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 Azria Health Park Place during CMS and state inspections, most recent first.
The facility failed to maintain kitchen sanitation and pest control, resulting in extensive water damage, pest infestations, and unsanitary food storage and preparation areas. Staff reported daily sightings of mice, cockroaches, and flies, with years of accumulated grime and recurring flooding making cleaning difficult. Cleaning logs were missing or outdated, and multiple residents and staff experienced gastrointestinal symptoms, including diarrhea and vomiting, which some attributed to the food served. Food containers were found contaminated with mouse droppings and dead maggots, and expired food was served to residents.
Surveyors found the facility failed to provide a clean, comfortable, and homelike environment, with observations of mold, musty odors, soiled mattresses and linens, water damage, and pest activity. There were repeated shortages of appropriately sized briefs, gloves, wipes, and linens, leading staff to use makeshift solutions and leaving residents in soiled conditions. Staff and residents reported infrequent cleaning, persistent odors, and confusion over cleaning responsibilities, all contributing to an environment that did not meet required standards.
The facility did not provide enough nursing staff to meet residents' needs for toileting and timely call light response, resulting in multiple residents waiting extended periods for assistance, including one left on the toilet for half an hour and another in a soiled brief. Staff and resident interviews, as well as facility records, confirmed frequent delays and inadequate staffing, with reliance on agency and management staff to fill gaps. Call light response times often exceeded the expected 15 minutes, and ongoing concerns were documented in resident council meetings and grievance logs.
Facility leadership failed to ensure adequate supplies of incontinence products and linens, resulting in staff using makeshift solutions for resident care. Multiple staff and residents reported persistent shortages, unclean resident rooms, and a kitchen infested with mice, cockroaches, and flies. The kitchen and other facility areas suffered from structural disrepair, flooding, and foul odors, with management often unaware or unresponsive to ongoing issues reported by staff.
The facility was repeatedly cited for infection control and homelike environment deficiencies, with QAPI meeting minutes showing ongoing discussion of the same issues without documented follow-through or resolution. The DON could not explain the lack of follow-through, and the RDO confirmed that previous leadership did not implement the QAPI plan as required.
Staff failed to follow infection control protocols during resident transfers and incontinence care, including not changing gloves or sanitizing hands between tasks, using a mechanical lift sling from another resident's room without sanitizing it, and not utilizing Enhanced Barrier Precautions for a resident with an indwelling catheter. These actions were inconsistent with facility policy and standard precautions.
Staff failed to lock bed brakes while providing care to a resident with significant mobility impairments, resulting in the bed moving and the resident expressing fear of falling. Additionally, staff did not follow manufacturer instructions for mechanical lift use during transfers for two residents, including improper sling attachment and incorrect positioning of the lift's leg bar. Facility policies and competency checks were found lacking in guidance and oversight for safe transfer practices.
The facility failed to protect residents from abuse, as evidenced by incidents involving rough handling and threatening behavior by a CNA. Despite complaints, the CNA continued to work without immediate suspension or investigation. The facility's delayed response and inadequate implementation of abuse policies placed residents at risk.
The facility failed to maintain a homelike environment by allowing clutter in the hallways of both the North and South Halls, leading to safety hazards and resident conflicts. Equipment such as mechanical lifts, carts, and wheelchairs obstructed passage, causing residents in wheelchairs to argue and staff to intervene. A surveyor also tripped over an open mechanical lift leg. The facility lacked specific policies for equipment storage and wheelchair transport, contributing to the unsafe conditions.
The facility was found to have significant sanitation and food safety deficiencies. Staff were observed handling food without proper hygiene, such as not washing hands and using bare hands to serve food. The kitchen had unsanitary conditions, including unlabeled and undated food items, improper hair net usage, and broken equipment. A container of strawberries was found spoiled, indicating poor adherence to food storage policies. The dietician and DON confirmed the need for proper sanitation practices.
The facility failed to report abuse allegations involving three residents in a timely manner, leading to an Immediate Jeopardy situation. One resident reported rough treatment during pericare, while another was allegedly handled roughly and threatened by a CNA during a transfer. Delays in reporting these incidents to authorities violated facility policies and placed residents at risk.
The facility experienced significant delays in responding to resident call lights, with documented response times often exceeding 20 minutes and sometimes extending over an hour. Resident council meetings and interviews highlighted ongoing concerns about these delays, particularly during weekends and night shifts. Despite efforts to maintain adequate staffing and improve response times, the facility's policy expectation of answering call lights within 15 minutes was not consistently met.
The facility failed to provide required Medicare Liability Notices and Beneficiary Appeals forms to three residents within the mandated 48-hour window after the end of skilled services. Two residents did not receive the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN), and one resident's SNFABN lacked the necessary cost disclosure.
A facility failed to accurately document a resident's discharge destination in the MDS assessment, indicating a hospital discharge instead of a community setting. The error was acknowledged by the Social Worker, who suggested it might have been due to the resident's initial hospital admission.
A facility failed to update the PASRR level 1 screening for a resident with moderate cognitive impairment and multiple diagnoses, including a delusional disorder. The resident's care plan and medication records indicated changes in treatment that required a new PASRR screening, which was not submitted. The oversight was acknowledged by the facility's social worker and regional nurse consultant.
The facility failed to track and document behaviors for residents on psychiatric medications, leading to discrepancies in records. A resident with moderate cognitive impairment and multiple diagnoses was on antipsychotic therapy, but the care plan lacked specific behavioral interventions. Another resident with similar impairments had inconsistent documentation of behaviors in the MAR and EHR. A third resident with intact cognition had discrepancies between nursing notes and the EHR. Staff interviews revealed a lack of awareness of behavior monitoring duties.
A resident with Diabetes Mellitus did not receive insulin correctly due to an LPN's failure to follow proper procedures. The LPN did not prime the insulin pen, hold it to the skin for the recommended time, or perform hand hygiene. Interviews with staff confirmed these steps were not followed, which could result in incomplete medication administration.
Widespread Kitchen Sanitation and Pest Control Deficiencies
Penalty
Summary
The facility failed to maintain the kitchen in a safe and hygienic manner, resulting in unsanitary conditions and pest infestations. Direct observations revealed significant water damage in the kitchen and basement, including missing and collapsing ceiling tiles, moist surfaces, and water beading near food preparation areas. The kitchen floor was covered in sticky substances and food particles, with blackened grout in high-traffic areas. Multiple sticky traps containing rodent droppings, fur, and insects were found near dry storage, and peaches past their expiration date were served to residents. Small worm-like insects and insect eggs were observed in floor drains filled with food debris, and rodent droppings were found under and in front of the oven. Mold-like substances were present on sponges and in floor drains, and kitchen equipment was covered in grime. Unlabeled and open bags of food were found in freezer units. Staff interviews confirmed ongoing issues with rodents, cockroaches, ants, and flies in the kitchen, with several staff members reporting daily sightings of mice and expressing frustration over the lack of management response. Staff described the kitchen as extremely dirty and difficult to clean, with years of accumulated grime and recurring flooding during heavy rain. Cleaning logs were missing or incomplete, with the last documented logs dating back several months. The pest control contractor's records noted ongoing sanitation issues, such as standing water and accessible garbage, but did not document pest activity, which was inconsistent with staff and resident reports. The dietary manager and other staff confirmed frequent rodent activity, including the discovery of mouse nests and droppings in food storage areas. Residents and staff reported an increase in gastrointestinal symptoms, including diarrhea and vomiting, over the past month. Several residents and staff attributed these symptoms to the food served at the facility, with some residents reporting persistent diarrhea since admission. The infection preventionist did not track single-day episodes of gastrointestinal symptoms, but surveillance records documented multiple cases of diarrhea, vomiting, and abdominal pain, including one resident hospitalized with colitis. The kitchen and storage areas were found to have food containers contaminated with mouse droppings, dead maggots, and sticky residues, further indicating a failure to protect food from contamination and maintain sanitary conditions.
Failure to Maintain Clean, Homelike Environment and Adequate Resident Care Supplies
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment for its residents, as evidenced by multiple observations of unsanitary and unsafe conditions throughout the building. Surveyors noted the presence of black substances resembling mold and dirt in air conditioning vents, musty odors, missing wall bases, stained and soiled mattresses and linens, and evidence of water damage such as caved-in ceilings and water-stained walls. The North and South Halls, shower rooms, laundry, and basement areas all exhibited significant cleanliness and maintenance issues, including cracked tiles, biofilm in drains, missing non-skid strips, and the presence of mouse droppings and flies. Residents and staff reported persistent odors of urine and infrequent cleaning of rooms and equipment, with some residents lying in soiled beds and reporting that their rooms were not cleaned regularly. The facility also failed to maintain adequate supplies of personal care items and linens. Observations revealed repeated shortages of appropriately sized briefs, gloves, cleansing wipes, and linens in both the North and South Hall supply rooms, as well as the central supply area. Staff interviews confirmed that shortages were frequent, with staff sometimes resorting to makeshift solutions such as stapling briefs together or using washcloths in place of wipes. Staff reported that supplies often ran out before new shipments arrived, and that communication about supply needs did not always result in timely restocking. Residents corroborated these accounts, stating that they were sometimes left in soiled conditions due to lack of supplies, and that the facility often ran short on briefs and other essentials, especially toward the end of the week. Interviews with staff and residents further highlighted the impact of these deficiencies. Residents described being dressed in wet beds, smelling of urine, and seeing mice in their rooms. Staff reported confusion over responsibilities for cleaning mattresses and equipment, and housekeeping staff indicated that they did not clean mattresses or strip linens. The facility's policies required a clean, sanitary, and homelike environment, but observations and interviews demonstrated that these standards were not being met. The lack of adequate supplies and poor environmental maintenance directly contributed to the failure to honor residents' rights to a safe and comfortable living environment.
Failure to Provide Sufficient Staff for Timely Resident Assistance
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, particularly in the areas of toileting assistance and timely response to call lights. Multiple observations documented residents waiting extended periods for assistance, including one resident with a history of hip fracture and impaired mobility who was left sitting on the toilet for half an hour with her catheter bag improperly positioned, and another resident who waited in a soiled brief for staff to assist with changing. Call lights were observed to be activated for prolonged periods without response, and residents and their roommates reported repeatedly calling for help without timely staff intervention. Interviews with residents revealed consistent concerns about delayed responses to call lights, with some reporting waits of up to two hours for assistance with transfers and personal care. Residents described staff placing multiple briefs on them to reduce the frequency of changes, which caused discomfort. Staff interviews confirmed that staffing levels were inadequate, with frequent reliance on agency staff and management personnel filling in for direct care roles. Staff reported being called to work extra hours and noted that most residents required assistance from two staff members, especially for transfers involving mechanical lifts. Review of facility records, including call light response reports, resident council meeting notes, and the facility assessment, corroborated the observations and interviews. Call light response times frequently exceeded the facility's 15-minute expectation, with some instances documented at over an hour. Resident council notes and grievance logs indicated ongoing concerns about call light response times, with multiple residents expressing dissatisfaction over several months. The facility assessment acknowledged the high acuity and dependency of the resident population, but staffing plans and actual staffing levels did not consistently ensure timely care and response to resident needs.
Failure to Maintain Adequate Supplies, Cleanliness, and Pest Control
Penalty
Summary
Facility leadership failed to provide adequate management, resulting in insufficient incontinent and linen supplies, unclean resident environments, and a kitchen infested with vermin. Observations revealed black substances on air conditioner vents, missing wall bases, stained and unmade beds, foul odors, and minimal supplies in utility rooms. Staff interviews confirmed frequent shortages of gloves, wipes, and briefs, with staff resorting to makeshift solutions such as using washcloths or tying pull-ups to fit residents. Residents and staff reported running out of clean linens regularly, and soiled linens with deep stains were observed, some of which could not be cleaned and had to be discarded. Multiple staff and residents reported ongoing pest infestations, including mice, ants, cockroaches, and flies, particularly in the kitchen and resident rooms. The kitchen was described as extremely dirty, with years of accumulated grime, frequent flooding, and evidence of rodent nests and droppings. Staff reported that management was repeatedly informed of these issues, but little to no action was taken. The kitchen also suffered from structural issues such as leaking ceilings and standing water, and cleaning documentation was lacking or unavailable. Housekeeping and maintenance concerns extended to other facility areas, with reports of leaking ceilings, water-stained walls, and mice droppings found on laundry. Staff and residents noted that rooms were not cleaned frequently enough, and pest issues were downplayed by management. Leadership, including the Acting Administrator and Regional Director of Operations, were often unaware of the extent of the problems, citing lack of staff reporting and infrequent presence in affected areas. The facility's failure to maintain a clean, safe, and adequately supplied environment was corroborated by resident council meeting notes and multiple staff and resident interviews.
Failure to Address Repeated Quality Deficiencies in QAPI Process
Penalty
Summary
The facility failed to ensure an effective process for addressing previously identified quality deficiencies, as evidenced by repeated citations for infection control and maintaining a safe, clean, and homelike environment in both 2023 and 2024. Despite the facility's QAPI plan outlining a monitoring process using multiple data sources, it did not specify a method for addressing recurring deficiencies. Review of QAPI meeting minutes since November 2024 revealed that the same issues were repeatedly discussed without documented follow-through or resolution. During interviews, the DON, who serves as the acting QAPI designee, was unable to explain the lack of follow-through or documentation regarding these repeated issues, and the RDO acknowledged that previous leadership had not implemented the QAPI plan as intended.
Failure to Follow Infection Control Practices During Resident Care and Transfers
Penalty
Summary
Surveyors identified multiple failures in infection prevention and control practices during direct observation, record review, and staff interviews. Staff were observed transferring a resident with an indwelling catheter using a mechanical lift sling taken from another resident's room without sanitizing it, and without utilizing Enhanced Barrier Precautions (EBP) as required for residents with indwelling medical devices. Staff interviews confirmed that EBP should have been used during such high-contact activities, and that each resident should have their own clean sling or a properly sanitized one if shared. In another instance, staff provided incontinence care to a resident with chronic conditions including a left above-knee amputation and moisture-associated skin disorder. During care, staff failed to consistently change gloves and sanitize hands between tasks, and handled clean supplies and equipment with contaminated gloves. Soiled linens were placed on top of a trashcan in the resident's room, and the mechanical lift was wheeled to a common area after use, raising concerns about environmental contamination. Additionally, staff were observed providing pericare to a resident with dementia and incontinence without changing gloves or sanitizing hands between dirty and clean tasks. Interviews with the Infection Preventionist, Director of Nursing, and other nursing staff confirmed that facility policy requires glove changes and hand hygiene between tasks and after glove removal, as well as disinfection of equipment between residents. These lapses were inconsistent with the facility's own infection control policies and standard precautions.
Failure to Lock Bed Brakes and Improper Mechanical Lift Use During Resident Transfers
Penalty
Summary
Staff failed to lock the brakes on a resident's bed while providing incontinence care and repositioning, resulting in the bed moving during the process. The resident, who had a history of left above-the-knee amputation, fracture, muscle weakness, morbid obesity, and anxiety disorder, was dependent on staff for transfers and had a documented risk for falls. During the observed care, the resident expressed concern about falling, and the Regional Nurse present confirmed that the bed brakes were not engaged and that the resident was positioned close to the edge of the bed. Additionally, staff did not operate a mechanical lift according to manufacturer instructions during transfers for two residents. In one instance, the sling strap was looped around the armrest of a wheelchair, requiring adjustment while the resident was suspended in the lift. The mechanical lift's leg bar was not spread as recommended by the manufacturer during the transfer, and the lift encountered obstacles under the bed. The staff involved did not demonstrate competency in the safe use of the mechanical lift, and the facility's policy lacked specific guidance on the correct positioning of the lift's leg bar during transfers. Interviews with facility leadership confirmed that staff were expected to follow manufacturer instructions for mechanical lifts, but there had been no recent competency audits or survey preparation related to transfers. The facility's observation form for lift/transfer safety did not include detailed steps for using mechanical lifts, and the relevant policies did not address the specific issues observed during the transfers.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from abuse, as evidenced by incidents involving three residents. One resident reported experiencing pain after pericare was performed by a CNA, who was described as rough. Despite the resident's complaint, the CNA continued to work without immediate suspension or investigation. The resident's care plan noted a history of false allegations, but the facility did not take immediate action to ensure the resident's safety or investigate the claim thoroughly. Another incident involved a CNA reportedly using excessive force while repositioning a resident and making threatening statements. The CNA continued to work with residents until the incident was reported to the DON two days later. The resident involved had communication deficits, making it difficult to ascertain the full extent of the incident. The facility's delayed response and failure to immediately suspend the CNA placed residents at risk. The facility's investigation into these incidents was inadequate, as staff continued to work without proper oversight or immediate action. The facility's policies on abuse and neglect were not effectively implemented, leading to a situation where residents were not adequately protected from potential harm. The lack of timely reporting and investigation of abuse allegations contributed to the deficiency.
Removal Plan
- All facility staff education provided on Abuse and Neglect Standards and Reporting.
- The facility will continue to educate facility staff on Abuse and Neglect upon hire, as needed, and increase education associated with abuse scenario training monthly.
- Residents were interviewed related to abuse concerns.
- All active employee files were reviewed for mandatory abuse education and disciplinary actions associated with allegations or potential abuse/neglect.
Cluttered Hallways and Lack of Policies Lead to Unsafe Environment
Penalty
Summary
The facility failed to ensure a homelike environment and reduce clutter in the hallways of both the North and South Halls, which led to several incidents involving residents and staff. Observations revealed that equipment such as mechanical lifts, shower chairs, PPE bins, trash and soiled laundry carts, medication carts, treatment carts, and wheelchairs were parked along the hallways and handrails, obstructing passage. On multiple occasions, residents in wheelchairs were unable to pass each other due to the clutter, resulting in arguments and the need for staff intervention. Additionally, a surveyor tripped over an open mechanical lift leg in the South Hall, further highlighting the safety hazards posed by the cluttered environment. The facility lacked specific policies for equipment storage and transporting residents in wheelchairs, as confirmed by interviews with the Regional Corporate Nurse Consultant and the Regional Director of Operations. The Homelike Environment policy, revised in February 2021, stated that residents should be provided with a safe, clean, comfortable, and homelike environment, which was not upheld in this case. The absence of a policy for equipment storage and the improper use of wheelchairs without foot pedals contributed to the unsafe and cluttered conditions observed in the facility.
Sanitation and Food Safety Deficiencies in Facility
Penalty
Summary
The facility failed to maintain sanitary conditions in food storage and service, as observed during a survey. Staff C was seen serving dinner without washing her hands after licking her finger and touching her lips. Additionally, Staff D and Staff E were observed with improper hair net usage, allowing hair to hang outside the net. The kitchen inspection revealed several unsanitary conditions, including dried leaves and dirt on the floor, stained ceiling tiles, and unlabeled and undated food items in refrigerators and freezers. The facility's policies on food storage, preparation, and hygiene were not adhered to, as evidenced by the lack of proper labeling, dating, and storage of food items. Further observations showed that the dietary staff did not follow proper hygiene practices. Staff X and Staff T, both CNAs, were seen serving meals with their thumbs inside pudding bowls, and Staff X and Staff L handled dinner rolls with bare hands, applying butter and jelly without gloves. The facility's policies require gloves to be worn when handling ready-to-eat food and for gloves to be changed between tasks, which was not followed. The dietician and DON confirmed that staff should not have direct contact with residents' food without proper sanitation measures. The facility's equipment and storage areas were also found to be in poor condition. A refrigerator thermometer was broken, and the temperature was above the safe level for food storage. Unlabeled and undated food items, such as diced chicken and barbeque sauce, were found in the refrigerators and freezers. A container of strawberries in syrup was found to be spoiled, with visible mold and a foul smell, indicating it had been stored far beyond the recommended time. These findings highlight a significant lapse in maintaining food safety and hygiene standards as per the facility's policies.
Failure to Timely Report Abuse Allegations
Penalty
Summary
The facility failed to ensure timely reporting of abuse allegations involving three residents, leading to an Immediate Jeopardy situation. For one resident, an incident occurred where the resident reported feeling pain during pericare, alleging rough treatment by a CNA. Despite the resident's initial complaint, the nurse's assessment found no physical signs of abuse, and the resident later denied any pain. However, the incident was not reported to the Department of Inspections, Appeals, and Licensing (DIAL) until several weeks later, indicating a delay in the reporting process. Another incident involved a resident with cognitive impairments who was allegedly handled roughly by a CNA during a transfer. The CNA reportedly made threatening remarks to the resident, which were overheard by another staff member. This staff member did not report the incident immediately, leading to a delay in addressing the potential abuse. The resident later confirmed feeling rough handling but denied feeling unsafe. The delay in reporting this incident to the appropriate authorities further contributed to the Immediate Jeopardy finding. The facility's policies required immediate reporting of abuse allegations, but staff failed to adhere to these protocols. The incidents were not reported within the required timeframes, and staff involved continued to work with residents, potentially placing them at risk. The facility's failure to protect residents from abuse and ensure timely reporting of allegations resulted in a serious deficiency, necessitating immediate corrective actions.
Removal Plan
- All facility staff education on Abuse and Neglect Standards and Reporting initiated. Facility will continue to educate facility staff on Abuse and Neglect upon hire, as needed, and increase education associated with abuse scenario training monthly.
- Residents were interviewed related to abuse concerns.
- All active employee files were reviewed for mandatory abuse education and disciplinary actions associated with allegations or potential abuse/neglect.
- Progress notes, grievances, and critical events reviewed routinely by facility staff to identify potential abuse, neglect, and exploitation opportunities, and act upon these immediately. The facility implemented an event tracking log to review these items routinely, and allow key staff to view approaching timelines, and trend and track the events.
Delayed Call Light Response in LTC Facility
Penalty
Summary
The facility failed to respond to resident call lights in a timely manner, as evidenced by multiple instances of extended response times documented in resident council minutes, staff disciplinary records, and resident interviews. The resident council meetings consistently highlighted concerns about call light response times, with residents noting improvements but still expressing dissatisfaction. Staff disciplinary records for CNAs revealed repeated instances of call lights being left unanswered for over 20 minutes, with some response times extending to over an hour. Resident interviews corroborated these findings, with several residents reporting delays in receiving assistance, particularly during weekends and night shifts. The facility's policy on call light response, revised in September 2022, emphasized the importance of timely responses, yet the facility's staffing levels appeared insufficient to meet this standard consistently. The facility assessment indicated an effort to maintain adequate staffing, but the documented response times suggest that these efforts were not always successful. The Regional Director of Operations acknowledged the issue, noting that call light response times were part of the facility's Quality Assurance Performance Improvement process. Despite some improvements in response times since March 2024, the facility continued to experience significant delays, particularly during evening and night shifts. The Director of Nursing stated that the expectation was for call lights to be answered within 15 minutes, but this standard was not consistently met, as evidenced by the documented response times and resident feedback.
Failure to Provide Required Medicare Notices
Penalty
Summary
The facility failed to provide the required Medicare Liability Notices and Beneficiary Appeals forms to three sampled residents within the mandated 48-hour window after the end of skilled services. For Resident #26, the Notice of Medicare Non-Coverage (NOMNC) was issued and signed within the required timeframe, but the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) was missing. Similarly, for Resident #204, the NOMNC was signed by the power of attorney within the required window, but the SNFABN was not provided. Resident #205 received both the NOMNC and SNFABN within the required timeframe, but the SNFABN lacked the necessary disclosure of the cost of services if the resident chose to pay out of pocket. Interviews with the Regional Director of Operations and the President of Clinical Reimbursement revealed uncertainty as to why SNFABNs were not issued for Residents #26 and #204. The President of Clinical Reimbursement confirmed that Resident #205's SNFABN should have included the cost of services. The facility's policy states that SNFABNs are to be provided if the beneficiary intends to continue services and the Skilled Nursing Facility believes the services may not be covered under Medicare.
Inaccurate MDS Assessment Documentation
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessment tool for one resident, leading to a discrepancy in the documentation of the resident's discharge destination. The MDS assessment for the resident indicated that he was discharged to a short-term general hospital, while other documentation, including the Discharge Plan and Notice of Transfer Form, indicated that the resident was discharged to a waiver-based housing with home health. This inconsistency was identified during a review of the resident's records. Interviews with facility staff revealed that the President of Clinical Services, who signs off on MDS assessments, was unaware of the reason for the incorrect documentation and speculated that the Social Worker might have selected the wrong option. The Social Worker acknowledged the error, stating that the resident was not discharged to the hospital and suggested that the mistake might have occurred because the resident was initially admitted from a hospital. The Social Worker admitted that the discharge to a community setting should have been documented on the MDS.
Failure to Update PASRR Screening for Resident with Significant Change
Penalty
Summary
The facility failed to submit a new preadmission screening and resident review (PASRR) level 1 screening for a resident who experienced a significant change in condition. The resident, identified as having moderate cognitive impairment, had a history of stroke, non-Alzheimer's dementia, hemiparesis, seizure disorder, depression, and psychotic disorder. The resident's care plan, revised in November 2024, documented a delusional disorder and the use of antipsychotic and antidepressant therapy. The medication administration record for November 2024 showed daily use of Olanzapine and Venlafaxine. The original PASRR level 1 screening from August 2022 did not document the resident's delusional or psychotic disorder, nor did it document depression or a seizure disorder, despite the resident's current treatment with Olanzapine. The facility's policy required a new PASRR screening if there was a significant change in treatment needs. The regional nurse consultant confirmed that the facility did not have an updated PASRR, and the social worker acknowledged that the change in treatment and diagnosis required a resubmission, which was overlooked during the resident's reevaluation.
Inadequate Behavioral Documentation for Residents on Psychotropic Medications
Penalty
Summary
The facility failed to adequately track and document behaviors for residents taking psychiatric medications, as evidenced by discrepancies in the records of three residents. Resident #32, with moderate cognitive impairment and multiple diagnoses including stroke and psychotic disorder, was on antipsychotic and antidepressant therapy. The care plan directed staff to use non-drug approaches but did not specify the behaviors or interventions. The Medication Administration Record (MAR) and nursing progress notes documented behaviors on various dates, yet the electronic health record (EHR) showed no behaviors, indicating a lack of consistent documentation. Resident #11, also with moderate cognitive impairment and psychiatric diagnoses, was receiving psychotropic medication. The care plan mentioned non-drug approaches but lacked specifics. The MAR included medications for psychiatric conditions but did not document non-pharmacological interventions for behavioral issues. Nursing progress notes and the EHR lacked consistent documentation of behaviors, with only one entry in the EHR noting no behaviors observed. Resident #24, with intact cognition and psychiatric diagnoses, was on psychotropic medication therapy. The care plan noted manipulative behavior but did not specify non-drug interventions. The MAR documented anxious behaviors on one day, while nursing progress notes recorded behaviors on multiple days, with specific behaviors noted only once. The EHR contained no documentation of behaviors, showing a discrepancy with the nursing progress notes. Interviews with staff revealed a lack of awareness and understanding of behavior monitoring responsibilities, contributing to the deficiency.
Failure to Administer Insulin Correctly
Penalty
Summary
The facility failed to administer insulin correctly to a resident with Diabetes Mellitus, leading to a significant medication error. During a medication pass, an LPN was observed administering insulin Lispro using a pen-injector without performing necessary steps such as priming the pen and purging two units of insulin to ensure it was functioning properly. The LPN also did not hold the pen to the resident's skin for the recommended duration to ensure complete administration of the medication. Additionally, the LPN did not perform hand hygiene before preparing the medication, which is a critical step in preventing contamination and ensuring patient safety. Interviews with the Regional Corporate Nurse Consultant and the Director of Nursing revealed that the LPN did not follow the manufacturer's instructions for the insulin pen, which included priming the pen and holding it to the skin for at least five seconds. The Director of Nursing stated that the expectation is for staff to follow these guidelines, and the Licensed Pharmacist confirmed that failure to perform these steps could result in the resident not receiving the full dose of medication. The manufacturer's insert for the Lispro pen injector also outlined these steps as necessary for safe and effective usage.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 241 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Des Moines
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Trinity Center At Luther Park | 0.8 mi | — | 17 | 1 |
| Rehabilitation Center Of Des Moines | 0.9 mi | — | 14 | 0 |
| University Park Nursing And Rehabilitation Center | 1.3 mi | — | 4 | 0 |
| Valley View Village | 2.1 mi | — | 4 | 0 |
| Ramsey Village | 2.4 mi | — | 4 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.