Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Alameda Care Center during CMS and state inspections, most recent first.
Kitchen food safety practices were not followed when a KA was observed without a hair net, several refrigerated and frozen food items had no delivery or open dates, and the Ice Scoop Cleaning Log was missing required time and initials entries. The DS stated hair nets are required, food items must be dated and labeled, and the ice scoop must be cleaned and documented daily.
Incomplete informed consent for psychotropic medication: A resident with severely impaired cognition and no decision-making capacity received Mirtazapine for depression, but the psychotropic drug consent form was missing both the physician’s signature and the LPN/LVN name and signature. The LVN and DON both confirmed the form was incomplete, while facility policy required prescriber and nurse signatures to document that the resident or responsible party was informed and consented to the antidepressant treatment.
The facility failed to provide written information and assistance regarding advance directives for two residents. One resident had dementia and lacked decision-making capacity, and the other had severe cognitive impairment, pulmonary fibrosis, and no documented AD or CPR status. Staff interviews confirmed that written AD materials were not provided to residents or responsible parties, and one responsible party was not followed up with after an initial email inquiry.
Open EHR Left Visible During Medication Pass: An LVN left a laptop open on a med cart in the hallway while administering meds in residents’ rooms, allowing two residents’ medication information to remain visible. One resident had dementia and mood disorder with severely impaired cognition, and the other had schizoaffective disorder and seizure disorder with severely impaired cognition. The DON stated residents have the right to privacy of their medical records, and the LVN acknowledged the screen should not have been left open and visible.
Failure to Release Wheelchair Restraint During Mealtime: A resident with Parkinson’s disease and dementia was observed seated in a wheelchair with a non-self-release belt fastened during mealtime while being fed by a CNA. The physician’s order and care plan directed that the restraint be released every 2 hours for ADL care, activities, and mealtimes, but the CNA stated she forgot to remove it. An LVN and the DON confirmed the restraint should have been released during mealtime and that the care plan was not followed.
MDS Did Not Reflect Resident’s Depression Diagnosis: A resident’s Face Sheet and psychiatric notes documented major depressive disorder, but the MDS did not list depression in Active Diagnoses. The MDS Coordinator and DON both confirmed the omission and stated the MDS was not accurately coded, while the resident’s cognition was severely impaired and the resident lacked capacity to understand and make decisions.
A resident with unspecified dementia and schizoaffective disorder had a PASRR Level I screen that identified a serious mental disorder, but the facility did not follow up to obtain a PASRR Level II evaluation after the resident had been isolated during the COVID-19 period. The DON stated the facility missed resubmitting a new PASRR Level I screen, and the resident also had impaired cognition, lacked decision-making capacity, and needed assistance with multiple ADLs.
Improper G-Tube Medication Administration: An LVN administered two ordered meds through a resident’s G-tube by slow push instead of first using gravity flow as required by facility policy. The resident had severe cognitive impairment, a G-tube, and orders for enteral meds including acetaminophen and metoprolol for pain and CHF. The DON stated the policy calls for each med to be given separately by gravity flow, with gentle push only if necessary.
Improper Crushing of Ordered Medications: An LVN crushed and administered a resident’s Depakote delayed-release tablet despite an order stating it was not to be crushed, and also crushed Buspirone HCL, Keppra, and Sinemet for another resident even though there were no orders to crush them. Both residents had severely impaired cognition, and the DON stated staff should follow the medication orders as written.
Failure to Follow CP Medication Review Recommendations: A resident with muscle weakness and paranoid schizophrenia remained on Seroquel 50 mg QHS and Lexapro 10 mg daily after the CP recommended considering dose reduction for both medications. The DON stated the recommendations were not communicated to the physician and no dose reduction attempt was made, despite facility policy requiring monthly pharmacist review and GDR attempts for psychotherapeutic medications unless clinically contraindicated.
Medication administration errors exceeded the allowed rate when an LPN crushed medications that were ordered to be given whole. One resident’s Depakote DR 125 mg was crushed and mixed with applesauce despite an order not to crush, and another resident’s Buspirone, Keppra, and Sinemet were also crushed even though there was no crushing direction in the orders. The LPN stated she had seen others do this before, while the DON stated staff should follow the order as written.
Inaccurate Face Sheet Included Discontinued Dysphagia Diagnosis: A resident’s Face Sheet still listed dysphagia even after ST discontinued that diagnosis, and the MDS did not identify dysphagia. The MDSC and DON both confirmed the record was not updated and was inaccurate, while the ST stated the resident did not have dysphagia based on her assessment.
Oxygen tubing for a resident with acute respiratory failure and SOB was observed looping onto the floor, and the IPN stated floor contact can contaminate the tubing and increase infection risk. The facility also did not report a new syphilis diagnosis for another resident to public health within the required timeframe, despite positive RPR and FTA-ABS results and treatment with doxycycline; the DON and IPN acknowledged the reporting failure.
A resident with dementia, encephalopathy, and DM experienced episodes of blood‑tinged urine, but the COC form showed an inaccurate time for family notification, documenting contact before the first reported episode. An RN and an LVN performed straight catheterizations on two occasions to obtain urine for UA and C&S, yet neither invasive procedure nor the resident’s tolerance was documented in the medical record. Later, UA and urine culture results indicating possible infection were reported by the lab, but there was no documentation that the physician was notified of these results, contrary to the facility’s charting policy requiring complete, accurate documentation of treatments, services, and provider notifications.
A resident with dementia, encephalopathy, diabetes, and total incontinence experienced two episodes of blood‑tinged urine during a night shift, which were reported by a CNA to an LVN. Although hematuria was documented at 3 a.m. and again at 6:30 a.m., the physician was not notified until the oncoming RN contacted the physician after 7 a.m. Later, a urinalysis with culture and sensitivity ordered for this resident was reported to the facility in the evening, but the physician was not notified until the following afternoon, as shown by a delayed text of the lab report from the facility phone. Multiple nurses and the DON stated that the physician should have been notified immediately of both the hematuria and the lab results, and facility policy requires prompt physician notification for changes in condition such as hematuria and for laboratory reports.
A resident with dementia, encephalopathy, diabetes, and documented severe cognitive impairment experienced episodes of blood-tinged urine, which were reported by a CNA to an LVN and led to physician orders for urinalysis with culture and sensitivity and possible straight catheterization for urine collection. Although the urine specimen was obtained via straight catheterization and the resident did not have an indwelling catheter, the resulting care plan documented interventions for monitoring and caring for a Foley catheter, including catheter care every shift and maintaining catheter alignment. The DON later confirmed that the resident never had an indwelling catheter and that the care plan was not individualized or accurate, despite facility policy requiring individualized care plans based on resident needs and physician orders.
Surveyors found that staff failed to provide ordered skin treatments and obtain or act on dermatology consult orders for three residents with rashes. One resident with severe cognitive impairment had physician-ordered hydrocortisone cream for chest and abdominal rashes, but multiple treatment entries on the TAR were left blank, and nursing leadership confirmed this meant the treatment was not given. Another cognitively impaired resident with generalized dermatitis had an order for clotrimazole-betamethasone cream, yet no treatments were documented for nearly two weeks after the order lapsed, and an existing dermatology consult order was never acted upon for months while only a wound care NP followed the case; the NP reported being told by facility leadership not to order scabies testing or aggressive treatment. A third resident with rashes on multiple body areas had an order for dermatology consultation and ongoing rash documentation, but dermatology was not notified and the resident was not seen by a dermatologist until about a month later, when a dermatologist finally visited to evaluate multiple residents with rashes.
During a scabies outbreak, the facility failed to follow its infection control, skin assessment, and communicable disease reporting policies. A resident was readmitted with rashes, but weekly rash assessments were not documented, and the wound care provider and dermatologist were not properly notified despite existing orders and care plan interventions. When two residents ultimately tested positive for scabies at acute care hospitals, the facility did not document one of the notifications in the medical record and did not report the second confirmed case to the State Survey Agency, contrary to its outbreak and unusual occurrence policies. Several exposed residents, including a roommate and dining contacts, did not receive documented daily skin assessments as required by facility guidelines, and a staff member with a rash was treated but not evaluated with a skin scraping or tracked via a line list of resident contacts. The facility also did not provide training or competency validation on skin scraping for treatment nurses before they performed the procedure.
Surveyors found that the facility did not develop or implement person-centered care plans for two residents with significant behavioral and skin integrity needs. One resident with dementia and Alzheimer’s disease exhibited new spitting and aggressive behavior during showering, which was reported by staff but never incorporated into a behavior care plan. Another resident with a pressure ulcer was observed using a wedge pillow to offload the sacral area, yet there was no care plan addressing this device, and staff confirmed its absence. The same resident repeatedly refused repositioning, with CNAs reporting refusals to an LVN, but no care plan was created to address the refusal, and the issue was not escalated to an RN, despite facility policies requiring assessment, documentation of refusals, and comprehensive, measurable care plans for such problems.
A resident with severe cognitive impairment, incontinence, and existing sacral and heel pressure injuries did not consistently receive ordered daily wound treatments, as multiple entries on the TAR were left blank without documented reasons, despite detailed physician orders and facility policy requiring verification and documentation of wound care. Prior to transfer to a hospital, an RN completed transfer paperwork but only inspected the sacral area and did not perform or document a full head-to-toe skin assessment, contrary to the facility’s transfer and pressure injury prevention policies. Additionally, staff used a wedge pillow to offload the resident’s sacral area without obtaining a physician order, even though facility policy required physician-ordered pressure reduction surfaces and device selection to minimize tissue damage.
The facility failed to timely report an allegation that a CNA slapped a cognitively impaired resident during a supervised shower. The resident, who had dementia, Alzheimer's disease, and generalized weakness and required staff supervision for bathing, became agitated and spit at the CNA during the shower. A student later told another CNA that the CNA had slapped the resident in the face. That CNA did not directly report the allegation to the ADM, despite facility policy requiring mandated reporters to ensure all alleged abuse is reported to the state agency, Ombudsman, and law enforcement within two hours. The ADM later confirmed the allegation had not been reported as required and stated that failure to report could cause psychological distress and potential further abuse for the resident.
A resident with severe cognitive impairment, incontinence, and existing pressure injuries had inconsistent and inaccurate skin documentation, including a Skin Issues record that listed multiple stage 3 and stage 4 pressure ulcers when staff later confirmed only one stage 4 sacrococcyx ulcer was present. Additionally, the MAR showed that LVNs documented administration of Depakote, Mirtazapine, and Potassium on days when the resident was actually hospitalized and not in the facility. Staff interviews confirmed that these entries were incorrect and not in accordance with facility policies requiring accurate, complete charting and verification of resident presence and identity before documenting medication administration.
The facility failed to follow professional standards and its own scabies policies for multiple residents with rashes and pruritus. One resident with a history of dermatitis, diabetes, and Parkinson’s disease had progressively spreading, itchy rashes documented over several months without timely skin scraping or dermatology consultation, and was later confirmed positive for scabies. The facility did not promptly identify and assess all exposed residents, initially limiting its contact list to roommates and only later adding dining companions, with no documented assessments for other contacts. A roommate with generalized rashes received prophylactic permethrin and contact isolation, but skin scraping was ordered and performed only after treatment, and there was no evidence of dermatology evaluation before or during this process. Several direct-care staff, including a treatment nurse, CNA, and LVN, were not informed of the confirmed scabies case until days after the facility learned of the result, and a CNA was observed providing care to an exposed resident under enhanced barrier precautions without PPE. Leadership acknowledged delays in skin scraping, lack of timely assessments of exposed residents, and reliance on absent dermatology services, while a NP reported management pushback on ordering skin scrapings due to concerns about outbreak designation and fines.
The facility failed to ensure that treatment nurses and an IPN were competent to perform skin scraping procedures used to help diagnose skin conditions. Employee file reviews showed that competency assessments completed for these nurses did not include skin scraping, and there was no documentation that this skill was assessed upon hire or annually. The DSD and DON acknowledged that skin scraping was not part of the nurses’ competency evaluations and that, without this assessment, the procedure might not be performed correctly, potentially affecting diagnostic accuracy, despite facility policies and scabies control guidelines requiring appropriate clinical skills and demonstrated competency before assignment.
Staff failed to maintain accurate and timely medical records for several residents, including one who was documented as receiving topical treatment after being transferred to a hospital, and multiple residents who underwent STAT skin scrapings for dermatitis. In these cases, the nurse who actually performed the procedures did not document them on the TARs, while another nurse who only observed later signed the TARs days after the procedures and guessed the times. One resident’s initial admission assessment documented no skin issues, but a reassessment the next day showed widespread rashes, and the subsequent STAT skin scraping was not properly recorded at the time it was performed. These actions conflicted with facility policies requiring complete, objective, and accurate documentation of treatments, including the date, time, and identity of the staff providing care.
A resident with dementia and high fall risk was left unsupervised at a dining room entrance and subsequently fell. After the incident, the facility did not promptly update the care plan, complete a Fall Risk Evaluation, or provide required 72-hour monitoring. Documentation and notifications to the MD and responsible representative were also delayed, contrary to facility policy.
A resident with dementia and high fall risk experienced a fall after being left in the dining room entrance by a CNA. Staff interviews and record review showed that required notifications to the MD and resident representative were not made, and the Change in Condition assessment and monitoring were not completed until several days later, contrary to facility policy.
A facility did not report an allegation of staff-to-resident physical abuse to required authorities after a staff member claimed a CNA pushed a resident with dementia and high fall risk. The administrator did not report the incident, citing lack of injury and considering the allegation as hearsay, despite facility policy requiring immediate reporting of suspected abuse.
The facility did not obtain food from approved sources and failed to store, prepare, distribute, and serve food according to professional standards, resulting in a deficiency related to food safety and handling.
Surveyors observed that facility trash bins were repeatedly overfilled and left uncovered, with cardboard bins open and overflowing. Both the DSS and DON confirmed that these conditions did not comply with facility policies requiring covered waste containers and timely disposal, as outlined in the waste control and pest control procedures.
A facility failed to create and implement a care plan for a resident exhibiting disrobing behavior, despite repeated incidents and staff awareness, and did not document required monitoring for adverse effects in a resident receiving carbidopa-levodopa for Parkinson Disease. These deficiencies were confirmed by staff interviews and record reviews, showing a lack of adherence to person-centered care planning and monitoring policies.
Licensed nursing staff failed to rotate subcutaneous insulin injection sites for two residents with diabetes, administering repeated injections in the same areas despite physician orders, facility policy, and manufacturer guidelines requiring site rotation. This practice was confirmed through record review and staff interviews, and was inconsistent with professional standards of care.
Surveyors found that several residents with cognitive impairments and high fall risk had furniture or equipment placed on their fall mats, and two residents had bed controllers with exposed wires. Staff and the DON confirmed these practices compromised resident safety and did not follow facility policies or manufacturer instructions, which require keeping mats clear and equipment in good repair.
The facility failed to ensure proper pharmaceutical services by not documenting the disposition of an extra Augmentin tablet for a resident, administering carbidopa-levodopa ER at the wrong time for another resident with Parkinson's disease, and not reconciling a controlled medication emergency kit in a medication room at each shift change, as required by facility policy.
A Pharmacy Consultant did not identify or report irregularities in the monthly drug regimen reviews for two residents. One resident prescribed valproic acid for bipolar disorder did not have specific behavior monitoring in place, and another resident on carbidopa-levodopa for Parkinson Disease lacked documentation of monitoring for adverse effects. The consultant acknowledged these omissions, and facility policies required such monitoring and reporting to the DON and prescriber.
A resident prescribed carbidopa-levodopa for Parkinson’s Disease was not monitored for adverse effects as required by their care plan and facility policy. Review of the MAR showed no documentation of monitoring, and both nursing staff and the DON confirmed the absence of required monitoring for side effects such as dyskinesia. This failure to implement the care plan and follow policy resulted in noncompliance with medication monitoring standards.
A resident received four medications at times not consistent with physician orders, as an LVN administered famotidine, buspirone, hydrochlorothiazide, and losartan outside the facility's required 60-minute window. This resulted in four medication errors out of 26 opportunities, leading to a medication error rate of 15.38%, which was confirmed by both the LVN and DON as not following facility policy and the '5 rights' of medication administration.
Surveyors found that two residents with diabetes received subcutaneous insulin injections without proper rotation of injection sites, as required by physician orders, facility policy, and manufacturer guidelines. Nursing staff and the DON confirmed that insulin was repeatedly administered in the same anatomical areas, and records showed multiple instances of this practice. This failure constituted a significant medication error.
Surveyors found that two residents' inhalation medications were not labeled with open dates as required by manufacturer instructions and facility policy, making it impossible to determine if the medications were expired. An LVN and the DON confirmed that multi-dose products must be labeled with the date opened, and the lack of labeling prevented staff from verifying the medications' effectiveness.
Several residents with medical conditions requiring No Added Salt (NAS) diets were provided with extra salt packets on their meal trays, despite clear dietary orders and facility policy prohibiting this. Both residents with intact and impaired cognition were affected, and staff interviews confirmed that kitchen staff did not check tray tickets for NAS diet orders, resulting in the failure to follow prescribed therapeutic diets.
The facility failed to ensure complete and accurate medical records for three residents, including missing documentation of informed consent verification for psychotropic medications and failure to record the administration of an antibiotic in the MAR. Staff and leadership confirmed these omissions, resulting in incomplete records regarding treatment discussions and medication administration.
Personal belongings, including bags, a sweater, a cellphone, and sunglasses, were found in the clean laundry room by a laundry staff member, contrary to facility infection control policies. The items were observed near clean linens, and staff interviews confirmed that personal belongings are not allowed in this area, as lockers are provided elsewhere for storage. Facility leadership acknowledged the failure to maintain the cleanliness and infection control standards required for the laundry area.
The facility did not have a program in place to monitor antibiotic use, as required. Surveyors found no evidence of a system to track or evaluate antibiotic administration to residents.
Several residents were found with unsafe equipment, including a fall mat with peeling covers and bed remote controls with frayed or exposed wires. Staff and the DON confirmed these issues were not identified or reported as required, despite facility policies mandating regular checks and maintenance to ensure a safe environment.
A deficiency was cited for not ensuring a resident's right to dignity, self-determination, communication, and the exercise of their rights. The report does not specify the exact actions or events that led to this failure.
Residents were not fully informed or did not fully understand their health status, care, and treatments, as they were not provided with sufficient information about their medical condition and the care or treatments being administered.
The facility did not prevent the use of unnecessary psychotropic medications or medications that could restrain a resident's ability to function, resulting in a deficiency related to medication management.
Two residents did not receive pressure ulcer prevention interventions as ordered, including the failure to apply heel protectors for a resident with a stage three sacral ulcer and not setting a low air loss mattress according to another resident's weight, despite clear physician orders and facility policy.
A resident with severe cognitive impairment and multiple diagnoses did not receive required face-to-face visits from the attending physician or psychiatrist, as all visits were conducted by nurse practitioners instead. Facility records lacked documentation of direct physician visits, and staff confirmed that the mandated visits by the AP and Psych MD did not occur, contrary to facility policy.
Two residents were not aware of the location or availability of the facility's latest survey results, as the survey binder was stored in an inaccessible location with an unreadable label. Staff confirmed that residents were only told to ask for the binder, rather than having direct access, which did not align with facility policy requiring survey results to be easily accessible.
Kitchen Food Safety and Labeling Deficiencies
Penalty
Summary
Safe and sanitary food storage and food preparation practices were not maintained in the kitchen. During observation, Kitchen Aide 1 was seen in the kitchen without a hair net, and the aide stated he forgot to wear one despite having received in-services requiring it. The Dietary Supervisor stated that all staff must wear hair nets in the kitchen to prevent hair from falling into food and causing contamination. Facility policy also stated that a hair net or head covering that completely covers all hair should be worn at all times. Food items were also found without required dating. In the refrigerator, 2 and a half packs of cheese had no date showing when they were delivered or opened, and in the freezer, 7 veggie burger patties had no date showing when they were delivered or opened. Staff stated they did not know when the items were received, when they would expire, or when they should be discarded. The Ice Scoop Cleaning Log was missing the time and staff initials for 6/12/2026, 6/13/2026, and 6/14/2026, and the Cook stated there was no confirmation that the ice scoop had been cleaned on those dates. The Dietary Supervisor stated staff are required to clean the ice scoop daily and record the time and initials, and facility policy required food items to be properly covered, dated, and labeled in dry storage, refrigerator, and freezer areas.
Incomplete informed consent for psychotropic medication
Penalty
Summary
The facility failed to complete an informed consent for Resident 3’s psychotropic medication, Mirtazapine, which was ordered for depression and administered as a 15 mg tablet at bedtime. Resident 3’s face sheet showed admission and readmission to the facility, and the history and physical signed by the attending physician stated that the resident did not have the capacity to understand and make decisions. The MDS also identified the resident’s cognition as severely impaired and noted use of a high-risk antidepressant drug. The resident’s psychotropic drug informed consent form, dated 1/30/2026, was reviewed and showed that the physician signature line was left blank. The licensed nurse printed name and signature lines were also left blank. The MAR showed that Resident 3 received Mirtazapine from 6/1/2026 through 6/16/2026. During interview and record review, the LVN stated the consent did not include the licensed nurse’s signature or name and therefore was not complete and valid. The DON also stated the form was missing both the physician’s signature and the licensed nurse’s name and signature. Facility policy required the prescriber to sign the informed consent after explaining the treatment, risks, alternatives, and other required information, and required the licensed nurse to verify the consent information and sign to confirm its accuracy and completion. The facility’s psychotropic medication use policy identified antidepressants as psychotropic drugs, and the resident rights policy stated residents have the right to be informed of and participate in their care planning and treatment.
Failure to Provide Advance Directive Information and Document Code Status
Penalty
Summary
The facility failed to provide written information concerning residents’ rights under state law to make decisions about medical care and failed to offer assistance in formulating an advance directive for two sampled residents. For one resident, the admission record showed diagnoses including anxiety disorder and dementia, and the H&P stated the resident did not have the capacity to understand and make decisions, with the daughter identified as the primary decision maker. During review, the resident’s Advance Directive Acknowledgment did not contain the primary decision maker’s signature, and the Social Services Director stated that written materials about advance directive rights had not been provided to residents or family members. For the second resident, the admission record showed admission from a general acute care hospital with pulmonary fibrosis. The MDS indicated severe cognitive impairment with dependence on staff for eating, dressing, and personal hygiene, and the H&P stated the resident did not have the capacity to understand and make decisions. The H&P also stated there was no advance directive executed and CPR status was not indicated. The interdisciplinary team notes showed the responsible party attended the meeting, but no code status was documented, and the care plan for advance directive did not indicate that an advance directive had been initiated or include CPR status. Interviews with facility staff confirmed the missing documentation and lack of follow-up. The Medical Records Director stated the resident did not have an advance directive. The DON stated the resident should have an advance directive or documentation of code status, and the Social Services Director stated she emailed the responsible party about an advance directive but did not follow up after no response. The facility policy stated that upon admission the resident or representative is to be provided written information concerning rights under state law to make medical care decisions, and if the resident is incapacitated, the information may be provided to the legal representative.
Open EHR Left Visible During Medication Pass
Penalty
Summary
The facility failed to maintain privacy of confidential information for two residents when LVN 3 left an electronic health record open and unattended on top of a medication cart in the hallway during medication administration. For one resident, the record showed an original admission on 2/23/2024 and a readmission with diagnoses including unspecified dementia and unspecified mood disorder; the MDS dated 5/31/2026 indicated severely impaired cognition and need for partial to substantial assistance with activities of daily living. During a medication pass observation on 6/16/2026 at 3:57 p.m., LVN 3 stepped away and left the laptop screen open, displaying that resident’s medication information where it was visible in the hallway while she was in the resident’s room administering medication. A similar event occurred for a second resident whose record showed an original admission on 6/25/2018 and readmission with diagnoses including schizoaffective disorder and seizure disorder. The MDS indicated severely impaired cognition and total dependence on staff for several personal care tasks. During a medication pass observation on 6/16/2026 at 4:22 p.m., LVN 3 again stepped away and left the medication cart in the hallway with the laptop screen open, and the resident’s medication information was visible while she was in the room administering medication. LVN 3 stated she should not have left the computer screen open and visible, and the DON stated residents have the right to privacy of their medical records and that the computer should have been closed to prevent unauthorized viewing.
Failure to Release Wheelchair Restraint During Mealtime
Penalty
Summary
The facility failed to ensure one resident was free from the use of a physical restraint when staff did not remove a non-self-release belt as directed by the physician’s order and the resident’s care plan. The resident had diagnoses including Parkinson’s disease, dementia, and major depressive disorder, and the attending physician’s history and physical stated the resident did not have the capacity to understand and make decisions. The MDS indicated the resident had moderately impaired cognitive ability, required maximum assistance for transfers, and had a trunk restraint. The physician’s order, active as of 6/16/2026, directed that the non-self-release belt be used while the resident was in the wheelchair for safety because the resident continuously attempted to slide down and out of the wheelchair unassisted due to Parkinson’s disease and dementia. The same order also directed that the restraint be released every 2 hours for ADL care, activities, and mealtime. The resident’s care plan, initiated 5/6/2026, likewise directed that the restraint be released every 2 hours for ADL care, activities, and mealtimes and stated the goal was to minimize injury and complications from restraint use. During observation on 6/15/2026, the resident was seated in the wheelchair with the non-self-release belt fastened around the waist and wheelchair while being fed by a CNA, and the belt remained in place during mealtime. The CNA stated she was supposed to remove the restraint during mealtime but forgot. The LVN confirmed there was a physician order to remove the restraint during mealtime and stated it should have been removed based on the order. The DON later reviewed the order and care plan and stated the restraint should have been released during mealtime and that the care plan was not followed.
MDS Did Not Reflect Resident’s Depression Diagnosis
Penalty
Summary
The facility failed to ensure that Resident 69’s diagnosis of major depressive disorder was reflected in the active diagnoses section of the resident’s MDS. Resident 69’s Face Sheet listed major depressive disorder recurrent along with diabetes mellitus and schizophrenia, and the resident’s psychiatric progress notes documented complaints of depression, emotional mood swings, and neurocognitive impairment, with diagnoses of schizophrenia and major depressive disorder. The resident’s HP also indicated the resident did not have the capacity to understand and make decisions, and the MDS showed cognition was severely impaired. During concurrent interview and record review, the MDS Coordinator stated the MDS did not include depression under Active Diagnoses even though it was listed on the Face Sheet, and stated it should be included because the resident has diagnoses of depression. The DON also reviewed the Face Sheet and MDS and stated the Face Sheet was accurate, the MDS did not accurately code depression under Active Diagnoses, and the MDS should include the diagnosis so the assessment contains all necessary information and the care plan includes appropriate monitoring of the resident’s behavior. The facility policy stated each individual who completes a portion of the MDS must certify the accuracy of that portion by dating and signing the assessment and identifying each section completed.
PASRR Level II Follow-Up Not Completed for Resident With Schizoaffective Disorder
Penalty
Summary
The facility failed to follow up on PASRR requirements for one resident with diagnoses that included unspecified dementia and schizoaffective disorder. The resident was originally admitted on 12/8/2020 and readmitted on 11/22/2022. The resident’s H&P dated 4/21/2026 stated the resident did not have the capacity to understand and make decisions, and the MDS dated 5/15/2026 indicated moderately impaired cognition and need for supervision or touching assistance with multiple activities of daily living, including eating, oral hygiene, toileting hygiene, bathing, dressing, footwear, and personal hygiene. A PASRR Level I screening dated 11/22/2022 identified that the resident had a serious diagnosed mental disorder, schizoaffective disorder. During the 6/16/2026 interview and record review, the DON stated that DHCS had been unable to complete the PASRR Level II because the resident was isolated as a health or safety precaution during the COVID-19 period, and that after isolation ended the facility should have resubmitted a new PASRR Level I screen and requested a PASRR Level II evaluation. The DON stated the facility missed conducting a new PASRR Level I screen for the resident. The facility policy stated staff were to review PASRR information regularly, follow up with the DHCS/DDS contractor on Level II determination/recommendation, and document and maintain records.
Improper G-Tube Medication Administration
Penalty
Summary
The facility failed to follow its policy for administering medications through a gastrostomy tube for one resident with a G-tube. Resident 11 was admitted and re-admitted with diagnoses including osteoarthritis and attention to gastrostomy, and the MDS indicated severe cognitive impairment and the presence of a G-tube. The resident’s physician orders included enteral feed orders allowing medications and fluids via G-tube, acetaminophen liquid 20 mL via G-tube twice daily for pain, and metoprolol tartrate 12.5 mg enterally twice daily with feeding for CHF. During a medication administration observation, an LVN administered acetaminophen and metoprolol through the resident’s G-tube by slow push. When asked about the facility’s policy, the LVN stated she used the slow push so the medications would not mix and said she was fairly new. The DON later reviewed the facility policy titled, Administering Medications through an Enteral Tube, and stated the policy requires each medication to be administered separately by gravity flow, with gentle pushing only if necessary. The DON stated the LVN should have tried gravity first and then used slow push only if there was resistance or if the resident was anxious and needed the medication faster.
Improper Crushing of Ordered Medications
Penalty
Summary
The facility failed to ensure that Resident 46’s Depakote delayed-release 125 mg tablet was administered as ordered. Resident 46 was admitted with diagnoses including unspecified dementia and unspecified mood disorder, and the MDS indicated severely impaired cognition and need for assistance with activities of daily living. The physician’s order directed that Depakote be given as one tablet by mouth twice a day, with instructions that it was not to be crushed and was to be given with food. During a medication pass observation, an LVN prepared Resident 46’s medication from the bubble pack, crushed the Depakote delayed-release tablet, mixed it with applesauce, and administered it to the resident. When questioned afterward, the LVN stated there was no direction to crush the medication and acknowledged that she should have confirmed with the provider whether it could be crushed. The LVN also stated that crushing could affect the medication’s efficacy because of different absorption time. The facility also failed to ensure that Resident 7’s Buspirone HCL 2.5 mg, Keppra 1000 mg, and Sinemet 10-100 mg were administered as whole tablets. Resident 7 had diagnoses including schizoaffective disorder and seizure disorder, and the MDS indicated severely impaired cognition and total dependence on staff for personal care. The physician’s orders did not include directions to crush these medications, yet during the medication pass the LVN crushed all three tablets, mixed them with applesauce, and administered them by spoon. The DON stated that nurses should follow the order and not crush medications without direction, and that Depakote delayed-release tablets must not be crushed while Buspirone, Keppra, and Sinemet were to be taken as whole tablets since there was no direction to crush them.
Failure to Follow Pharmacist Medication Review Recommendations
Penalty
Summary
The facility failed to ensure the Consultant Pharmacist’s monthly Medication Regimen Review recommendations were followed for a resident with diagnoses including muscle weakness and paranoid schizophrenia. The resident’s MDS indicated the resident sometimes made self-understood and sometimes understood others, and required substantial to maximal assistance with several activities of daily living, including oral hygiene, toileting hygiene, and lower body dressing. During review of the resident’s records with the DON, the Consultant Pharmacist recommended dose reduction of Seroquel 50 mg at bedtime and later recommended dose reduction of Lexapro 10 mg daily. The resident’s eMAR showed Seroquel 50 mg continued throughout February and March, and Lexapro 10 mg continued throughout March. The DON stated the recommendations were not communicated to the physician and no attempt at dose reduction was conducted per the CP recommendation. Facility policy stated a licensed pharmacist reviews each resident’s medication regimen at least monthly, and the psychotherapeutic medication policy stated GDR will be attempted during at least two quarters during the first year unless clinically contraindicated.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure that its medication error rate remained below 5 percent. Surveyors identified 4 medication errors out of 30 total opportunities, resulting in an overall error rate of 13.33% and affecting two residents who were observed during medication administration. The errors involved medications that were ordered to be given without crushing, but were instead crushed and mixed with applesauce before being administered. Resident 46 had diagnoses including unspecified dementia and unspecified mood disorder, and the MDS indicated severely impaired cognition. The physician’s order for Depakote delayed release 125 mg directed that the tablet be given whole, not crushed, and with food. During medication pass observation, LVN 3 removed the medication from the bubble pack, crushed the Depakote delayed release tablet, mixed it with applesauce, and administered it to the resident. Resident 7 had diagnoses including schizoaffective disorder and seizure disorder, and the MDS indicated severely impaired cognition. The physician’s orders included Buspirone HCL 2.5 mg three times daily, Keppra 1000 mg twice daily, and Sinemet 10-100 mg before meals twice daily. During observation, LVN 3 crushed all three medications, placed them in separate medication cups, mixed them with applesauce, and administered them with a spoon. In interview, LVN 3 stated there was no direction to crush the medications and that she had done so based on prior observation of other nurses. The DON stated nurses should follow the order and not crush medications without direction, and noted that Depakote delayed release must not be crushed and that Buspirone, Keppra, and Sinemet are to be taken as whole tablets when no crushing instruction is present.
Inaccurate Face Sheet Included Discontinued Dysphagia Diagnosis
Penalty
Summary
The facility failed to maintain an accurate and up-to-date Face Sheet for one resident when an outdated diagnosis of dysphagia remained listed on the admission record after speech therapy discontinued that diagnosis. The resident’s Face Sheet showed admission and readmission information along with diagnoses including diabetes mellitus and dysphagia, while the resident’s history and physical indicated the resident lacked capacity to understand and make decisions, and the MDS dated 5/15/2026 did not identify dysphagia. During record review and interview, the MDS Coordinator confirmed the Face Sheet still listed dysphagia even though speech therapy discontinued the diagnosis on 5/5/2026, and stated the Face Sheet was not updated and was not accurate. The DON also acknowledged the Face Sheet was inaccurate because it continued to include dysphagia after it had been discontinued, and the speech therapist stated the resident did not have dysphagia based on her assessment and that the diagnosis had been discontinued.
Oxygen Tubing Contamination and Failure to Timely Report Syphilis
Penalty
Summary
The facility failed to ensure that the oxygen tubing for one resident was not touching the floor. Resident 17 was admitted and later readmitted with diagnoses including acute respiratory failure and shortness of breath. The resident’s MDS indicated the resident had limited ability to make self-understood and understand others at times, and required supervision or touching assistance with several activities of daily living, including oral hygiene, toileting hygiene, showering, dressing, footwear, and personal hygiene. The physician’s order directed oxygen at 2 LPM via nasal cannula, titrated up to 5 LPM for oxygen saturation less than 92% every shift. During observation, Resident 17 was found in bed sleeping and connected to an oxygen concentrator via nasal cannula tubing that formed a loop with the middle portion laying on the floor. A concurrent observation with the IPN again found the tubing forming a loop with the middle portion touching the floor. The IPN stated that tubing touching the floor can increase the risk of infection because the floor is dirty and can contaminate the tubing, and stated that a portion of the tubing is placed in the plastic bag hanging in the oxygen concentrator machine to prevent it from touching the floor. The facility also failed to report a resident’s new diagnosis of syphilis to CDPH within 24 hours. Resident 92 was admitted and later readmitted with diagnoses including schizophrenia and syphilis, and the MDS indicated severe cognitive impairment with the need for setup or clean-up assistance with eating. The physician ordered doxycycline hyclate 100 mg twice daily for syphilis, and the care plan addressed the infection and follow-up with CDPH. Records from the hospital showed positive RPR and FTA-ABS results, and the facility’s STD morbidity report was dated after the diagnosis had been identified. The DON stated the facility did not report the syphilis diagnosis to public health, and the IPN stated the facility was a mandated reporter because it was providing treatment and should have reported the diagnosis within 24 hours according to facility policy.
Failure to Maintain Accurate and Complete Medical Record for a Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate and complete medical record for a resident with significant cognitive impairment and multiple medical diagnoses. The resident was admitted with encephalopathy, unspecified dementia, and diabetes mellitus, and was documented as lacking capacity to make decisions, with severely impaired cognitive skills and total bowel and bladder incontinence. On a change of condition (COC) form dated 2/13/2026, a CNA reported to an LVN that the resident had blood‑tinged urine in their diaper at 3 a.m. and again at 6:30 a.m. However, the COC also showed that the family member was notified at 12 midnight, a time that preceded the first documented episode of blood‑tinged urine. During review, the DON confirmed that the midnight entry was not an accurate time and stated that the LVN should have documented the actual time the family member was called. The facility also failed to document invasive nursing procedures performed to obtain urine specimens for ordered urinalysis and culture and sensitivity testing. Physician orders dated 2/13/2026 included urinalysis with culture and sensitivity and allowed straight catheterization if a clean‑catch specimen could not be obtained. An RN stated that on 2/13/2026 she, with assistance from an LVN, performed straight catheterization on the resident to obtain a urine sample, but there was a labeling issue with the specimen. The assisting LVN confirmed she helped with the straight catheterization on 2/13/2026 and that she later performed another straight catheterization on 2/14/2026 after learning the specimen should have been placed in a tube instead of a cup. The LVN acknowledged that neither the initial nor the repeat straight catheterization was documented in the resident’s medical record, despite recognizing that these were invasive procedures and that documentation of how the resident tolerated them was important. The DON confirmed that these procedures should have been documented and that the facility failed to record two invasive procedures in the resident’s record. Additionally, the facility did not document physician notification of the resident’s laboratory results. Laboratory reports showed that the urine specimen was received on 2/17/2026, with urinalysis results reported to the facility that evening and urine culture results reported three days later. Review of the resident’s progress notes for those dates revealed no documentation that the physician was notified of either the urinalysis or urine culture results. An RN stated she worked earlier shifts on both days and that LVNs on later shifts should have received the faxed lab results and sent them to the physician, and she acknowledged that the results may have indicated signs of a urinary infection and that nurses should have documented physician notification. The DON confirmed there was no documented evidence of physician notification for these lab results and stated that failing to document meant physician notification was not done, and that the facility’s charting and documentation policy—which requires complete, accurate, objective documentation of services, procedures, and notifications—was not followed, resulting in an incomplete and inaccurate medical record for the resident.
Failure to Promptly Notify Physician of Hematuria and Abnormal Urinalysis Results
Penalty
Summary
The deficiency involves the facility’s failure to promptly notify a physician of a resident’s change in condition and subsequent abnormal laboratory results. The resident was admitted with diagnoses including unspecified encephalopathy, unspecified dementia, and diabetes mellitus, and was documented as lacking capacity to make decisions, with severely impaired cognitive skills and complete bowel and bladder incontinence. On the night in question, a CNA reported to an LVN at 3 a.m. that the resident’s diaper contained blood‑tinged urine. The LVN documented hematuria with no associated pain or burning. At 6:30 a.m., the CNA reported a second episode of blood‑tinged urine. Despite these findings, the physician was not notified until 7:13 a.m., when the oncoming RN contacted the physician after being informed that hematuria had occurred at 3 a.m. and again at 6:30 a.m. Interviews with nursing staff and the DON confirmed that the LVN on duty should have notified the physician immediately upon the first observation of blood‑tinged urine at 3 a.m., in accordance with facility expectations. RN 2, LVN 2, RN 1, and the DON each stated that the physician should have been informed right away of the hematuria, and that there was a delay in physician notification. The facility’s Change in Condition policy, which lists hematuria and laboratory reports as changes requiring prompt handling, specifies that the physician shall be called promptly upon any change in condition, with documentation of all contacts or attempts. A second failure occurred related to the resident’s urinalysis with culture and sensitivity, which had been ordered on the same date as the hematuria. The laboratory results were reported to the facility on 2/17/2026 at 7:37 p.m. RN 1, who worked only until 3 p.m. that day, stated that after her shift the assigned LVNs should have received any faxed lab results and sent an electronic message with the results to the physician that same day. Review of facility phone text messages with the DON showed that a picture of the resident’s urinalysis result was not sent to the physician until the following afternoon, and there was no indication of physician notification on the date the results were received. The DON stated that LVNs should have notified the physician of the urinalysis result when it was received so the physician could proceed with an appropriate plan of care, and acknowledged there was a delay in physician notification.
Failure to Accurately Individualize Care Plan for Resident With Hematuria
Penalty
Summary
The facility failed to develop and implement an accurate, person-centered care plan for a resident who experienced hematuria. The resident was admitted with diagnoses including unspecified encephalopathy, unspecified dementia, and diabetes mellitus, and was documented as lacking capacity to make decisions and having severely impaired cognitive skills. The MDS indicated the resident was always incontinent of bowel and bladder. On one date, a Change of Condition note documented that a CNA reported to an LVN that the resident had blood-tinged urine in their diaper on two occasions during the early morning. A physician order was obtained for a urinalysis with culture and sensitivity, with permission to perform straight catheterization for urine collection if a clean catch specimen could not be obtained. The resident’s care plan, initiated in response to the hematuria, documented interventions related to monitoring and caring for an indwelling Foley catheter, including monitoring the catheter and changing it or the bag as ordered, providing Foley catheter care every shift, and maintaining proper alignment of the Foley catheter. However, interview and record review confirmed that the resident did not have an indwelling catheter and that urine for the ordered tests was obtained via straight catheterization. The DON acknowledged that the care plan was not individualized or accurate, stating that the resident never had an indwelling catheter and that the care plan should have reflected the use of straight catheterization and been consistent with the resident’s actual needs and orders, in contrast to the facility’s policy requiring individualized care plans.
Failure to Provide Ordered Rash Treatments and Timely Dermatology Consultations
Penalty
Summary
The deficiency involves the facility’s failure to provide skin treatments and specialty consultations as ordered, and to obtain necessary physician orders, for three residents with rashes. For one resident with schizoaffective disorder, dementia, and chronic hepatitis B, a skin reassessment on 1/15/2026 documented rashes on the chest and abdomen, and a physician order was in place to cleanse the rash and apply hydrocortisone 1% cream on the day and evening shifts for four weeks. Review of the Treatment Administration Record (TAR) for 1/2026 showed blank entries for the ordered treatment on multiple shifts, and both the Registered Nurse Supervisor and the MDS nurse stated that blank TAR entries meant the treatment was not provided or signed. Facility policy on administering medications required that medications and treatments be administered in accordance with prescriber orders and documented with date, time, dosage, route, and the initials/signature of the person administering. A second resident, admitted with Parkinson’s disease, dementia, and unspecified dermatitis, had a physician order dated 10/2/2025 to cleanse generalized rashes on the bilateral upper and lower extremities and chest with normal saline and apply clotrimazole-betamethasone cream on day and evening shifts for four weeks. Wound care NP notes on 10/28/2025 and 11/11/2025 documented generalized dermatitis and a plan to cleanse with normal saline and apply clotrimazole 1% and betamethasone 0.05% cream twice daily. However, the November 2025 TAR showed no treatment documented from 11/1/2025 to 11/13/2025. Treatment Nurse 1 stated that the resident still had rashes during that period, that the treatment order had not been renewed, that there was no documented physician order for the rash during those dates, and that no treatment was provided. The RNS and MDS nurse confirmed that without a physician order and documentation, the rash treatment was not provided for 13 days, despite facility policies on administering medications, non-pressure sore management, and alteration in skin integrity that required assessment, physician notification, and treatment orders for skin alterations. The same resident had an order on 5/17/2025 for a dermatology consultation and follow-up treatment as indicated, but wound care notes from 2/25/2025 through 12/25/2025 repeatedly documented generalized fungal or unspecified dermatitis without any documentation that a dermatologist evaluated the resident. The Infection Preventionist confirmed that the resident was transferred to an acute care hospital on 1/16/2026 with body rashes, and Treatment Nurse 1 stated the resident was never seen by a dermatologist and was only seen by the wound care NP. The RNS stated that the dermatologist did not assess the resident’s rashes from the date of the order until transfer, a period of almost eight months, and that the NP was a wound care specialist, not a dermatologist. The NP reported that he had raised the issue of scabies testing and treatment with the DON before 12/25/2025 but was told not to order scabies tests or aggressive treatment because of concerns about a potential scabies outbreak and staffing, and that the facility intervened to prevent him from ordering scabies tests and treatment. Facility wound care policy required verification of a physician’s order for wound procedures, and the submitted scabies prevention guideline called for access to clinicians experienced in recognizing scabies and confirmation by skin scraping. A third resident, admitted with cerebral infarction, dementia, and pneumonia, had an order dated 12/25/2025 for a dermatology consult and follow-up treatment as indicated. A skin reassessment on 12/26/2025 documented rashes on the bilateral upper and lower extremities, chest, and back, and a care plan dated 1/5/2026 included an intervention to notify dermatology of non-response. Skin rash reports on 1/9/2026 and 1/24/2026 documented ongoing rashes, and the TAR for 1/2026 showed the resident received triamcinolone twice daily for dermatitis throughout the month. Treatment Nurse 1 stated this resident was the roommate of the resident later confirmed with scabies in the hospital, had rashes since 12/26/2025, and was not seen by a dermatologist until 1/26/2026, when the dermatologist came to evaluate multiple residents with rashes after the other resident’s positive scabies test. The RNS stated the facility should have followed the physician order for dermatology consultation and that a one-month delay in notifying dermatology could worsen the resident’s rashes. Treatment Nurse 1 further stated that RNs obtain dermatology consultation orders and notify dermatology by fax or phone, but she did not call because the facility did not have a dermatologist until 1/26/2026. Facility policies on non-pressure sore management and change in condition required physician notification and follow-through when residents developed rashes, and the RNS stated that when this resident developed rashes on 12/26/2025, a change in condition should have been created and the physician order followed.
Failure to Implement Scabies Outbreak Control, Skin Assessment, and Reporting Procedures
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow its infection prevention and control program, skin assessment policies, and communicable disease reporting procedures during a scabies outbreak. One resident was readmitted with documented rashes on the chest and abdomen, but weekly Skin Rash Reports were not initiated or completed after the readmission, despite facility policies requiring weekly skin inspections and documentation of non‑pressure skin conditions and rashes. Treatment nurses and other nursing staff acknowledged that weekly rash assessments were not performed or documented on multiple Thursdays, and the Minimum Data Set nurse and Resident Nursing Supervisor confirmed that the facility’s policies on Prevention of Pressure Injuries/Skin Breakdown, Body Checks, and Alteration in Skin Integrity were not followed. Staff stated that without weekly rash documentation, the progress of the rash and effectiveness of treatment could not be evaluated, and that the resident’s rashes could worsen. The facility also failed to notify the wound care provider and dermatologist and to document key clinical information related to the scabies outbreak. After the resident’s readmission with rashes, there was no documentation that the wound care physician or nurse practitioner was informed, and no subsequent wound care notes were found. The nurse practitioner, infection preventionist, MDS nurse, RN, and Resident Nursing Supervisor all stated that the wound care provider should have been notified and that there was no documentation of such notification. Although there was an order and care plan intervention for a dermatology consult, treatment nurses did not ensure that the dermatologist who visited on two separate dates was informed of this resident’s rashes, and the dermatologist’s progress notes showed that only nine other residents were evaluated and treated. The administrator and infection preventionist stated that the dermatologist should have been notified of all residents with rashes, including this resident. Additionally, when the facility was notified by an outside hospital that this resident tested positive for scabies, the marketer relayed the information verbally to the administrator, but there was no documentation of this notification in the resident’s medical record, contrary to the facility’s Charting and Documentation policy requiring complete and accurate documentation. The facility did not properly recognize and report the scabies outbreak to the State Survey Agency and did not complete required surveillance and assessments for exposed residents and staff. One resident had previously tested positive for scabies at another hospital, and the infection preventionist stated the facility was informed of this result. When a second resident later tested positive for scabies at a different hospital, the administrator acknowledged being notified but did not report this second confirmed case to the State Survey Agency, despite facility policies and county guidelines defining an outbreak as two or more cases and requiring reporting within 24 hours. The administrator later acknowledged that the facility’s Scabies: Prevention and Control policy and Unusual Occurrences policy were not followed. The infection preventionist and Resident Nursing Supervisor confirmed that the facility was considered to be in a scabies outbreak and that such outbreaks should be reported. The facility also failed to perform and document daily skin assessments on four residents who were identified as exposed through room sharing and dining contact, despite facility guidelines and policies requiring daily skin assessments on exposed residents and daily assessments for roommates of infected residents until the case was resolved. The deficiency further includes failures related to staff training, competency, and case tracking. The Director of Staff Development/Infection Preventionist and Resident Nursing Supervisor stated that no in‑service education, training, or competency evaluation on skin scraping was provided to the treatment nurses before they performed skin scrapings on residents during the outbreak. They acknowledged that the nurses were not checked for competency and that training should have been done before skin scraping procedures were carried out. Additionally, a certified nursing assistant who developed lower back rashes was treated with Elimite cream but was not assessed for scabies via skin scraping, and the facility did not develop a line list identifying this staff member’s resident contacts for the six weeks prior to symptom onset, as required by the facility’s submitted Acute Communicable Disease Control Program–Scabies Prevention and Control Guidelines. These guidelines also required preparation of line lists for symptomatic healthcare workers and residents and daily skin assessment documentation on all exposed residents, which the facility did not complete.
Failure to Develop Person-Centered Care Plans for Behavior, Pressure Ulcer Interventions, and Treatment Refusals
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered care plans addressing specific behaviors and clinical needs for two residents. For one resident with dementia, Alzheimer’s disease, and generalized weakness, the admission record showed the resident was admitted in September 2025, and a subsequent H&P documented that the resident lacked capacity to understand and make decisions. An MDS assessment later indicated the resident could sometimes understand others and make self-understood and required supervision with toileting and showering. Progress notes from early January 2026 documented that this resident became verbally and physically restless and had an anger outburst before a shower, then became physically aggressive during the shower, yelling and spitting at a CNA. Multiple staff, including the DSD and Administrator, confirmed that the resident had spit at the CNA, and the MDS nurse stated the resident had behaviors of spitting and kicking but acknowledged there was no care plan addressing the spitting behavior. The facility also failed to develop a care plan for another resident’s use of a wedge pillow and for that resident’s refusal of repositioning. During observation in early February 2026, a wedge pillow was seen on the resident’s left side in the room. The treatment nurse explained that the wedge pillow was used to keep the resident’s sacral area off the bed to prevent worsening of a pressure ulcer, but confirmed there was no care plan for the use of the wedge pillow. The MDS nurse and RN 1 both reviewed the care plans and stated there was no care plan for the wedge pillow, and the MDS nurse stated there should be a care plan for its use because it guides nurses on how to care for the resident. The RN supervisor stated that interventions provided to address the resident’s pressure ulcer should have a care plan, and that without a care plan, nurses would not be able to evaluate if the intervention was effective and it could possibly cause worsening of the pressure ulcer. In addition, the same resident was described by the treatment nurse as noncompliant with repositioning, and other staff confirmed ongoing refusals. The MDS nurse stated there was no care plan developed for the resident’s refusal to be repositioned and that a care plan helps minimize further decline or prevent worsening of pressure ulcers, and that without such a care plan the resident’s wound can worsen. An LVN reported that CNAs had informed her of the resident’s refusal to be repositioned; she spoke with the resident, who continued to refuse, but she did not develop a care plan and did not report the noncompliance to an RN, stating that RNs develop care plans. The LVN stated a care plan should have been developed and that without a care plan for refusal of repositioning, the resident’s wound could worsen. The RN supervisor similarly stated that a care plan should have been developed to address the resident’s refusal of repositioning to ensure resident rights for refusal were followed and to prevent worsening of the pressure ulcer. Facility policies on behavioral assessment, pressure ulcer prevention, wound care, and comprehensive person-centered care plans all required assessment of new behaviors, individualized interventions, documentation of refusals, and development and revision of care plans with measurable objectives and timeframes, which were not followed in these instances.
Failure to Provide Ordered Wound Care, Complete Transfer Skin Assessment, and Obtain Order for Wedge Pillow
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with physician orders and facility policy for a cognitively impaired resident with existing pressure injuries. The resident was admitted with metabolic encephalopathy, dementia, and pressure ulcers to the sacral area and left heel, and was documented as severely impaired in decision-making, fully dependent for ADLs, and always incontinent of bowel and bladder. Physician orders dated 7/19/2025 directed specific daily wound care for left heel and sacrococcyx deep tissue injuries, and subsequent orders on 11/11/2025, 12/17/2025, and 1/20/2026 specified detailed daily treatments for sacrococcyx stage 3 and later stage 4 pressure injuries, including cleansing solutions, topical agents, and dressings. Review of the Treatment Administration Records (TARs) from August 2025 through January 2026 showed multiple dates on which the ordered treatments were left blank, including 8/3/2025, 11/25/2025, 12/24/2025, 1/20/2026, and 1/27/2026. Interviews with the MDS nurse, RN supervisor, and other nursing staff confirmed that blank entries on the TAR indicated the treatment nurse did not sign for and therefore did not perform the ordered wound care. Staff acknowledged that if the treatment was not done, the pressure ulcer could worsen. The facility’s wound care policy required verification of a physician’s order, performance of the ordered wound care, and documentation of the type of wound care given, the date and time, the resident’s position, and the name and title of the person performing the care. The RN supervisor stated that if treatment is not done, the treatment nurse must document the reason, such as resident refusal or being too busy and endorsing the task to other staff, but such documentation was not present for the missed treatments. The deficiency also includes the facility’s failure to perform and document a complete head-to-toe skin assessment prior to the resident’s transfer to a general acute care hospital. On the transfer date, the resident’s Interact Assessment Form noted generalized weakness and decline in ADLs, and the Resident Transfer Record documented a sacrococcyx stage 3 pressure ulcer. RN 1 stated that for any transfer, a complete head-to-toe skin assessment should be done and documented on the transfer form and reported to the receiving hospital. RN 2 reported that, at the DON’s direction, she completed the Discharge Summary Report and Resident Transfer Record but only looked at the sacral area and did not perform a full body skin assessment, and therefore could not say whether the resident had rashes elsewhere. The facility’s Transfer/Discharge policy required a complete body check when possible, with findings documented, and the Prevention of Pressure Injuries policy required comprehensive skin assessments on admission, with each risk assessment, and prior to discharge. Additionally, the facility failed to obtain a physician order for the use of a wedge pillow for this resident. During observation, a wedge pillow was seen on the resident’s left side. The treatment nurse stated the wedge pillow was used to keep the sacral area off the bed to prevent worsening of the pressure ulcer. Review of the physician orders showed no order for the wedge pillow, and both RN 1 and the treatment nurse acknowledged that a physician order was required before the resident could use a wedge pillow and that the DON or RN supervisor should have obtained such an order. The facility’s policies on pressure ulcers and prevention of pressure injuries specified that the physician orders pertinent wound treatments, including pressure reduction surfaces, and that medical devices should be selected with consideration to minimizing tissue damage, reinforcing the need for an order for this device.
Failure to Timely Report Alleged Staff-to-Resident Abuse
Penalty
Summary
The facility failed to timely report an allegation of employee-to-resident abuse involving Resident 2 to the State Survey Agency, Ombudsman, and local law enforcement within two hours as required by its abuse policy. Resident 2 had been admitted with dementia, Alzheimer's disease, and generalized weakness, and a subsequent H&P documented that the resident did not have capacity to understand and make decisions. An MDS later indicated Resident 2 could sometimes understand others and make self-understood and required staff supervision for toileting and showering. On the date of the incident, progress notes documented that Resident 2 became verbally and physically restless and angry before a shower, then calmed and agreed, but became physically aggressive, yelled, and spit at CNA 1 during the shower. During interviews, CNA 2 reported that while CNA 1 was showering Resident 2 and CNA 2 and a student were showering another resident in the same shower room, the resident became agitated. After the shower, Student 1 told CNA 2 that CNA 1 had slapped Resident 2 in the face. CNA 2 stated she instructed the student to report it and the student said she already had, and CNA 2 did not report the allegation directly to the Administrator, even though she acknowledged she should have. The Director of Staff Development stated CNA 1 reported only that Resident 2 became combative and spit at her, and that CNA 1 tried to block the spit with her hands. The Administrator, referencing the facility’s abuse and mistreatment policy, confirmed that all alleged and substantiated violations must be reported to the state agency and other required agencies within two hours, and stated that CNA 2 did not report the allegation on the day of the incident, resulting in the failure to meet the facility’s reporting requirements. The Administrator stated that not reporting allegations of abuse could cause Resident 2 psychological distress and potentially further abuse.
Inaccurate Skin and Medication Documentation in Resident Medical Record
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate and complete medical record for a resident with multiple serious medical conditions. The resident was admitted with diagnoses including metabolic encephalopathy, a stage 4 sacral pressure ulcer, and unspecified dementia, and was documented as having severely impaired cognitive skills and total dependence on staff for activities of daily living, with bowel and bladder incontinence. An admission reassessment documented pressure ulcers on the left heel and sacrococcyx, and the MDS indicated two unstageable pressure injuries present on admission. Subsequent skin documentation was inconsistent and inaccurate. A Skin Issues record dated 12/11/2025 indicated one stage 3 sacrococcyx pressure ulcer, while a Skin Issues record dated 1/6/2026 indicated four stage 3 pressure ulcers and one stage 4 pressure ulcer. During interviews and concurrent record review, the Treatment Nurse stated that the 1/6/2026 Skin Issues entry was not accurate and that the resident had only one stage 4 sacrococcyx pressure ulcer. The Treatment Nurse and a Registered Nurse both acknowledged that this inaccurate documentation made the medical record inaccurate and could cause confusion in care. The facility’s Charting and Documentation policy required that documentation in the medical record be objective, complete, and accurate. The facility also failed to accurately document medication administration for this resident while the resident was hospitalized. The resident’s orders included Depakote three times daily, Mirtazapine at bedtime, and Potassium chloride daily. The resident was transferred to a general acute care hospital on 1/14/2026 and returned on 1/19/2026. However, the January MAR showed that one LVN documented administration of Depakote on 1/15/2026 at noon, and another LVN documented administration of Mirtazapine, Potassium, and Depakote on 1/16/2026 at various times, despite the resident being in the hospital on those dates. The MDS nurse confirmed that check marks on the MAR indicated medications were administered and stated this documentation was incorrect because the resident was not in the facility. Nursing staff and the Registered Nurse Supervisor stated that nurses are supposed to verify that residents are in the facility, verify identity, and sign the MAR after actual medication administration, in accordance with the facility’s Charting and Documentation and Administering Medications policies, which require accurate recording of medications administered.
Failure to Timely Identify, Test, and Communicate Scabies Cases and Exposures
Penalty
Summary
The deficiency involves the facility’s failure to follow its own scabies identification and control policies and professional standards of practice for multiple residents with rashes and pruritus. One resident with a history of dermatitis, diabetes mellitus type 2, and Parkinson’s disease was admitted and later readmitted with progressively spreading rashes on the chest, bilateral upper and lower extremities, back, and abdomen. The resident’s care plan for skin integrity noted a skin rash and included interventions such as administering treatment as ordered and notifying dermatology for non-response. Over several months, skin rash reports documented complaints of itchiness on multiple dates, but there was no documented evidence that a skin scraping was performed or that a dermatologist was consulted, despite staff acknowledging that skin scraping is used to confirm scabies and that the facility had a scabies policy describing diagnostic procedures. The resident was eventually transferred to an acute care hospital for altered mental status and abnormal vital signs, with documentation noting a body rash, and a subsequent scabies examination on a later date showed a positive result for scabies. After the positive scabies result for this resident, the facility did not promptly or comprehensively identify and assess all exposed residents and staff as required by its scabies policy and the referenced Acute Communicable Disease Control (ACDC) guidelines. The Director of Staff Development (DSD) produced a new Scabies Case Contact Line List that initially included only the resident and two roommates, with no documented assessments of other exposed residents. The DSD later stated that residents who sat beside the affected resident in the dining room were only added to the line list several days after the facility became aware of the positive scabies result, and the Director of Nursing (DON) acknowledged that residents exposed in the dining room were not assessed after the positive test. Another cognitively impaired resident who attended the same dining room and activities and was identified as exposed was not assessed for scabies, and there was no documentation of assessments for other contacts beyond roommates and later-identified dining companions. The facility also failed to ensure timely and appropriate diagnostic testing and treatment sequencing for the roommate with generalized rashes. This roommate was admitted without documented skin issues, but a skin reassessment the following day showed rashes on bilateral upper and lower extremities, chest, and back. The care plan identified skin rash with interventions to administer treatment as ordered and notify dermatology of non-response. Physician orders later directed prophylactic permethrin cream application and contact isolation for possible exposure to rashes, and the medication administration record showed the permethrin was given. However, staff interviews and record review revealed that a skin scraping for this resident was ordered and performed only after the permethrin treatment had already been administered, and there was no documented evidence that a dermatologist had assessed this resident or that a skin scraping was done prior to treatment. During observation, this resident was noted to have extensive pruritic rashes in classic scabies distribution, and a CNA was seen in the room under enhanced barrier precautions without wearing PPE while touching room surfaces. Communication failures compounded these issues, as several staff members who provided direct care to the resident with confirmed scabies were not promptly informed of the positive result. A treatment nurse, a CNA, and an LVN each reported that they were not notified of the positive scabies diagnosis until two to four days after the facility became aware of it, despite having been assigned to care for the resident and having observed or managed the resident’s itching and rashes. The DSD stated she did not know if staff who cared for the resident before the positive test were notified, and the nurse practitioner reported that he was not informed of the positive scabies result. The nurse practitioner also stated that he received pushback from facility management, including the administrator, DON, and infection preventionist, when he raised concerns about ordering skin scrapings for residents with rashes, and that management expressed concern that positive scabies findings could trigger an outbreak designation and fines. The DON acknowledged that the facility had not had a dermatologist for two years, that they waited for dermatology services to determine which residents needed skin scraping, and that the facility failed to consider timely skin scraping tests and assessments for residents exposed to the confirmed scabies case. The facility’s own scabies policy and the ACDC guidelines it referenced required careful examination of roommates of infected residents, daily assessments of asymptomatic exposed residents, prompt evaluation of patients on affected units, immediate placement of suspected cases on contact precautions, preparation of line lists of symptomatic residents and their contacts, evaluation of contacts, and provision of prophylactic treatment to contacts within a short time frame. Despite these written procedures, the survey findings showed that only limited contact tracing and delayed listing of dining room contacts occurred, that not all exposed residents were assessed, that diagnostic skin scrapings were delayed or not performed for symptomatic residents, and that staff and practitioners were not promptly informed of a confirmed scabies case. Staff interviews, observations, and record reviews consistently demonstrated gaps between the written policies and the actual practices related to scabies identification, testing, communication, and contact management.
Failure to Ensure Nurse Competency in Skin Scraping Procedures
Penalty
Summary
The facility failed to ensure that three licensed nursing staff members were competent to perform skin scraping procedures, a skill necessary for diagnosing certain skin conditions. Review of the employee file for Treatment Nurse 1, hired on 11/13/2024, showed a competency skills assessment dated 1/14/2025 that did not include skin scraping. Treatment Nurse 2, hired on 2/11/2025, had a competency skills assessment dated 2/12/2025, also without any documented assessment of skin scraping. The Infection Preventionist Nurse, hired on 6/12/2024, had a competency skills assessment dated 10/13/2025, which likewise did not include skin scraping procedures. There was no documentation that any of these staff had been assessed for competency in performing skin scraping upon hire or annually. During interviews and concurrent review of employee files, the Director of Staff Development acknowledged that the competency assessments for these nurses did not include skin scraping and stated that without such assessments, the facility would not know if the nurses were performing the procedure correctly. The Director of Nursing confirmed that there were no skin scraping competency assessments completed on the licensed nurses and stated that, without these assessments, the procedure had the potential not to be done properly and could negatively affect the accuracy of results. Review of the facility’s Scabies Prevention and Control Guidelines indicated expectations for evaluation of residents and staff for scabies and access to diagnostic skills of clinicians experienced in recognizing scabies. The facility’s Competency Assessment policy stated that each employee must demonstrate competency related to skills and techniques necessary to provide care and that competency must be completed prior to assignment, which was not met for the skin scraping procedure for the identified staff.
Inaccurate and Late Documentation of Treatments and Skin Procedures
Penalty
Summary
The deficiency involves failures in maintaining complete, accurate, and professionally acceptable medical records for multiple residents. For one resident with diagnoses including dermatitis, type 2 diabetes mellitus, and Parkinson's disease, the facility admitted the resident in December 2024 and later readmitted them. The resident’s MDS dated early December 2025 showed severely impaired cognitive skills for daily decision making. Physician orders dated January 9, 2026, directed application of clotrimazole-betamethasone cream twice daily for unspecified dermatitis. A Change of Condition Interact Assessment Form dated January 16, 2026, showed the resident was transferred to a general acute care hospital on that date. However, the Treatment Administration Record (TAR) for January 2026 contained the treatment nurse’s initials on January 17, 2026, as if care had been provided while the resident was already hospitalized. The treatment nurse stated she forgot to change the chart code to hospitalized and acknowledged the documentation was not accurate. Another deficiency involved inaccurate and incomplete documentation of a second resident’s skin condition and related procedures. This resident, admitted in January 2023 with diagnoses including cerebral infarction, muscle weakness, and essential hypertension, had an MDS indicating moderately impaired cognitive skills for daily decision making. A clinical admission assessment dated December 25, 2025, documented the resident’s skin as warm, dry, with normal color and turgor and no skin issues. However, a skin reassessment dated December 26, 2025, documented rashes on bilateral lower and upper extremities, chest, and back. Physician orders dated January 26, 2026, directed a STAT skin scraping for unspecified dermatitis. The TAR for January 2026 initially showed no licensed nurse initials or time for the STAT skin scrape. A treatment nurse later stated he had only observed another treatment nurse perform the skin scraping, signed the TAR two days after the procedure, did not remember the actual time, and guessed the time for this and other residents’ procedures. The nurse who actually performed the skin scraping confirmed she did not document the procedure in the TAR and that the documentation was not timely or accurate. Similar documentation issues occurred for two additional residents with cognitive impairment and multiple medical diagnoses, including unspecified dementia, essential hypertension, age-related osteoporosis, and metabolic encephalopathy. For both residents, physician orders dated January 26, 2026, directed STAT skin scrapings for unspecified dermatitis. Their TARs for January 2026, when first printed, showed no licensed nurse initials or times for the ordered STAT skin scrapings. The observing treatment nurse later reported he had been watching another treatment nurse perform the procedures because he had not done skin scrapings before, and he signed both residents’ TARs two days after the procedures. He stated he did not remember the actual times and guessed the times, documenting the same time for both residents. The treatment nurse who performed the procedures confirmed she did not document the skin scrapings in the TARs and acknowledged the documentation was not timely or accurate. The Director of Nursing, when reviewing these records, stated that the documentation for all involved residents was not accurate and that the facility failed to follow its own charting and documentation policies, which require objective, complete, and accurate documentation of treatments, including date, time, and the name and title of the individual providing care.
Failure to Implement and Document Post-Fall Interventions and Monitoring
Penalty
Summary
A deficiency occurred when the facility failed to implement and document appropriate interventions following a resident's fall. The resident, who had diagnoses including dementia, Alzheimer's disease, muscle weakness, and difficulty walking, was identified as high risk for falls upon admission. On the day of the incident, the resident was left at the entrance of the dining room by a CNA who then clocked out. Shortly after, the resident was found on the floor, having fallen, with no staff witnessing the actual fall. Following the fall, the facility did not develop or update a care plan with interventions specific to the incident. The Fall Risk Evaluation was not updated after the event, and there was no documentation of 72-hour post-fall monitoring as required by facility policy. The Change of Condition (COC) assessment and care plan updates were not completed until several days after the fall, rather than during the same shift or the following day as expected. Additionally, there was no documented evidence that the physician or responsible representative were notified at the time of the incident. Facility policy required immediate and thorough documentation, including a complete body check, notification of the physician and family, care plan entry, and post-fall assessment, none of which were completed in a timely manner. The lack of prompt assessment, documentation, and intervention following the fall placed the resident at risk for further incidents and did not ensure adequate supervision or accident prevention.
Failure to Notify Physician and Resident Representative After Resident Fall
Penalty
Summary
The facility failed to notify the medical doctor and the resident representative after a resident experienced a fall. The resident, who had diagnoses including dementia, Alzheimer's disease, muscle weakness, and difficulty walking, was identified as high risk for falls upon admission. On the day of the incident, the resident was left in the dining room entrance by a CNA, and subsequently found on the floor by staff. Multiple staff interviews confirmed the fall occurred, but there was no immediate documentation or notification to the physician or resident representative. A review of the electronic medical record revealed that a Change in Condition (COC) assessment was not completed on the day of the fall, and was only created several days later. The Director of Nursing confirmed that the COC should have been completed during the same shift as the incident, and that the required 72-hour monitoring and care plan updates were not performed until a week after the fall. There was also no evidence that the physician or resident representative were notified at the time of the incident. Facility policies require prompt documentation and notification following a change in condition or incident, including notifying the physician and family, completing a COC assessment, and implementing monitoring. The lack of timely documentation and notification was confirmed by both record review and staff interviews, indicating a failure to follow established procedures after the resident's fall.
Failure to Report Alleged Physical Abuse to Authorities
Penalty
Summary
The facility failed to report an allegation of employee-to-resident physical abuse to the State Survey Agency, the ombudsman, and local law enforcement as required by its own policy. The incident involved an activities assistant alleging that a certified nursing assistant pushed a resident in a wheelchair, which was considered a potential act of abuse. Despite the allegation, the administrator did not report the incident, citing that the resident had no injuries and that the information was considered hearsay rather than a direct report. The resident involved had significant cognitive and physical impairments, including dementia, Alzheimer's disease, muscle weakness, and a high risk for falls. The resident was dependent on staff for most activities of daily living and did not have the capacity to make decisions. On the day of the incident, the resident was found on the floor after being left in the dining room by the CNA, and there were conflicting accounts from staff regarding how the resident ended up on the floor. The administrator reviewed CCTV footage but did not preserve it, as it was automatically erased after five days. Interviews with staff revealed that the term "push" was used by the activities assistant, leading to the CNA's suspension and eventual termination. The administrator acknowledged that any allegation of abuse, including those based on staff statements or hearsay, should be reported within two hours according to facility policy. However, the administrator did not report the incident, stating it was not directly reported to her and was considered hearsay, despite recognizing that the use of the word "push" raised concerns for abuse.
Failure to Follow Food Procurement and Safety Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events are provided in the report.
Improper Disposal and Storage of Facility Garbage and Refuse
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, as observed on multiple occasions. On two separate mornings, the blue trash bin was found overfilled with its lid not fully shut, and the cardboard box bin was left open without a lid. Photographic evidence was taken to document these findings. During interviews, the Dietary Service Supervisor acknowledged that the trash bins were not closed and that the cardboard bin was overflowing and uncovered. The Director of Nursing also confirmed, upon reviewing the photographs, that the facility did not follow its own policy and procedure regarding garbage disposal, which requires bins to be covered to prevent pest attraction and disease spread. A review of the facility's policies indicated that all waste should be disposed of daily and as needed, trash bins should be covered at all times, outside garbage bins must remain closed, and cardboard boxes should be broken down and disposed of promptly. The pest control policy also requires the facility to maintain an effective pest control program and prohibits the accumulation of garbage and trash, mandating daily removal. The observed failure to keep trash bins closed and to promptly dispose of cardboard boxes was inconsistent with these established policies.
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with disrobing behavior. The resident, who had diagnoses including mood disorder, major depressive disorder, and psychotic disorder, was noted to have severely impaired cognition and was dependent on staff for dressing. Despite observations and staff interviews confirming that the resident had been removing her clothes repeatedly over a two-week period, there was no care plan addressing this behavior. Nursing staff acknowledged awareness of the behavior but did not assess or create a care plan to address the resident’s dignity and respect needs related to disrobing. Additionally, the facility failed to implement a care plan for another resident prescribed carbidopa-levodopa for Parkinson Disease. The care plan indicated the need to monitor for adverse effects of the medication, such as dyskinesia, and to alert the physician if necessary. However, review of the Medication Administration Record (MAR) revealed no documentation of monitoring for adverse effects throughout the month. Both the RN and DON confirmed that monitoring should have been documented and that the lack of monitoring could result in adverse effects going unnoticed. Interviews with staff, including the DON and Pharmacy Consultant, confirmed that the facility did not follow its own policy and procedure for comprehensive, person-centered care planning. The policy required measurable objectives and timetables to meet residents’ needs, including monitoring for medication side effects and addressing behavioral issues. The failure to develop and implement appropriate care plans for both residents resulted in deficiencies related to maintaining residents’ dignity and monitoring for unnecessary medication use.
Failure to Rotate Insulin Injection Sites per Professional Standards
Penalty
Summary
Licensed nursing staff failed to provide care in accordance with professional standards by not rotating subcutaneous insulin administration sites for two residents with diabetes. For one resident with dementia and severe cognitive impairment, records showed repeated insulin injections were administered in the same areas of the abdomen and arms over several months, despite physician orders and manufacturer guidelines specifying the need to rotate sites. Interviews with the MDS Coordinator and nursing staff confirmed that injection sites were not rotated as required, and staff acknowledged this practice was inconsistent with both facility policy and professional standards. A second resident, diagnosed with metabolic encephalopathy, diabetic neuropathy, and moderate cognitive impairment, also received insulin injections at repeated sites without proper rotation. Review of medical records and interviews with nursing staff revealed multiple instances where insulin was administered in the same location, contrary to physician orders and facility policy. The Director of Nursing confirmed that staff should have checked previous injection sites in the electronic health record to ensure proper rotation, which was not done. Facility policy and manufacturer guidelines for all types of insulin administered to these residents clearly indicated the necessity of rotating injection sites to prevent complications. Despite these clear directives, the nursing staff did not adhere to the required procedures, as evidenced by documentation and staff interviews. This failure to rotate injection sites was directly observed and confirmed during the survey process.
Failure to Maintain Accident Hazard-Free Environment and Equipment Safety
Penalty
Summary
Surveyors identified that the facility failed to maintain a resident environment free from accident hazards for seven residents reviewed for accidents. Specifically, multiple residents who were assessed as high risk for falls and had orders for low beds with bilateral floor mats were found to have furniture or medical equipment placed on top of their fall mats. Observations included chairs, side tables, and bed wheels positioned on the mats, which staff and the DON acknowledged could compromise the mats' effectiveness in preventing injury. Facility policies and manufacturer instructions for the mats explicitly stated that heavy objects should not be left on the mats, as this could cause indentations and damage, reducing their protective function. In addition to the issues with fall mats, two residents were found to have bed controllers with visible, frayed, or exposed wires. Staff interviews confirmed that such conditions should have been reported to maintenance for immediate replacement, as per facility policy. The DON stated that exposed wires on bed controllers are not acceptable and should be addressed promptly to prevent potential harm. Facility policies required the maintenance department to keep all equipment in a safe and operable condition at all times. The residents involved had significant cognitive impairments, including diagnoses such as Alzheimer's disease, dementia, Parkinson's disease, and other conditions affecting their ability to make decisions or care for themselves. Many were dependent on staff for mobility and activities of daily living and had documented histories of falls or high fall risk. Despite these vulnerabilities and the presence of care plans and physician orders intended to mitigate injury risk, the facility did not ensure that environmental safety interventions were properly implemented and maintained.
Failure to Ensure Proper Pharmaceutical Services and Medication Accountability
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for two residents and in one medication room, resulting in multiple deficiencies. For one resident with a history of cerebral infarction, dementia, and urinary tract infection, the facility received eight tablets of Augmentin as ordered by the physician. However, only seven tablets were administered and documented, with the remaining tablet unaccounted for. The Medication Disposition Log was not completed for the extra tablet, and the bubble pack was missing. The Director of Nursing acknowledged that the medication was likely discarded without proper logging, contrary to facility policy, which requires all discontinued or leftover medications to be logged and destroyed in the presence of two licensed nurses. Another resident with Parkinson's disease was prescribed carbidopa-levodopa extended-release to be administered at midnight, in addition to immediate-release doses throughout the day. The Medication Administration Record showed that the extended-release dose was consistently given at 6:30 a.m. instead of midnight, as ordered by the physician. Both the registered nurse and the Director of Nursing confirmed that this constituted a medication error, as the medication was not administered according to the prescriber's order, and the timing was not in accordance with facility policy. Additionally, in one medication room, an emergency medication kit containing controlled medications was not reconciled at every shift change as required. The kit, stored in a refrigerator, lacked an accountability log for the month reviewed. Staff interviews confirmed that all controlled medications, including those in emergency kits, should be reconciled at each shift change to ensure accountability and prevent diversion. The Director of Nursing confirmed that this process was not followed for the emergency kit in question.
Pharmacy Consultant Failed to Identify and Report Medication Monitoring Irregularities
Penalty
Summary
The Pharmacy Consultant (PC) failed to identify and report irregularities during the monthly drug regimen review (MRR) for two residents. For one resident with bipolar disorder, the PC did not ensure that there was monitoring for specific, measurable target behaviors related to the use of valproic acid, a psychotropic medication. The resident's records indicated a prescription for valproic acid to address extreme irritability affecting activities of daily living, with instructions to monitor episodes of irritability and aggression. However, the MRRs for May and June did not document any identified irregularities or report the lack of behavior monitoring to the attending physician or Director of Nursing (DON). For another resident with Parkinson Disease, the PC did not ensure monitoring for adverse effects associated with the use of carbidopa-levodopa. The care plan indicated a risk for adverse effects and the need for monitoring, but the Medication Administration Record (MAR) did not contain documentation of such monitoring. The MRRs for April, May, and June did not identify or report the absence of adverse effect monitoring to the attending physician or DON. During interviews, the PC acknowledged failing to identify and report the lack of appropriate monitoring for both residents in the monthly written reports. Facility policies and procedures required comprehensive MRRs, evaluation of medication therapy responses, and documentation and reporting of resident-specific irregularities or clinically significant risks to the DON and prescriber. The PC's failure to follow these requirements resulted in the deficiencies cited.
Failure to Monitor for Adverse Effects of Carbidopa-Levodopa
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary drugs by not monitoring for adverse effects associated with carbidopa-levodopa, a medication prescribed for Parkinson’s Disease. The resident’s care plan specifically identified the risk of adverse effects, such as dyskinesia, and directed staff to monitor for these effects and alert the physician as needed. However, a review of the Medication Administration Record (MAR) for the relevant period showed no documentation of such monitoring. Interviews with both a registered nurse and the Director of Nursing confirmed that monitoring for adverse effects should have been documented on the MAR, in accordance with the care plan. Both staff members were unable to locate any evidence of monitoring for adverse effects related to carbidopa-levodopa during the specified timeframe. The lack of documentation indicated that the care plan was not implemented as intended, and the resident’s needs were not adequately addressed. The facility’s policies and procedures required monitoring for adverse consequences of medications and prompt reporting of any such events. The policies also specified that licensed nurses should review drug regimens for adequate monitoring and that adverse consequences should be minimized by following clinical guidelines. Despite these requirements, the facility did not ensure that monitoring for adverse effects of carbidopa-levodopa was performed or documented for the resident, resulting in a failure to comply with both internal policy and regulatory standards.
Medication Error Rate Exceeds Regulatory Threshold Due to Late Administration
Penalty
Summary
The facility failed to ensure that its medication error rate remained below five percent, as required by regulation. During an observation, a Licensed Vocational Nurse (LVN) administered four medications—famotidine, buspirone, hydrochlorothiazide, and losartan—to a resident at a time different from what was ordered by the resident’s physician. The medications were given outside the facility’s policy window of 60 minutes before or after the scheduled administration time, which was confirmed by both the LVN and the Director of Nursing (DON) during interviews. The LVN acknowledged not following the '5 rights' of medication administration, specifically the right time, and identified these as medication errors. The resident involved had a medical history including anxiety, hypertension, and gastro-esophageal reflux disease, and was prescribed the medications for these conditions. The Medication Administration Record (MAR) and physician orders specified exact times for each medication, which were not adhered to during the observed administration. The facility’s policies and procedures clearly outlined the requirement to administer medications within a one-hour window of the prescribed time, and to verify the correct time before administration. A review of facility policies further confirmed that administering medications at the wrong time constitutes a medication error. The incident resulted in four medication errors out of 26 opportunities, leading to a medication error rate of 15.38%, which exceeds the regulatory threshold. Both the LVN and DON confirmed that the medications were not administered according to physician orders or facility policy, and these actions were classified as medication errors.
Failure to Rotate Insulin Injection Sites Leads to Significant Medication Errors
Penalty
Summary
Surveyors identified that the facility failed to ensure residents were free from significant medication errors by not rotating subcutaneous insulin administration sites as required by physician orders, manufacturer guidelines, and professional standards. For one resident with dementia and type 2 diabetes, records showed repeated insulin injections were administered in the same anatomical areas over multiple dates, despite explicit orders and care plan interventions to rotate sites. Interviews with the MDS Coordinator and nursing staff confirmed that insulin administration sites were not rotated, and staff acknowledged this was contrary to both the physician's orders and best practice guidelines. A second resident, diagnosed with metabolic encephalopathy and diabetes with neuropathy, also received insulin injections without proper site rotation. Documentation revealed multiple instances where insulin was administered repeatedly in the same location, such as the left lower quadrant of the abdomen or the same arm, over several days. Nursing staff and the DON confirmed that the administration sites were not rotated as required, and acknowledged that staff should have checked previous administration sites in the electronic health record to avoid repetition. Review of facility policies and manufacturer guidelines for insulin administration further supported the requirement to rotate injection sites to prevent complications. The facility's own policy, as well as the prescribing information for the insulins used, specified that injection sites should be rotated within the same general area. Despite these clear directives, the facility did not ensure compliance, resulting in a significant medication error for both residents.
Failure to Label and Store Inhalation Medications per Manufacturer and Facility Policy
Penalty
Summary
Surveyors observed that the facility failed to properly label and store certain inhalation medications in accordance with manufacturer requirements and facility policy. Specifically, an open budesonide inhalation solution foil pouch for one resident was found in a medication cart without a date indicating when the pouch was opened, and three inhalation solutions remained inside the open pouch. Manufacturer guidelines require that once opened, the foil pouch should be stored at room temperature and the contents used or discarded within two weeks. The lack of labeling made it impossible to determine if the medication was still within its effective period. Additionally, an open and used budesonide and formoterol inhalation aerosol for another resident was found stored at room temperature without a date indicating when the inhaler was removed from its foil pouch. According to manufacturer instructions, this inhaler should be used or discarded within three months of opening. The absence of an open date meant staff could not verify whether the medication was still effective or had expired. Interviews with the LVN and DON confirmed that facility policy requires multi-dose products to be labeled with the date opened to track expiration, and that failure to do so prevents staff from determining the beyond-use date. Review of facility policies and manufacturer instructions further supported the requirement for proper labeling and timely use or disposal of these medications. The observed deficiencies were limited to the medications found in one medication cart and involved two residents receiving inhalation treatments for respiratory conditions.
Failure to Follow No Added Salt Diet Orders for Multiple Residents
Penalty
Summary
The facility failed to follow its own menu and nutritional guidelines by providing extra packets of salt to residents who were prescribed No Added Salt (NAS) diets. Multiple residents with medical conditions such as hypertension, heart disease, and impaired cognition were observed to have received salt packets on their meal trays, despite clear dietary orders specifying NAS diets. This was confirmed through record reviews, resident interviews, and direct observation of meal service, where kitchen staff routinely added salt and pepper packets to all trays without checking individual dietary restrictions. Residents affected included those with intact cognition who reported receiving extra salt packets, as well as residents with impaired cognition who were unable to advocate for themselves. The dietary orders for these residents specifically required NAS diets due to their medical conditions, including hypertension, heart failure, and atherosclerotic heart disease. The facility's menu and policy also indicated that NAS diets should not include salt packets, and that dietary staff are responsible for ensuring therapeutic diets are prepared and served as ordered. Interviews with the Dietary Service Supervisor and the Director of Nursing confirmed that the kitchen staff did not check tray tickets for NAS diet orders and acknowledged that this practice could negatively impact residents' medical conditions. The deficiency was identified through a combination of record review, resident council feedback, direct observation of meal trays, and staff interviews, all of which demonstrated a failure to adhere to prescribed dietary restrictions for residents requiring NAS diets.
Incomplete Medical Records and Informed Consent Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for three residents. For one resident with depressive disorder, dementia, and psychosis, the informed consent for a psychotropic medication did not document the method used to verify that the physician discussed the risks and benefits with the resident or their representative. Both the LVN and RN confirmed that the consent form was incomplete, as the section indicating how the consent was verified was left blank. The Director of Nursing also acknowledged that the consent was not complete due to missing documentation on the verification method. For another resident with depression, dementia, and anxiety disorder, the informed consent for a mood-stabilizing medication was also incomplete. The consent form lacked the date beside the physician's signature and did not indicate how the informed consent was verified by the licensed nurse. Both the LVN and RN identified these omissions during their review, and the DON confirmed that the consent was not complete because the physician's signature was not dated and the verification method was not documented. Additionally, for a resident with cerebral infarction, dementia, and a urinary tract infection, the administration of an antibiotic (Augmentin) was not documented in the Medication Administration Record (MAR) as having been given at the prescribed time. Although the Emergency Kit Pharmacy Log showed that the medication was administered, this was not reflected in the resident's MAR. The Infection Preventionist and DON both confirmed that the lack of documentation in the MAR resulted in inaccurate medical records, as it was unclear whether the resident received the medication as ordered.
Personal Belongings Found in Clean Laundry Room Violating Infection Control Policy
Penalty
Summary
A deficiency was identified when personal belongings, including two bags, a sweater, a cellphone, and a pair of sunglasses, were observed inside the clean laundry room. These items belonged to a laundry staff member and were found hanging by the door and placed under the air-conditioning unit near a table with folded clean linens. The Housekeeping Manager confirmed that the items belonged to the staff member, and the Infection Preventionist stated that personal belongings are not permitted in the clean laundry area, as this area is designated for washed linens and clothes and must remain clean. Further interviews revealed that laundry staff are provided with lockers in the janitor room for storing personal items, and facility policy prohibits employee personal belongings from being left in the laundry area. The Director of Nursing acknowledged that the facility failed to keep the laundry area clean and free from potential infection related to the placement of personal belongings, which could result in cross contamination. Facility policies reviewed also indicated that clean linen must be protected from environmental contamination.
Failure to Monitor Antibiotic Use
Penalty
Summary
The facility failed to implement a program that monitors antibiotic use. There is no evidence provided that the facility had a system in place to track, review, or evaluate the administration of antibiotics to residents. The absence of such a program was identified during the survey, indicating that the facility did not take necessary actions to ensure appropriate antibiotic stewardship.
Failure to Maintain Safe Condition of Essential Equipment
Penalty
Summary
The facility failed to maintain essential electrical and patient care equipment in safe operating condition for five residents. Observations and interviews revealed that one resident's fall mat had peeling covers, compromising its integrity and the homelike environment. The fall mat was intended as an intervention for a resident with severe cognitive impairment, high fall risk, and a history of falls, as documented in the care plan and medical records. Both the LVN and DON confirmed that the mat's condition was unacceptable and did not meet facility standards for safety or environment. Additionally, four residents were found to have bed remote controls with frayed or exposed wires. These residents had varying degrees of cognitive impairment and physical dependency, with some at high risk for falls. Staff, including CNAs and the DON, acknowledged during interviews that exposed or frayed wires on bed controls posed a risk of electrocution and should have been reported immediately to the maintenance department for replacement. Observations confirmed the presence of these hazards in resident rooms, and staff admitted to not noticing or reporting the issues in a timely manner. Review of facility policies and procedures indicated that maintenance services are responsible for ensuring all equipment is safe and operable, and that staff are expected to identify and report hazards. The policies also emphasized the importance of providing a safe, clean, and homelike environment, and specifically addressed the need for electrical safety and the prevention of accident hazards. Despite these policies, the facility did not ensure that equipment such as fall mats and bed controls were maintained in safe condition, resulting in the identified deficiencies.
Failure to Honor Resident Rights to Dignity and Self-Determination
Penalty
Summary
A deficiency was identified regarding the failure to honor a resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report notes that the facility did not ensure these resident rights were upheld, but does not provide specific details about the actions or inactions that led to this deficiency, nor does it mention any particular events or residents involved. No additional information about the medical history or condition of any resident at the time of the deficiency is provided in the report.
Failure to Inform Residents of Health Status and Treatments
Penalty
Summary
Residents were not fully informed or did not fully understand their health status, care, and treatments. The deficiency was identified based on findings that residents were not provided with adequate information regarding their medical condition and the care or treatments they were receiving. This lack of communication resulted in residents not being able to make informed decisions about their care.
Unnecessary Use of Psychotropic Medications
Penalty
Summary
The facility failed to prevent the use of unnecessary psychotropic medications or the use of medications that may restrain a resident's ability to function. This deficiency indicates that residents were administered psychotropic drugs without adequate justification or in a manner that could limit their functional abilities. The report does not provide specific details about the residents involved, their medical histories, or their conditions at the time of the deficiency.
Failure to Implement Pressure Ulcer Prevention Interventions
Penalty
Summary
The facility failed to provide pressure ulcer care consistent with professional standards for two residents. For one resident with a history of stage three sacral pressure ulcer, contractures, and severe cognitive impairment, there was a physician's order to apply heel protectors to both feet at all times, both in bed and in a wheelchair. Observations revealed that the resident was not wearing heel protectors, and both the CNA and LVN assigned to the resident confirmed that the heel protectors were not applied. The CNA was unaware of the order, and the LVN acknowledged responsibility for ensuring the use of pressure-relieving devices but confirmed the protectors were not in place. The RN also confirmed the order and stated that staff should have ensured the heel protectors were applied as the resident was at high risk for pressure ulcers due to fragile skin, contractures, and poor nutrition. For another resident with a stage four right gluteal pressure injury, dementia, diabetes, and severe cognitive impairment, there was a physician's order for a low air loss mattress (LALM) to be set according to the resident's current weight. The resident's weight was documented as 114 lbs, but the LALM was observed to be set at 160 lbs. The Infection Preventionist and DON both confirmed that the mattress should have been set to 120 lbs, the closest available setting to the resident's weight. The incorrect setting was not in accordance with the physician's order or the facility's care plan, which specified that the LALM should be set based on the resident's current weight to minimize the risk of skin breakdown. Facility policy and procedures required staff to review care plans, identify risk factors, and implement appropriate interventions, including the use of pressure-relieving devices and support surfaces. The operations manual for the LALM also specified that the mattress should be adjusted according to the patient's weight. Despite these guidelines, staff failed to ensure that the prescribed interventions were implemented for both residents, as evidenced by the lack of heel protectors and the incorrect LALM setting.
Failure to Ensure Required Physician and Psychiatrist Visits
Penalty
Summary
The facility failed to ensure that a resident received required face-to-face visits from both the attending physician (AP) and the psychiatrist (Psych MD) as mandated. Specifically, the AP did not make an initial face-to-face visit within 30 days of admission during the first 90 days, and the Psych MD did not conduct a required visit as per physician orders. Instead, nurse practitioners (NPs) conducted all visits for both the AP and the Psych MD, with no documentation of direct visits from the physicians themselves. Review of the resident's medical record confirmed the absence of progress notes or history and physical documentation from either the AP or the Psych MD. The resident involved had diagnoses including cerebral ischemia, unspecified dementia, and insomnia, with documentation indicating severely impaired cognitive skills and lack of capacity to make decisions. Despite orders for psychiatric consultation and follow-up, only NPs performed these visits. Interviews with nursing staff and the DON confirmed that the AP and Psych MD did not see the resident, and the facility's policy requiring physician visits was not followed. The DON acknowledged the failure to ensure required physician visits occurred.
Failure to Ensure Resident Access to Survey Results
Penalty
Summary
The facility failed to ensure that two residents who attended a Resident Council Meeting were aware of the availability and location of the facility's latest survey results. During interviews, both residents stated they did not know where to find the survey results or how the facility addressed previously identified deficiencies. The residents expressed a desire to be informed about the facility's most recent survey inspection results and the corrective actions taken. Observation and interviews with staff revealed that the survey result binder was stored under a cabinet in the dining room, with a label too small for residents to read. Although the facility maintained two survey binders—one in the front lobby and one in the dining room—residents were only informed that they could ask staff to access the binder. Staff acknowledged that the binder should be easily accessible to residents without staff assistance. Review of facility policies confirmed that survey results should be maintained in an area frequented by residents and be readily accessible for examination.
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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 7,198 citations issued within 25 miles in the last 12 months — including the 23 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Burbank
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Burbank Healthcare & Rehab | 0.1 mi | ★★★★★ | 88 | 1 |
| Griffith Park Healthcare Center | 0.1 mi | ★★★★★ | 44 | 1 |
| Dreier's Nursing Care Center | 1.7 mi | ★★★★★ | 19 | 0 |
| Broadway Manor Care Center | 2.6 mi | ★★★★★ | 18 | 0 |
| Royal Palms Post Acute | 2.6 mi | ★★★★★ | 43 | 0 |
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