Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Crystal Ridge Care Center during CMS and state inspections, most recent first.
A resident with dementia, dysphagia, and a recent femur fracture had an order and care plan goal for fluid intake of at least 1500 mL/day, with instructions to notify the MD if the weekly average fell below this level. Facility records, including the MAR and CNA intake documentation, contained multiple missing and inconsistent entries for oral fluids, house nourishments, and I&O totals across several shifts. A nursing weekly summary showed the resident’s average intake was about 1000 mL/day, but there was no documented MD notification despite this being below the ordered threshold. The DON and RD confirmed that accurate I&O documentation and weekly review were required by facility policy to guide care and that deficiencies in intake were to be reported to the physician, which did not occur in this case.
A resident with dementia, severe cognitive impairment, and a very high elopement risk score eloped from the facility after leaving through a door near a smoking area, unlatching a gate, and walking to a nearby road, where a truck picked the resident up and transported the resident to an apartment complex. The resident had orders for a wander guard on the left ankle to be checked every shift and a care plan intervention to ensure an identification band or other identification was in place, but staff reported the resident frequently tried to elope and would remove or cut off the wander guard. On observation, the resident was found without an identification band, and staff confirmed this, while also reporting that no alarm was heard at the time of the elopement, demonstrating a failure to provide adequate supervision and monitoring for a known high-risk resident.
A resident with dementia and a high risk for elopement was able to leave the facility unsupervised and undetected, despite staff awareness of recent exit-seeking behaviors and a care plan identifying the risk. The resident was missing for 45 minutes before being found by police, indicating a failure to provide adequate supervision as required by facility policy.
Surveyors found expired and undated food items in the freezer and dry food cupboards, including cream puffs, dried parsley, brown gravy mix, cereal, and cherry jello mix. Both the DS and RD confirmed that staff are expected to label and discard expired or undated foods, in accordance with facility policy.
Three residents experienced deficiencies in care when medications were left at bedside without proper supervision, a cervical collar was used without a current physician order, and a gastrostomy tube was not checked or flushed as ordered before medication administration. Nursing staff did not follow established protocols or physician orders, resulting in lapses in safe medication and treatment practices.
A resident with dementia and a history of wandering was observed without a required wanderguard bracelet, despite staff documentation indicating it was in place. Staff confirmed the absence of the device, which was ordered for safety and required to be checked each shift, resulting in a failure to follow established safety protocols.
A resident with anxiety received frequent PRN lorazepam administrations over several months without a required stop date on the medication order. The pharmacy consultant confirmed that the medication regimen review did not identify this irregularity, and facility policy required such orders to have clear documentation and periodic review.
A resident with Guillain-Barre Syndrome and adult failure to thrive developed a stage four pressure ulcer to the sacrococcyx, but the facility did not initiate a significant change in status assessment (SCSA) as required. The MDS Coordinator confirmed the assessment was not completed, and facility policy mandates such assessments after significant changes in condition.
A resident with moderate cognitive impairment and a history of mental illness was found self-administering vitamin D3 and storing multiple unidentified medications in their room without staff knowledge. Nursing staff and the Infection Preventionist were unaware of these behaviors, and there was no documentation of behavior monitoring in the clinical records or MAR, despite facility policy prohibiting self-administration and requiring comprehensive care plans.
A resident with dementia and diabetes, requiring assistance with eating, was observed seated at a dining table that was too high for comfortable eating during a meal. Staff placed the meal tray on the table at chest level, and a nurse confirmed the table's inappropriate height. Facility policy required staff to assist residents to a comfortable dining position, but this assistance was not provided.
A resident with Alzheimer's Disease experienced pain due to thick, discolored, and long toenails that were not evaluated or treated by a podiatrist. Despite the facility's process for monthly podiatry visits and a binder for tracking ancillary services, there was no evidence the resident received podiatric care since admission. Staff acknowledged the condition and pain, but the necessary referral and treatment were not provided.
A resident with multiple chronic conditions and moderate cognitive impairment was not seen by a physician every 30 days during the first 90 days of admission, as required. Facility records and staff interviews confirmed the absence of documented physician or nurse practitioner visits for two consecutive months, resulting in noncompliance with mandated visit intervals.
Three residents experienced medication administration errors when nurses failed to follow physician orders, including not checking respirations before giving an opioid, not verifying gastrostomy tube placement or flushing before medication administration, and not wearing gloves when handling a hazardous drug. These actions resulted in a medication error rate of 12%.
A resident with multiple chronic conditions did not receive timely follow-up dental care as recommended by a hygienist, despite documented need for additional cleaning and preventative services. Observation revealed decayed and missing teeth, and the resident reported oral pain. The Social Services Director was unable to find evidence that the recommended dental treatment was provided.
A resident with dysphagia, muscle weakness, and severe cognitive impairment was not given ordered adaptive eating equipment, including a plate guard and two-handled cup with lid, during meals. This resulted in food and drink spills and increased dependence on staff, despite documented recommendations and facility policy requiring these devices.
Two residents were exposed to infection risks when a nurse reattached a contaminated gastrostomy tube cap after it fell on the floor, and a CNA touched the inside of a nosey cup with bare hands and long fingernails before assisting a resident with a drink. Both actions were acknowledged by staff as breaches of infection control policy.
A resident with significant mobility impairments and dependent on staff for ADLs was found in bed with the call light on the floor and not within reach. An LPN confirmed the call light was not accessible, and the DON stated that the expectation is for call lights to be within reach to allow residents to request assistance. Facility policy also requires call lights to be easily accessible to residents.
A facility failed to follow its medication administration policy when an LN documented administering medication to a resident, despite another nurse actually administering it. The resident, with a history of diabetes and depression, refused the LN's presence, leading to another nurse administering the medication. However, the LN signed the MAR, resulting in inaccurate documentation.
A resident was found storing prescribed medications in an unlocked bedside drawer, contrary to the facility's policy requiring medications to be stored in a locked cart. The resident, with a history of congestive heart failure, had medications including a blood thinner and diuretic in their room. A nurse confirmed the medications were prescribed to the resident and should have been securely stored, as per policy.
A resident's room in an LTC facility had a persistently sticky floor, posing an infection control concern. The issue was attributed to the resident frequently spilling his urinal and his roommate urinating on the floor. Despite daily mopping, the floor remained sticky, and staff interviews confirmed the ongoing problem. The infection preventionist acknowledged the sticky floor as an infection control issue.
A facility failed to administer medications on time to three residents due to technical issues with the medication dispensing software. Despite assistance from the DON, an LVN was unable to complete the morning medication pass, resulting in delays for residents with conditions such as COPD, hypertension, and diabetes. The facility's policy requires medications to be given within one hour of the prescribed time, which was not met in this instance.
A resident with COPD did not receive an incentive spirometer (IS) as prescribed, despite documentation indicating otherwise. The resident was supposed to receive IS treatments four times daily, but staff failed to provide the device, leading to a potential adverse impact on the resident's health.
The facility failed to properly store and label medications, leading to potential errors. A discontinued medication was not removed from a medication cart, which was also left unlocked and unattended. Additionally, there was a discrepancy between the physician's instructions and the pharmacy label for Pradaxa, risking medication errors. A resident expressed concerns about missing medications.
A resident with specific dietary preferences did not receive a requested meal change, resulting in hunger throughout the night. Despite submitting a request for a grilled cheese sandwich instead of raviolis, the kitchen staff did not fulfill the request due to miscommunication and lack of awareness of alternate meal procedures. The resident was given snacks instead, which he did not want.
Failure to Accurately Monitor and Report Hydration Status for a Resident
Penalty
Summary
The deficiency involves the facility’s failure to accurately and consistently monitor and document a resident’s fluid intake as ordered and care planned. The resident was admitted with diagnoses including a displaced intertrochanteric fracture of the right femur, dementia, and dysphagia. The resident had a physician order for hydration that required notifying the MD if the weekly 7‑day fluid intake average was less than 1500 mL/day, and the Nutritional Risk Assessment set a goal of at least 1500 mL/day to meet nutrition and hydration needs. The care plan identified risk for malnutrition and dehydration with interventions to monitor intake and output and provide supplements as ordered. Record review showed multiple gaps and inconsistencies in intake documentation. On the MAR for the month reviewed, there was missing documentation of the amount consumed for ordered house nourishment on several dates and for 240 mL of fluid given with medication passes on multiple evenings. Total intake and output documentation was also missing for specified evening and night shifts. CNA fluid intake documentation showed at least one missing entry, and the DON confirmed that after an initial 14‑day I&O monitoring period by nurses, CNAs were expected to continue documenting I&O under tasks, but there were missing entries. The DON also acknowledged that documentation should be complete to ensure accurate assessment of the resident’s status and that incomplete documentation could affect outcomes and care provided. The Nursing Weekly Summary dated mid‑month documented that the resident’s average 24‑hour intake was approximately 1000 mL/day, below the ordered 1500 mL/day threshold, yet there was no documented evidence that the physician was notified as required by the hydration order. During interviews, the DON stated that nurses averaged fluid intake weekly and were to notify the physician if the average was less than 1500 mL/day, and that if residents did not meet their daily fluid intake, she and the MD should have been notified. The RD stated that the 1500 mL/day goal was based on the resident’s needs and weight and that accurate documentation was important because it was used to guide care and interventions. The facility’s Intake and Output policy required intake and output to be recorded each shift by nursing assistants and licensed nurses, reviewed weekly by a designated licensed nurse, and that deficiencies in fluid intake or balance be reported to the physician, but these requirements were not met for this resident.
Failure to Prevent Elopement of High-Risk Resident
Penalty
Summary
The facility failed to ensure a safe environment and adequate supervision for a resident with severe cognitive impairment and a very high elopement risk score of 14. The resident had diagnoses including unspecified dementia with anxiety and mood disturbance and was care planned with a goal that the resident would not leave the facility without a responsible party, with an intervention to assure an identification band or other form of identification was in place. Physician orders directed staff to check the placement of a wander guard on the resident’s left ankle every shift, monitor skin, and notify the physician as needed. Staff interviews revealed that the resident frequently attempted to elope and would remove or cut off the wander guard. According to the Director of Staff Development, the resident left the facility through a door near the smoking area, unlatched a gate, and walked to a road behind the facility, where a truck picked the resident up and transported the resident to a nearby apartment complex, and a person there called 911. A nurse who was present on the day of elopement stated she did not hear an alarm and confirmed the resident had a history of trying to elope and manipulating or removing the wander guard. During an observation in the resident’s room, the resident was not wearing an identification band, and the nurse confirmed this finding. The DON acknowledged that a wander guard is only effective when worn and that residents have the right to be safe in the facility. The facility’s wandering and elopement policy stated that the facility will identify residents at risk of unsafe wandering and strive to prevent harm.
Failure to Prevent Elopement in High-Risk Resident with Dementia
Penalty
Summary
The facility failed to provide adequate supervision to prevent a resident with dementia and a high risk for elopement from leaving the premises unsupervised and undetected. The resident, who was admitted with a diagnosis of dementia and assessed as having no cognitive understanding, had a documented high risk for wandering and elopement. The care plan identified the resident as being at risk for elopement due to dementia. Despite these assessments, the resident began exhibiting exit-seeking behaviors several days prior to the incident, which was noted by staff. On the day of the incident, the resident was last seen in their room by the DON, but was later found missing and subsequently located by the police after being gone for 45 minutes. Staff interviews confirmed awareness of the resident's exit-seeking behavior and high elopement risk, but increased supervision was not implemented. Facility policy required identification and intervention for residents at risk of unsafe wandering, but these measures were not effectively carried out for this resident.
Failure to Properly Store and Label Food Items
Penalty
Summary
The facility failed to ensure that food was stored in accordance with professional standards, as evidenced by the presence of expired or undated food items in both the freezer and dry food cupboards. During a kitchen tour with the Dietary Supervisor, surveyors observed an undated bag of cream puffs in the dessert freezer, as well as undated dried parsley, brown gravy mix, and a bowl of cereal in a covered plastic container in the cupboards. Additionally, a powdered cherry jello mix was found with a preparation date but was past its use-by date. The Dietary Supervisor confirmed these findings and stated that dietary staff are expected to properly label and discard expired foods. The Registered Dietician also confirmed that undated or expired food should be thrown out. Review of the facility's policy indicated that opened dry food items must be tightly closed, labeled, and dated.
Failure to Follow Professional Standards in Medication and Treatment Administration
Penalty
Summary
The facility failed to ensure that care and services were provided according to accepted standards of practice for three residents. For one resident with moderate cognitive impairment and a history of mental illness, a licensed nurse left a cup containing eight medications at the bedside, including an antibiotic, vitamins, and other prescribed medications. The nurse did not observe the resident taking the medications and documented administration in the electronic Medication Administration Record before confirming ingestion. The resident was not authorized to self-administer medications, and facility policy prohibits leaving medications at the bedside unless a physician and the interdisciplinary team have determined the resident is capable of self-administration. Another resident, who had undergone cervical spine fusion and was admitted with a cervical disc disorder, was observed wearing a cervical collar. The resident reported being told by nursing staff to always wear the collar per doctor's order. However, the physician's order for the cervical collar had been discontinued, and the surgical incision had resolved with no further treatment ordered. Nursing staff failed to clarify or follow the current physician's order regarding the use of the cervical collar. A third resident with dysphagia and a gastrostomy tube (GT) had a physician's order to check GT placement and flush the tube with water before and after medication administration. During medication administration, a nurse did not check the GT placement or perform a pre-flush as ordered, instead administering the medication without confirming tube position or patency. The nurse acknowledged not following the order and not using a stethoscope to check placement, which was required for the resident's safety. Facility policy requires checking tube placement and flushing before and after medication administration.
Failure to Ensure Wanderguard Use for Resident with Wandering Risk
Penalty
Summary
A deficiency occurred when a resident with dementia and a history of wandering and exit-seeking behavior was not wearing a wanderguard bracelet as ordered. The resident's medical record included a physician's order for a wanderguard to be worn on the right ankle, with nursing staff required to check its placement every shift. Despite this, during an observation, the resident was seen without the wanderguard, even though the Medication Administration Record for that shift had been signed off by the nurse as if the device was in place. Staff present at the time confirmed the absence of the wanderguard and speculated that the resident may have removed it. The facility's policies on wandering and elopement, as well as on assistive devices, require identification of at-risk residents and the provision of safety interventions such as wanderguards. The Director of Nursing confirmed in an interview that the resident should always have the wanderguard on as ordered. The failure to ensure the resident was wearing the wanderguard as prescribed constituted a lapse in following safety protocols for residents at risk of wandering.
Failure to Ensure PRN Psychotropic Medication Order Included Required Stop Date
Penalty
Summary
A deficiency occurred when the facility failed to identify and address an irregularity in the medication regimen review for a resident admitted with anxiety. The resident had a physician's order for lorazepam, an anti-anxiety psychotropic medication, to be administered every four hours as needed (PRN), but the order did not include a required stop date. The medication was administered frequently over several months, as evidenced by the Medication Administration Record, which showed the resident received lorazepam 31 times in March, 38 times in April, and 27 times in May. During an interview, the Pharmacy Consultant confirmed that the PRN lorazepam order lacked an end date and stated that a medication regimen review should have prompted a recommendation to the physician to include a 14-day stop date, in accordance with regulations. Facility policies reviewed indicated that PRN psychotropic medications require clear physician documentation for continued use and that monthly medication regimen reviews should identify medications that need to be tapered, discontinued, or changed. The failure to follow these procedures resulted in the resident potentially receiving unnecessary medication.
Failure to Complete Significant Change Assessment After Development of Stage Four Pressure Ulcer
Penalty
Summary
The facility failed to initiate a significant change in status assessment (SCSA) for a resident who developed a stage four pressure ulcer to the sacrococcyx. The resident, admitted with Guillain-Barre Syndrome and adult failure to thrive, was found to have a stage four pressure ulcer as documented in multiple wound care consult notes. Despite the presence of this severe wound, which was being treated per physician orders, the required SCSA was not completed within the mandated timeframe after the ulcer was identified. During interviews and record reviews, the MDS Coordinator confirmed that the SCSA was not performed and acknowledged that it should have been initiated 14 days after the wound was established. The Director of Nursing stated that it was her expectation for MDS assessments to be completed properly and on time. Facility policy also required a comprehensive assessment following a significant change in a resident's condition, in accordance with OBRA regulations, but this was not followed in this case.
Failure to Implement and Monitor Care Plan for Resident Self-Administering Medications
Penalty
Summary
The facility failed to ensure that a comprehensive care plan to monitor newly identified behaviors was followed for a resident with a history of schizophrenia, PTSD, and other mental disorders. The resident, who had moderate cognitive impairment and was under conservatorship, was observed taking a bottle of vitamin D3 from his closet and stated he had been self-administering the medication daily, contrary to the prescribed every-other-day regimen. Staff interviews revealed that the nursing staff were unaware of the presence of this medication in the resident's room, and facility policy did not allow residents to keep medications at bedside or self-administer medications. The resident also disclosed that he had collected other medications in his room since admission and was unsure of their identity or whether he had reported not taking them. Further interviews with facility staff, including the Infection Preventionist and the Director of Nursing, confirmed that they were not aware of the resident storing or self-administering medications. The care plan had been updated to address the resident's psychosocial behaviors, such as hiding medications and ordering over-the-counter medications from outside sources, but there was no evidence of behavior monitoring documented in the clinical records or Medication Administration Record (MAR). The facility's policy required comprehensive care plans with measurable objectives and timetables, but this was not implemented for the resident's newly identified behaviors.
Resident Seated at Inappropriately High Dining Table During Meal
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including dementia and diabetes mellitus, was seated at a dining room table that was too high for comfortable eating during a lunch meal. The resident's Minimum Data Set indicated severely impaired cognition and a need for set up or clean-up assistance with eating, and the care plan identified moderate nutritional risk with interventions to assist the resident to the dining room for meals and provide queuing and feeding assistance as needed. During observation, staff placed the resident's lunch tray on a table that was at chest level, making it difficult for the resident to eat comfortably. A licensed nurse confirmed the table was too high, and the Director of Nursing stated that staff are expected to assist residents to a comfortable position while dining. The facility's policy required assistance with meals as needed, but this was not provided in this instance.
Failure to Provide Timely Podiatry Care for Resident with Painful Toenails
Penalty
Summary
A deficiency occurred when a resident with Alzheimer's Disease was not evaluated or treated by a podiatrist despite having thick, discolored, and long toenails. The resident was admitted to the facility in January 2025, and concerns about his toenails were first noted by his responsible party in March, who observed that the toenails were long and appeared to have fungus. The responsible party did not attempt to trim the nails due to their thickness. On observation, the resident's toenails were found to be thick, long, curved inward, and discolored yellow and black. The resident reported foot pain, and a CNA and a licensed nurse both acknowledged the condition of the toenails, with the nurse stating that the nails appeared to have fungus and could cause pain or potentially cut the skin. Further investigation revealed that the facility had a process for scheduling monthly podiatrist visits and maintaining a binder listing residents needing ancillary services, including podiatry. However, there was no evidence that the resident had received any podiatric care since admission. The facility's policy indicated that social services were responsible for making referrals for ancillary services such as podiatry, but this was not done for the resident in question.
Failure to Provide Timely Physician Visits During Initial Admission Period
Penalty
Summary
The facility failed to ensure that a resident received timely physician visits as required during the first 90 days of admission. Specifically, documentation and interviews confirmed that the resident was not seen by the attending physician every 30 days, as mandated by both facility policy and federal regulations. The Medical Records Director verified that there was no evidence of a physician or nurse practitioner visit in the resident's medical chart for two consecutive months. The Medical Director acknowledged challenges in maintaining the required visit schedule due to difficulties in finding practitioners to assist at the facility. The resident in question was admitted with multiple diagnoses, including diastolic heart failure, sleep apnea, and peripheral vascular disease, and had moderate cognitive impairment as indicated by a BIMS score of 12. During interviews, the resident expressed uncertainty about the frequency of physician visits, and the DON confirmed the expectation for monthly visits during the initial 90-day period. The lack of documented visits for November and December was substantiated through record review, confirming the deficiency in meeting required physician visit intervals.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a 12% error rate for three sampled residents. In one instance, a licensed nurse administered Dilaudid 6 mg to a resident with chronic pain without first counting the resident's respirations, as required by the physician's order. The nurse acknowledged not following the order, which specified withholding the medication if the resident's respiratory rate was less than 12. Another incident involved a nurse administering medication via gastrostomy tube (GT) to a resident with dysphagia without checking the tube's placement or flushing it with water prior to administration, both of which were required by the physician's order. The nurse admitted to not performing these steps, stating she forgot her stethoscope and did not verify the tube's position or perform the pre-flush for safety. A third deficiency occurred when a nurse handled and administered Finasteride, a hazardous drug, to a resident with a cancer diagnosis without wearing gloves, contrary to the medication's instructions and facility policy. The nurse acknowledged not following the required safety precautions, which were clearly indicated on the medication packaging and in the physician's order. Facility policies reviewed confirmed the necessity of adhering to prescriber orders and infection control procedures during medication administration.
Failure to Provide Timely Dental Care Following Clinical Recommendation
Penalty
Summary
The facility failed to ensure that a resident received timely dental treatment as recommended by a dental hygienist. The resident, who was admitted with diagnoses including diastolic heart failure, sleep apnea, and peripheral vascular disease, was evaluated by a traveling hygienist who documented heavy calculus and inflammation, and recommended additional cleaning visits, a fluoride varnish, and regular preventative maintenance. The hygienist specifically advised a follow-up visit in three months. Despite these recommendations, there was no evidence that the resident received the necessary follow-up dental care. During an observation, the resident was noted to have several decayed and missing teeth and reported experiencing mouth and tooth pain. The Social Services Director confirmed that although dental services were available monthly and a tracking binder was maintained, there was no documentation of the recommended dental treatment being provided to the resident.
Failure to Provide Adaptive Eating Equipment During Meals
Penalty
Summary
A deficiency occurred when a resident with dysphagia, generalized muscle weakness, and severe cognitive impairment was not provided with adaptive eating equipment as ordered and recommended. During a meal observation, the resident did not have a plate guard or a two-handled cup with a lid, resulting in food spilling off the plate and onto the table and clothing. The CNA present stated that she frequently reminded kitchen staff to provide these items, and the SLP confirmed that the resident should have had these assistive devices during meals, as previously recommended to support self-feeding and prevent spills. Record reviews showed that the resident's meal ticket, SLP evaluation, and physician orders all specified the need for a plate guard and two-handled cup with lid at all meals. Facility policy also required that adaptive devices be provided as ordered and documented on tray cards. Despite these documented needs and orders, the resident did not receive the necessary adaptive equipment during the observed meal.
Failure to Maintain Infection Control During Enteral Medication Administration and Mealtime Assistance
Penalty
Summary
A deficiency occurred when a licensed nurse, while administering medications via a gastrostomy tube (GT) to a resident with dysphagia, dropped the red cap of the GT port onto the floor and then reattached the contaminated cap to the GT port. The nurse acknowledged that this action could result in infection, and the facility's policy required strict aseptic technique during enteral nutrition administration. The resident's medical record indicated a need for regular GT tube flushing before and after medication administration. Another deficiency was observed when a certified nursing assistant (CNA) assisted a resident with a history of COVID-19 and severe cognitive impairment during mealtime. The CNA, while separating two stacked nosey cups, touched the inside of the cup with her bare hands and long fingernails before pouring a drink and assisting the resident. Both the infection preventionist and the CNA acknowledged that this practice did not adhere to infection control standards, and the facility's policy required following standard precautions in all situations.
Call Light Not Accessible to Dependent Resident
Penalty
Summary
A deficiency was identified when a resident with hemiplegia and hemiparesis, who required substantial to maximal assistance with activities of daily living and was dependent for toileting, was found in bed with the call light on the floor and not within reach. During observation and interview, a licensed nurse was unable to locate the call light on the bed and confirmed it was on the floor, acknowledging that it should have been within the resident's reach. The resident's care plan indicated a need for assistance due to bed-bound status and included an intervention to encourage the use of the call light for assistance. The Director of Nursing stated that the expectation was for the call light to be within reach, noting that its absence could make it difficult for the resident to request assistance for needs such as pain medication, toileting, and transferring. Review of the facility's policy and procedure on answering call lights confirmed that staff are required to ensure the call light is within easy reach of residents who are in bed or confined to a chair.
Inaccurate Medication Administration Documentation
Penalty
Summary
The facility failed to adhere to its medication administration policy and procedure for a resident, resulting in inaccurate documentation. The policy required that the individual administering medication must document the administration on the electronic Medication Administration Record (eMAR) with their signature and title. However, a Licensed Nurse (LN) documented administering medication to a resident when, in fact, another nurse administered the medication on their behalf. This discrepancy was confirmed during a review of the Medication Administration Record (MAR) and interviews with the involved LN and the Director of Nursing (DON). The resident involved had a history of type 2 diabetes with diabetic neuropathy and major depressive disorder. The resident scored a 15 on the Brief Interview for Mental Status, indicating intact memory. The resident refused to allow the LN into their room, preferring another nurse to administer medications. Despite this, the LN prepared the medications and had another nurse administer them, but still signed the MAR as if they had administered the medications themselves. This occurred on multiple occasions, as evidenced by the MAR records, leading to inaccurate documentation and potential confusion.
Medication Storage Deficiency in Resident's Room
Penalty
Summary
The facility failed to ensure the safe storage of medications for one resident, who was found to have medication stored in an unlocked drawer of their bedside table. This was observed during an interview and record review, where the resident produced a small container with capsules and a pill, stating that they sometimes received incorrect dosages and would store the medication in the drawer when the nurse was not present. The resident had a history of diastolic congestive heart failure and was prescribed medications including a blood thinner, which they identified as being stored in their room. Licensed Nurse B confirmed that the medications found in the resident's room were indeed prescribed to the resident and should have been stored in the locked medication cart, as per the facility's policy. The Director of Nurses also confirmed that medications were to be stored in the locked cart and not in resident rooms. This oversight had the potential for unauthorized access to medications not prescribed to others, highlighting a lapse in adherence to the facility's medication storage policy.
Infection Control Concern Due to Sticky Floor in Resident's Room
Penalty
Summary
The facility failed to maintain a sanitary environment for a resident, leading to a potential infection control issue. The deficiency was identified when the floor in the resident's room was observed to be sticky, with visible footprints and tracks from a wheelchair. The resident confirmed that the floor was consistently sticky. The housekeeper acknowledged the issue, stating that the resident frequently spilled his urinal on the floor, and his roommate also contributed to the problem by urinating on the floor and tracking it with his wheelchair. Despite daily mopping, the floor remained sticky. Interviews with various staff members, including licensed nurses, a certified nurse assistant, and the housekeeping supervisor, confirmed the persistent issue of the sticky floor. The facility's infection preventionist also recognized the sticky floor as an infection control concern. The housekeeping supervisor admitted to being unaware of the specific cause of the sticky floor until the day of the interview, despite the problem persisting for several months since the resident moved into the room.
Medication Administration Delays in LTC Facility
Penalty
Summary
The facility failed to administer medications to three residents in a timely manner as per physician's orders and professional standards. This deficiency was identified during an observation, interview, and record review. The facility's policy required medications to be administered safely and timely, in accordance with prescribed orders. However, on the day of the survey, three residents did not receive their morning medications within the required time frame, which is one hour before or after the prescribed time. Resident 2, who has chronic obstructive pulmonary disease, kidney failure, gout, and hypertension, reported not receiving all her morning medications. The Medication Administration Record (MAR) confirmed that her 8:00 am medications, including allopurinol, aspirin, vitamin B12, and metoprolol, were not signed as given. Similarly, Resident 3, with conditions such as hypertension, glaucoma, depression, and dementia, had multiple medications not administered on time, including cyclosporine emulsion, docusate sodium, and several others. Resident 4, diagnosed with diabetes, heart disease, seizures, and hypertension, also had numerous medications not signed as given, including metformin, hydralazine, and gabapentin. The delay in medication administration was attributed to technical issues faced by LVN A, who was logged out of the computer software used for dispensing medications multiple times. Despite assistance from the Director of Nursing (DON), the issue persisted, leading to incomplete medication passes for the residents. The DON confirmed that the medications were not administered within the required time frame, as per the facility's policy.
Failure to Provide Incentive Spirometer to Resident with COPD
Penalty
Summary
The facility failed to provide an incentive spirometer (IS) to a resident with chronic obstructive pulmonary disease (COPD), despite having a physician's order for its use. The resident was admitted with diagnoses including COPD, kidney failure, and dysphagia, and was supposed to receive IS treatments four times per day for 14 days. However, during an observation and interview, it was revealed that the resident had never received the IS since being admitted to the facility, and there was no IS present in the resident's room. The facility's records indicated that the IS treatments were documented as given, but interviews with staff revealed discrepancies. A registered nurse confirmed the absence of the IS in the resident's room, and a licensed vocational nurse admitted to documenting the treatment as given without actually administering it, mistakenly believing that a respiratory therapist was responsible for the treatment. This failure to provide the prescribed respiratory care had the potential to adversely affect the resident's health and well-being.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper medication storage and labeling, leading to potential medication errors and drug misuse. A discontinued medication, glipizide, was not removed from an active medication drawer in Medication Cart B2, and was mistakenly prepared for administration to a resident. This resident, who was admitted with diagnoses including type 2 diabetes, liver failure, heart disease, and depression, was at risk of receiving a medication that should have been discontinued. Additionally, the medication cart was observed unlocked and unattended, which is against the facility's policy for medication storage. Furthermore, there was a discrepancy between the physician's instructions on the Medication Administration Record (MAR) and the pharmacy label instructions for Pradaxa, a medication used to prevent blood clotting. The MAR indicated a dosage of 75 mg, two tablets once a day, while the pharmacy label indicated 150 mg, one tablet. This inconsistency was confirmed by the Licensed Vocational Nurse, highlighting a potential for medication errors. The resident expressed concerns about missing medications, indicating a lack of confidence in the medication administration process.
Failure to Provide Requested Meal Leads to Resident Hunger
Penalty
Summary
The facility failed to provide a nourishing meal to a resident, resulting in the resident being hungry throughout the night. The resident, who had intact cognition and specific food preferences documented in his Nutrition Care Plan, requested a change to his dinner menu from raviolis to a grilled cheese sandwich, salad, and chicken noodle soup. He submitted this request to a Certified Nursing Assistant (CNA) by 9:15 am. However, when dinner was served, the resident received raviolis, which he sent back, expecting the requested substitute meal. The kitchen staff did not fulfill this request, and the resident was instead given snacks, which he did not want. The incident was further complicated by a lack of communication and understanding among the staff. The CNA who took the resident's request to the kitchen was informed by a kitchen staff member that the kitchen was closed and no more food would be prepared. The Dietary Coordinator later acknowledged that the Dietary Assistant was unaware of the procedure for alternate meals and did not relay the resident's request. This miscommunication resulted in the resident not receiving the meal he requested and being left hungry that night.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 99 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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Grass Valley
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Golden Empire | 0.6 mi | — | 4 | 0 |
| Grass Valley Healthcare Center | 0.6 mi | — | 44 | 0 |
| Wolf Creek Care Center | 1.1 mi | — | 3 | 0 |
| Westview Healthcare Center | 19.3 mi | — | 9 | 0 |
| Siena Skilled Nursing & Rehabilitation Center | 20 mi | — | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.