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 Park Vista At Morningside during CMS and state inspections, most recent first.
A resident with significant physical and cognitive impairments was not evaluated for hot beverage safety, resulting in a hot tea spill that caused burns. Staff failed to promptly notify licensed nursing personnel or provide immediate and appropriate interventions, leading to delayed assessment, documentation, and treatment of the burn injury. Two other residents were also not assessed for hot beverage safety as required by facility policy.
A resident with a full thickness skin tear did not receive wound care as ordered by the physician, with staff applying foam dressings instead of Steri-Strips and not consistently assessing the wound. Documentation and monitoring were incomplete, and the wound later developed cellulitis, indicating a failure to follow prescribed wound care protocols.
A resident with respiratory failure and dependence on supplemental oxygen was not consistently provided with continuous oxygen therapy as ordered by the physician. Oxygen saturation levels were not maintained above the prescribed threshold, and the resident experienced a significant drop in oxygen saturation, resulting in transfer to an acute care facility. Nursing staff confirmed the resident should have been on continuous oxygen, in accordance with facility policy and physician orders.
Staff failed to follow infection control protocols, including hand hygiene and proper use of gloves, during wound care and while delivering meals to residents in contact isolation. A nurse used expired hand sanitizer and reused supplies that should have been discarded, while a CNA did not wear gloves or perform hand hygiene after contact with contaminated items, then provided care and delivered meals to other residents. These actions were not in accordance with facility policies and were acknowledged by staff and the DON.
Surveyors found that two residents' medical records were incomplete and inaccurate, with missing or incorrect documentation of intake, output, and eating percentages for one resident, and a lack of documentation regarding a hot tea spill incident for another. Facility staff confirmed missed charting and failure to initiate required change of condition documentation, contrary to facility policy.
The facility failed to meet sanitary requirements in the kitchen, with issues such as improper labeling and dating of food items, expired items, and inadequate cleanliness of equipment. Food brought in by visitors was also not properly labeled or dated. Additionally, food storage practices were not followed, with items stored on the floor and cross-contamination risks present.
A resident experienced significant weight loss over seven weeks, with inadequate nutritional intake and insufficient follow-up on RD recommendations. Despite the facility's P&P for weight management, timely interventions were not implemented, and there was no documented communication with the physician regarding the exhausted nutritional interventions. Interviews with staff confirmed the lack of follow-up and communication, contributing to the deficiency.
The facility failed to provide proper respiratory care for four residents, with issues including incorrect oxygen administration, improper storage, and outdated equipment. A resident received oxygen at a higher rate than ordered, and nasal cannulas were not stored or changed as required. An LPN confirmed these findings, and the DON and Administrator were informed.
The facility failed to provide adequate pharmaceutical services, resulting in medication discrepancies and unavailability of necessary medications for residents. Medications were left at a resident's bedside, and another resident's routine medications were unavailable, potentially leading to poor health outcomes. Discrepancies in the Omnicell system and a breakdown in communication with the pharmacy contributed to these deficiencies.
A resident did not receive a scheduled dose of the antibiotic piperacillin sodium tazobactam as ordered by the physician. The medication was to be administered every six hours for a UTI, but the 0600 hours dose was missed. This was confirmed by the resident and verified by RN 2 during a medical record review.
The facility failed to properly store and label medications in a medication room and two medication carts. An opened tuberculin vial lacked an open date, expired food thickener packets were found, and a bag of home medications was unlabeled. Temperature logs were incomplete. Expired Non-Adhesive Pads were in one cart, and two residents' topical medications lacked open dates.
The facility failed to follow the planned menu for three residents, as they did not receive the garlic breadstick included in their meal tickets. This oversight was due to a kitchen staff error, which was not caught by the checking process involving a third server and nursing staff. The issue was confirmed by the CDM and Chef de Cuisine.
The facility failed to maintain accurate medical records for a resident, with missing documentation for behavior monitoring related to psychotropic medications. This included medications for poor meal intake, anxiety, and hyperventilation. The MDS Coordinator confirmed the nursing staff's responsibility to complete this documentation.
The facility failed to ensure proper infection control practices, as LVNs did not don appropriate PPE when administering medications to residents on enhanced barrier precautions. Additionally, improper storage of incontinence briefs and isolation carts touching trash bins were observed, posing a risk of infection spread.
The facility failed to educate and offer influenza and pneumococcal vaccinations to five residents, as required by its policies. Educational materials detailing the risks and benefits were not provided, nor was the type of pneumococcal vaccine specified. This was confirmed by the IP during a review.
The facility failed to maintain two ice machines in safe operating condition by not following the manufacturer's cleaning and sanitizing guidelines. The Maintenance Director admitted that the machines were not cleaned as required, and an orange residue was observed on one machine's spout, indicating improper cleaning.
The facility failed to conduct complete entrapment risk assessments for residents using bed side rails, assessing only some of the necessary zones. This oversight involved three residents, including one who used side rails for repositioning and another who lacked decision-making capacity. The Maintenance Director confirmed the incomplete assessments, which could lead to potential entrapment risks.
A facility failed to assess a resident for the safety of self-administering eye drops and did not obtain a physician's order or develop a care plan for this practice. The resident was observed with the medication on their bedside table and stated they used it as needed, but there was no documentation supporting this self-administration in their medical record.
A facility failed to ensure a call light was within reach for a resident, posing a risk of delayed care. The resident, who required assistance due to immobility and cognitive impairment, was observed in a wheelchair with the call light on the floor. The MDS Coordinator confirmed the call light was out of reach, although the resident could press it when accessible.
A facility failed to provide and document information on formulating an advance directive for a resident, as required by policy. The resident, who did not have an advance directive, had a legally recognized decision-maker. However, the medical record lacked documentation showing that the resident or their responsible party was informed of their rights. The SSD confirmed this oversight during an interview.
A facility failed to provide the SNF ABN Form CMS-10055 to a resident's responsible party when the resident's Medicare Part A skilled services benefits were exhausted. The facility's guidelines require this notice to be given when a resident no longer needs daily skilled services but remains in the facility. The Social Services Director confirmed the oversight during an interview.
The facility failed to complete and transmit the MDS for discharge for two residents, as required by the CMS RAI Manual. The MDS Coordinator confirmed that the assessments for these residents, who were discharged, were not completed and transmitted within the specified timeframe.
The facility failed to properly store garbage in three of five dumpsters, which were overfilled and unable to close completely. This was observed during an inspection with the Maintenance Director. The FDA Food Code requires that outdoor refuse receptacles be covered with tight-fitting lids. The facility's policy also mandates covered trash bins for infection control. The EVS Director and other staff acknowledged the issue.
Failure to Assess Hot Beverage Safety and Provide Timely Burn Care
Penalty
Summary
The facility failed to ensure that residents were evaluated for their ability to safely handle and consume hot beverages, as required by its own policies and procedures. Specifically, three residents were not assessed for hot liquid safety, including a resident with significant physical and cognitive impairments such as hemiplegia, hemiparesis, aphasia, and lack of capacity to make medical decisions. Despite the facility's policy mandating hot liquid safety evaluations upon admission, readmission, and change of condition, no such assessments were documented for these residents. An incident occurred in which the resident spilled hot tea onto her lap during lunch. Staff present at the time, including two restorative nursing assistants, did not immediately notify a licensed nurse or supervisor as required by facility policy. Instead, they patted the resident dry and allowed her to finish her dessert before informing a CNA, who later reported the incident to licensed nursing staff. The delay in notification resulted in a lack of prompt assessment and intervention for the burn injury. Following the incident, the resident developed blisters on her left upper thigh, which were not discovered until the following day during routine care. Documentation of the injury, physician notification, and appropriate treatment were not initiated until approximately 30 hours after the incident. The initial intervention included the application of ice to the burn, which is not recommended and can be harmful. There was no evidence that the resident's condition was promptly assessed, that a physician's order for burn treatment was obtained, or that the resident was properly monitored in the immediate aftermath of the incident.
Failure to Provide Wound Care as Ordered and Inadequate Monitoring
Penalty
Summary
The facility failed to provide necessary wound care services to a resident with a full thickness skin tear on the right lower leg. The physician's order specified the application of Steri-Strips every shift for 21 days, monitoring for infection or drainage, and specific actions if drainage or infection was noted. Medical record review showed that the treatment administration record was marked as completed, but interviews with nursing staff revealed inconsistencies in the actual care provided. Staff reported using a foam dressing instead of Steri-Strips and did not consistently open the dressing to assess the wound, relying instead on monitoring for pain and discharge around the dressing. The treatment nurse admitted to cleansing the wound without a physician's order and acknowledged that the wound care orders were incomplete and should have been clarified. Documentation in the resident's progress notes indicated the presence of a full thickness skin tear with visible adipose tissue and serosanguinous drainage, and later development of cellulitis requiring antibiotic therapy. The care plan included providing treatment as ordered, but staff interviews and record reviews indicated that the wound was not always treated according to the physician's instructions, and wound monitoring and documentation were not accurately performed. These actions and inactions led to a failure in providing the necessary wound care services as ordered.
Failure to Provide Continuous Oxygen Therapy as Ordered
Penalty
Summary
The facility failed to provide necessary respiratory care services for one resident who had diagnoses including lung cancer, acute and chronic respiratory failure with hypoxia, and dependence on supplemental oxygen. The physician's order required continuous oxygen administration via nasal cannula, with oxygen saturation to be maintained above 92%. Medical record review showed that the resident's oxygen saturation was recorded at 92% on room air and with nasal cannula on multiple occasions, and at 93% on room air. Despite the order for continuous oxygen, the resident was not consistently maintained on supplemental oxygen as prescribed. On one occasion, the resident's oxygen saturation dropped significantly from 93% to 51% within less than an hour, leading to the resident being transferred to an acute care facility. Interviews with nursing staff confirmed that the resident should have been on continuous oxygen and that the oxygen should have been titrated to maintain the ordered saturation level. The facility's policy required that all physician orders be specific and complete, and that treatments be administered as ordered, but these requirements were not met in this case.
Infection Control Lapses in Wound Care and Contact Isolation
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices for three of nine sampled residents, resulting in multiple breaches of protocol. During wound care for one resident, a treatment nurse did not perform hand hygiene or change gloves after removing a soiled dressing, and used the same gloves to handle clean supplies and enter the restroom. The nurse also used an expired alcohol-based hand sanitizer and returned unused gauze, which had been brought into the resident's room, back to the treatment cart for use with other residents. The nurse acknowledged that hand hygiene should have been performed and that unused, potentially contaminated supplies should have been discarded. A certified nursing assistant (CNA) was observed delivering meal trays and providing care in contact isolation rooms without wearing gloves or performing hand hygiene after touching contaminated items. The CNA handled residents' bedside tables, adjusted bedding, and fed a resident without gloves or hand hygiene, and then proceeded to deliver another meal tray to a different resident without sanitizing hands. The CNA admitted to not following proper personal protective equipment (PPE) and hand hygiene protocols when entering contact isolation rooms. Facility policy reviews confirmed that staff are required to perform hand hygiene after removing soiled dressings, dispose of unused disposable supplies brought into resident rooms, and wear gloves and gowns when entering contact isolation rooms. Staff interviews, including with the Director of Nursing (DON), confirmed awareness of these policies and acknowledged the observed failures to adhere to them.
Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to ensure complete and accurate documentation of medical information for two of nine sampled residents. For one resident, there were multiple instances where intake, output, and eating percentage documentation were either missing or incorrectly recorded. Physician orders required monitoring and documenting intake and output every shift, but several entries were left blank or marked as 'not applicable' without justification. Similarly, eating percentages were either not documented or recorded inaccurately. The Director of Nursing confirmed that these omissions and incorrect entries were due to missed charting and acknowledged that the documentation was not accurate. For another resident, the facility did not document an incident in which the resident spilled hot tea on her left thigh. Although the event was verbally reported to nursing staff and the resident was evaluated and treated for redness and later blisters, there was no corresponding documentation in the medical record regarding the incident on the day it occurred. Staff interviews confirmed that the incident was not documented, and the required change of condition process was not initiated at the time of the event. Facility policies required that all services, changes in condition, and incidents be documented objectively, completely, and accurately in the medical record to facilitate communication among the interdisciplinary team. The lack of documentation for both the intake/output monitoring and the incident involving the hot tea spill resulted in incomplete clinical records for the affected residents.
Sanitary Violations in Kitchen and Improper Food Labeling
Penalty
Summary
The facility failed to adhere to sanitary requirements in the kitchen, as evidenced by improper labeling and dating of food items. During an inspection, it was observed that several food items in Refrigerator 1, such as tilapia filets, cleaned chicken, mushrooms, egg salad, chopped onions, and tomato wedges, were not labeled according to the facility's policy. Additionally, expired items like pork chops, mushrooms, marinated vegetables, chopped tomatoes, and Tuscan Caesar dressing were found. Similar issues were noted in Freezer 1, the pantry area, Refrigerator 2, and Freezer 2, where various food items were not labeled as required. The facility also failed to ensure that food brought in by visitors for residents was properly labeled and dated. In Refrigerator 3, several items, including whipped cream cheese spread, veggie spread, ranch dressing, a croissant sandwich, and a bagel with spread, were found unlabeled and undated. Some items were labeled with the resident's name but lacked a date, and expired items like a Silk soy milk carton were also present. The facility's policy required these items to be dated and discarded after three days, but this was not consistently followed. Furthermore, the facility did not maintain cleanliness and proper storage practices in the kitchen. Food items were stored on the floor in Freezer 1, contrary to USDA Food Code requirements. Equipment such as the can opener, blender, microwave, oven, and plate lowerator were found with residues and substances indicating inadequate cleaning. Additionally, there was a failure to prevent cross-contamination, as egg salad was stored on a shelf designated for raw meats, posing a risk of foodborne illnesses to residents.
Failure to Address Resident's Significant Weight Loss
Penalty
Summary
The facility failed to ensure timely Registered Dietitian (RD) evaluations and interventions for a resident experiencing significant weight loss. The facility's policy and procedure (P&P) for weight management required identification and intervention for significant weight variance, but these were not implemented in a timely manner for the resident. The resident experienced a weight loss of 23.4 lbs over seven weeks, with multiple instances of significant weekly and monthly weight loss percentages. Despite the resident's oral intake being consistently below the assessed needs, there was no documented evidence of timely RD or physician intervention to address the ongoing weight loss. The resident's medical records indicated a pattern of inadequate nutritional intake, with a high percentage of meals consumed at 50% or less. The RD made several recommendations, including dietary changes and the use of nutritional supplements, but these were not effectively communicated or followed up with the physician. The RD's recommendations on 7/25/24 to notify the physician about the exhausted nutritional interventions were not documented as communicated, and there was no evidence of further evaluation or recommendations from the physician or RD from 7/25/24 to 8/15/24. Interviews with facility staff, including the RN, DON, and RD, confirmed the lack of documented follow-up on the RD's recommendations and the failure to notify the physician. The RD acknowledged the absence of follow-up documentation regarding the resident's weight loss during the critical period. The DON confirmed that the nursing staff should have carried out the RD's recommendations promptly, ideally the next day, but this did not occur, contributing to the deficiency in addressing the resident's nutritional needs.
Inadequate Respiratory Care and Equipment Management
Penalty
Summary
The facility failed to provide appropriate respiratory care for four residents, as evidenced by several deficiencies in the administration and management of oxygen therapy. Resident 36 was observed receiving oxygen at four liters per minute, contrary to the physician's order of two to three liters per minute. Additionally, the humidifier was empty, and the oxygen nasal cannula and storage bag were not changed timely, being dated 11/20/24. LVN 1 confirmed these observations and was unaware of the correct physician's order. The MDS Coordinator also verified the discrepancy in the oxygen administration. For Resident 32, the nasal cannula was improperly stored on top of the oxygen concentrator instead of inside the storage bag when not in use, and both the nasal cannula and storage bag were undated or outdated. Similar issues were observed with Resident 31, whose nasal cannula was not stored properly and was undated, with the storage bag dated 11/20/24. Resident 18's nasal cannula was found on the floor, unlabeled, and not stored in a sanitary manner. LVN 1 confirmed these findings and acknowledged the improper storage and labeling of the equipment. The DON and Administrator were made aware of these deficiencies.
Medication Management Deficiencies in LTC Facility
Penalty
Summary
The facility failed to provide adequate pharmaceutical services, resulting in medication discrepancies and unavailability of necessary medications for residents. One resident had medications left at their bedside, and another resident did not have their routine medication available, which could potentially lead to poor health outcomes. The facility's failure to ensure accurate reconciliation and disposal of medications was evident in the discrepancies found in the Omnicell automatic drug delivery system. The facility's policies and procedures for the Automated Drug Delivery System (ADDS) were not followed, leading to several discrepancies in medication counts. For instance, there were unexplained changes in the bin quantities of medications such as zolpidem, hydralazine, tramadol, and levofloxacin. The Director of Nursing (DON) and pharmacy staff were unable to provide explanations for these discrepancies, indicating a lack of proper oversight and accountability in medication management. Additionally, a resident's routine medications, Eliquis and zinc sulfate, were not available due to a failure in the reordering process. Despite multiple attempts by a Licensed Vocational Nurse (LVN) to contact the pharmacy, the medications were not delivered in a timely manner. This highlights a breakdown in communication and coordination between the facility and the pharmacy, further contributing to the deficiency in pharmaceutical services.
Failure to Administer Prescribed Antibiotic
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors. Specifically, Resident 25 was not administered the piperacillin sodium tazobactam antibiotic as ordered by the physician. The physician's order, dated 11/29/24, required the medication to be administered intravenously every six hours for seven days to treat a urinary tract infection. On 12/2/24, Resident 25 reported not receiving the 0600 hours dose during the previous night shift. A review of the resident's Infusion Medication Administration Record confirmed the omission of the dose. RN 2 acknowledged and verified these findings during an interview and concurrent medical record review.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications in one of its medication storage rooms and two medication carts. In the medication room, an opened tuberculin vial was found in the refrigerator without an open date, and an opened box of instant food thickener contained multiple expired packets. Additionally, a bag of home medications without a resident's name was stored on the counter. The temperature log for the medication room had multiple missing entries, which were verified by the Director of Nursing (DON). In Medication Cart A, three packets of Non-Adhesive Pad were found to be expired. In Medication Cart C, topical medications for two residents were not labeled with an open date, as per the facility's policy. The medical records for these residents showed physician orders for the use of diclofenac sodium topical gel for pain management, but the medications were not properly labeled with open dates, which was confirmed by the staff.
Menu Adherence Failure for Three Residents
Penalty
Summary
The facility failed to adhere to the planned menu for three residents, resulting in a deficiency related to nutritional needs. On the specified date, three residents did not receive the garlic breadstick as indicated on their meal tickets. Resident 43, who was supposed to receive a pureed garlic breadstick and butter, did not have it on her meal tray. Similarly, Resident 40's meal tray was missing the soft and buttered garlic breadstick, and Resident 22 also did not receive the pureed garlic breadstick and butter as per his meal ticket. These discrepancies were verified by the Certified Dietary Manager (CDM) and other staff members. The issue arose due to an oversight by the kitchen staff responsible for serving the pureed bread, who missed including the garlic breadstick on the first few trays. Despite having a third server on the line to check the trays and nursing staff performing a final check before meals were served, the error was not caught in time. The CDM and Chef de Cuisine acknowledged the mistake during an interview, indicating that the process for checking meal trays was not effectively implemented in this instance.
Incomplete Medical Records and Behavior Monitoring Deficiency
Penalty
Summary
The facility failed to maintain accurate and complete medical records for one of the sampled residents, identified as Resident 30. The medical record review revealed multiple instances of missing documentation related to behavior monitoring for various psychotropic medications prescribed to Resident 30. These medications included Remeron for poor meal intake, buspirone for verbalization of feeling anxious, Ativan for anxiety manifested by biting nails and scratching, and lorazepam for hyperventilation. The missing documentation spanned several dates and shifts, indicating a pattern of incomplete record-keeping. Additionally, the facility did not ensure the monitoring of behavior for psychotropic medication on another resident's Medication Administration Record (MAR), identified as Resident 2. This oversight had the potential to impact the resident's care needs due to the incomplete and inaccurate medical record. During an interview and concurrent medical record review, the MDS Coordinator confirmed that the nursing staff should have completed the documentation for Resident 30's behavior monitoring and noted that any inability to do so should have been documented in the progress notes.
Infection Control Lapses in PPE Usage and Storage Practices
Penalty
Summary
The facility failed to implement a safe and sanitary environment to prevent the transmission of infections for three residents. Specifically, the facility did not ensure that Licensed Vocational Nurses (LVNs) donned appropriate personal protective equipment (PPE) when administering medications to residents on enhanced barrier precautions (EBP). For Resident 26, who was on EBP due to a gastrostomy tube, LVN 3 was observed multiple times administering medications and performing medical procedures without wearing an isolation gown. Additionally, the isolation cart for Resident 26 was improperly placed, touching the trash bin inside the room. Similarly, LVN 2 did not wear an isolation gown while administering medication to a nonsampled resident, Resident 2, who required EBP due to a wound. The isolation cart for Resident 2 was also inside the room, indicating a lack of adherence to infection control protocols. Both LVNs were unaware of the residents' EBP status, which contributed to the oversight in PPE usage. Further observations revealed improper storage of incontinence briefs and isolation carts touching trash bins in residents' rooms. In Room A, a stack of incontinence briefs was stored on top of the isolation cart, and in Room B, Resident 31's incontinence briefs were stored on the floor. These practices posed a risk of spreading infection, as acknowledged by LVN 1 during interviews. The facility's failure to maintain proper infection control measures for these residents highlights significant lapses in adherence to established protocols.
Failure to Educate and Offer Vaccinations
Penalty
Summary
The facility failed to ensure that five residents, including four from the final sample and one non-sampled, were educated and offered influenza and pneumococcal vaccinations. Specifically, the facility did not provide educational materials detailing the risks and benefits of these vaccines to Residents 12, 21, 24, 25, and 507. Additionally, the facility did not specify which type of pneumococcal vaccine was offered to these residents, as required by the facility's policies and procedures. The medical records for each of these residents lacked documentation showing that the educational materials were provided or that the type of pneumococcal vaccine was specified. This oversight was confirmed during an interview and concurrent medical record review with the Infection Preventionist (IP), who acknowledged the findings. These failures put the residents at risk for infection and transmission of pneumococcal and influenza infections.
Improper Maintenance of Ice Machines
Penalty
Summary
The facility failed to maintain essential kitchen equipment, specifically two of the three ice machines, in safe operating condition. The ice machines were not cleaned and sanitized according to the manufacturer's guidelines, as required by the facility's policy and procedure. The policy stated that internal components of the ice machines must be cleaned and sanitized at least twice a year per manufacturer guidelines. However, the Maintenance Director confirmed that the ice machines were not cleaned per these guidelines. Instead, the facility cleaned the filters weekly and the inside every three months, without using any chemicals, which deviated from the manufacturer's instructions. During an observation, an orange residue was noted on the spout of Ice Machine 2, indicating a lack of proper cleaning. The Maintenance Director acknowledged this finding and admitted that the icemaker and ice storage bin had not been cleaned as required. The failure to follow the manufacturer's cleaning and sanitizing instructions had the potential to affect the health status of the residents, as the equipment might not function as intended.
Incomplete Entrapment Risk Assessments for Bed Rails
Penalty
Summary
The facility failed to ensure accurate and complete entrapment assessments for residents using bed side rails, which could lead to potential entrapment, serious injury, or death. The report highlights that the facility did not assess all necessary zones for entrapment risk as per the Hospital Bed System Dimensional and Assessment Guidance. Specifically, the Maintenance Director only assessed Zones 2, 3, and 4, neglecting Zones 1, 5, 6, and 7, which are critical areas where entrapment could occur. Resident 507, who had the capacity to understand and make decisions, used the side rails to reposition herself in bed. Her entrapment risk evaluation indicated the use of side rails as an enabler for independence and safety, but the assessment did not cover all potential entrapment zones. Similarly, Resident 30, who lacked the capacity to understand and make decisions, also had side rails as enablers, but the assessment was incomplete, missing several zones. The Maintenance Director confirmed the oversight during an interview. Resident 38, who could understand and make decisions, used the side rails for support while turning in bed. Her entrapment risk evaluation also failed to assess all necessary zones, with only Zones 2 and 3 being checked. The Maintenance Director acknowledged the incomplete assessments during a review of the documentation. Interviews with staff, including a CNA and the DON, confirmed the findings, indicating a systemic issue with the facility's assessment process for bed safety.
Failure to Assess and Document Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a resident was assessed for the safety and clinical appropriateness of self-administering medications. Specifically, Resident 507 was observed to have a bottle of carboxymethylcellulose sodium ophthalmic solution 0.5% eye drops on their bedside table and stated that they self-administered the drops when experiencing dry eyes. However, there was no documentation in the resident's medical record indicating that a physician's order was obtained or that a care plan was developed to address the self-administration of this medication. The facility's policy on self-administration of medications requires an assessment by the interdisciplinary team (IDT) to determine if self-administration is safe and appropriate for each resident. Additionally, the policy mandates that specific medications for self-administration be listed in the physician's orders and documented in the resident's care plan. In this case, the facility did not comply with its policy, as there was no evidence of an assessment, physician's order, or care plan for Resident 507's self-administration of eye drops. This oversight had the potential to lead to unsafe medication administration and negatively impact the resident's physiological well-being.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a call light was within reach for a nonsampled resident, identified as Resident 307. During an observation on November 18, 2024, at 0900 hours, Resident 307 was seen awake and sitting in a wheelchair with the call light on the floor, out of reach. A review of the facility's policy and procedure from October 2010 indicated that call lights should be within easy reach when a resident is in bed or confined to a chair. Resident 307's medical records showed a care plan addressing risks related to bowel incontinence and deficits in daily living self-care performance, requiring staff assistance for toileting and repositioning. At 1005 hours, the MDS Coordinator confirmed the call light was out of reach and verified that Resident 307 could press the call light when it was accessible.
Failure to Inform Resident of Advance Directive Rights
Penalty
Summary
The facility failed to provide and document information on how to formulate an advance directive for Resident 508, as required by their policy. The policy, revised on 6/24/15, mandates that written information regarding the rights to formulate an advance directive be provided to residents and their responsible parties. Resident 508, who was admitted to the facility on an unspecified date, did not have an advance directive according to the Social Services Evaluation dated 11/21/24. The POLST dated 11/19/24 indicated that the resident had a legally recognized decision-maker. However, the medical record lacked documentation showing that Resident 508 or their responsible party was informed of their rights to formulate an advance directive. During an interview on 12/3/24, the SSD confirmed that neither Resident 508 nor the responsible party had been informed of these rights.
Failure to Provide SNF ABN Form CMS-10055
Penalty
Summary
The facility failed to provide the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) Form CMS-10055 to a resident's responsible party, which is required when a resident no longer requires daily skilled services but remains in the facility. This deficiency was identified during a review of the facility's Beneficiary Notice Guidelines, which indicated that the SNF ABN should be provided regardless of payer type. The medical record review for the resident, who was admitted and readmitted to the facility, showed that their Medicare Part A skilled services benefits were exhausted on May 17, 2024. An interview with the Social Services Director (SSD) confirmed that the responsible party was not given the SNF ABN Form CMS-10055, despite the exhaustion of benefits, which should have been done to allow informed decision-making regarding Medicare services.
Failure to Complete and Transmit Discharge MDS Assessments
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) for discharge was completed and transmitted to the Centers for Medicare & Medicaid Services (CMS) for two nonsampled residents, identified as Residents 42 and 46, who were reviewed for resident assessments. According to the facility's guidelines, as outlined in the CMS RAI Manual Version 3.0 Chapter 2, Discharge Assessments for Return Not Anticipated must be completed within 14 days after the discharge date and submitted within 14 days after the MDS completion date. However, a closed medical record review initiated on December 5, 2024, revealed that Resident 42, who was discharged on July 3, 2024, and Resident 46, who was discharged on July 5, 2024, did not have their discharge MDS assessments completed and transmitted. During an interview and concurrent medical record review, the MDS Coordinator confirmed these findings, acknowledging the failure to complete and transmit the required assessments.
Improper Garbage Storage in Facility Dumpsters
Penalty
Summary
The facility failed to ensure proper storage of garbage in three out of five dumpsters, which were observed to be overfilled, preventing the lids from closing completely. This observation was made during an inspection conducted with the Maintenance Director. The FDA Food Code 2022 requires that receptacles for refuse be kept covered with tight-fitting lids if stored outside. The facility's policy, dated January 2015, also mandates that trash be moved in covered bins for infection control purposes. The Environmental Services (EVS) Director acknowledged that the dumpster lids should always be covered. The findings were also acknowledged by the CDM, Food and Nutrition Manager, and Chef de Cuisine.
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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 Fullerton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Pavilion At Sunny Hills | 1.1 mi | — | 7 | 0 |
| Greenfield Care Center Of Fullerton, Llc | 1.1 mi | — | 15 | 0 |
| Terrace View Care Center | 1.2 mi | — | 28 | 0 |
| St Elizabeth Healthcare Center | 1.2 mi | — | 25 | 0 |
| Gordon Lane Care Center | 1.7 mi | — | 0 | 0 |
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