Above average — CMS composite of the measures below.
The next survey window likely opens around October 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 Alden Terrace Convalescent Hospital during CMS and state inspections, most recent first.
Residents Fed While Staff Stood Over Them: Three residents with dementia and dysphagia were observed being fed lunch in the dining room while CNA staff stood over them, causing the residents to extend their necks upward as they ate. The residents required assistance with eating and other ADLs, and staff stated they usually feed residents while standing. The DON said feeding should be done at eye level for dignity, and the facility policy states residents needing meal assistance should not be fed while staff stand over them.
An LVN left a computer screen at nurses’ station 2 accessible and unattended, allowing a surveyor to view a resident’s PHI, including name, DOB, SSN, address, and diagnoses. The resident had multiple diagnoses, including DM2, weakness, depression, HTN, and cardiomegaly, and records showed the resident needed cues/supervision and staff help with ADLs. The LVN stated she thought the screen was hidden and acknowledged exposing the resident’s privacy and identity information.
A resident with schizoaffective disorder, bipolar disorder, and HTN had no care plan documented for those diagnoses. The MDS showed cognitive impairment and substantial/maximal assistance to dependency with ADLs, and the chart review confirmed the absence of a specific care plan despite an assessment noting schizophrenia.
Missing Annual Staff Competencies and Performance Evaluations: The facility failed to document annual performance evaluations and annual competency assessments for multiple staff members, including LVNs, the ADON, and CNAs. The DSD and DON stated these reviews are required upon hire and annually, and a CNA reported not remembering the last time she completed annual skills competency and said she had not completed abuse training since hire. File review showed missing competency and performance documentation across several years for multiple employees.
Dietary aides were observed in the kitchen without hairnets properly covering their hair while performing food prep tasks. One aide said they forgot, another thought a hairnet was on, and a third had the hairnet sitting on top of a hair bun instead of fully covering the head. Staff stated residents could get sick, and the facility policy required hair nets or head coverings to completely cover all hair at all times.
Missing Current Hospice Certification in Resident Chart: A resident receiving hospice care had diagnoses including cerebral atherosclerosis, HF, and AFib, and the MDS showed severely impaired cognitive skills and hospice use. The hospice binder did not contain a current certification of terminal illness after the prior certification expired, and both an LVN and the DON stated the hospice chart should include the current recertification completed every 3 months.
Excess Residents in Combined Bedroom: A room identified as [ROOM NUMBER]/320 was observed with six beds and five residents living there, while facility records and the ADM indicated the space was treated inconsistently as either one room or two separate rooms. The room had one hallway entrance, and the ADM stated it had never been separated. A resident in the room said the space was adequate but preferred a partition for more privacy. The facility policy stated bedrooms accommodate no more than two residents at a time.
A resident alleged being hit on the shoulder by another resident, resulting in pain and limited arm movement. Although the incident was witnessed by an OT and assessed by nursing staff, the facility did not report the abuse allegation to the state survey agency within the required two-hour timeframe, as mandated by facility policy.
A resident with epilepsy experienced a seizure, and the facility failed to monitor the resident during the night shift as ordered by the NP. The resident's care plan required monitoring for seizure activity and vital signs, but no documentation or vital signs were recorded during the night shift, contrary to facility policy.
A facility failed to accurately document seizure activity for a resident with epilepsy and diabetes. The MAR incorrectly showed a seizure during a night shift due to an LVN's documentation error, despite confirmation from the LVN and an RN supervisor that no seizure occurred. This resulted in an incomplete and inaccurate medical record, violating the facility's documentation policy.
The facility failed to maintain the dignity of two residents by referring to them as 'feeders' due to their need for feeding assistance. Staff, including an LVN, RNA, and CNA, used this term as part of the RNA feeding program, despite acknowledging it as disrespectful. Both residents required substantial assistance with daily activities, including eating, and were observed being fed while being labeled as 'feeders.' The facility's policy emphasized treating residents with respect and addressing them by their proper names, which was not followed in these cases.
The facility failed to maintain updated advance directives for three residents, resulting in incomplete acknowledgment forms lacking necessary signatures from representatives. These residents, with conditions such as dementia and COPD, had impaired cognition and required assistance with daily activities. The Social Services Director acknowledged the process but did not ensure compliance with facility policy.
The facility failed to maintain safe food storage and sanitation practices, with expired mixed fruits in the refrigerator, stained cups stored as clean, and improper use of kitchen towels. These actions risked cross-contamination and foodborne illness for residents.
A resident's urinary catheter was not anchored as per physician's orders, risking discomfort and dislodgement. Despite the resident's medical conditions requiring careful catheter management, observations showed the catheter unsecured for several days. Staff acknowledged the oversight, which contradicted facility policy and CDC guidelines.
A facility failed to label a resident's nasal cannula with the date, time, and initials, as required by their oxygen administration policy. The resident, with conditions such as dementia and peripheral vascular disease, had orders for oxygen at 2 lpm for shortness of breath. An LVN confirmed the tubing was unlabeled, and the DON stated it should be changed weekly and labeled to prevent infection.
The facility failed to maintain sanitary conditions in the dumpster area, with one dumpster overfilled and uncovered, and trash littering the surrounding area. This was observed during an interview with the Dietary Supervisor, who acknowledged the need for proper trash management. The Maintenance Supervisor confirmed daily cleaning routines, emphasizing the importance of covering trash to prevent pest attraction. Facility policy and FDA guidelines require dumpsters to be closed and free of litter.
A resident's urinal was improperly placed on an oxygen concentrator, touching the oxygen tubing, which violated the facility's infection control policy. This was confirmed by a family member and an LVN, who acknowledged the infection control risk. The resident had a history of dementia and required oxygen for shortness of breath.
A facility failed to notify a resident's designated healthcare decision maker before discharging the resident to a friend's home. Despite attempts to contact the decision maker, the facility proceeded with the discharge based on information from another family member. The primary physician was not informed about the inability to reach the decision maker, contrary to the facility's policy.
A facility failed to provide correct information in a Notice of Proposed Transfer and Discharge for a resident, listing the wrong agency for discharge appeals and omitting the reason for discharge. The resident, with diagnoses including diabetes and vascular dementia, was cognitively intact and required supervision for daily activities. The Care Plan indicated discharge due to improved health, but this was not reflected in the Notice.
A facility failed to isolate a resident suspected of having scabies and did not ensure staff wore PPE, leading to potential infection spread. The resident, showing symptoms, was not isolated from roommates, and staff did not use PPE during care. The Infection Preventionist Nurse confirmed the oversight, and the Director of Nursing acknowledged the care plan was not implemented, violating the facility's scabies prevention policy.
A resident with scabies was not isolated as per the care plan, leading to a deficiency in care. Despite orders for isolation when Elimite was applied, the resident was placed with roommates, and staff did not use PPE. The resident showed signs of scabies, but the facility's policy did not require isolation for prophylactic treatment, resulting in a failure to implement the care plan.
A resident with a history of diabetes and other health issues developed fluid-filled blisters on their left arm, which were not properly assessed or documented by the facility's staff. Despite signs of infection, the wound care specialist was not informed of the resident's diabetes or the presence of drainage. The care plan was delayed, and the resident was eventually hospitalized for cellulitis and sepsis, highlighting deficiencies in documentation and communication.
Residents Fed While Staff Stood Over Them
Penalty
Summary
The facility failed to provide care in a manner that maintained or enhanced resident dignity and respect for three residents who were being fed lunch in the common dining room. During the meal observation, CNA 4, CNA 5, and CNA 6 were seen standing while feeding Resident 78, Resident 111, and Resident 180, and the residents were observed extending their necks upward toward the staff as they ate. The report states that the residents had severely impaired cognitive skills for daily decision-making and required varying levels of assistance with eating, oral hygiene, bed mobility, transfers, and dressing. Resident 78 had diagnoses including dementia, dysphagia, protein calorie malnutrition, difficulty walking, abnormal gait mobility, type 2 diabetes, and hypertension. Resident 111 had diagnoses including dementia, type 2 diabetes, chronic gastritis, dysphagia, anxiety disorder, bipolar disorder, abnormal gait mobility, and hypertension. Resident 180 had diagnoses including dementia, dysphagia, failure to thrive concerning food and fluid intake, difficulty walking, abnormal gait mobility, and hypertension. When interviewed, CNA 4 stated she had a lot of residents and had no chair to sit on, CNA 5 stated she usually feeds residents while standing up, and CNA 6 stated he usually feeds residents while standing up. The DON stated staff should sit at eye-to-eye level with residents while feeding them for dignity and said feeding residents while standing looks hurried, is impersonal, and there is no connection with the resident. The facility policy also stated residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity, for example, not standing over residents while assisting them with meals.
Failure to Protect Resident PHI on an Unattended Computer Screen
Penalty
Summary
The facility failed to ensure confidentiality of Resident 13’s personal and medical information when LVN 4 left a computer screen accessible at nurses’ station 2/med cart 2. During a concurrent observation, the surveyor found the computer screen open and unattended; when the track pad was touched, the screen displayed Resident 13’s name, date of birth, social security number, address, and medical diagnoses. Approximately two minutes later, LVN 4 arrived at the nurses’ station and stated she was assigned there and thought she had left the screen hidden. Resident 13’s record showed admission and readmission to the facility with diagnoses including type 2 diabetes mellitus, generalized muscle weakness, major depressive disorder, essential hypertension, and cardiomegaly. The H&P indicated Resident 13 was able to make decisions for ADLs, while the MDS indicated poor decision-making, need for cues and supervision, and dependence on staff for ADLs. The facility’s records also showed LVN 4 had received HIPAA education, and facility policies stated that resident personal and medical records would be kept private and confidential.
Missing Care Plan for Mental Health Diagnoses
Penalty
Summary
A comprehensive care plan was not developed for Resident 9’s schizoaffective disorder and bipolar disorder in accordance with the facility’s policy and procedures. Resident 9 was admitted on 4/6/2011 and readmitted on 9/25/2025 with diagnoses including schizoaffective disorder, bipolar disorder, and hypertension. The resident’s MDS dated 10/7/2025 indicated cognitive impairment and that the resident required substantial/maximal assistance to dependency with ADLs. During a concurrent interview and record review on 11/20/2025, LVN 2 reviewed Resident 9’s electronic and paper chart and stated there was no care plan noted for the resident’s schizoaffective disorder or bipolar disorder. The resident’s Multidisciplinary Progress Record dated 10/20/2025 indicated an assessment of schizophrenia. The DON stated that a care plan is used to follow the plan for residents’ care, that it should be initiated as soon as a condition occurs, and that if the resident does not have a specific care plan for schizoaffective and bipolar disorders, behaviors may not be addressed specifically.
Missing Annual Staff Competencies and Performance Evaluations
Penalty
Summary
The facility failed to complete annual performance evaluations and annual competency assessments for six of six employees reviewed, contrary to its policies titled Performance Evaluations and Competency Assessments. During interviews, the Director of Staff Development stated that annual skills competencies are important to ensure nurses are following correct protocols and are capable of carrying out their duties, and that performance evaluations are used by managers and supervisors to identify areas for improvement. A CNA stated she did not remember the last time she completed annual skills competency and said she had not completed abuse training since hire. A review of seven employee files with the Director of Staff Development showed missing documentation for multiple staff members. One LVN hired on 12/22/2022 had no documented annual performance evaluation for 2023 and no documented annual competencies for 2023 or 2025. Another LVN hired on 7/11/2012 had documented annual competencies for 2023, 2024, and 2025, but no documented annual skills check for those years. The ADON hired on 5/14/2013 had no documented annual competency for 2023. A CNA hired on 2/25/2024 had no documented annual competencies for 2025. Another CNA hired on 10/20/2004 had no documented annual competencies for 2022, 2023, and 2024. A CNA hired on 5/9/2024 had no documented annual performance evaluation for 2025. The DON stated all staff are supposed to complete annual competencies and annual performance evaluations upon hire and annually, and that if staff do not complete annual competencies yearly, they can forget how to care for residents and could make mistakes with certain skills.
Improper Hairnet Use in Kitchen
Penalty
Summary
Dietary aides 1, 2, and 3 were observed in the kitchen without hairnets properly covering their hair while performing food service tasks. During the observation and interview, DA 3 stated, "I thought there is one on my head," DA 1 stated, "I forgot," and DA 2 was observed with the hairnet sitting on top of a hair bun instead of covering the entire head and stated, "Oh I didn't know." When asked about the potential harm, DA 1, DA 2, and DA 3 stated that residents could get sick, and DA 2 added that they were supposed to wear the hairnet while working. The facility policy titled Sanitation and Infection Control stated that a hair net or head covering which completely covers all hair should be worn at all times.
Missing Current Hospice Certification in Resident Chart
Penalty
Summary
The facility failed to ensure necessary care was provided consistently for a resident receiving hospice services by not maintaining the resident’s current hospice certification of terminal illness in the chart. Resident 4 was admitted to the facility with diagnoses including cerebral atherosclerosis, heart failure, and atrial fibrillation, and the record showed the resident was admitted under hospice care and remained on hospice after a decline in condition over the prior year. The resident’s MDS indicated severely impaired cognitive skills for daily decision making and that hospice care was being received while a resident. A review of the hospice binder on 11/20/2025 showed there was no hospice certification of terminal illness after 10/8/2025. During interview and record review, LVN 3 stated the resident was currently receiving hospice services but the hospice chart did not contain the current certification after 10/8/2025, and that the chart should contain the current certification because hospice must recertify every three months. The DON stated the certification of terminal illness is completed every three months and should be in the hospice chart to show the resident requires hospice services and receives the care needed. The facility’s hospice contract stated medical records and documentation maintained by each party shall be available for review, and the facility hospice policy stated the facility is responsible for obtaining the physician certification and recertification of terminal illness for each resident.
Excess Residents in Combined Bedroom
Penalty
Summary
The facility failed to ensure that one resident room accommodated no more than 4 residents per room. During observation, room [ROOM NUMBER]/320 was found to contain six beds and five residents were observed residing in the room. The room had one door to the hallway and two nameplates outside the door indicating the room was for room [ROOM NUMBER] and 320. Facility staff later measured the space and determined room [ROOM NUMBER]/320 measured 507 square feet. Facility records and interviews showed the room was treated as two separate rooms, with the Client Accommodation Analysis listing room [ROOM NUMBER] as 252 square feet with an approved capacity of three residents and room [ROOM NUMBER] as 247 square feet with an approved capacity of three residents. However, the facility map showed room [ROOM NUMBER] located between two other rooms and no room [ROOM NUMBER] existed. The Administrator stated room 319/320 was one room and had never been two separate rooms, and later stated six residents could reside in the room at one time. Resident 106 stated they lived in room [ROOM NUMBER]/320 and preferred a partition or blocked-off side to create two separate rooms for more privacy. The facility policy stated bedrooms accommodate no more than two residents at a time.
Failure to Timely Report Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to follow and implement its abuse policy for one of three sampled residents after an allegation of abuse was made. On 3/15/25, a resident reported that another resident hit her on the left shoulder, resulting in pain and limited movement of her left arm. The incident was witnessed by an occupational therapist, who intervened and informed the second resident to use the resident's name instead of tapping her. The registered nurse supervisor was notified and assessed the resident, finding no bruising or discoloration, but the resident continued to complain of pain. The nurse practitioner was notified, and orders for pain management and an x-ray were given, with the x-ray result being negative. Despite the resident's allegation of being hit and subsequent pain, the facility did not report the allegation of abuse to the state survey agency within two hours as required by their policy. Interviews with staff, including the assistant director of staff development, confirmed that the facility's policy mandates reporting any abuse allegations to the administrator and the state agency within two hours of awareness. However, the director of nursing and administrator stated they did not report the incident because the occupational therapist witnessed the event and determined that no abuse occurred. The facility's policy on abuse and mistreatment requires reporting all alleged and substantiated violations to the state agency and taking necessary corrective actions based on the investigation results. In this case, the failure to report the allegation in a timely manner constituted a deficiency in following established abuse reporting protocols, regardless of the staff's assessment of the situation.
Failure to Monitor Resident After Seizure
Penalty
Summary
The facility failed to monitor a resident who experienced a change in condition, specifically a seizure, in accordance with professional standards of practice. The resident, who had a history of epilepsy and diabetes mellitus, experienced a petit mal seizure lasting approximately 30 seconds. Following the seizure, the resident's nurse practitioner was notified and gave orders to continue monitoring the resident. However, during the night shift, the facility did not take the resident's vital signs or document any monitoring activities, which was a deviation from the facility's policy on managing changes in condition. The resident's care plan, initiated on the day of the seizure, included goals and interventions to observe for seizure activity and notify the physician as needed. Despite this, the director of staff development confirmed that no vital signs were taken, and no nursing documentation was completed during the night shift. The facility's policy required documentation of vital signs each shift and reassessment of the resident's condition as needed, which was not adhered to in this instance.
Inaccurate Documentation of Seizure Activity
Penalty
Summary
The facility failed to ensure the accuracy of medical records for a resident, specifically regarding the monitoring and documentation of seizure activity. The resident, who had a history of epilepsy and diabetes mellitus, was supposed to be monitored for seizures every shift, with the results documented in the Medication Administration Record (MAR). On a specific date, the MAR incorrectly indicated that the resident experienced a seizure during the night shift, as a result of a documentation error by a licensed vocational nurse (LVN). Upon review, both the LVN and a registered nurse supervisor confirmed that the resident did not have a seizure on the night in question. The LVN admitted to mistakenly entering the wrong information in the MAR, which should have indicated no seizure activity. This error led to an incomplete and inaccurate medical record for the resident, contrary to the facility's policy that requires documentation to be objective, complete, and accurate.
Residents Referred to as 'Feeders' Compromises Dignity
Penalty
Summary
The facility failed to ensure that staff did not refer to residents requiring assistance with feeding as 'feeders,' which compromised the dignity and respect of the residents involved. Specifically, two residents, identified as Residents 101 and 114, were referred to as 'feeders' by various staff members, including a Licensed Vocational Nurse (LVN), a Restorative Nursing Assistant (RNA), and a Certified Nursing Assistant (CNA). This terminology was used because these residents were part of the RNA feeding program, which grouped residents needing feeding assistance together. The use of the term 'feeder' was acknowledged by staff as disrespectful, and it was noted that residents should be treated with respect and dignity. Resident 114 was admitted with diagnoses including adult failure to thrive, chronic obstructive pulmonary disease, hypertension, and muscle weakness, and required substantial assistance with daily activities, including eating. Similarly, Resident 101, who had diagnoses of hypertension and depression, also required maximal assistance with eating and other daily activities. Observations during meal times confirmed that these residents were assisted with feeding while being referred to as 'feeders.' The facility's policy on dignity emphasized treating residents with respect and addressing them by their proper names, which was not adhered to in these instances.
Failure to Maintain Updated Advance Directives
Penalty
Summary
The facility failed to ensure that the advance directives for three residents were complete and updated, which is a violation of the residents' rights to have their medical treatment wishes honored. Specifically, the facility did not maintain an accurate and current copy of the residents' advance directives in their clinical records. This deficiency was identified for three out of four sampled residents, who had various medical conditions including dementia, chronic obstructive pulmonary disease, hypertension, and muscle weakness. The Minimum Data Set (MDS) assessments indicated that these residents had impaired cognition and required assistance with activities of daily living. During an interview, the Social Services Director (SSD) explained the process for obtaining signatures on advance directive acknowledgment forms, which involves the resident's representative and the resident's physician. However, the review revealed that the acknowledgment forms for the three residents lacked the necessary signatures from their representatives. The facility's policy requires that the SSD or designee inquire about the existence of any written advance directives upon admission, but this was not adequately followed, leading to the deficiency.
Deficient Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and preparation practices, as observed during a survey. Thirteen small containers of previously prepared mixed fruits were found in the walk-in refrigerator with an expired use-by date. The cook acknowledged that the fruits were prepared for a previous date and should have been discarded to prevent serving expired food to residents. The Dietary Supervisor confirmed that food should be labeled and dated, and expired items should be discarded according to the facility's policy. Additionally, clean resident cups stored on racks were observed with red color stains, which were identified as thickened cranberry juice stains. The Registered Dietitian stated that the cups should have been rewashed and not placed on racks for air drying, as they could cross-contaminate resident beverages. The Dishwasher admitted that the cup was missed during the checking process, which goes against the facility's policy and procedures for dishwashing and sanitizing equipment and surfaces. Furthermore, wet kitchen wiping cloths were improperly stored on kitchen counters and reused to clean food contact surfaces and equipment. Dietary Aides were observed using the same cloths to clean different surfaces without returning them to a sanitizer solution, as required by the facility's policy. The Registered Dietitian confirmed that kitchen towels should be stored in a sanitizer solution when not in use to prevent cross-contamination, aligning with the U.S. Food and Drug Administration Food Code requirements.
Failure to Anchor Urinary Catheter
Penalty
Summary
The facility failed to properly anchor a urinary catheter for a resident, as per the physician's order, which could lead to discomfort and potential dislodgement. The resident, who was readmitted with conditions including benign prostatic hyperplasia, obstructive and reflux uropathy, and urinary retention, had a physician's order to secure the urinary catheter tubing daily to minimize dislodgement. However, during an observation, it was noted that the catheter was not anchored to the resident's leg, and the resident confirmed it had not been secured for the past two or three days. Further observations and interviews revealed that the catheter was not anchored, and the treatment nurse acknowledged the absence of an anchor, stating it should be in place to prevent dislodgement or tugging. The Director of Nursing also confirmed that the catheter should be anchored to prevent pain and ensure it remains in place. The facility's policy and CDC guidelines emphasize the importance of securing catheters to prevent complications, but these were not followed in this instance.
Failure to Label Oxygen Equipment
Penalty
Summary
The facility failed to provide necessary respiratory care services for a resident by not labeling the nasal cannula with the date, time, and initials as per the facility's policy on oxygen administration. This oversight was observed during a survey, where the nasal cannula attached to the resident's oxygen concentrator was found undated and exposed to air. The resident, who had been readmitted to the facility with diagnoses including dementia, cerebral aneurysm, and peripheral vascular disease, had physician orders for oxygen administration at 2 liters per minute via nasal cannula as needed for shortness of breath. During interviews, a Licensed Vocational Nurse (LVN) confirmed that the oxygen tubing was not labeled and could not specify when it was attached to the concentrator. The Director of Nursing (DON) stated that oxygen tubing should be changed weekly and labeled to prevent infection. The facility's policy indicated that oxygen equipment should be dated and stored in a clean bag when not in use. The failure to label the nasal cannula had the potential to cause complications associated with oxygen therapy, including infection.
Improper Trash Disposal and Sanitation
Penalty
Summary
The facility failed to maintain the trash stored in the dumpster areas in a sanitary manner. During an observation and interview with the Dietary Supervisor, it was noted that one of the two garbage dumpsters outside the kitchen was overfilled with cardboard boxes and left uncovered. Additionally, the surrounding floor area was littered with various trash items, including plastic utensils, gloves, plastic bags, disposable lunch trays, plates, and a resident meal ticket. This situation was identified as having the potential to attract pests. The Dietary Supervisor acknowledged that the cardboard boxes should be flattened to fit in the dumpster, allowing the lids to close properly. The Maintenance Supervisor confirmed that the housekeeping staff is responsible for cleaning the trash on the floor daily at 2 pm and emphasized the importance of keeping the trash covered to prevent pests. The facility's policy, as well as the FDA Food Code, both require that outside dumpsters be kept closed and free of surrounding litter to prevent access by insects and rodents.
Improper Placement of Urinal on Oxygen Concentrator
Penalty
Summary
The facility failed to implement its infection control policy and procedures by allowing a urinal to be improperly placed on an oxygen concentrator, which was in contact with the oxygen tubing for a resident. This practice was observed during a survey and was confirmed by both a family member and a Licensed Vocational Nurse (LVN). The LVN acknowledged that the urinal should not have been touching the oxygen tubing or the concentrator, as it posed an infection control issue that could lead to respiratory infections. The resident involved had a medical history that included dementia, cerebral aneurysm, occlusion and stenosis of the carotid artery, and peripheral vascular disease. The resident required oxygen administration at 2 liters per minute via nasal cannula as needed for shortness of breath. The facility's infection control policy, reviewed earlier in the year, emphasized maintaining a safe and sanitary environment to prevent disease transmission, which was not adhered to in this instance.
Failure to Notify Healthcare Decision Maker Before Resident Discharge
Penalty
Summary
The facility failed to notify the designated healthcare decision maker for a resident regarding the resident's discharge plan. The resident, who had designated a family member as their healthcare decision maker through a Power of Attorney for Healthcare, was discharged to a friend's home without the facility obtaining consent from the designated decision maker. Despite several attempts to contact the family member, the facility did not succeed in reaching them and proceeded with the discharge based on information from another family member who claimed the designated decision maker did not want to be involved. Additionally, the facility did not inform the resident's primary physician that they were unable to contact the designated healthcare decision maker before proceeding with the discharge. The facility's policy and procedures require notifying the responsible party and providing discharge instructions, which were not adequately followed in this case. The Director of Nursing acknowledged the failure to document the notification to the primary physician about the inability to reach the designated decision maker.
Deficiency in Transfer/Discharge Notice
Penalty
Summary
The facility failed to provide the correct information in the Notice of Proposed Transfer and Discharge for a resident, resulting in a deficiency. The Notice, issued on 9/9/24, contained the incorrect address and telephone number of the agency responsible for handling discharge appeals, listing the state survey agency instead. Additionally, the Notice did not specify the reason for the resident's discharge, which is a requirement. This oversight was confirmed during a review of the Notice with the Medical Record Director, who acknowledged the error and emphasized the importance of providing the correct agency information for appeal purposes. The resident involved was originally admitted to the facility on 3/12/24 and readmitted later with diagnoses including diabetes, difficulty walking, and vascular dementia. The Minimum Data Set indicated that the resident was cognitively intact and required supervision for various daily activities. The Care Plan initiated on 9/9/24 included a physician's order for discharge home, stating that the resident no longer needed the facility's services. However, the Notice failed to reflect this reason for discharge. Interviews with the Director of Nursing confirmed that the resident's health had improved, justifying the discharge, but this was not communicated in the Notice as required by policy.
Failure to Implement Scabies Isolation and PPE Protocols
Penalty
Summary
The facility failed to provide a safe, sanitary, and comfortable environment, leading to the potential spread of scabies among residents and staff. Resident 1, who was suspected of having scabies, was not placed in isolation on the date when symptoms were first observed. Despite the presence of rashes and itching, Resident 1 was not isolated from roommates, and no contact precaution signage or PPE cart was available outside the room. Staff members, including CNAs and LVNs, confirmed that they did not wear PPE when providing care to Resident 1, and they were not asked to monitor themselves for symptoms of scabies. The facility's Infection Preventionist Nurse (IPN) acknowledged that Resident 1 showed signs and symptoms of scabies and confirmed that the resident was not isolated during the treatment with Elimite cream. The IPN admitted that the facility's policy, which required isolation precautions for suspected scabies cases, was not followed. Additionally, there was no log or list maintained to monitor staff who were exposed to Resident 1, and the IPN recognized that staff vigilance was lacking. The Director of Nursing (DON) confirmed that Resident 1's care plan, which included contact isolation precautions, was not implemented. The facility's policy and procedures for scabies prevention and control, which required immediate isolation of symptomatic residents and staff education, were not adhered to. This oversight in implementing the care plan and infection control measures contributed to the potential spread of scabies within the facility.
Failure to Implement Care Plan for Resident with Scabies
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident diagnosed with scabies, a parasitic infestation. The resident was admitted with conditions including benign prostatic hyperplasia and cognitive impairments, requiring maximal assistance for activities of daily living. Despite the physician's order to isolate the resident from roommates when Elimite, a medication for scabies, was applied, the care plan was not followed. The resident was not placed on contact isolation, and staff did not use personal protective equipment when providing care. Observations and interviews revealed that the resident had multiple rashes and was scratching due to discomfort, yet no contact precaution signage or PPE cart was present outside the resident's room. The resident was placed in a room with two roommates, contrary to the care plan's instructions. The Infection Preventionist Nurse confirmed that the resident showed signs of scabies and should have been isolated, but the facility's policy did not require isolation for prophylactic treatment, leading to a failure in implementing the care plan. The Director of Nursing acknowledged that the care plan was not implemented, and the Infection Preventionist Nurse admitted to not maintaining a log to monitor staff exposure to the resident. The facility's policy required the care plan to be implemented upon admission and throughout the assessment process, but this was not adhered to, resulting in a deficiency in care for the resident.
Failure to Document and Communicate Wound Condition Leads to Hospitalization
Penalty
Summary
The facility failed to properly assess and document a resident's wound, leading to inadequate treatment and care. Multiple nurses documented the resident's condition using identical language, indicating a lack of thorough assessment and individual evaluation. The resident, who had a history of diabetes, chronic kidney disease, and dementia, developed fluid-filled blisters on the left upper extremity. Despite the presence of brown drainage and signs of infection, the facility did not inform the wound care specialist of the resident's diabetes diagnosis or the drainage, which could have influenced the treatment plan. The resident's care plan for the blister and risk of infection was not initiated until after the resident had been transferred to a hospital, indicating a delay in addressing the change in condition. Interviews with staff revealed inconsistencies in the assessment and documentation of the wound, with some staff noting significant blistering and drainage, while others did not report these observations. The lack of comprehensive documentation and communication among staff and with the wound care specialist contributed to the resident's condition worsening, resulting in hospitalization for cellulitis and sepsis. The facility's failure to document the wound's characteristics, such as size, drainage, and signs of infection, hindered effective communication with medical professionals and delayed appropriate interventions. The resident was eventually transferred to a hospital where they were diagnosed with severe sepsis and cellulitis, requiring antibiotic treatment and consideration for surgical debridement. The deficiency highlights the need for accurate and timely documentation and communication in managing residents' health conditions.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 7,032 citations issued within 25 miles in the last 12 months — including the 36 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 Los Angeles
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Alvarado Care Center | 0.1 mi | ★★★★★ | 30 | 1 |
| Olympia Convalescent Hospital | 0.1 mi | ★★★★★ | 4 | 1 |
| California Post Acute | 0.4 mi | ★★★★★ | 9 | 0 |
| Alta View Post Acute | 0.4 mi | ★★★★★ | 31 | 0 |
| Grand Park Convalescent Hospital | 0.5 mi | ★★★★★ | 1 | 0 |
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