Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
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 Manning Gardens Care Center, Inc during CMS and state inspections, most recent first.
A resident with significant comorbidities and recent MCA stroke fell and sustained facial injuries when his sock became caught on a lifted floor vent while ambulating to the bathroom. He reported that the vent had been raised for some time and that prior concerns to maintenance had not led to correction. Nursing documentation confirmed the fall, associated facial abrasion, bruising, and nosebleed, and recorded the resident’s statement that his sock got stuck in the vent. The maintenance supervisor later acknowledged that the vent in that room had a lifted corner and that other room vents could lift, move, or crack. A subsequent observation identified multiple rooms with lifted, broken, sharp-edged, or unsecured floor vents, despite facility policies requiring an environment free from accident hazards and a safe, clean, homelike environment.
A resident admitted for short‑term rehab after multiple pelvic and lumbar fractures and recent pelvic fixation surgery was placed in a bed that she reported still had used linens, a blanket, and a pillow with used tissues from a prior occupant, with the bedside drawer and closet containing that prior resident’s belongings and the floor visibly dirty with sticky residue. Another resident in the room stated the bed, closet, and drawer still held the previous resident’s items, and a housekeeper later observed sticky material on the floor and cleaned the room only after the new resident complained. The DSD and other staff acknowledged that the closet and bedside drawer had not been emptied after the prior resident’s discharge and that the bed had been on hold until shortly before the new admission, while facility policies required a clean, sanitary, and orderly environment with clean bed linens and respect for residents’ private space and property.
The facility failed to maintain safe, even doorway transition strips between resident rooms and the hallway, resulting in cracked, uneven, and in one case over-height strips that impeded wheelchair and walker movement. A resident with muscle weakness reported falling and injuring his back when his wheelchair could not clear the raised strip and he attempted to stand and push it backward. Other residents with COPD, dementia, fibromyalgia, sepsis, DM2, and lumbar discitis described difficulty crossing the strips, including wheelchairs spinning or turning and needing staff assistance to enter or exit rooms. CNAs reported that the bumpy strips made it hard to push residents in wheelchairs and shower chairs, especially heavier residents, and that the uneven surfaces could cause falls. The DOM and DSD acknowledged the strips were cracked, uneven, and potentially hazardous, while facility policies and ADA standards required surfaces to be maintained in good repair, free of hazards, and with vertical changes in level not exceeding 1/4 inch.
Surveyors found that staff improperly disposed of used blue rubber gloves in open personal trash bins at the bedside and mixed them with soiled linen in designated barrels, contrary to facility policy. These actions resulted in contaminated PPE being placed in containers not intended for such waste, exposing residents and staff to potential infection risks. Staff and leadership interviews confirmed that these practices were unacceptable and not in line with infection control protocols.
A resident suffered second-degree burns on her thigh when a CNA spilled hot water from a pitcher obtained from a coffee machine set at 165°F. The resident, who required assistance for transfers and personal hygiene, experienced severe pain and needed hydrocodone for relief. The facility's video surveillance confirmed the CNA's actions, and the incident was recognized as physical abuse due to the unsafe water temperature.
A resident suffered second-degree burns when a CNA provided hot water from a coffee machine, measured at 165°F, which spilled onto the resident's thigh. The facility failed to monitor water temperatures, with the dining room sink also reaching 140°F. Staff were unaware of safe temperature ranges, contributing to the incident.
Two residents in an LTC facility experienced deficiencies in their care plans. One resident's plan lacked assessment and interventions for bed rail use, posing a safety risk. Another resident's plan failed to address edema and brace use, leading to wounds and pain. Staff interviews revealed missing physician orders and inadequate training, resulting in improper care and potential harm.
The facility failed to maintain an effective infection prevention and control program, leading to multiple deficiencies. Staff stored personal items on the ice machine, risking cross-contamination. A resident's feeding tube bottle lacked a start date, and an LVN did not follow proper PPE and hand hygiene protocols. Another LVN failed to sanitize a glucometer properly. Dirty decorations and improper catheter bag placement further increased infection risks.
The facility failed to ensure safe food storage and handling, with perishable food left in a resident's room without proper labeling or refrigeration, an open jar of garlic without an open date, bran muffins missing a labeled date, and dented tomato sauce cans stored for use. These actions violated the facility's policies and posed potential health risks to residents.
The facility failed to maintain an environment free from insects and potential rodent entry, with flies observed in resident rooms, dining areas, and activity rooms, and holes in the laundry room wall. Staff confirmed the persistent issue of flies, posing infection risks to residents. The pest control program was deemed ineffective, with fly traps often unplugged or not working.
A resident with asthma was denied the right to keep her albuterol inhaler at bedside for self-administration, despite having no cognitive impairment and expressing the need due to her condition. The facility staff failed to obtain a doctor's order or assess the resident's ability to self-administer, as required by policy. Interviews revealed a lack of understanding and training among staff regarding the policy on self-administration of medications.
A resident experienced discomfort due to a waffle mattress set to its firmest setting, and staff were not trained to adjust it. Despite the resident's clear complaints, the nursing staff incorrectly relied on maintenance for adjustments, contrary to the facility's expectations and the manufacturer's instructions. This oversight resulted in the resident's discomfort and posed a risk for skin breakdown.
A resident with severe cognitive impairment had bed rails installed without proper assessment, physician order, or consent, posing a risk of entrapment. The facility's policy requiring interdisciplinary assessment and informed consent was not followed, and regular bed rail checks were not conducted.
A facility failed to document the administration of lorazepam, a controlled medication, for a resident with major depressive disorder and adjustment disorder. The LVN responsible admitted to forgetting to record the administration in the Narcotic Binder, which is crucial for ensuring accurate medication dispensing and preventing errors. The oversight was confirmed by another LVN and the DON, highlighting the importance of accurate documentation for controlled substances.
The facility was found to have four rooms with more than the allowed number of residents, each accommodating five residents instead of the maximum four. Despite this, the rooms met the residents' needs, with adequate space and facilities, and did not adversely affect their health and safety.
A facility failed to provide the minimum required square footage per resident in eight multiple resident rooms. During a survey, it was found that rooms did not meet the regulatory requirement of at least 80 square feet per resident. Despite this, the facility maintained that there was sufficient room for nursing care and resident ambulation, with accessible wheelchairs and toilet facilities, adequate closets and storage space, and available bedside stands. The facility requested a waiver to continue, asserting no adverse effects on residents' health and safety.
A resident with a history of hemiplegia and hemiparesis underwent a swallowing evaluation, but the LTC facility failed to obtain the results in a timely manner. The resident, who had a PEG tube, pulled it out and was transferred to the hospital, where it was revealed that a puree diet was recommended. The delay in obtaining the evaluation results was due to a lack of communication and follow-up among staff, placing the resident at risk for inadequate nutritional intake.
Failure to Maintain Safe Flooring Vents Resulting in Resident Fall and Injury
Penalty
Summary
The facility failed to maintain a resident environment free from accident hazards by not identifying, repairing, or replacing unsecured, lifted, or damaged floor vents in multiple resident rooms. One resident, an older male with complex medical problems and multiple comorbidities, had been admitted for short-term and long-term rehabilitation following a large middle cerebral artery (MCA) stroke that resulted in contralateral paralysis, facial drooping, and speech deficits. On the day of the incident, the resident was observed with a bruise under the left eye and an abrasion on the left cheek and reported that he had fallen in his room when his sock became caught on a lifted floor vent as he attempted to walk to the bathroom. According to the resident, the floor vent in his room had been lifted prior to his fall, and he had previously notified maintenance personnel about the issue, but no action had been taken. He stated that his sock got stuck in the vent, causing him to fall forward and hit his face, resulting in a nosebleed, bruising under the eye, and fear for his safety and eye. The resident reported that after the fall, the maintenance staff entered the room and repaired the vent, and that while staff offered help after the fall, he felt that staff had not cared about his earlier safety concerns when the vent was lifted. He also stated that other rooms in the facility had broken and lifted vents that could lead to injuries to other residents. Nursing documentation for the incident indicated that a nurse entered the resident’s room during the early morning hours to change his G-tube feeding and observed him attempting to use the restroom. The nurse noted the resident falling and found him lying face down on the floor, with a light nosebleed and a 0.5 cm by 0.5 cm abrasion and bruise under the left eye on the cheek. The resident told the nurse that his sock had gotten stuck in the floor vent as he tried to go to the bathroom, and the nurse documented that maintenance was notified to check the vent and that a slip was placed in the maintenance box. The maintenance supervisor later stated that the corner piece of the vent in the resident’s room had lifted and fallen inside the vent and acknowledged that vents on the floor had the potential to lift, move, or crack, creating safety hazards. During a facility-wide observation of rooms, seven rooms were identified with floor vents that were lifted, had broken pieces, sharp corners or edges, or were not secured in place. The director of staff development agreed that these vents could pose safety hazards for residents and staff and stated that, to her knowledge, the vents had been in this condition for a long time and that no residents or staff had previously expressed safety concerns. She also stated that some rooms had solid, secured vent pieces while others did not and was unable to explain the discrepancy. The facility’s policies on Safety and Supervision of Residents and Quality of Life–Home like environment stated that the facility strives to make the environment as free from accident hazards as possible, that safety risks and environmental hazards are to be identified on an ongoing basis through training, monitoring, reporting, and QAPI review, and that residents are to be provided with a safe, clean, comfortable, and homelike environment. The conditions of the floor vents and the resulting fall demonstrated a failure to adhere to these policies.
Failure to Provide Clean, Prepared Room for New Admission
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, clean, comfortable, and homelike environment for a newly admitted resident. The resident, an adult female admitted for short‑term rehabilitation after a traumatic fall with multiple pelvic and lumbar fractures and recent pelvic fixation surgery, arrived at the facility by medical transport after an eight‑hour ambulance ride. She reported that, despite the facility having more than 24 hours’ notice of her admission, she was placed in a bed that still had used linens and a blanket from the prior resident, with a pillow containing used tissues underneath. She also reported that the bedside drawer and closet contained the previous resident’s personal belongings and that the room’s floor was dirty with sticky residue. The resident stated she was transferred into this bed and remained there for a couple of hours before clean linens were provided and housekeeping cleaned the room. Interviews and observations by multiple staff and another resident corroborated key aspects of these concerns. The Director of Staffing Development acknowledged that the closet and bedside drawer had not been emptied after the prior resident’s discharge and that the floor cleanliness issue was addressed only after the new resident complained. The DSD explained that the bed had been on hold for the previous resident until midnight and that the new resident was admitted to that bed around 6:20 a.m., but she could not verify whether the bed and linens were dirty at the time of admission. The Infection Prevention Nurse stated that she learned the resident was very upset about the dirty bed and sticky floor and confirmed that having dirty floors and beds was not acceptable and could be a potential source of infection. The Business Manager confirmed seeing sticky residue on the floor later that morning and acknowledged that the resident reported belongings from the previous resident in the bedside drawer, though he did not personally inspect the storage areas. Additional interviews further supported that the room and storage areas were not properly prepared before the resident’s admission. A roommate stated she witnessed the new resident being placed in a dirty bed that still contained the prior resident’s belongings and that the closet, drawer, and bed all had items from the previous resident, whose bed was being held. Housekeeping staff described the facility’s usual room turnover process, in which CNAs are expected to strip the bed and remove personal belongings so housekeeping can disinfect the bed, clean the floor, and clean storage areas once emptied. One housekeeper, who worked the morning of the admission, stated that when she entered the room after the resident’s arrival, the resident complained about a dirty bed, dirty floor, and belongings in the closet and drawer; the housekeeper observed sticky material on the floor and then cleaned the room. Another RN acknowledged seeing items in the closet and directing a CNA to empty it for the new resident’s use. The administrator later stated that if a bed was on hold, personal belongings and drawers would not be cleared and housekeeping would not clean those areas, but the bed itself should still be cleaned after transfer or discharge, and he conceded that this admission was an unusual circumstance and that staff may not have realized the previous resident’s belongings needed to be removed before admitting the new resident. The facility’s own policies required a safe, clean, sanitary, and homelike environment, including clean bed and bath linens, and emphasized resident dignity, respect for private space and property, and maintenance of a safe, sanitary, and comfortable environment to prevent and manage transmission of infections. Despite these policies, the resident was admitted to a room where the bed, linens, floor, and storage areas were not confirmed to have been cleaned or cleared between residents, and multiple interviews confirmed that personal belongings from the prior resident remained in the closet and bedside drawer at the time of admission. These actions and inactions led to the cited deficiency related to the resident’s right to a safe, clean, comfortable, and homelike environment and to receiving treatment and supports for daily living safely.
Cracked, Uneven Doorway Transition Strips Create Mobility Hazards
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment when multiple transition strips between resident rooms and the hallway were cracked, uneven, and in at least one case higher than the ADA standard. Observations showed that the transition strip at one room entrance was approximately 0.5 inches high and made of wood, exceeding the 0.25-inch maximum vertical change allowed by ADA standards, while other strips were cracked and uneven. The Director of Maintenance confirmed that the transition strips to rooms 1, 2, 3, 4, 5, 6, 9, 10, 12, 14, 15, 16, 17, 18, 19, 20, and 21 were high, uneven, cracked, and could be difficult for residents to pass safely. The facility’s own policies required the environment to be free from accident hazards and the building to be maintained in good repair and free from hazards, but these conditions persisted. One resident reported a fall that occurred approximately one month prior while attempting to exit his room in a wheelchair. This resident, who had diagnoses including Hepatitis C, Coccidioidomycosis, and muscle weakness and a BIMS score of 15, stated he could not push his wheelchair over the “lip” at the doorway. He described turning and attempting to stand to push the wheelchair backward over the transition strip, at which point the wheelchair moved and he lost his balance, falling onto his bottom and injuring his back. He indicated that he routinely propelled himself backward in the wheelchair to get over the transition strip because the larger back wheels made it easier to cross the uneven surface, and he pointed out that the strip at his doorway was cracked and uneven. Other residents and staff corroborated that the transition strips created difficulty and potential for loss of control when moving in and out of rooms. One resident with COPD, hypertensive heart disease, dorsalgia, dementia, and a BIMS score of 11 stated that the transition strip at his room made it difficult to enter and exit and sometimes caused his wheelchair to spin or turn as he crossed it. Another resident, who used a wheelchair for seven years due to fibromyalgia and had diagnoses including sepsis, type 2 diabetes, cellulitis, and hypertensive heart disease, stated that while she could manage the strip herself, she had observed other residents going backward in their wheelchairs to cross the strips, which she believed could cause a fall, and noted that shuffling residents could trip on cracked, uneven strips. A fourth resident, with diagnoses including lumbar discitis, sepsis, type 2 diabetes, and a cutaneous abscess of the back and a BIMS score of 13, reported being unable to get past the transition strip at her doorway with a walker or wheelchair and having to call staff for assistance. Staff interviews further described the impact of the defective transition strips on resident mobility and safety. A CNA stated that pushing residents in wheelchairs over the bumpy transition strips was difficult and that some strips were more cracked and uneven than others and could cause a fall. Another CNA reported that the strips made it difficult to push residents in both wheelchairs and shower chairs, noting that the small, hard wheels of shower chairs made crossing the strips more difficult and that going backward in a wheelchair could cause it to tilt backward. This CNA also stated that the uneven strips could cause a fall when moving forward in a wheelchair or shower chair and that assisting heavier residents over the strips was more difficult and carried a higher risk of falling. The Director of Staff Development, after observing the strips to the identified rooms, stated that they were cracked and uneven, could be a fall hazard, and that the strips should be flat, smooth, and even so residents and staff could pass without difficulty. Despite these observations and statements, the Administrator asserted that the transition strips were not hazardous and attributed the reported fall to the resident’s choice to go backward in his wheelchair, while also acknowledging that the facility should provide a safe, functional, sanitary, and comfortable environment. The facility’s written policies on Safety and Supervision of Residents and Maintenance Service required ongoing identification of safety risks and environmental hazards, QAPI review of safety and incident data, and maintenance of the building in good repair and free from hazards. The ADA standards referenced in the report required floor surfaces to be stable, firm, slip resistant, and limited vertical changes in level to a maximum of 1/4 inch. The presence of cracked, uneven, and in at least one case over-height transition strips at multiple room entrances, combined with resident and staff reports of difficulty, loss of control, and a documented fall associated with these strips, demonstrate that the facility did not adhere to these standards and policies in maintaining the environment.
Improper Disposal of Used PPE and Soiled Linen
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by improper disposal of used blue rubber gloves and mixing of soiled linen with waste products. Surveyors observed that personal trash bins without lids, located at the bedsides of five residents, contained used blue rubber gloves. These bins were intended for residents' personal use and not for the disposal of contaminated personal protective equipment (PPE). Staff members, including CNAs, were observed or reported to have discarded used gloves in these open bins after providing care, despite facility policy requiring such items to be disposed of in lidded bins or designated containers. Further observations revealed that two of six large yellow barrels labeled for soiled linen in the east hall also contained used blue rubber gloves, sometimes mixed directly with soiled linen and without proper containment. Staff interviews confirmed that soiled linen barrels were dedicated for linen only, and that used PPE should be contained in plastic bags and discarded in gray bins with lids. Laundry staff reported having to separate trash from soiled linen, increasing their exposure to contamination. The improper disposal practices were acknowledged as unacceptable by the Infection Preventionist, Director of Maintenance, DON, and Administrator during interviews. The report included specific details about a resident who was admitted after back surgery and later transferred to the hospital with an infection. This resident witnessed a CNA discarding used gloves with stool into her personal trash bin, which did not have a lid, resulting in direct contact with contaminated material. The facility's policies and procedures, as well as CDC guidelines, were reviewed and found to require proper containment and disposal of infectious waste, which was not followed in these instances.
Resident Suffers Burns Due to Hot Water Spill
Penalty
Summary
The facility failed to protect a resident from physical abuse when a Certified Nursing Assistant (CNA) spilled hot water onto the resident's left thigh, resulting in second-degree burns. The incident occurred when the resident requested hot water to wash her face, and the CNA brought a pitcher filled with hot water from the kitchen's coffee machine, which was set at 165 degrees Fahrenheit. The CNA placed the pitcher on the bedside table without a lid, and when the table was moved, the pitcher tipped over, spilling the hot water onto the resident's thigh. The resident, who had a history of a right femur fracture and an unspecified open wound on the left lower leg, experienced severe pain and required hydrocodone for pain management. The resident's cognitive status was assessed as minimally impaired, with a Brief Interview for Mental Status (BIMS) score of 15. The resident was dependent on assistance for transfers and personal hygiene, which contributed to her vulnerability during the incident. The facility's video surveillance confirmed that the CNA obtained the hot water from the coffee machine, contrary to her initial statement that it was from the dining room sink. The dining room sink's hot water was also found to be out of the acceptable temperature range, reaching 140 degrees Fahrenheit. The Director of Nursing and the Administrator acknowledged that the water temperatures exceeded the safe limit of 120 degrees Fahrenheit, which could cause skin injury, and recognized the incident as physical abuse due to the exposure to scalding hot water.
Unsafe Water Temperatures Lead to Resident Burn Injury
Penalty
Summary
The facility failed to maintain a safe environment for residents by not ensuring that water temperatures were within a safe range, leading to an accident involving a resident. A Certified Nursing Assistant (CNA) provided a resident with hot water from a coffee machine, which was measured at 165 degrees Fahrenheit, significantly above the safe limit of 120 degrees Fahrenheit. This hot water was placed in a pitcher without a lid on the resident's bedside table, and when the table was moved, the pitcher tipped over, spilling the scalding water onto the resident's left thigh, resulting in second-degree burns. The Maintenance Supervisor was unaware of the unsafe water temperatures in the dining room sink, which was measured at 140 degrees Fahrenheit. The facility's policy did not specify how often water temperatures should be monitored and documented, leading to a lack of oversight and control over water temperature safety. Staff members, including CNAs and Licensed Vocational Nurses (LVNs), were not aware of the acceptable water temperature range and the potential for burns, indicating a gap in training and communication regarding safety protocols. The resident involved in the incident had a history of a right femur fracture and an unspecified open wound on the left lower leg. At the time of the incident, the resident was dependent on assistance for transfers and personal hygiene. The resident experienced severe pain from the burns, requiring the administration of hydrocodone. The facility's failure to monitor and control water temperatures, combined with inadequate staff training, directly contributed to the resident's injury.
Deficiencies in Care Planning for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for two residents, leading to significant deficiencies in their care. For Resident 1, the care plan did not include an assessment or interventions for the use of bed rails, which are considered a restrictive device. This oversight was identified during an observation where bed rails were raised on both sides of the resident's bed without any documented physician orders, consent, or a care plan addressing their use. The Licensed Vocational Nurse (LVN) acknowledged the absence of necessary documentation and stated that bed rails could be unsafe if not properly assessed, potentially putting the resident at risk of harm. Resident 3's care plan was also found lacking, as it did not address the resident's edema or the use of a brace for the right leg. This deficiency was highlighted during observations and interviews where the resident reported pain and wounds caused by the brace. The Certified Nursing Assistant/Rehabilitation Nurse Assistant (CNA/RNA) and Clinical Supervisor Nurse (CSN) noted the improper application of the brace and inadequate wound care, which led to a bleeding wound on the resident's ankle. The Treatment Nurse (TN) was unaware of the resident's wounds until the issue was brought to attention, indicating a lack of communication and monitoring. Interviews with various staff members, including the Director of Nursing (DON) and the Physical Therapist (PT), revealed that there were no physician orders or care plans in place for the use of the brace, and nurses had not received training on its application. The DON confirmed that the wound was avoidable and emphasized the importance of having a care plan to monitor the resident's condition and ensure proper care. The facility's policies and procedures were not followed, resulting in inadequate care and potential harm to the residents.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, resulting in multiple deficiencies. Staff were observed storing personal lunch bags and a drink canister on top of the dining room ice machine, contrary to the facility's policy. This practice posed a risk of cross-contamination and exposure to foodborne illnesses for residents, staff, and visitors. Additionally, a resident's feeding tube bottle was not labeled with a start date, which could lead to the administration of expired nutrition, increasing the risk of infection. In another instance, an LVN did not adhere to proper procedures for donning PPE and performing hand hygiene while providing care to a resident on enhanced barrier precautions. The LVN also placed supplies on an unclean windowsill and failed to clean a feeding pump, which could lead to cross-contamination and infection. Furthermore, another LVN did not follow hand hygiene protocols before checking blood sugar levels for two residents and did not properly sanitize the glucometer, risking cross-contamination. Additional observations included dirty Halloween decorations on a dining table where a resident was eating, and a resident's urine catheter bag placed on their lap during a meal, both of which were against infection control practices. These actions increased the risk of infection due to cross-contamination. The facility's policies and procedures were not followed, leading to potential health risks for the residents.
Food Storage and Labeling Deficiencies in Facility
Penalty
Summary
The facility failed to ensure the safe storage and handling of food in several instances, leading to potential health risks for residents. In Resident 105's room, perishable food brought by family members was left on the bedside table without proper labeling or refrigeration, contrary to the facility's policy. The food, which included stew and a bread product, was brought in hot but had become cold, and there was no indication of when it was brought in or when it should be consumed by. Interviews with staff, including a Registered Nurse, Licensed Vocational Nurse, Interim Dietary Manager/Registered Dietician, Director of Nursing, and Infection Preventionist, revealed that the facility's policy for handling food brought by family members was not followed, posing a risk of foodborne illness to the resident. In the kitchen, an open jar of garlic was found without an open labeled date, which is required to track the shelf-life and ensure it is not used beyond its expiration. The Dietary Manager and Interim Dietary Manager/Registered Dietician acknowledged that the lack of labeling could lead to the use of expired food, increasing the risk of foodborne illness and cross-contamination. The facility's policy on sanitation and infection control mandates that all perishable food items be properly labeled and dated, which was not adhered to in this case. Additionally, a case of bran muffins was found in the refrigerator with a missing labeled date, and two dented tomato sauce cans were stored in the pantry for use instead of being set aside for return or disposal. The absence of proper labeling on the bran muffins could lead to serving expired items, while the dented cans pose a risk of bacterial contamination, including botulism. The facility's policy requires that frozen foods be labeled with the date they were placed in the freezer and that canned goods be inspected for damage and set aside if compromised, which was not done, further endangering resident safety.
Insect and Rodent Control Deficiencies
Penalty
Summary
The facility failed to maintain an environment free from insects and potential rodent entry, as evidenced by the presence of flies in resident rooms, dining areas, and activity rooms, as well as holes in the laundry room wall that could allow rodents to enter. Observations revealed flies in Resident 40's room, who was unable to move due to a tumor on her leg, and in the dining room where an inoperable fly trap was noted. Interviews with staff, including CNAs and the Director of Nursing, confirmed the persistent issue of flies, which posed a risk of infection to residents. Resident 23, who was moderately cognitively impaired, also experienced flies in his room, with a fly swatter present on his nightstand. Staff interviews indicated that flies were a common problem, particularly during the summer, and that fly traps and fans were used to mitigate the issue. However, the pest control program was deemed ineffective, as confirmed by the Maintenance Supervisor, who noted that fly traps were often unplugged or not working. In the activities room, flies were observed landing on residents' food and on the residents themselves during restorative dining. The Maintenance Assistant confirmed that the bug light in the room was not functioning. Additionally, holes in the laundry room wall were identified as a potential entry point for rodents, which could lead to cross-contamination and infection risks. The Maintenance Supervisor acknowledged the need for repairs and the inadequacy of the current pest control measures.
Failure to Allow Self-Administration of Medication
Penalty
Summary
The facility failed to uphold a resident's right to self-administer medications, specifically an albuterol inhaler, which the resident wanted to keep at her bedside. The resident, who had been diagnosed with asthma and traumatic pneumothorax, expressed her desire to have the inhaler nearby due to her condition that made breathing difficult at times. Despite having no cognitive impairment, as indicated by a BIMS score of 15, the resident's request was denied by the nursing staff, who informed her that she was not allowed to keep medications in her room. This decision was made without obtaining a doctor's order or assessing the resident's ability to self-administer the medication, as required by the facility's policy. Interviews with staff revealed a lack of understanding and training regarding the facility's policy on self-administration of medications. A CNA confirmed hearing the resident's request and the subsequent denial by nurses, while an LVN admitted to being unaware of the policy allowing residents to keep medications at bedside. The Director of Nursing acknowledged that residents could store medications at bedside if deemed clinically appropriate and safe by the interdisciplinary team, which had not been done in this case. The facility's policy outlined the need for a comprehensive assessment by the interdisciplinary team to determine a resident's capability to self-administer medications, which was not conducted for this resident.
Failure to Adjust Pressure Relief Mattress Leads to Resident Discomfort
Penalty
Summary
The facility failed to meet professional standards of practice for a resident, identified as Resident 40, who reported discomfort with her waffle mattress, a pressure relief mattress overlay. The mattress was set to its firmest setting, which made the resident feel hot and uncomfortable. Despite the resident's complaints, the staff, including a CNA, RN, and LVN, were unaware of how to adjust the mattress to improve comfort, as they had not been trained on its use. The resident, who was admitted with a diagnosis of a mass/lump on her right lower limb and morbid obesity, was cognitively intact and expressed her discomfort clearly. The physician had ordered an alternating pressure mattress to prevent skin breakdown, but the staff did not follow the instructions provided in the owner's manual for adjusting the mattress. The manual outlined a method for checking and adjusting the mattress firmness to ensure optimal pressure redistribution and resident comfort. Interviews with various staff members, including the Maintenance Supervisor, Director of Staff Development, and Director of Nursing, revealed a lack of training and understanding regarding the operation of the waffle mattress. The nursing staff incorrectly relied on maintenance for adjustments, contrary to the facility's expectations and the manufacturer's instructions. This oversight resulted in the resident's discomfort and posed a risk for skin breakdown.
Failure to Assess and Document Bed Rail Use
Penalty
Summary
The facility failed to ensure that a resident was properly assessed for the risk of entrapment from bed side rails. The resident, who was severely cognitively impaired with a BIMS score of 3, had bed rails installed without a documented assessment, physician order, or consent. The resident's medical records lacked a care plan for the use of bed rails, and there was no indication for their use. This oversight had the potential to cause serious harm, injury, or death to the resident. During an observation, the resident was found sleeping with bed rails raised at the head of the bed, and fall mats were placed on both sides. However, the facility's policy required an interdisciplinary assessment and informed consent before the use of bed rails, which was not followed. The Licensed Vocational Nurse confirmed that there were no orders, care plans, or assessments documented for the use of bed rails, and acknowledged that bed rails are considered a restrictive device that could be unsafe if not properly assessed. The Maintenance Supervisor admitted that no regular bed rail checks were conducted, and there was no log of such checks. The maintenance department relied on CNAs or nurses to report any issues with bed rails, which were then addressed. The facility's policy emphasized the need for regular inspections and assessments to prevent injuries from bed-related equipment, but these procedures were not implemented, leading to the deficiency.
Failure to Document Controlled Medication Administration
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for a resident when a controlled medication, lorazepam, was administered but not documented on the controlled substances count sheet. This oversight occurred during an observation where it was noted that the lorazepam administration at 8:00 a.m. was not recorded in the Narcotic Binder. The Licensed Vocational Nurse (LVN) responsible admitted to forgetting to document the administration, which is a critical step to ensure accurate dispensing and prevent potential medication errors. The resident involved had been admitted with diagnoses of major depressive disorder and adjustment disorder. The failure to document the administration of lorazepam, a medication used to manage anxiety and maintain calmness, posed a risk of double dosing and potential side effects. Interviews with another LVN and the Director of Nursing confirmed the importance of maintaining accurate records for controlled substances to prevent theft and ensure proper medication administration.
Excessive Resident Occupancy in Rooms
Penalty
Summary
The facility failed to ensure that each bedroom accommodated no more than four residents in four of the 19 rooms surveyed. Specifically, rooms 1, 2, 5, and 6 each contained five residents, exceeding the maximum allowed occupancy. This was observed during the survey conducted from November 5 to November 8, 2024. Despite the excess number of residents, the report notes that each room met the particular needs of the residents, providing adequate closet and storage space, accessible wheelchair and toilet facilities, sufficient room for nursing care, and space for residents to ambulate. Bedside stands were available for each resident, and the health and safety of residents were not adversely affected by the continuance of this waiver.
Deficiency in Room Square Footage
Penalty
Summary
The facility failed to provide the minimum required square footage per resident in eight of 19 multiple resident rooms during a survey conducted from 11/5/24 through 11/8/24. Specifically, rooms 1, 2, 5, 6, 9, 10, 11, and 12 did not meet the regulatory requirement of at least 80 square feet per resident. This deficiency was identified during an observation and interview with the Maintenance Supervisor, who confirmed that the rooms did not meet the minimum square footage per resident. Despite this, the facility maintained that there was sufficient room for nursing care and resident ambulation, with accessible wheelchairs and toilet facilities, adequate closets and storage space, and available bedside stands. The facility requested that a waiver continue in effect, asserting that the waiver would not adversely affect the health and safety of residents.
Failure to Implement Recommended Diet Plan
Penalty
Summary
The facility failed to implement the recommended diet plan for a resident who underwent a swallowing evaluation. The resident, who had a history of hemiplegia and hemiparesis following a cerebral infarction, was admitted with a PEG tube for nutritional intake. Despite undergoing a swallowing evaluation on May 2, 2024, the facility did not obtain the results until May 17, 2024, after the resident had pulled out the PEG tube and was transferred to the hospital. The hospital informed the resident's responsible party that the resident had passed the evaluation and recommended a puree diet. The delay in obtaining the swallowing evaluation results was attributed to a lack of communication and follow-up among the facility's staff. The RN assigned to the resident on the day of the evaluation informed the Director of Social Services that the hospital would fax the results, but no follow-up was conducted to ensure the results were received. The Director of Medical Records was not aware of the evaluation, and the facility's policy required the charge nurse to communicate with Medical Records to obtain necessary documents. The Director of Nursing and the Administrator acknowledged the failure to follow up on the evaluation results, which was against the facility's policy. The resident's condition at the time of the deficiency included severe cognitive impairment, requiring extensive assistance with daily activities, and the need for a puree diet as recommended by the swallowing evaluation. The facility's failure to obtain and implement the evaluation results in a timely manner placed the resident at risk for inadequate nutritional intake and potential aspiration. The facility's policy and procedure required obtaining follow-up paperwork for residents returning from appointments, which was not adhered to in this case.
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Nursing homes near Fresno
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| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Vineyards At Fowler | 4.7 mi | — | 24 | 0 |
| Fowler Care Center | 6.4 mi | — | 1 | 0 |
| Grace Healthcare Center | 6.4 mi | — | 30 | 0 |
| Rolling Hills Care Center | 8.1 mi | — | 0 | 0 |
| Sierra Vista Healthcare | 8.3 mi | — | 18 | 0 |
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