incident occurred when the resident was being transferred for a shower, and the unsafe sling was used despite the aides' awareness of its condition. The resident suffered significant injuries from the fall, including a traumatic brain injury and multiple fractures. Interviews and record reviews revealed that Hospitality Aide A was not qualified to perform mechanical lift transfers, as she had not passed her clinicals to become a certified nursing assistant. Despite this, she had been performing such tasks for several months. The staff coordinator and other CNAs were aware of her actions but did not intervene. Additionally, the aides did not report the unsafe condition of the sling to a nurse, which was a critical oversight that contributed to the incident.
Inadequate Supervision and Unsafe Equipment Use During Resident Transfer
Penalty
Summary
The facility failed to ensure that residents received adequate supervision and assistance devices to prevent accidents, specifically during mechanical lift transfers. This deficiency was observed in the case of a resident who was transferred using a mechanical lift with a sling that was visibly unsafe. The sling had broken bottom loops and frayed top loops, yet it was still used by a hospitality aide who was not qualified to perform such transfers. The aide did not report the unsafe condition of the sling to a nurse before using it, which was outside the scope of her job description. The resident involved in the incident was an elderly female with a history of significant medical conditions, including a nontraumatic intracerebral hemorrhage, hemiplegia, hemiparesis, and diabetes with neuropathy. She required extensive assistance with activities of daily living and was assessed to need two-person mechanical lift assistance for transfers. During the transfer, the resident fell and sustained injuries, including a skin tear, bruising, and swelling, after hitting her head on the mechanical lift. Interviews with staff revealed a lack of awareness and adherence to job descriptions and safety protocols. The hospitality aide involved had not passed her clinical certification and was not authorized to perform direct care tasks, including mechanical lift transfers. Despite this, she had been performing such tasks for several months, with the knowledge of some staff members, including a staff coordinator who mistakenly believed she was qualified. The incident highlighted a breakdown in communication and supervision, as well as a failure to inspect equipment for safety before use.
Unsafe Equipment Use Leads to Resident Injury
Penalty
Summary
The facility failed to maintain mechanical, electrical, and patient care equipment in a safe operating condition, resulting in a serious incident involving a resident. The resident, who had a history of nontraumatic intracerebral hemorrhage, hemiplegia, hemiparesis, and diabetes, was being transferred using a mechanical lift when the sling broke, causing her to fall and sustain multiple injuries. The resident was dependent on staff for transfers and required a mechanical lift with two-person assistance due to her impaired physical mobility. The incident occurred when a Hospitality Aide, who was not qualified to perform CNA tasks, used a mechanical lift to transfer the resident. The aide, along with a CNA, noticed that the sling's blue hooks were already ripped and decided to use the green hooks, which were also in poor condition. Despite recognizing the sling's unsafe condition, they proceeded with the transfer, resulting in the sling breaking and the resident falling to the floor. The aide admitted to not being qualified to perform such tasks and acknowledged that she had been performing CNA duties without proper certification or training. The facility's investigation confirmed that the sling was unsafe for use, with multiple hooks torn and frayed. The Director of Nursing (DON) acknowledged that there was no system in place to ensure the inspection of slings for wear and tear, and the maintenance supervisor only checked the mechanical lifts, not the slings. The DON also admitted that the Hospitality Aide had been performing mechanical lift transfers without proper qualifications, and there was a lack of monitoring to prevent such incidents. The failure to maintain safe equipment and ensure qualified staff were performing transfers led to the resident's fall and subsequent injuries.
Resident Abuse by CNA During Transfer
Penalty
Summary
The facility failed to protect a resident from physical abuse by a Certified Nursing Assistant (CNA). The incident involved a CNA who pulled the resident's hands during an attempted transfer from a lying to a sitting position, despite the resident's repeated requests to stop due to pain. This resulted in a bruise on the resident's right hand, which was tender to touch. The resident, who had a history of rheumatoid arthritis and polyosteoarthritis, was cognitively intact and capable of making informed decisions. The incident occurred shortly after the resident was admitted to the facility. The resident expressed fear and distress following the encounter, leading to self-isolation in her room. The facility's investigation confirmed the abuse, noting that the CNA's actions were inappropriate and caused physical harm. The resident reported feeling unsafe and expressed concerns about the potential for further harm, indicating a significant impact on her emotional well-being. Interviews with staff and the resident revealed that the CNA did not heed the resident's requests to stop the painful transfer, and the resident was left feeling vulnerable and mistrustful of the facility's staff. The facility's failure to immediately assess and document the resident's injuries after the allegation of abuse was made further compounded the situation, highlighting a lapse in the facility's response to the incident.
Failure to Implement Abuse Prevention Policies
Penalty
Summary
The facility failed to implement its written policies and procedures to prevent abuse, neglect, and exploitation of residents, specifically in the case of a resident who was abused by a CNA. The incident involved the CNA attempting to transfer the resident from her bed by pulling her by her arms and hands, which resulted in bruising. Despite the facility's policy requiring immediate action, the CNA was not relieved of duty immediately after the abuse was confirmed, and instead, was allowed to return to work the same night. The resident involved was a female with a history of rheumatoid arthritis, polyosteoarthritis, and scoliosis, who required assistance with activities of daily living. At the time of the incident, she was assessed to have a moderately impaired cognitive status. The resident reported that the CNA's actions caused her pain and fear, and she expressed a lack of trust in the staff following the incident. The facility's investigation confirmed the abuse, noting the resident's bruised and tender hand, but the CNA was only counseled and reassigned to another hall rather than being terminated immediately as per the facility's policy. Interviews with the Director of Nurses and the Administrator revealed that the facility's policy was not followed, as the CNA was not terminated immediately despite the confirmed abuse. The Director of Nurses acknowledged that the disciplinary action was delayed and not conducted face-to-face, and the Administrator admitted to not agreeing with terminating the CNA at the time, despite the policy requirements. This failure to adhere to the facility's abuse and neglect policy led to the identification of an Immediate Jeopardy situation, indicating a significant risk to resident safety.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 169 citations issued within 25 miles in the last 12 months — including the 8 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Taylor
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Falcon Ridge Rehabilitation | 11.2 mi | ★★★★★ | 2 | 0 |
| Will-o-bell | 14.7 mi | ★★★★★ | 8 | 0 |
| San Gabriel Rehabilitation And Care Center | 14.8 mi | ★★★★★ | 5 | 2 |
| Park Place Care Center | 15.1 mi | ★★★★★ | 17 | 3 |
| Bel Air At Teravista | 15.5 mi | ★★★★★ | 4 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.