Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Alcott Rehabilitation Hospital during CMS and state inspections, most recent first.
A resident with severe cognitive impairment received a haircut without prior consent from their responsible party, despite facility policy requiring such consent for residents unable to make decisions. Interviews confirmed that staff did not inform or obtain approval from the resident's representative before providing the personal care service.
Two residents dependent on staff for ADLs did not receive scheduled showers or timely feeding assistance. One resident missed multiple scheduled showers without documentation or notification to the responsible party, while another waited over 30 minutes for feeding after meal delivery due to staff workload. Facility policies requiring scheduled care and proper documentation were not followed.
The facility failed to label laundry bins and reusable isolation gowns as clean or dirty in the laundry room, and staff observed unlabeled bins containing fabrics and gowns stored without clear clean/dirty identification. The facility also stored expired N95 masks in multiple supply areas and expired COVID-19 antigen test kits in a storage closet; the CSP, RN, IPN, and DON stated expired masks would not provide protection and expired tests could produce inaccurate or false positive results.
A resident with stroke-related diagnoses, vascular dementia, severe cognitive impairment, and dependence for multiple ADLs was observed lying in bed unclothed from the waist down with the room door wide open and the privacy curtain open, making the resident visible from the hallway. An LVN confirmed the resident was exposed and stated staff needed to provide privacy and protect the resident because the resident was confused and unaware of the exposure; an RN and the DON also stated residents must be kept private and dignified when unable to do so themselves.
Advance Directive Documentation Not Completed: The facility failed to document that advance directives were discussed and written information was provided for a resident admitted with aftercare following joint replacement, a right artificial knee joint, and type 2 DM. Admissions stated the Advance Directive Acknowledgement Form had not been completed or reviewed with the resident or family, while the resident said her daughter handled the paperwork and the DON stated advance directives are completed prior to or on admission.
Confidentiality Breach in Discarded Medication Bottles: Two residents’ medication bottles were found in a disposal bin with their names and identifying information still attached. An RN stated that discontinued or wasted non-narcotic meds were placed in the bin and sent to the pharmacy without removing labels, while the DON stated that resident names should not remain on discarded bottles and that LNs should blacken out or peel off personal information. The residents had diagnoses including dysphagia following cerebral infarction, gout, generalized weakness, traumatic subdural hemorrhage, pulmonary fibrosis, and emphysema.
Inaccurate MDS coding for restorative nursing services: The facility failed to accurately assess two residents' RNP participation in the MDS. One resident with stroke-related diagnoses had a walking RNP with ambulation documented in the care plan and flow sheets, but the MDS showed no qualifying 15-minute daily RNP in the look-back period. Another resident with PVD and an above-the-knee amputation had AAROM RNP for the upper and lower extremities documented in the care plan and observation, yet the MDS also did not reflect qualifying RNP minutes. The MDSC and DON stated the interventions did not specify the number of minutes, and the DON stated the MDS was not accurate.
Failure to Provide Restorative Nursing Services for Mobility and ROM: Two residents had care plans for restorative nursing programs, one for ambulation and one for AAROM to the UE and LE. Record review showed multiple days in which the scheduled restorative services were not documented, and RNA and DON interviews confirmed the blank days meant the services were not performed and there was no documentation of refusal. One resident had significant neurologic impairment and the other had multiple chronic conditions including PVD and an above-knee amputation.
A facility room exceeded the 4-bed limit, with a room housing 5 residents and measuring 377 square feet. Observations showed privacy curtains, working call-lights, a dresser, and a bedside table for each resident, and an assigned CNA stated there were no space issues and room existed for wheelchairs. The facility’s waiver request acknowledged the room did not meet the regulation, while the facility policy required at least 80 square feet per resident in multiple-occupancy bedrooms.
Resident rooms did not meet the required square footage standard in 24 of 63 rooms, including multiple shared rooms listed in the survey findings. Observations showed the rooms had privacy curtains, call-lights, a dresser, and a bedside table, and staff and residents interviewed reported enough space to move around and provide care. The facility’s room waiver letter requested a variance for the undersized rooms and stated the rooms were consistent with resident needs and did not compromise safety.
During a COVID-19 outbreak, staff failed to follow infection control protocols, including not performing hand hygiene after resident contact and not wearing required N95 respirators. An EVSD did not sanitize hands after disposing of a cup for a resident, while a CNA and a dietary aide were observed wearing surgical masks instead of N95s, despite facility policy and public health guidance requiring N95 use during the outbreak.
The facility failed to implement adequate infection control measures during a COVID-19 outbreak. Staff did not consistently wear N95 masks or perform COVID-19 tests at the start of their shifts. Resident activities were not paused, and a non-COVID-19 positive resident was bathed in a shower room reserved for COVID-19 patients. Additionally, air purifiers were not placed in all hallways as required, increasing the risk of virus spread.
The facility failed to screen visitors for COVID-19 symptoms during an outbreak, as observed when a family member entered unmasked and unscreened. The visitor log lacked proper documentation, and no staff were designated to enforce screening, despite the outbreak involving two residents. The IP and DON confirmed the lapse in screening, contrary to facility policy.
A facility failed to maintain a resident's dignity during mealtime when a CNA stood over a resident with dementia and feeding difficulties, instead of sitting at eye level as required by policy. The DON confirmed that staff should be seated to protect resident dignity, aligning with the facility's policy on promoting respect during mealtimes.
A resident with severe cognitive impairment and depression had a care plan that included attending church services, which they no longer enjoyed. Facility staff confirmed the resident preferred spending time with family, but the care plan was not updated to reflect this change. Observations showed the resident was not assisted to attend church services, contrary to their care plan.
The facility failed to update care plans for two residents with pressure ulcers. One resident's care plan did not reflect current wound care treatment, while another's included outdated interventions for pressure injury prevention. Staff interviews confirmed the need for updated care plans to ensure continuity of care.
A resident at moderate risk for pressure ulcers did not receive necessary pressure-relieving devices or regular repositioning as per their care plan. Staff were unaware of the resident's needs, and there was no documentation of repositioning or pressure reduction, increasing the risk of pressure sores.
A resident with hemiplegia and contracture was not provided with the prescribed frequency of passive range of motion exercises and knee splint assistance as per their care plan. The facility's RNA program was not followed, leading to a deficiency in maintaining the resident's mobility.
The facility failed to label an opened vial of Novolin R with an open date, as required by the manufacturer. During an inspection of a medication cart, it was found that the vial was stored at room temperature without an open date, making it impossible to determine its expiration. An LVN confirmed the oversight, acknowledging the risk of administering expired insulin, which could lead to poor blood sugar control. Facility policies require medications to be stored and labeled according to manufacturer recommendations.
The facility lacked a policy for storing and reheating leftover food brought by residents' families or visitors, potentially leading to foodborne illnesses. Staff interviews revealed that the facility discouraged storing perishable food and had no refrigerator for residents' use. The policy required food to be consumed or discarded within two hours, with nonperishable items allowed in sealed containers in resident rooms, but lacked procedures for residents wanting to store food.
A resident with a history of falls and severe cognitive impairment experienced multiple falls due to the facility's failure to accurately assess fall risk and implement effective interventions. The care plan lacked specific monitoring frequencies, leading to inadequate supervision and repeated falls. Interviews revealed that the facility's policies on fall prevention were not effectively implemented, contributing to the resident's risk of harm.
The facility was found non-compliant with the regulation limiting resident rooms to a maximum of four occupants, as room [ROOM NUMBER] housed five residents. Despite staff assurances of adequate space for care, including the use of a Hoyer lift, the facility's policy requires rooms to provide at least 80 square feet per resident for comfort and privacy.
The facility failed to meet the required 80 square feet per resident in 24 out of 63 rooms. Measurements showed that rooms did not provide adequate space per resident, despite staff believing there was enough space for care. The facility's policy mandates at least 80 square feet per resident in multiple occupancy rooms, which was not achieved.
Failure to Obtain Consent from Resident Representative for Personal Care
Penalty
Summary
The facility failed to obtain consent from a resident's responsible party (RP) before providing a haircut to a resident who was unable to make decisions due to severely impaired cognitive skills. The resident, admitted with diagnoses including dementia, right femur fracture, lack of coordination, and dysphagia, was assessed as having no capacity to understand or make decisions and was dependent on staff for most activities of daily living. Despite this, the facility's hairdresser cut the resident's hair without prior consent from the RP. Interviews with the resident's RP, the Activities Director, and the Social Services Designee confirmed that consent was not obtained before the haircut was given. The facility's policy stated that the resident representative has the right to exercise the resident's rights to the extent delegated and that residents must be informed in advance of care to be furnished. The failure to obtain consent resulted in a violation of the resident representative's right to make decisions on behalf of the resident.
Failure to Provide Scheduled Showers and Timely Feeding Assistance
Penalty
Summary
The facility failed to provide necessary care and assistance with activities of daily living (ADLs) for residents who were dependent on staff for showers and feeding. One resident, admitted with diagnoses including dementia, right femur fracture, lack of coordination, and dysphagia, was scheduled to receive showers every Monday and Thursday. However, the resident did not receive showers on three scheduled days, and there was no documentation explaining the missed showers. Staff interviews revealed that the resident was not given showers due to being resistive, and instead, a bed bath was provided. Despite this, there was no documentation that the resident's responsible party was notified of the missed showers, as required by facility policy. Another resident, also with dementia and dysphagia, was dependent on staff for feeding. During observation, this resident's breakfast tray was delivered and left on the bedside table for over 30 minutes before staff assisted with feeding. Staff interviews indicated that the CNA responsible for feeding had multiple residents to assist, resulting in delays. The restorative nursing assistant confirmed that food trays are delivered promptly but should not be left for extended periods, as the food can become cold. A review of facility policies confirmed that residents are to be assisted with bathing and feeding according to their care plans and schedules, and that documentation should reflect the care provided and any deviations. The facility's failure to provide scheduled showers, timely feeding assistance, and proper notification and documentation constituted deficiencies in meeting residents' ADL needs.
Unlabeled Laundry Items and Expired Infection Control Supplies
Penalty
Summary
The facility failed to maintain infection control measures by not ensuring laundry bins and reusable isolation gowns were labeled as clean or dirty in the laundry room. During observation with the Maintenance Worker, light gray fabrics were seen in a yellow unlabeled laundry bin next to the dryer, and a gray bin labeled only as laundry was observed next to the washing machine without identifying whether it was for clean or dirty items. Yellow shiny reusable washable gowns were also observed in plastic drawers without clean or dirty labels. The Maintenance Worker stated the yellow bin was for clean clothes, the gray bin was for dirty clothes, and the gowns were PPE isolation gowns that should have been labeled clean or dirty; the worker also stated that if items were not labeled correctly, it could cause cross-contamination. The facility also failed to remove expired infection control supplies from storage areas. In the basement medical supply storage, 1 box of N95 masks and 68 boxes of N95 masks were observed with expiration dates, and in a hallway storage closet 90 boxes of N95 masks with expiration dates were observed. In a storage closet between resident rooms, 18 expired COVID-19 antigen test kits were observed in an opened box and 2 closed boxes of COVID-19 antigen test kits were also observed with expiration dates. The CSP stated it was everyone's responsibility to check expiration dates, and the RN, IPN, and DON stated expired N95 masks would not provide protection, could rip, and could cause a break in infection control, while expired COVID-19 antigen tests could give inaccurate or false positive readings.
Resident Left Exposed During Care
Penalty
Summary
The facility failed to respect Resident 110’s rights to dignity and privacy when the resident was left exposed from the waist down with the room door wide open and the privacy curtain open. Resident 110 was admitted on 6/2/2025 and readmitted on 8/2/2025 with diagnoses including sequelae of cerebral infarction, immunodeficiency, dysphagia following cerebral infarction, anxiety disorder, vascular dementia without behavioral disturbance, bilateral knee contractures, and lack of coordination. The H&P dated 6/14/2025 indicated the resident had fluctuating capacity to understand and make decisions, and the MDS dated 9/9/2025 indicated severe cognitive impairment and need for partial/moderate assistance with rolling, transfers, toileting hygiene, bathing, lower body dressing, and footwear. During observation on 12/3/2025, Resident 110 was seen lying on her back in bed with pants down around her ankles, exposing her stomach, pelvis, pubic area, and legs to the hallway outside the room. LVN 2 confirmed the resident was unclothed and visible from the hallway, then closed the privacy curtain and stated staff needed to provide privacy and protect the resident because she was confused and not aware she was exposed. RN 2 stated staff needed to help residents maintain privacy and dignity when they were unable to do so or were confused, and the DON stated it was not appropriate to leave a resident exposed and visible to others. The facility policy titled Promoting/Maintaining Resident Dignity stated staff are to protect and promote resident rights, maintain resident privacy, and treat each resident with respect and dignity.
Advance Directive Documentation Not Completed
Penalty
Summary
The facility failed to ensure Resident 84’s medical record was updated to document that advance directives were discussed and that written information was provided to the resident and/or responsible party. Resident 84 was admitted with diagnoses including aftercare following joint replacement, presence of a right artificial knee joint, and type 2 diabetes mellitus without complications. The resident’s H&P dated 11/21/25 indicated the resident had the capacity to understand and make decisions. During a concurrent interview and record review on 12/02/25, Admissions stated that the Advance Directive Acknowledgement Form had not been completed for Resident 84 and that the form had not yet been reviewed with the resident or family because the resident was recently admitted. Admissions stated he still needed to ask the resident/family about advance directives and noted that he normally reviews the form on admission. During an interview on 12/04/25, the resident stated she did not know anything about paperwork because her daughter signed and handled the papers when she was admitted. The DON stated that advance directives are done prior to admission or on admission. The facility policy stated that on admission the facility will determine whether the resident has executed an advance directive and, if not, determine whether the resident would like to formulate one, and provide information about the right to refuse medical or surgical treatment and formulate an advance directive.
Confidentiality Breach in Discarded Medication Bottles
Penalty
Summary
The facility failed to appropriately destroy or remove identifiable information from discarded medication bottles for two residents. During observation in the medication room, two medication bottles with the residents’ names and information still attached were found in a blue disposal bin. One resident had diagnoses including dysphagia following cerebral infarction, gout, and generalized muscle weakness, and the other resident had diagnoses including traumatic subdural hemorrhage without loss of consciousness, pulmonary fibrosis, and emphysema. Both residents’ MDS assessments indicated they could make themselves understood and understand others. During interview, the RN stated that discontinued or wasted non-narcotic medications, including bottles with resident names on them, were placed in the bin and sent back to the pharmacy for disposal without removing the labels. The DON stated that medication bottles should not have a resident’s name on them when discarded and that licensed nurses should blacken out or peel off labels with personal information. The facility policy on confidentiality stated that resident personal and medical records are to remain secure and confidential, regardless of the form of storage or location.
Inaccurate MDS coding for restorative nursing services
Penalty
Summary
The facility failed to ensure the MDS assessment for the Restorative Nursing Program (RNP) was accurately completed for two sampled residents, Resident 79 and Resident 86. For Resident 79, the admission record showed diagnoses including hemiplegia, hemiparesis, cerebral infarction, Alzheimer's disease, and dementia. The care plan indicated the resident was on the RNP for walking because of potential decline in walking skills related to a cerebrovascular accident, with a goal to maintain ambulation with an assistive device and facilitate transfers. The care plan intervention directed staff to ambulate the resident up to 90 feet with minimal assistance and a front wheeled walker every day five times a week as tolerated. The Documentation Survey Report for Resident 79 showed the resident was on the RNP for walking and was ambulated on 9/23/2025 and 9/24/2025. However, the MDS dated 9/29/2025 indicated the resident did not receive at least 15 minutes a day of the RNP during the prior 7 calendar days. For Resident 86, the admission record showed diagnoses including PVD, hyperlipidemia, osteoarthritis, lack of coordination, and acquired absence of the left leg above the knee. The Documentation Survey Report showed the resident was on the RNP for AAROM of the bilateral upper extremities using 2 pound weights and AAROM of the right lower extremity and left hip five times a week as tolerated, with documentation that the resident received these exercises on 9/17/2025. The MDS for Resident 86 indicated the resident did not receive at least 15 minutes a day of the RNP during the prior seven calendar days. The care plan revised 9/30/2025 identified the resident's RNP for AAROM due to potential decline in ROM related to the left above-the-knee amputation and included goals to support independence, hygiene, functional mobility, and reduce skin breakdown risk. During observation, RNA 1 assisted Resident 86 with bilateral upper extremity exercises using 2 pound weights and AAROM exercises for the right lower extremity and left hip, and the session lasted from 10:34 AM to 10:50 AM. RNA 1 and RNA 2 stated the RNP exercises usually took 10 to 15 minutes or 15 minutes per resident. The MDS Coordinator and DON stated the MDS for Resident 79 and Resident 86 did not indicate the residents were on an RNP because the interventions did not specify how many minutes the exercises were to take place, and the DON stated the MDS was not accurate because it did not indicate the residents were on the RNP.
Failure to Provide Ordered Restorative Nursing Mobility and ROM Services
Penalty
Summary
The facility failed to provide restorative nursing services to maintain or improve mobility and ROM for two residents. One resident was admitted with diagnoses including hemiplegia, hemiparesis, cerebral infarction, Alzheimer's disease, and dementia. That resident's care plan, initiated 4/4/2025, identified a restorative nursing program for walking with a goal to maintain ambulation with an assistive device and facilitate transfers, with an intervention to ambulate up to 90 feet with minimal assistance and a front wheeled walker every day five times a week as tolerated. A review of the resident's MDS dated 9/29/2025 showed severely impaired cognition and need for assistance with walking. The Documentation Survey Report for 11/1/2025 through 11/30/2025 showed ambulation documentation on some days, but no documentation on 11/3, 11/6, 11/7, 11/12, 11/13, 11/18, 11/19, 11/24, and 11/25. During interview and record review, RNA 1 confirmed the missing documentation and stated those blank days indicated the restorative walking program was not performed. RNA 1 also stated there was no documentation that the resident refused the service. The facility also failed to provide restorative AAROM services for another resident. That resident was readmitted on 1/7/2025 with diagnoses including PVD, hyperlipidemia, osteoarthritis, lack of coordination, and acquired absence of the left leg above the knee. The care plan revised 9/30/2025 identified a restorative nursing program for AAROM to the right lower extremity, left hip, and bilateral upper extremities, with interventions for AAROM using 2-lb weights to both upper extremities and AAROM to the right lower extremity and left hip five times a week as tolerated. The Documentation Survey Report for 11/1/2025 through 11/30/2025 showed restorative AAROM documentation on some days, but no documentation on 11/3, 11/6, 11/7, 11/12, 11/13, 11/18, 11/19, 11/24, and 11/25. RNA 1 confirmed the missing documentation and stated those blank days indicated the AAROM was not performed, with no documentation that the resident refused. The DON also reviewed the records and stated the purpose of the restorative program was to maintain the residents' current level of mobility and ROM.
Excess Residents in a Shared Room
Penalty
Summary
The facility failed to meet the requirement for no more than four residents per room in one of 63 resident rooms, identified as room [ROOM NUMBER]. During multiple observations from 12/1/2025 to 12/4/2025, nursing staff were observed with adequate space to provide care to the residents in room [ROOM NUMBER]. Each resident in the room was observed to have privacy curtains, working call-lights, a dresser, and a bedside table. Review of the facility’s room waiver request letter dated 12/4/2025 showed that room [ROOM NUMBER] did not meet the 4-bed-per-room regulation. The letter stated the room was in accordance with the special needs of residents and would not adversely affect residents’ health and safety or impede their ability to attain highest practicable well-being. It also documented that room [ROOM NUMBER] had 5 resident beds and measured 377 square feet, or 75.4 square feet per resident. During interview, CNA 4 stated she was assigned to room [ROOM NUMBER], that the room had five beds, that there were no issues with the space, and that there was room to place wheelchairs. The facility policy stated resident bedrooms must be designed and equipped for adequate nursing care, comfort, and privacy and must measure at least 80 square feet per resident in multiple resident bedrooms.
Resident Rooms Did Not Meet Required Square Footage
Penalty
Summary
The facility failed to ensure 24 of 63 resident rooms met the required 80 square feet per resident standard for multiple resident rooms. The rooms identified in the report included room [ROOM NUMBER], 6, 8, 12, 19, 24, 26, 30, 32, 37, 39, 40, 41, 45, 46, 48, 50, 54, 56, 58, 59, 61, 62, and 63. During multiple room observations from 12/1/2025 through 12/4/2025, staff observed that resident rooms had privacy curtains, working call-lights, a dresser, and a bedside table, and that there was adequate space to provide care in each room. A review of the facility’s room waiver letter dated 12/4/2025 showed the facility requested a variance for the 24 rooms because they had less than 80 square feet per bed. The letter stated the rooms were in accordance with the special needs of the residents and would not adversely affect resident health, safety, or well-being, and that resident, staff, and visitor safety would not be compromised. Interviews with CNA 3, LVN 4, LVN 5, Resident 31, and Resident 78 reflected that they did not report feeling crowded or having problems with room space, and the facility’s policy stated resident bedrooms must measure at least 80 square feet per resident in multiple resident bedrooms.
Failure to Follow Infection Control Protocols During COVID-19 Outbreak
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices among staff during a COVID-19 outbreak. Specifically, the Environmental Services Director (EVSD) did not perform hand hygiene after disposing of a cup for a resident in a room, as observed by the Infection Preventionist (IP). The EVSD acknowledged that not sanitizing hands could contribute to the spread of infections, and the IP confirmed that this lapse could result in infection transmission. Additionally, two other staff members, a Certified Nursing Assistant (CNA 2) and a Dietary Aide (DA 1), were observed not wearing the required N95 respirator masks during the outbreak. DA 1 was seen wearing a surgical mask in the kitchen and only switched to an N95 mask upon noticing the presence of the Director of Nursing (DON) and a surveyor. CNA 2, who was responsible for screening employees and visitors at the facility entrance, was also observed wearing a surgical mask instead of an N95 respirator. Both the IP and DON confirmed that all staff were required to wear N95 masks during the outbreak, and failure to do so could contribute to the spread of COVID-19. A review of facility policies indicated that hand hygiene and the use of appropriate personal protective equipment (PPE), including N95 respirators during outbreaks, were required. The facility's records also showed that the EVSD, CNA 2, and DA 1 had declined COVID-19 vaccination. The observations and interviews confirmed that staff did not consistently follow established infection control protocols, including hand hygiene and use of N95 respirators, as required by facility policy and public health guidance during the outbreak.
Inadequate Infection Control Measures During COVID-19 Outbreak
Penalty
Summary
The facility failed to implement its infection prevention and control policies during a COVID-19 outbreak, as observed by surveyors. Staff members were not consistently wearing N95 masks, which are essential for protection against airborne particles, during the outbreak. Instead, some staff, such as Certified Nursing Assistant 1, were observed wearing surgical masks and only switching to N95 masks when directly caring for COVID-19 positive residents. Additionally, staff members were not adhering to the requirement to perform COVID-19 tests at the beginning of their shifts, with some testing only twice a week or not at all. The facility also did not pause resident activities as required during the outbreak. An observation revealed 13 residents sitting close together in the activity/dining room, contrary to the guidelines to limit crowding in communal areas. Furthermore, the facility failed to use a dedicated shower room for COVID-19 positive residents, as evidenced by a non-COVID-19 positive resident being bathed in a shower room reserved for COVID-19 patients. This practice increased the risk of exposure and potential spread of the virus within the facility. Moreover, the facility did not place portable air purifiers with HEPA filters in all hallways, as recommended to reduce airborne contaminants. Only two air purifiers were observed, one in the west nursing station and another in the activity room, which was insufficient according to the local health department's guidelines. These deficiencies in infection control practices had the potential to facilitate the spread of COVID-19 among residents, staff, and visitors.
Failure to Screen Visitors During COVID-19 Outbreak
Penalty
Summary
The facility failed to implement and maintain proper infection control procedures during a COVID-19 outbreak by not screening family members and visitors for signs and symptoms of the virus. Observations revealed that a family member entered the facility unmasked and without undergoing the required screening process. The visitor screening log, which was supposed to record visitors' COVID-19 test results and symptoms, was not properly filled out, and there was no designated staff to ensure compliance with the screening process. Interviews with the Infection Preventionist (IP) and the Director of Nursing (DON) confirmed that visitors were not being screened for COVID-19 symptoms, despite the ongoing outbreak in the facility. The IP acknowledged that the outbreak began with two residents testing positive, and no staff were affected at the time. The facility's policy required active screening of visitors, but this was not enforced, potentially allowing the virus to spread among residents and staff.
Failure to Maintain Resident Dignity During Mealtime
Penalty
Summary
The facility failed to maintain or enhance the dignity and respect of a resident, identified as Resident 51, during a mealtime interaction. Resident 51, who was readmitted to the facility with diagnoses including dementia, lack of coordination, muscle weakness, and dysphagia, required partial to moderate assistance with eating. The Minimum Data Set (MDS) indicated that Resident 51 had severely impaired cognition and would hold food in their mouth after meals. During an observation, Certified Nursing Assistant (CNA) 3 was seen standing over Resident 51 while feeding them lunch, rather than sitting at eye level as required by the facility's policy. CNA 3 acknowledged during an interview that she was supposed to be sitting down while feeding Resident 51 to maintain eye contact and respect the resident's dignity. The Director of Nursing (DON) confirmed that staff should be seated at eye level with residents during feeding to protect their dignity and prevent them from feeling disrespected. The facility's policy on promoting and maintaining resident dignity during mealtimes, reviewed earlier in the year, emphasized the importance of treating residents with respect and dignity, and required staff to be seated while feeding residents whenever possible.
Failure to Update Resident's Person-Centered Care Plan
Penalty
Summary
The facility failed to update the person-centered care plan for a resident diagnosed with major depressive disorder, dementia, and muscle wasting. The resident, who had severe cognitive impairment and was totally dependent on staff for daily activities, had a care plan that included participation in activities of their choice, specifically attending church services. However, observations revealed that the resident was not assisted to attend church services, and staff indicated that the resident did not enjoy attending these services and preferred spending time with family. Interviews with facility staff, including a Rehabilitation Nursing Assistant and the Activities Director, confirmed that the resident no longer enjoyed attending church services and preferred family interactions. Despite this change in preference, the resident's care plan was not updated to reflect their current interests. The facility's policy on comprehensive care plans requires that care plans be consistent with resident rights and include measurable objectives and timeframes to meet the resident's needs, which was not adhered to in this case.
Failure to Update Care Plans for Residents with Pressure Ulcers
Penalty
Summary
The facility failed to review, update, and revise the care plans for two residents, leading to deficiencies in their care. Resident 71, who was admitted with dementia and a Stage III sacral pressure ulcer, did not have an updated care plan reflecting the current wound care treatment. The physician's orders specified a daily treatment regimen, but the care plan was not revised to include these details. Observations and interviews with the treatment nurse and MDS coordinator confirmed that the care plan was not updated, which is crucial for ensuring continuity of care. Resident 75, diagnosed with Type II diabetes, major depressive disorder, and vascular dementia, was at moderate risk for developing pressure ulcers. The care plan for this resident included interventions for both a low air loss mattress and an alternating pressure pad, which was confusing and not reflective of the current treatment plan. Observations and interviews with nursing staff revealed that the resident only had an alternating pressure pad, and the care plan should have been revised to remove the unnecessary intervention for the low air loss mattress. The facility's policy on comprehensive care plans requires that they be person-centered and updated to reflect the resident's current medical, nursing, and psychosocial needs. However, the failure to update the care plans for Residents 71 and 75 resulted in a lack of clarity and potential gaps in the provision of necessary care and treatment. Interviews with the Director of Nursing and other staff highlighted the importance of resolving outdated interventions to ensure residents receive appropriate care.
Failure to Provide Pressure Ulcer Prevention for At-Risk Resident
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care for a resident assessed as being at moderate risk for developing pressure ulcers. The resident, who had a history of Type II diabetes, major depressive disorder, and vascular dementia, was not provided with necessary pressure-relieving devices such as pillows or heel protectors for the left and right heels, as outlined in their care plan. Additionally, the resident was not repositioned every two hours and as needed, which was a required intervention to prevent skin breakdown. Observations and interviews revealed that the staff, including a Certified Nurse Assistant and a Registered Nurse, were not aware of or did not follow the care plan interventions for the resident. The Director of Staff Developer confirmed that the resident was not included in the list of those needing repositioning every two hours, and there was no documentation of repositioning or pressure reduction from the heels for a specific period. This oversight placed the resident at increased risk for developing pressure sores, contrary to the facility's policy on pressure injury prevention and management.
Failure to Provide Prescribed Restorative Nursing Services
Penalty
Summary
The facility failed to provide appropriate services for a resident, identified as Resident 84, who was at risk for decline in range of motion (ROM) and mobility. Resident 84, who had a history of hemiplegia, hemiparesis, contracture of the left knee, and osteoporosis, was enrolled in a Restorative Nursing Aide (RNA) program. The care plan required passive range of motion (PROM) exercises and knee extension splint assistance to be provided regularly. However, the documentation revealed that these services were not consistently delivered as per the care plan. Specifically, the resident received PROM and knee splint assistance fewer times than prescribed in both September and October 2024. During a review and interview with the Director of Nursing (DON), it was confirmed that the RNA program was not followed as documented. The DON acknowledged that the staff did not adhere to the prescribed frequency of RNA services, which was crucial for maintaining the resident's mobility and preventing further decline. The facility's policy on the Restorative Nursing Program emphasized the importance of maintaining or improving a resident's abilities, but the staff failed to implement the plan as required.
Failure to Label Opened Novolin R Vial
Penalty
Summary
The facility failed to ensure that an opened vial of Novolin R, a medication used to control blood sugar, was labeled with an open date as required by the manufacturer's specifications. During an observation of the West Medication Cart, it was found that the vial was stored at room temperature without an open date label. According to the manufacturer's product labeling, vials of Humulin R stored at room temperature should be used or discarded within 42 days. The absence of an open date made it impossible to determine the expiration date, increasing the risk of administering expired insulin. During an interview, the Licensed Vocational Nurse (LVN 1) confirmed that the Novolin R was opened but not labeled with an open date. LVN 1 acknowledged that without an open date, it was not possible to know how long the Novolin R had been stored at room temperature, which could lead to medical complications due to poor blood sugar control if expired insulin was administered. The facility's policy on medication storage and labeling requires that all medications be stored according to the manufacturer's recommendations and that multi-use vials include the date they were initially opened or accessed.
Lack of Policy for Storing Resident Food Brought by Visitors
Penalty
Summary
The facility failed to have a policy addressing the storage and reheating of leftover food brought in by residents' families or visitors, which could potentially lead to foodborne illnesses. Interviews with staff, including registered nurses and the Director of Staff Development (DSD), revealed that the facility's policy discouraged storing perishable food and encouraged families to bring only enough food for one meal, with leftovers to be discarded or taken home. However, there was no refrigerator available for residents to store food, and the facility did not have a clear policy or procedure for safely storing food if residents insisted on keeping leftovers. The Director of Nursing (DON) confirmed that the facility's policy required food to be consumed or discarded within two hours and did not allow for the storage of outside food. The policy allowed nonperishable food to be stored in resident rooms in sealed containers, but it was the responsibility of the resident or their representative to maintain these items. Despite these guidelines, there was no established procedure for handling situations where residents wanted to store food, indicating a gap in the facility's policy and procedures for ensuring safe and sanitary food storage and handling.
Failure to Prevent Falls for At-Risk Resident
Penalty
Summary
The facility failed to provide an environment free from accident hazards for Resident 306, who was at risk for falls due to a history of falling and severe cognitive impairment. The facility did not accurately assess the resident's fall risk, as the fall risk assessment was incorrectly completed, leading to an underestimation of the resident's fall risk. This incorrect assessment contributed to inadequate interventions and monitoring to prevent falls. Resident 306 experienced multiple falls, including incidents on 9/16/2024 and 9/17/2024, due to insufficient supervision and ineffective interventions. The care plan for the resident did not include specific and individualized interventions to address the resident's fall risk, and the facility staff failed to frequently check the resident when in the wheelchair, as recommended. The lack of specific frequency for monitoring in the care plan further contributed to the resident being left unsupervised, resulting in falls. Interviews with facility staff, including the DON, revealed that the interventions in place were not adequately tailored to the resident's needs, and there was no documentation of frequent checks as required. The facility's policies on fall prevention and comprehensive care plans were not effectively implemented, as the care plan did not reflect the resident's specific needs and risk factors, leading to repeated falls and potential harm to the resident.
Non-Compliance with Resident Room Capacity
Penalty
Summary
The facility failed to comply with the requirement that resident rooms hold no more than four residents, as observed in room [ROOM NUMBER], which housed five residents. This deficiency was identified during an observation and interview conducted on 10/17/2024. A Certified Nursing Assistant (CNA 1) stated that there were no issues providing care in the room, even when using a Hoyer lift, as there was sufficient space. Similarly, Registered Nurse (RN 1) expressed that there was enough space to provide care and no complaints had been received from residents regarding room size. The facility's policy, revised on 3/27/2024, mandates that resident rooms must be designed for adequate nursing care, comfort, and privacy, with at least 80 square feet per resident in multiple resident bedrooms.
Deficiency in Room Size Requirements
Penalty
Summary
The facility failed to ensure that 24 out of 63 rooms met the required 80 square feet per resident in multiple occupancy rooms. During an observation, the Maintenance Supervisor measured the rooms and found that they did not meet the required space per resident. The rooms in question had varying square footage, with some rooms accommodating up to five beds, yet not providing the necessary space per resident as mandated by the facility's policy and procedures. Interviews with facility staff, including a Certified Nursing Assistant and a Registered Nurse, revealed that they believed there was enough space in the rooms to provide care, including the use of equipment like a Hoyer lift. They also stated that there were no complaints from residents regarding room size, and if any complaints arose, residents could be moved to larger or single occupancy rooms if available. Despite these assertions, the facility's policy requires that resident rooms measure at least 80 square feet per resident in multiple occupancy rooms, which was not met in the observed rooms.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Los Angeles
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Windsor Gardens Convalescent Hospital | 0.2 mi | ★★★★★ | 26 | 0 |
| Sunray Healthcare Center | 0.7 mi | — | 32 | 2 |
| The Rehabilitation Center On Pico | 0.7 mi | ★★★★★ | 18 | 0 |
| St Andrews | 1 mi | ★★★★★ | 0 | 0 |
| East Terrace Rehabilitation & Wellness Centre, Lp | 1.4 mi | ★★★★★ | 29 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.