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 Lincoln Square Post Acute Care during CMS and state inspections, most recent first.
A resident reported that a nurse spoke to him in a rude manner in the snack room, allegedly accusing him of being a thief and stating he would be the main suspect if items went missing. The resident told a nurse supervisor about the interaction and later described it as verbal abuse to another nurse, a transition-of-care nurse with his insurance, and the Ombudsman. One nurse on duty confirmed the resident said he felt abused and reported this to the supervisor. The involved nurse denied calling the resident a thief and did not actually report the incident to administration despite initially claiming she had, and no documentation of the event was found in the EMR. The concern was handled as a grievance rather than an abuse allegation, and the facility did not follow its abuse policy requiring immediate reporting of known or suspected abuse to the administrator and external authorities.
A resident with severe cognitive impairment exited the facility through an unsecured rear Dining Room door and was missing for over an hour before staff noticed. The resident, who had not previously been identified as an elopement risk, sustained injuries after falling outside and was found at a nearby hospital. The door lacked an alarm or Wander Guard system at the time, and staff were unaware of the resident's absence until a routine check during dinner service.
The facility failed to protect residents' privacy by discarding meal tickets containing sensitive information in the kitchen garbage. Observations showed a Dietary Aide disposing of these tickets improperly, and interviews with staff confirmed the lack of a proper disposal process. The Registered Dietician and DON acknowledged this practice violated HIPAA and facility policies.
The facility failed to maintain food safety standards, with expired and improperly labeled food, non-food items in storage, and unclean equipment. Expired strawberries and tomatoes were found, and food items lacked proper labeling. Non-food items were stored in the dry food area, and the coffee machine's water filter was not maintained. A dirty fan, wet pans, and a dirty ice machine further compromised safety. These issues were confirmed by the Dietary Service Supervisor and Registered Dietician, posing a risk of illness to residents.
The facility failed to maintain proper garbage disposal, as observed with overflowing trash bins and open lids, contrary to the facility's normal process. Staff interviews confirmed the importance of closed lids to prevent pest issues, aligning with FDA guidelines on waste management.
The facility failed to implement an antibiotic stewardship program, leading to inappropriate antibiotic prescriptions for two residents. Antibiotics were prescribed without meeting infection criteria, and there was a lack of documentation and communication with medical staff. The facility's policies on antibiotic use were not followed, contributing to the deficiency.
A facility failed to maintain the dignity of a resident by not covering the resident's genital area with a sheet while sleeping. A CNA confirmed the exposure and acknowledged the expectation for covering residents to prevent loss of dignity. The ADON emphasized the importance of covering residents for dignity and making rounds to ensure decency. The resident preferred not wearing undergarments for easier bathroom use. The facility's policy requires staff to protect resident privacy.
A resident with type 2 diabetes experienced a hypoglycemic event after staff administered rapid-acting insulin without proper parameters and failed to notify the physician when the resident refused a meal. The insulin order lacked specific instructions on when to hold the medication, leading to a dangerously low blood glucose level and the need for emergency treatment.
A facility failed to accurately document narcotic medications for a resident under hospice care, leading to discrepancies in the Medication Administration Record (MAR). The resident, with chronic kidney disease and a non-pressure chronic ulcer, was prescribed Morphine Sulfate for pain management. Both facility LNs and hospice nurses administered the medication, but coordination and documentation were lacking. The Director of Nursing confirmed inaccuracies in the MAR, and the facility's policy for medication administration was not followed.
A resident was given an antibiotic without meeting the facility's criteria for its use, as required by the antibiotic stewardship program. The necessary Infection Screening Evaluation was not completed before the medication was administered, and there was no communication with the medical doctor about the lack of criteria met. The Pharmacist Consultant indicated that the antibiotic was not needed, and the facility's policies on infection prevention and control were not followed.
A resident with chronic kidney disease and a non-pressure chronic ulcer received incorrect dosages of Morphine Sulfate due to discrepancies between physician orders, MAR, and CDR. The facility's failure to follow medication administration policies led to the administration of incorrect dosages, as confirmed by the DON.
The facility failed to properly label, store, and dispose of medications, as observed with an unlabeled psyllium fiber supplement, an unlabeled cough medicine, and medications for a discharged resident found in the medication cart. The DON confirmed that these practices did not align with facility policy, posing a risk of medication errors.
A facility failed to implement proper infection prevention practices, leading to a deficiency. A resident was placed in a room with another who tested positive for RSV without Droplet Isolation Precautions. Additionally, a resident who tested positive for RSV was not placed under isolation precautions until several days later, increasing the risk of infection transmission. The facility's policy for Transmission-Based Precautions was not followed, resulting in a deficiency.
A facility failed to document the offer and consent for an influenza vaccine for a resident with COPD and dementia. The resident's conservator was not reached for consent, and no documentation of attempts was made. The facility's policy required annual vaccine offers and documentation of refusals.
A facility failed to submit a new Level I PASRR for a resident with schizophrenia, leading to an incomplete Level II Mental Health Evaluation. The resident was isolated for health precautions, and the necessary new Level I screening was not conducted, potentially risking the resident's care. The ADON and DON confirmed the oversight, acknowledging the risk of inadequate treatment and monitoring.
A resident was discharged with a discontinued medication due to a failure in medication reconciliation. The resident, who had been prescribed Mirtazapine for depression, was sent home with the medication despite it being discontinued. The error was identified during a review of discharge records, and the responsible nurse was counseled and no longer worked at the facility.
Failure to Report Resident’s Allegation of Verbal Abuse
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of verbal abuse in accordance with its abuse policy and mandated reporting requirements. A resident, admitted in 2025, stated that in the early morning hours of 1/10/26 he went to the snack room to get hot water for coffee and a licensed nurse told him he could not go into the snack room. The resident reported that this nurse accused him of being a thief and told him that if anything went missing he would be the number one suspect. The resident stated that the way the nurse spoke to him felt like verbal abuse and slander. He reported the incident to the licensed nurse supervisor, who told him he could enter the snack room to get hot water and that she would take care of it. In subsequent interviews, the involved nurse (LN 1) acknowledged asking the resident not to go into the snack room at night and to use the call light so staff could get snacks or hot water for him, explaining that night shift staff kept their belongings in the snack room. LN 1 denied calling the resident a thief or saying he would be the number one suspect if anything was missing. LN 1 stated she wrote a progress note in the electronic medical record and reported the incident to administration, but could not identify to whom she reported it and ultimately confirmed she did not actually report it, stating she did not see the relevance. Review of the resident’s electronic medical record showed no progress note documenting the incident. The facility’s grievance binder showed that the nurse supervisor completed a grievance form on 1/12/26 after the resident reported that a nurse was rude and told him it was not okay to take food from the snack room at night; the grievance did not characterize the concern as abuse. Additional interviews showed that the resident described the incident as verbal abuse to individuals outside the immediate facility chain. A transition-of-care nurse from the resident’s insurance reported that on 1/27/26 the resident called and stated he was verbally abused by a nurse, leading to a three-way call attempt to the Ombudsman’s office during which the resident left a voicemail stating he was verbally abused. Another nurse on duty the night of the incident (LN 2) stated the resident told him that a nurse had called him a thief and that he felt abused; LN 2 reported the incident to the nurse supervisor. The Ombudsman reported receiving a message that the resident had called on 1/26/26 and, upon returning the call, the resident stated that a nurse verbally assaulted him but did not provide the nurse’s name. The facility’s Elder/Dependent Adult Abuse policy required that any mandated reporter who has knowledge of an incident that reasonably appears to be abuse, or is told by an elder that they have experienced behavior constituting abuse, must immediately report the known or suspected abuse to the administrator and appropriate external authorities within specified time frames. Despite the resident’s statements to staff and others that he felt verbally abused, the allegation was not reported as required by policy and state law.
Resident Elopement and Injury Due to Unsecured Exit Door
Penalty
Summary
A deficiency occurred when a resident with a history of diabetes mellitus, chronic kidney disease, and spinal stenosis exited the facility through an unlocked rear Dining Room door and was missing for approximately one and one-half hours before staff became aware. The resident, who had a Brief Interview for Mental Status (BIMS) score of 6 indicating severe cognitive impairment, was found to have left the facility in her wheelchair and was later discovered at a nearby hospital emergency department after sustaining a fall and injuries, including facial lacerations and contusions. The incident was captured on facility camera footage, which showed the resident leaving through the rear Dining Room door, crossing the street, and moving out of camera view. Prior to the incident, the resident had not been assessed as being at risk for elopement, as indicated by multiple Elopement/Wandering Risk Assessments completed before the event, all scoring below the threshold for elopement risk. The resident had intermittent confusion and was ambulatory with assistance, including the ability to self-propel in a wheelchair. The facility had equipped the resident with a wheelchair alarm that sounded when she stood up, but there was no Wander Guard device in place before the incident. The rear Dining Room door, through which the resident exited, did not have an alarm or Wander Guard system at the time of the event. Staff became aware of the resident's absence during the dinner tray pass, after which a search was initiated, and the resident was eventually located at the hospital. Interviews with staff and administration confirmed that the rear Dining Room door was not considered a hazard prior to the incident, as the resident had not previously attempted to leave the facility. The door was not locked or alarmed, and its status as an exit was misunderstood among staff, with some believing it was not a designated fire exit. The lack of adequate supervision and environmental safeguards contributed to the resident's unsupervised exit and subsequent injury.
Improper Disposal of Meal Tickets Compromises Resident Privacy
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of residents' personal and medical records by improperly disposing of meal tickets in the kitchen garbage bin. During observations, it was noted that a Dietary Aide discarded uneaten food, used napkins, and residents' meal tickets into the trash. These meal tickets contained sensitive information such as residents' names, unit, room, and bed numbers, diet orders, allergies, food notes, and preferences. The Dietary Service Supervisor confirmed the practice and acknowledged the lack of a proper disposal process for these meal tickets. Interviews with the Registered Dietician and the Director of Nursing revealed that the practice of throwing meal tickets in the trash did not meet their expectations and violated HIPAA regulations. The Registered Dietician stated that the meal tickets should have been shredded to prevent unauthorized access to residents' information. The Director of Nursing emphasized that the meal tickets are part of the residents' medical records and should be shredded to protect against unauthorized access. The facility's policies on health information and confidentiality also indicated the need to secure residents' information against unauthorized access.
Food Safety and Storage Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food safety, as evidenced by several deficiencies observed during a kitchen tour. Expired food items, including strawberries and tomatoes, were found in the reach-in refrigerator and dry storage, posing a risk of foodborne illnesses to residents. Additionally, food items were improperly labeled and dated, which could lead to the consumption of spoiled food. The Registered Dietician acknowledged that the quality of produce was overlooked, and the findings did not meet the facility's expectations. Non-food items, such as folding chairs, were improperly stored in the dry food storage room, which is designated solely for food storage. The Dietary Service Supervisor was unable to provide a reason for the placement of these chairs. Furthermore, the water filter for the coffee machine was not changed according to the manufacturer's guidelines, and there was no tracking system in place to monitor the filter's usage. This oversight could result in contaminants entering the water supply. Additional issues included a dirty fan in the food preparation area, wet tray line pans and a food processor bowl, and a dirty ice machine. The fan, covered in a grey fuzzy substance, posed a risk of contaminating food with particles. Wet pans and a food processor bowl could foster the growth of microorganisms, while the ice machine's unclean condition could lead to resident illness. These conditions were confirmed by the Dietary Service Supervisor and the Registered Dietician, who stated that they did not meet the facility's expectations and could potentially make residents sick.
Improper Garbage Disposal Leading to Potential Pest Infestation
Penalty
Summary
The facility failed to maintain proper disposal of garbage and refuse, as observed during a survey. On the specified date, the trash bin for the facility was found overflowing with trash bags, and the lid was placed completely behind the bin. This situation was confirmed during an interview with a staff member, who indicated that the trash service had left the bins in that condition. The open and overflowing trash bins were not in line with the facility's normal process, as stated by the Dietary Services Supervisor, who emphasized the importance of keeping dumpster lids closed to prevent pest infestations. Further interviews with the Registered Dietician reinforced the expectation that dumpster lids should be closed and that garbage should not overflow to avoid sanitation issues and potential pest problems. The report references the 2022 Food Code by the FDA, which outlines the necessity of proper storage and disposal of garbage to minimize odors, prevent attraction and breeding of pests, and maintain sanitary conditions. The failure to adhere to these guidelines posed a risk of insect and rodent infestation due to the improper handling of waste.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to consistently implement an antibiotic stewardship program, which is crucial for ensuring that antibiotics are used only when necessary and appropriate. This deficiency was observed in the cases of two residents, where the Loeb and McGeer criteria were not consistently applied to assess the initiation and appropriateness of continued antibiotic use. For Resident 122, an antibiotic was prescribed for a suspected upper respiratory infection without meeting the necessary infection criteria, and there was no documentation of an infection screening evaluation on the day the antibiotic was first prescribed. In the case of Resident 56, an antibiotic was prescribed following a family member's request, despite the resident not meeting the infection screening criteria. The Infection Screening Evaluation was completed two days after the antibiotic was started, and it did not support the reason for the antibiotic prescription. There was no record of communication with the medical doctor to address the discrepancy between the prescribed antibiotic and the infection criteria. The facility's policies on antibiotic stewardship and infection prevention were not adhered to, as evidenced by the lack of appropriate documentation and communication regarding antibiotic prescriptions. The Pharmacist Consultant noted that inappropriate antibiotic orders were not addressed in stewardship meetings, as he was not invited to participate. This lack of adherence to established protocols and communication failures contributed to the deficiency in the facility's antibiotic stewardship program.
Failure to Maintain Resident Dignity by Ensuring Privacy
Penalty
Summary
The facility failed to ensure the dignity of Resident 119 by not covering the resident's genital area with a sheet while he was sleeping in bed. This incident was observed during a concurrent observation and interview with a Certified Nursing Assistant (CNA), who confirmed that the resident's genitals were exposed. The CNA acknowledged the expectation for residents' private parts to be covered to prevent a loss of dignity and feelings of shame. The Assistant Director of Nursing (ADON) also stated that residents should be covered with a sheet for dignity and that staff should make rounds to ensure residents are decently covered. Resident 119 mentioned a personal preference for not wearing undergarments to facilitate easier bathroom use. The facility's policy on Quality of Life - Dignity, revised in February 2020, indicates that staff should promote, maintain, and protect resident privacy, including bodily privacy.
Failure to Administer Insulin with Proper Parameters Leads to Hypoglycemic Event
Penalty
Summary
The facility failed to provide quality care to a resident with type 2 diabetes mellitus and diabetic chronic kidney disease when staff administered rapid-acting insulin without appropriate parameters. The insulin order did not include specific instructions on when to hold or not administer the insulin, leading to the administration of 10 units of Insulin Lispro to the resident when their blood glucose (BG) level was 129. This administration occurred despite the resident's responsible party indicating that the resident did not take insulin at home. Following the insulin administration, the resident refused their scheduled meal, which was not communicated to the physician by the staff. As a result, the resident experienced a hypoglycemic event with a dangerously low BG level of 36, requiring emergent medical treatment. The facility's documentation indicated that the resident was observed to be sleepy and sweaty, and emergency interventions, including the administration of a Glucagon Emergency Kit and orange juice with sugar, were necessary to stabilize the resident's condition. Interviews with facility staff, including a licensed nurse and the Director of Nursing, revealed that there was a lack of communication and clarification regarding the insulin order. The staff did not contact the physician to clarify the order or obtain hold parameters, which could have prevented the hypoglycemic event. The facility's protocols emphasized the importance of considering the risk of hypoglycemia and incorporating physician-ordered parameters into the care plan, which was not adhered to in this case.
Inaccurate Documentation of Narcotic Medication for Resident in Hospice Care
Penalty
Summary
The facility failed to ensure safe pharmaceutical services for a resident, identified as Resident 55, by not accurately documenting narcotic medications in the Medication Administration Record (MAR) when removed from the Controlled Drug Record (CDR). This discrepancy was observed during a review of Resident 55's records, which indicated that the dosages of Morphine Sulfate, a narcotic medication prescribed for pain, were not accurately recorded. The Director of Nursing (DON) confirmed that the staff documented Resident 55's doses of Morphine Sulfate inaccurately on the MAR for November and December 2024, and that the facility policy was not followed. Resident 55 was admitted with diagnoses including chronic kidney disease and a non-pressure chronic ulcer of the right midfoot and heel. The resident was under hospice care, which involved both facility licensed nurses (LNs) and hospice nurses administering Morphine Sulfate for pain management. However, there was a lack of coordination and documentation between the facility staff and hospice nurses regarding the administration of the medication. The hospice nurse, LN 2, stated that medications given by hospice nurses were obtained from the facility's medication cart and documented by facility LNs, but the hospice binder for Resident 55 was not found. The facility's policy and procedure for medication administration emphasized the importance of the 'Five Rights'—right resident, right drug, right dose, right route, and right time—and required a triple check of these rights during medication preparation. Despite these guidelines, the facility failed to maintain accurate records of the narcotic medication administration, which could potentially impact the well-being of Resident 55. The facility's policy also outlined responsibilities for administering prescribed therapies, including those determined appropriate by hospice, but these were not adequately followed in this case.
Failure to Adhere to Antibiotic Stewardship Program
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications. Resident 56 was administered an antibiotic, Levofloxacin, despite not meeting the criteria established by the facility's antibiotic stewardship program. The antibiotic was prescribed for chest congestion and left ear pain, but the necessary Infection Screening Evaluation was not completed prior to the initiation of the medication. The Nurse Consultant confirmed that the evaluation, which should have been done before starting the antibiotic, was only completed two days later and did not support the use of the antibiotic for the reasons it was prescribed. During a review of the resident's medical records, it was found that there was no communication with the medical doctor regarding the lack of criteria met for the antibiotic prescription. The Pharmacist Consultant noted that had the antibiotic been active during his drug regimen review, he would have recommended against its use, as the resident did not meet the infection criteria. The Pharmacist Consultant also highlighted that Levofloxacin is not typically prescribed for bronchitis unless there is a history of it progressing to pneumonia, which was not documented in this case. The facility's policies on infection prevention and antibiotic stewardship were not adhered to, as the protocols for monitoring antibiotic use and ensuring appropriate prescriptions were not followed. The facility's policy required that prescribers provide complete antibiotic orders with indications for use, which was not done in this instance. The failure to follow these protocols resulted in the unnecessary administration of an antibiotic to Resident 56, which could lead to adverse effects and the development of antibiotic-resistant organisms.
Resident Received Incorrect Dosage of Narcotic Pain Medication
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when the resident received more than the prescribed dose of a narcotic pain medication for over a month. The resident, who was admitted with chronic kidney disease and a non-pressure chronic ulcer, was prescribed Morphine Sulfate in varying concentrations and dosages over time. However, discrepancies were found between the physician's orders, the medication administration records (MAR), and the controlled drug record (CDR), leading to the administration of incorrect dosages. The physician's orders for Morphine Sulfate changed multiple times, specifying different concentrations and dosages for pain management. Despite these changes, the facility's records indicated that the resident received doses that were inconsistent with the prescribed orders. The Director of Nursing (DON) confirmed that the doses documented as given were less than those removed from the medication cart, indicating a failure to administer the correct dose. This discrepancy was attributed to errors in documentation by the staff, who did not follow the facility's policy on medication administration. The facility's policy required a triple check of the five rights of medication administration, which include the right resident, drug, dose, route, and time. However, this procedure was not followed, leading to the administration of incorrect dosages. The DON acknowledged that the staff failed to clarify the physician's orders, resulting in the resident not receiving the correct dose of pain medication. This oversight had the potential to impact the resident's quality of life and well-being.
Medication Storage and Labeling Deficiency
Penalty
Summary
The facility failed to ensure medications were labeled, stored, and disposed of according to standards of practice for a census of 57 residents. During an observation and interview, it was found that an opened, unlabeled container of psyllium fiber supplement and an opened, unlabeled bottle of cough medicine were stored in the medication cart. Additionally, medications for a discharged resident were also found in the medication cart. The Licensed Nurse (LN) acknowledged that these items should not have been in the medication cart and removed them. The Director of Nursing (DON) confirmed that medications for discharged residents should be removed from the medication cart, locked in a cabinet in the medication storage room, and destroyed routinely. The DON stated that the presence of discharged residents' medications in the cart posed a risk of being administered to another resident in error. The facility policy required open dates to be placed on medications, but this was not followed, as acknowledged by the DON. The facility's policy and procedure for the storage of medications indicated that medications should be stored safely and securely, with expiration dating and open dates clearly labeled, which was not adhered to in this instance.
Failure to Implement Droplet Isolation Precautions for RSV
Penalty
Summary
The facility failed to implement proper infection prevention practices for a census of 57 residents, leading to a deficiency. Resident 171 was placed in a room with another resident who tested positive for RSV without Droplet Isolation Precautions in place. This oversight occurred on December 15, 2024, and was confirmed through observation and interviews with facility staff. The lack of isolation precautions increased the risk of infection transmission to Resident 171, who was not tested for RSV as he showed no symptoms at the time. Resident 9, who tested positive for RSV on December 11, 2024, was not placed under Droplet Isolation Precautions until December 16, 2024. This delay in implementing isolation measures was confirmed by the facility's Infection Preventionist, who acknowledged that the facility's policy was not followed. The absence of isolation precautions for Resident 9 exposed other residents, staff, and visitors to the risk of RSV infection. The facility's policy, as outlined in their procedure for initiating Transmission-Based Precautions, was not adhered to in these cases. The policy requires that precautions be implemented when a resident has a confirmed infection and is at risk of transmitting it to others. The failure to follow this policy resulted in a deficiency, as the necessary precautions were not in place to prevent the spread of infection within the facility.
Failure to Document Influenza Vaccine Offer and Consent
Penalty
Summary
The facility failed to provide the influenza vaccine to one of the five sampled residents, identified as Resident 11, as there was no documented evidence in the resident's medical record that the vaccine had been offered, given, or refused. Resident 11 was admitted to the facility in 2022 with diagnoses including chronic obstructive pulmonary disease and dementia. The resident's admission record listed a conservator as the responsible party, with contact information provided. During a review of Resident 11's electronic medical record with the Infection Preventionist (IP), it was confirmed that there was no record of the influenza vaccination being offered or administered for the current flu season. The IP stated that attempts were made to contact the conservator for consent, but no response was received, and there was no documentation of these attempts in the medical record. In an interview with the Director of Nursing (DON) and the Nurse Consultant (NC), it was stated that the influenza vaccine was available and offered to residents starting in September, with documentation required on the consent form if the vaccine was given or declined. The DON indicated that the expectation was for the IP to document any attempts to obtain consent from a resident's responsible party. If contact could not be made, staff were expected to continue trying weekly and document these attempts in the resident's medical record. The facility's policy on the influenza vaccine, dated October 2019, required that all residents without medical contraindications be offered the vaccine annually, with refusals documented in the medical record.
Failure to Complete Required PASRR Evaluation
Penalty
Summary
The facility failed to submit a new Level I Preadmission Screening and Resident Review (PASRR) for a resident diagnosed with schizophrenia, who was admitted in 2022. The initial Level I PASRR indicated a positive result for suspected mental illness, necessitating a Level II Mental Health Evaluation. However, this evaluation was not completed because the resident was isolated as a health or safety precaution. The facility was required to submit a new Level I screening to reopen the case, but this was not done, potentially placing the resident at risk of not receiving necessary care or services. During interviews and record reviews, the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) confirmed that the Level II evaluation was not completed and a new Level I screening was not conducted. The ADON acknowledged that the resident's behavior could worsen without proper treatment, and the DON noted the potential for missing behavior monitoring and proper treatment, which could put both the resident and the facility at risk. The facility's policy on PASRR was reviewed, and it was confirmed that the policy was not followed, as a new Level I screening should have been completed to reflect the resident's mental health diagnosis.
Medication Reconciliation Failure at Discharge
Penalty
Summary
The facility failed to accurately complete a medication reconciliation for a resident at the time of discharge, resulting in the resident being sent home with a discontinued medication. The resident, who was admitted with diagnoses including depression and muscle weakness, was initially prescribed Mirtazapine, which was later discontinued. However, during the discharge process, Mirtazapine was included among the medications sent home, despite not being listed in the discharge instructions. The error was confirmed during a review of the resident's discharge records by the Director of Nursing and a Licensed Nurse. The nurse responsible for the discharge was counseled and no longer worked at the facility. The facility's policy required that medications be reconciled and verified against current physician orders, but this process was not followed, leading to the inclusion of the discontinued medication in the resident's discharge medications.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Stockton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Good Samaritan Rehab And Care Center | 0.3 mi | — | 1 | 0 |
| Hampton Post Acute | 1.1 mi | — | 14 | 0 |
| Noble Care Center | 1.2 mi | — | 5 | 0 |
| Fulton Gardens Post Acute, Llc | 1.7 mi | — | 3 | 0 |
| Brookside Care Center | 2.1 mi | — | 18 | 0 |
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