Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around October 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 Town & Country during CMS and state inspections, most recent first.
A resident with documented lack of decision-making capacity and unclear, slurred speech on the MDS had multiple skilled nursing evaluations recorded over several days indicating clear speech, contrary to staff observations. During interviews, an LVN, a treatment nurse, and a CNA all reported that the resident’s speech was not clear and was difficult to understand, and the DON verified that the medical record entries documenting clear speech were inaccurate and inconsistent with the resident’s actual condition.
A resident admitted with an ileostomy did not have a baseline care plan initiated within 48 hours, as required by facility policy. Despite clear hospital discharge instructions for ostomy care, hydration, and monitoring intake/output, staff did not document or implement these interventions, and the DON confirmed the omission.
A resident experienced nausea, vomiting, poor meal intake, and significant weight loss, but staff did not develop or update a care plan to address these changes in condition. Despite facility policy requiring care plan updates for such changes, interviews with the LVN, DON, and RD confirmed that no care plan was initiated for the resident's poor appetite and weight loss.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, as required.
The facility failed to ensure CNAs followed infection control practices by not wearing gowns during high-contact resident care activities, despite facility policies and signage indicating the requirement. This was observed when CNAs wore only masks and gloves while repositioning a resident, contrary to the guidelines for preventing MDRO transmission. Interviews confirmed the oversight, and the facility administrator acknowledged the findings.
The facility's kitchen failed to meet food safety and sanitation standards, with issues such as unclean ice machines, improperly stored ice scoopers, expired food items, and unsanitary utensils and equipment. Staff did not consistently wear hair and beard restraints, and hand hygiene practices were not followed, increasing the risk of foodborne illnesses among residents.
The facility failed to implement proper infection control measures for a resident with shingles, as a family member was not adequately informed about necessary precautions. Personal items were found in the laundry's clean folding area, violating infection control standards. Additionally, the facility lacked recent documentation for testing Legionella in water systems, with the last assessment completed in 2018.
The facility failed to properly clean two kitchen ice machines according to the manufacturer's instructions, potentially leading to unsanitary ice. The service provider used a sanitizing solution that did not contain the required active ingredient, resulting in residue and particles inside the machines. The DON acknowledged the need to follow the correct cleaning instructions.
The facility failed to conduct entrapment assessments and record measurements for residents using bed rails, affecting 16 out of 53 residents. Observations and interviews revealed that assessments were not performed, and necessary documentation was missing. The Director of Facilities admitted to not being familiar with entrapment zones, and inspections were only conducted upon discharge and quarterly, not upon admission or as needed.
A facility failed to obtain informed consent from a resident's responsible party for the use of side rails and alprazolam, a psychotropic medication. The resident, who lacked decision-making capacity, was observed using side rails without proper consent, and there was no documented consent for alprazolam in the medical records. Interviews with staff confirmed these deficiencies, highlighting a breach in the facility's policies and procedures.
The facility failed to obtain and maintain advance directives for six residents, despite acknowledgments in their records. Interviews and medical record reviews revealed that the facility did not follow up to secure these documents, and POLST forms were incomplete for two residents. This deficiency indicates a failure to adhere to the facility's policy on managing advance directives, potentially impacting residents' healthcare decisions.
A resident with severe cognitive impairment did not receive an individualized activity program to meet their interests, such as group activities and independent pursuits like watching TV and music-related activities. The facility documented the resident's participation in activities only three times, and observations showed the resident often remained in bed without sensory stimulation. The Director of Activities confirmed the lack of documented evidence for daily activities, despite the resident's care plan indicating a need for such engagement.
The facility failed to properly administer medications and monitor residents' conditions, leading to deficiencies in care. A resident received medications simultaneously against physician orders, another resident's significant weight changes were not reported to the physician, and a third resident's blood pressure was not documented when administering hypertension medication. These issues were confirmed by staff during interviews and record reviews.
The facility failed to ensure proper reconciliation and disposal of controlled medications for two residents. One resident's morphine and oxycodone/acetaminophen records did not match the actual count, and the LVN admitted to not signing the records immediately. Another resident's discontinued hydrocodone/acetaminophen was found in the medication cart. The DON confirmed that discontinued medications should be removed promptly, highlighting potential risks for drug diversion and medication errors.
The facility failed to adhere to physician-ordered parameters for medication administration for two residents. One resident received losartan potassium despite having a systolic blood pressure (SBP) below the prescribed threshold, while another received midodrine hydrochloride when their SBP was above the specified limit. These errors were confirmed by staff and acknowledged by the DON.
A facility failed to monitor side effects for a resident prescribed alprazolam for anxiety, as required by their policy. Despite a care plan intervention to monitor behaviors and side effects every shift, there was no documented evidence of such monitoring. This oversight was confirmed by an RN during an interview, highlighting a lapse in adherence to the facility's procedures for psychotropic drug use.
The facility failed to ensure proper storage and labeling of medications, leading to potential cross-contamination. Orally administered medications were stored with external use products, and disinfectant wipes were not separated from treatment supplies. Additionally, a medication bottle was found with sticky residue. These issues were confirmed by nursing staff and acknowledged by the DON.
The facility did not adhere to pureed diet recipes for three residents, potentially compromising their nutritional needs. During an observation, a staff member was seen preparing pureed biscuits and rice without following the specified recipes, using incorrect amounts of hot water. The RD, DSS, Executive Chef, and DON acknowledged the oversight.
The facility failed to provide palatable green beans to four residents, as observed during dining. The residents reported the green beans were tough and not easy to chew, which did not meet their dietary requirements. This issue was confirmed by staff, including an LVN and an RD, who acknowledged the problem with the texture of the green beans.
The facility failed to update its policy on the use and storage of foods brought by visitors and did not educate visitors on safe food handling. The facility lacked a designated refrigerator for resident use, and visitors were not informed about maintaining perishable foods at safe temperatures. This oversight could lead to foodborne illnesses among residents.
The facility failed to ensure resident privacy and confidentiality when the Director of Activities used her personal cell phone to take pictures of residents during activities, violating the facility's policy. The Director admitted to this action, and the Administrator confirmed that staff should use facility-provided devices for such purposes.
The facility failed to remove a CNA from resident care areas pending an alleged abuse violation. After a resident reported being hit by the CNA, the CNA was reassigned to care for another resident and remained at work until the end of her shift, contrary to the facility's policy. This was confirmed through interviews with the CNA, an LVN, and the Administrator.
Inaccurate Documentation of Resident Speech Status in Medical Record
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate, relevant, and complete documentation in the medical record for one resident, as required by its policy on medical record documentation. The facility’s policy, revised on 8/23/23, states that licensed staff and interdisciplinary team members must document all assessments, observations, and services in accordance with state law and facility policy, and that documentation must be accurate and contain sufficient detail about residents’ care and responses to care. For Resident 1, who was admitted on an unspecified date, the history and physical dated 1/11/26 documented that the resident had no capacity to understand and make decisions. The Minimum Data Set (MDS) assessment for this resident documented unclear speech characterized as slurred or mumbled words. Despite the MDS assessment indicating unclear speech, multiple skilled nursing evaluations dated 2/16, 2/18, 2/20, 2/21, 2/22, 2/24, 2/25, 2/27, and 3/1/26 documented that the resident’s speech was clear. During interviews on 3/9/26, LVN 1 stated that the resident was able to answer yes or no when asked about pain, but confirmed that the resident’s speech was not clear as documented. LVN 2, a treatment nurse, reported that when she assessed the resident’s skin, the resident’s speech was not clear. CNA 1 stated that the resident talked a little but was very hard to understand. In a subsequent interview, the DON reviewed the record and verified these findings, confirming that the documentation indicating clear speech was inaccurate in relation to the resident’s actual speech status.
Failure to Initiate Baseline Care Plan for Resident with Ileostomy
Penalty
Summary
The facility failed to initiate a baseline care plan within 48 hours of admission for a resident who had an ileostomy, as required by facility policy and procedure. Upon admission, the resident's medical records, including a hospital discharge summary, indicated specific instructions for ostomy care, hydration, and monitoring of intake and output to prevent dehydration. Despite this, the facility did not develop a baseline care plan addressing the resident's ileostomy care or the necessary nutritional interventions to maintain or prevent weight loss. Interviews with facility staff, including an LVN and the DON, confirmed that the resident's intake and output were not monitored and that a baseline care plan for ileostomy care was not initiated. The lack of a baseline care plan meant that essential information for the resident's care was not documented or implemented, contrary to the facility's own admission policy and procedures.
Failure to Develop Care Plan for Change in Condition
Penalty
Summary
A deficiency occurred when the facility failed to develop and implement a care plan for a resident who experienced a significant change in condition, specifically nausea, vomiting, poor meal intake, and notable weight loss. The facility's policy required that all changes in a resident's condition be communicated to the physician, documented in the nursing progress notes and twenty-four hour report, and that the resident's care plan be updated as indicated. Despite these requirements, the medical record review showed that the resident lost 17 pounds over four days and had complaints of nausea, but no care plan was initiated to address these issues. Interviews with facility staff, including an LVN, the DON, and the RD, confirmed that the resident's care plan was not updated to reflect the new problems of poor appetite and weight loss. The RD acknowledged that the resident was at risk for weight loss and verified that no care plan had been initiated to address the resident's poor intake and weight loss. The RD also stated that she did not initiate a care plan problem until the MDS was completed.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The deficiency involves a failure to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. The report indicates that care was not delivered in accordance with established directives, which may include not following prescribed treatments or disregarding the expressed wishes and objectives of the resident regarding their care. This lapse was observed during the survey process, but the report does not specify the number of residents affected, their medical histories, or their conditions at the time of the deficiency.
Inadequate PPE Use by CNAs During Resident Care
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistants (CNAs) adhered to evidence-based practices (EBP) for infection prevention and control, specifically regarding the use of personal protective equipment (PPE). The deficiency was observed when CNAs 2 and 3 were seen wearing only surgical masks and gloves while repositioning a resident in bed, despite a sign outside the resident's room indicating that both gloves and gowns were required for high-contact activities. This oversight was confirmed during interviews with CNA 2, who admitted uncertainty about the necessity of wearing a gown for such activities, and the Infection Preventionist (IP), who stated that a yellow gown was required. The facility's policies and procedures (P&P) for Enhanced Barrier Precautions and Infection Control Prevention and Control of Multidrug-Resistant Organism (MDRO) Transmission were reviewed, indicating that gowns should be worn during high-contact activities that pose a risk for transmission of MDROs. Despite these guidelines, the CNAs did not comply with the requirement to wear gowns, as verified by the Minimum Data Set (MDS) Registered Nurse (RN) and Director of Staff Development (DSD). The facility administrator acknowledged these findings, highlighting a lapse in adherence to infection control protocols designed to prevent the spread of infections.
Food Safety and Sanitation Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to meet food safety and sanitary requirements in the kitchen, as observed during a survey. The ice machines were not properly cleaned, with white residue and hardened crusts noted on their surfaces. Ice scoopers were not stored in a manner that protected them from contamination, contrary to the facility's policy. Additionally, several food items, including boiled eggs, hoagie breads, fries, and milk, were found to be past their best-by dates, posing a risk of serving expired products to residents. The kitchen equipment and utensils were not maintained in a sanitary condition. Multiple cutting boards were heavily marred, and various utensils such as spatulas, frying pans, measuring cups, scoopers, and a peeler were observed with discoloration and residue. A hot tray transportation warmer also had brown streak residue inside. Furthermore, kitchen staff were not adhering to dress guidelines, as observed with staff not wearing hair and beard restraints, which could lead to contamination of food. Hand hygiene practices were not consistently followed by the kitchen staff. Instances were noted where staff entered the kitchen and handled food without washing their hands or changing gloves, increasing the risk of cross-contamination. Additionally, water liners were transported uncovered in the hallway, contrary to facility protocol. These deficiencies collectively had the potential to cause foodborne illnesses among the medically vulnerable resident population who consumed food prepared in the facility's kitchen.
Infection Control Deficiencies in Resident Care, Laundry, and Water Management
Penalty
Summary
The facility failed to implement proper infection control measures for a resident with shingles, as evidenced by the lack of adherence to contact and droplet precautions. A family member visiting the resident was observed wearing inadequate personal protective equipment (PPE), including an untied gown and personal eyeglasses instead of goggles, and was not wearing gloves. The family member was not informed of the necessary precautions before entering the room, and the signage indicating the required precautions was not noticed by the visitor. The Licensed Vocational Nurse (LVN) on duty did not ensure the visitor was properly instructed on the precautions, which could have prevented the spread of infection. In the laundry room, the facility failed to maintain infection control standards by allowing personal items, such as a cellphone and body lotion, to be present in the clean folding area. This was confirmed by the Laundry Aide, who acknowledged that the items belonged to her. The Housekeeping Manager stated that the clean folding area should be free of personal belongings to prevent contamination of linens and the spread of infection. The facility also failed to maintain accurate documentation of its water management program, specifically regarding testing protocols for Legionella and other opportunistic pathogens. The last documented risk assessment was completed in 2018, and there was no recent documentation available. The Director of Facilities confirmed this oversight, acknowledging that testing was conducted by an outside company. The Administrator also acknowledged the findings, indicating a lapse in maintaining the required documentation for infection control in the water systems.
Improper Cleaning of Kitchen Ice Machines
Penalty
Summary
The facility failed to ensure that two ice machines in the kitchen were properly cleaned according to the manufacturer's instructions, which could lead to unsanitary ice being served. The Hoshizaki Instruction Manual, revised in November 2018, specifies the use of a sanitizing solution containing 5.25% sodium hypochlorite solution (chlorine bleach) for cleaning. However, the facility's service provider, Ram Air Engineering, used a different sanitizing concentrate that did not contain the specified active ingredient. During an observation, white and brown residue and gray particles were noted inside the ice machines, indicating improper cleaning. Interviews with the Maintenance Staff and the Registered Dietitian (RD) confirmed that the facility relied on an outside company to clean the ice machines every six months. The RD verified that the sanitizing solution used by the service provider did not comply with the Hoshizaki Instruction Manual's requirements. The Director of Nursing (DON) acknowledged these findings and confirmed that the current instructions from the manual should be followed to ensure the ice machines are properly sanitized.
Failure to Conduct Entrapment Assessments for Bed Rails
Penalty
Summary
The facility failed to ensure that entrapment assessments were completed and measurements were recorded during bed inspections for residents using bed rails. This deficiency was identified for 16 out of 53 residents who had bed rails, posing a potential risk of entrapment, serious injury, or death. The facility's policy required assessments to be conducted prior to the installation of bed rails, and periodically thereafter, to ensure the safety of residents. However, observations and interviews revealed that these assessments were not performed, and the necessary measurements were not documented. Several residents, including those with cognitive impairments and those requiring assistance with mobility, were observed using bed rails without documented evidence of entrapment assessments. Interviews with CNAs and LVNs confirmed the use of bed rails for mobility and repositioning, but also highlighted that the entrapment assessments were not part of the bed rail assessment process. The Director of Facilities admitted to not being familiar with the entrapment zones and confirmed that bed inspections were only conducted upon resident discharge and quarterly, rather than upon admission or as needed. The facility's documentation, including Bed Maintenance and Inspection forms, lacked evidence of entrapment zone assessments. The Director of Facilities acknowledged the absence of such documentation and the lack of knowledge regarding the use of the Bionix safety measuring device. The DON and Administrator were informed of these findings, which underscored the facility's failure to adhere to its own policies and procedures regarding bed rail safety and entrapment prevention.
Failure to Obtain Informed Consent for Psychotropic Medication and Side Rail Use
Penalty
Summary
The facility failed to ensure that Resident 43, who was deemed incapable of making medical decisions, was provided the right to self-determination regarding the use of psychotropic medication and side rails. Specifically, the facility did not obtain informed consent from Resident 43's responsible party for the use of side rails and the administration of alprazolam, an antianxiety medication. The facility's policies and procedures require informed consent to be obtained from the resident or their representative before initiating treatment with psychotropic drugs or installing side rails, but these protocols were not followed. Observations and medical record reviews revealed that Resident 43 was using bilateral 1/4 side rails without documented consent from a responsible party. Additionally, there was no evidence of informed consent for the use of alprazolam in the resident's medical records. Interviews with RN 1 and the DON confirmed these findings, indicating that the consent for bed rail use was incorrectly obtained from Resident 43, who lacked decision-making capacity, and that the consent for alprazolam was only signed by the physician and uploaded to the electronic medical record after the medication had already been administered.
Failure to Obtain and Maintain Advance Directives
Penalty
Summary
The facility failed to obtain and maintain copies of advance directives for six residents, which are legal documents stating a person's wishes about receiving medical care if they are no longer able to make decisions. This deficiency was identified through interviews, medical record reviews, and facility policy and procedure reviews. Specifically, the facility did not have copies of advance directives for Residents 8, 37, 43, 44, 320, and 669, despite acknowledgments in their records indicating that these documents existed and should have been provided to the facility. For Residents 8, 37, 43, and 669, the medical records showed that they had executed advance directives, but the facility failed to obtain or document attempts to obtain these directives. Interviews with the Social Services Designee confirmed that although these residents had advance directives, there was no follow-up to secure copies for the facility's records. Additionally, for Residents 44 and 320, the facility not only failed to obtain advance directives but also did not complete the POLST forms, which are crucial for documenting medical orders for life-sustaining treatment. The facility's policy on advance directives requires verification and modification of these documents upon admission, ensuring that residents' healthcare preferences are respected. However, the facility did not adhere to this policy, as evidenced by the incomplete documentation and lack of follow-up. Interviews with the Director of Nursing and other staff confirmed these findings, highlighting a systemic issue in managing advance directives and POLST forms, which could potentially lead to residents' healthcare decisions not being honored.
Failure to Provide Individualized Activity Program
Penalty
Summary
The facility failed to provide an individualized and ongoing activity program to meet the needs and interests of a resident with severe cognitive impairment. The resident, who was admitted for short-term therapy, expressed interest in group and independent activities such as watching TV, visitations, planting orchids, fishing, camping, and music-related activities. However, the facility only documented the resident's participation in activities on three occasions since admission, and there was no evidence of daily activities being provided to meet the resident's identified interests. Observations revealed the resident often remained in bed without sensory stimulation, and interviews with staff indicated a lack of consistent activity engagement. The Director of Activities acknowledged the resident's limited participation and the absence of documented evidence for daily activities, such as providing the Daily Chronicles or turning on the TV. The resident's care plan included encouraging independent activities, but the facility did not adequately document or implement these interventions, leading to potential social isolation and frustration for the resident.
Medication Administration and Monitoring Deficiencies
Penalty
Summary
The facility failed to provide appropriate medication administration for Resident 621, as observed during a medication administration session. LVN 3 did not adhere to the physician's order to administer furosemide 30 minutes before spironolactone-hydrochlorothiazide, instead giving both medications simultaneously. This oversight was confirmed during an interview with LVN 3, who acknowledged the error in following the prescription instructions. For Resident 37, the facility did not comply with the physician's order to notify the physician of significant weight changes. The resident experienced weight fluctuations of three pounds on multiple occasions, which should have triggered a notification to the physician as per the order. However, the medical records showed no evidence that the physician was informed of these changes, as verified by the DON during a review of the resident's records. Resident 52's care was compromised when the licensed nurse failed to document blood pressure readings before and after administering clonidine hydrochloride, a medication prescribed for hypertension. The medication was given as needed for high systolic blood pressure, but the necessary documentation to justify its administration and assess its effectiveness was missing. This lapse was acknowledged by the IP and the DON during interviews and record reviews.
Failure in Controlled Medication Reconciliation and Disposal
Penalty
Summary
The facility failed to provide adequate pharmaceutical services, specifically in the reconciliation and disposal of controlled medications for two residents. For one resident, a bubble pack of morphine was found with 10 tablets, but the controlled drug record indicated that 11 tablets should have been present after one was removed. Similarly, a bubble pack of oxycodone/acetaminophen was found with 103 tablets, while the record showed 104 tablets should have been present after one was removed. The Licensed Vocational Nurse (LVN) responsible admitted to not signing the controlled drug record or the Medication Administration Record (MAR) immediately after administering the medications, which is against the facility's policy. For another resident, a bubble pack of hydrocodone/acetaminophen was found in the medication cart despite the medication being discontinued. The LVN confirmed that the medication should not have been in the cart as it was discontinued. The Director of Nursing (DON) stated that nurses are required to remove discontinued medications at the end of their shift and bring them to the DON, or if discontinued on a weekend, remove them the following weekday. These lapses in procedure had the potential for drug diversion and medication errors.
Failure to Adhere to Medication Administration Parameters
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary medications, as evidenced by the administration of medications outside of the physician's ordered parameters. Resident 2 was prescribed losartan potassium to manage hypertension, with specific instructions to hold the medication if the systolic blood pressure (SBP) was less than 120 mmHg. However, the medication was administered on multiple occasions when Resident 2's SBP was below this threshold, with readings as low as 110/61 mmHg. This oversight was confirmed during an interview with the Infection Preventionist (IP) and acknowledged by the Director of Nursing (DON). Similarly, Resident 56 was prescribed midodrine hydrochloride for hypotension, with instructions to hold the medication if the SBP exceeded 110 mmHg. Despite this, the medication was administered on several occasions when the SBP was above the specified limit, with readings reaching as high as 132/79 mmHg. This error was verified by LVN 6 during a concurrent interview and medical record review, and the findings were also acknowledged by the DON. These failures indicate a lack of adherence to physician orders, potentially exposing the residents to unnecessary medications and associated side effects.
Failure to Monitor Side Effects of Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic drugs, specifically alprazolam, an antianxiety medication. The facility's policy required documentation of the resident's response to the medication, including progress towards goals and the presence or absence of adverse consequences. However, the medical record for the resident did not show documented evidence of monitoring for side effects related to the use of alprazolam. This oversight was confirmed during an interview with RN 1, who acknowledged the lack of documentation for side effect monitoring. The resident in question was admitted to the facility with no capacity to understand and make decisions. A physician's order was in place for alprazolam to be administered as needed for anxiety, and the medication was given on a specific date. The resident's care plan included interventions to monitor behaviors and side effects every shift, but the facility did not adhere to this plan. The failure to monitor side effects posed a potential risk to the resident's well-being, as the facility did not follow its own policy and procedures regarding the use of psychotropic drugs.
Improper Medication Storage and Labeling
Penalty
Summary
The facility failed to ensure proper storage, labeling, and disposal of medications, posing a risk for cross-contamination. During an inspection of Medication Room A, it was observed that orally administered medications were not stored separately from externally used medications. Specifically, Fever All suppositories were stored with oral loperamide tablets, DHEA mood and stress tablets were stored with eye drops, and nasal moisturizing spray was stored with earwax removal drops. These findings were verified by RN 1. Additionally, disinfectant wipes were not stored separately from medications and treatment supplies. In Medication Cart A, hand sanitizing wipes were stored with ammonia lactate lotion, Optifoam Gentle EX, and tubular elastic retainer net dressing. In Medication Cart B, germicidal disinfectant wipes were stored with NexTemp thermometer strips and a spill kit. Furthermore, a bottle of potassium chloride on Medication Cart C was found with sticky residue around its neck. These storage issues were confirmed by LVN 2 and LVN 3, respectively. The DON acknowledged the improper storage practices and emphasized the need for separate storage of orally administered and external medications.
Failure to Follow Pureed Diet Recipes
Penalty
Summary
The facility failed to ensure that pureed recipes were followed for three residents who were on a pureed diet. Specifically, the pureed recipes for biscuits and rice were not adhered to, which could potentially result in not providing nutritional meals that meet the residents' needs. The facility's policy and procedure for meal/tray assembly, revised in January 2024, requires that meals are prepared accurately to preserve nutrient content and that the current diet spreadsheet is followed at each meal period. However, during an observation on September 11, 2024, it was noted that the staff member responsible for preparing the pureed meals did not follow the recipes as outlined. During the preparation of pureed biscuits, the staff member added 34 oz of hot water to the blended biscuits, and for the pureed rice, 8 oz of hot water was added, deviating from the specified recipes. The staff member confirmed that no recipe was followed during the preparation. Subsequent interviews with the Registered Dietitian (RD), Dietary Services Supervisor (DSS), Executive Chef, and Director of Nursing (DON) confirmed the findings and acknowledged that the recipes should have been followed as per the instructions.
Failure to Provide Palatable Food
Penalty
Summary
The facility failed to ensure that the food provided to four residents was palatable, specifically regarding the texture of green beans served during dining observations. Residents 17, 26, 39, and 65 all reported that the green beans were tough and not easy to chew, which did not meet the dietary requirements for their respective diets. These observations were confirmed by staff, including a Licensed Vocational Nurse (LVN) and a Registered Dietitian (RD), who acknowledged the issue with the texture of the green beans. Resident 17, who had the capacity to understand and make decisions, was on a regular diet with an easy-to-chew texture requirement. Resident 26, who lacked decision-making capacity, was on a no-restriction diet with the same texture requirement. Resident 39, with fluctuating decision-making capacity, was on a no-added-salt diet with regular texture requirements. Resident 65, who was on a regular diet, also found the green beans tough and refused to eat them. The facility's policy on modified texture foods was not adhered to, as the green beans did not meet the required easy-to-chew texture, potentially affecting the residents' nutritional intake.
Deficiency in Food Safety Policy and Visitor Education
Penalty
Summary
The facility failed to update its policy and procedures (P&P) regarding the use and storage of foods brought to residents by family and visitors, as well as to educate visitors on safe food handling practices. The facility's P&P, revised in July 2023, acknowledged the right of residents to receive food from outside sources but required that such food be for immediate consumption. However, the facility did not have a designated refrigerator for resident use, as confirmed by the Registered Dietitian (RD) and the Director of Nursing (DON). This lack of proper storage facilities for perishable food items brought by visitors could potentially lead to foodborne illnesses among the medically vulnerable resident population. Additionally, the facility did not provide visitors with information on safe food handling practices, such as maintaining perishable foods at temperatures below 41 degrees Fahrenheit. The RD confirmed that visitors were informed that food should be for immediate consumption but were not educated on safe handling practices, including proper hand hygiene. The DON acknowledged these findings, indicating a gap in the facility's responsibility to ensure food safety for residents consuming food from outside sources.
Violation of Resident Privacy and Confidentiality
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of residents' personal and medical records by allowing the Director of Activities to use her personal cell phone to take pictures of residents during activities. This action was in direct violation of the facility's policy and procedure (P&P) titled 'Resident Photos,' which was revised on 4/19/24. The policy clearly states that residents have a right to privacy and confidentiality, including through photographs, videos, and digital recordings, and that permission must be obtained from the resident or their representative before taking photographs during facility events. During an observation and interview on 9/12/24, the Director of Activities admitted to using her personal cell phone to take pictures of residents and staff during a scheduled activity. She acknowledged that she was not supposed to have pictures of residents on her personal device. The facility's P&P, revised on 4/5/24, also prohibits employees from using personal cell phones while on the clock, except during meal or rest breaks. The Administrator confirmed that the facility provides devices such as Apple tablets and cell phones for staff use and that personal cell phones should not be used to take pictures of residents.
Failure to Remove CNA Pending Abuse Investigation
Penalty
Summary
The facility failed to remove a Certified Nursing Assistant (CNA 1) from resident care areas pending an alleged violation of abuse for a resident (Resident 1). According to the facility's policy and procedure (P&P) for reporting allegations of abuse, the accused employee should be removed from resident care areas and suspended pending the completion of the investigation. However, after Resident 1 reported that CNA 1 hit her left shoulder, CNA 1 was reassigned to care for another resident and remained at work until the completion of her shift. This was confirmed through interviews with CNA 1, LVN 3, and the Administrator, who acknowledged that CNA 1 was not sent home after the abuse allegation was reported. The incident was reported on a SOC 341 form, and the facility's Nursing Assignment Sheet showed that CNA 1 was assigned to different rooms, including Resident 1's room, on the day of the incident. The Administrator confirmed that the facility's protocol for abuse allegations involving staff members requires the alleged staff to be immediately excused from the facility and suspended pending the investigation. Despite this protocol, CNA 1 completed her shift and clocked out at 2251 hours on the day of the incident. The Administrator acknowledged the potential risk of having the alleged perpetrator remain in the facility, which could create an opportunity for retaliation against the victim.
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Nursing homes near Santa Ana
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Orange Healthcare & Wellness Centre, Llc | 0.5 mi | — | 24 | 0 |
| Mainplace Post Acute | 0.7 mi | — | 29 | 0 |
| French Park Care Center | 1.2 mi | — | 10 | 0 |
| Healthbridge Children's Hospital - Orange D/p Snf | 1.3 mi | — | 0 | 0 |
| The Hills Post Acute | 1.3 mi | — | 0 | 0 |
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