Below average — CMS composite of the measures below.
The next survey window likely opens around April 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 Alexandria Care Center during CMS and state inspections, most recent first.
A resident’s discharge record was incomplete and did not accurately reflect the resident’s condition at transfer to a boarding care facility. The chart included HF, DM2, cerebral infarction, and aphasia, but omitted dementia with psychosis from the DS and other transfer documents sent by the SSD. The DON acknowledged the DS and MDS were not updated for accuracy, while the MAR received by the boarding care facility did include psychosis.
Failure to transcribe and carry out an ordered treatment: A resident with severe cognitive impairment and diagnoses including DM2, HTN, and a history of falls developed a small chin abrasion while being shaved. An MD ordered cleansing with NS and application of triple antibiotic ointment, but the LVN stated the treatment was not entered on the TAR, and the DON confirmed the order was not fully carried out in the record.
Failure to update an elopement care plan: A resident with HF and DM had moderately impaired cognitive skills on MDS, and the care plan identified elopement risk related to wanting to leave the facility and cognitive loss/dementia. Progress notes documented repeated statements about leaving, a request for a wander guard, transfer to a more secure unit after looking for exit doors and becoming aggressive, and CNA reports that the resident tried to leave about once a week. RN stated the care plan should have been revised by the IDT at least quarterly and with changes in condition.
Inaccurate MDS Diagnosis Documentation: A resident’s MDS did not include active diagnoses of psychosis, insomnia, and dementia that were documented in psychiatry progress notes. The MDS nurse stated the diagnoses were not captured and was unsure why, while the DON stated nursing staff and the IDT should have ensured the new diagnoses were reflected in the MDS and medical record.
Improper Garbage and Dumpster Sanitation: A grey trash can near the trayline and dishwashing machine was left not fully covered when not in use, and the outside dumpster area had litter and dried brown spills on the dumpster. The DS stated the lid should be completely closed to prevent odors and flies, and both the DS and EVSS acknowledged the trash and spills were not acceptable due to infection control concerns.
A resident with dementia and weakness was observed with bilateral foam wedge cushions tucked under the fitted sheet while in bed, and staff stated the wedges restricted movement and were considered a restraint. Other residents had a bed alarm used without a documented restraint assessment, a bed positioned against the wall without order or consent, and a wheelchair lap tray used without the required assessment or two-hour removal documentation. DON and ADON staff acknowledged the devices and positioning could be restraints when the resident could not remove them or when they limited mobility.
Failure to Rotate Insulin Injection Sites: Licensed nursing staff did not rotate SQ insulin administration sites for two residents receiving insulin for DM. One resident with ESRD and DM2 had repeated insulin aspart injections in the right arm, while another resident with insulin-dependent diabetes had repeated Humalog, insulin aspart, and Lantus injections in the abdomen, especially the LLQ. RN and MDS staff stated the sites were not rotated and that the care plan did not address regular rotation.
Medications were left at the bedside for residents who were not assessed or authorized to self-administer, including an LPN leaving oral meds and lactulose unattended and a resident applying topical diclofenac on her own. Staff and the DON confirmed the facility medication administration process was not followed. In separate fall-prevention issues, a resident’s bed pad alarm was found turned off and another resident’s floor mat had a chair placed on top of it, reducing the intended safety protection.
A resident’s oxygen tubing was found touching the bed and floor, and two other residents’ oxygen humidifiers were observed without date labels, with one humidifier empty. Staff also found that oxygen was running above the ordered flow rate for two residents. RN staff stated the physician’s orders were not followed, and the DON stated that tubing and humidifiers must be labeled with the date initiated and that humidifiers provide moisture during oxygen administration.
A resident with schizoaffective disorder, MDD, and spina bifida had PRN acetaminophen and oxycodone/acetaminophen ordered for pain, with the opioid limited to severe pain rated 8 to 10. The MAR showed an RN administered the opioid for pain ratings of 6 and 7 on multiple occasions, and the RN stated she misread the order. The MDSC, ADON, and DON confirmed the medication was not given per the order and the facility pain medication policy was not followed.
A resident with ESRD on dialysis had a 1200 cc fluid restriction, but the record showed no physician order for I&O monitoring, no documentation of actual fluid intake on the MAR, and no comprehensive care plan addressing the restriction or the resident’s noncompliance. CNA staff reported giving fluids throughout the shift, noted outside drinks in the room, and said they were not instructed to record intake amounts or report them to an LN. RN and DON interviews confirmed the physician was not notified of the noncompliance and the care plan was not updated to address the resident’s fluid restriction needs.
Missing bed rail orders, consent, assessments, and care plans Four residents were observed with bilateral 1/2 bed rails elevated, but the chart lacked required documentation tied to their use. Depending on the resident, the facility had no physician order, no informed consent, no complete Bed Rail Evaluation, and no care plan for the bed rails. Staff confirmed the missing documentation during record review, and one evaluation was noted to be incomplete because the resident or representative had not been informed about the medical needs, benefits, side effects, or alternatives related to side rail use.
An LVN left a resident’s benazepril, aspirin, and fish oil at bedside for self-administration, documented them in the MAR before knowing whether they were taken, and documented Refresh Tears before actually giving them; the eye drops were then administered late. In a separate issue, a controlled drug count for another resident did not match the bubble pack inventory for pregabalin and methadone, with the LVN failing to sign the controlled substance record right away.
Medication Storage and Labeling Deficiencies: A PPD vial in a med room was found opened without an open date, a resident’s hydrocodone-acetaminophen bubble pack in a med cart had a broken seal and was taped over, and another resident’s morphine in the same med cart was expired. Staff stated the PPD should have been dated when first used, the removed tablet should not have been returned to the pack, and expired meds should have been removed from the cart.
A facility failed to follow its menu spreadsheet when pork roast portions served to residents on a regular diet did not match the listed 3 oz serving size. During observation, the pork roast was cut from scratch and not pre-portioned, and random servings weighed 2.52 oz, 3.7 oz, and 3.93 oz. The dietary supervisor stated the portions needed to be weighed to ensure residents received the nutrition required, and the facility’s menu policy and standardized recipe both called for serving menus as written with a 3 oz portion.
Food Not Served at Proper Temperature and Lacked Flavor: A dietary test tray found hot items served at low temperatures, including pork roast and seasoned black beans on both regular and puree trays. A resident with GERD, anxiety, and anemia said the food was substandard and gross; another resident with dysphagia, depression, and prostate CA said it did not taste good; a resident with dysphagia and malnutrition said the food did not taste good; and a resident with GERD, HTN, and DM2 said meals were very bland with no seasoning or flavor.
Puree diet foods were not prepared to meet IDDSI Level 4 texture standards. During a test tray observation, the puree smothered cabbage was flat and did not hold its shape, and the puree corn bread was sticky and did not fall from the spoon during the spoon tilt test without added pressure. The DS and RD stated these texture issues could make swallowing harder and were not consistent with the facility diet manual and IDDSI guidance.
Late Lunch Service: A resident with GERD, HTN, and DM2 was on a carb-controlled, NAS diet and needed supervision while eating. Staff stated lunch was scheduled for noon, but trayline service ran late and the last meal cart did not reach the unit until mid-afternoon. The DS acknowledged that residents sometimes complain of late meal service and that delays occurred because staff were nervous and double-checking food textures.
Unsafe food storage and preparation practices were observed in the kitchen. The walk-in refrigerator and dry storage areas had dirt, debris, and residue; several racks, trays, and drying surfaces were rusted, chipped, cracked, or peeling; foods were mislabeled; a dented can was stored with intact cans; no thermometer was present in dry storage; and staff were observed cross-contaminating food by keeping a soiled towel near produce and using the same board and knife for chicken and bread. Staff also wore dangling jewelry, watches, and nail polish during food prep.
Incomplete psychotropic consent and MAR documentation were found for two residents. One resident with depression and intact cognition had psychotropic medications ordered, but the record lacked complete consent documentation and no physician progress note showed the treatment discussion. Another resident with Parkinson’s disease and intact cognition had multiple scheduled meds that were not signed off on the MAR by an LVN and an RN, despite facility policy requiring immediate documentation after administration.
A resident receiving hospice for terminal lung cancer had missing CHHA visit notes, an absent updated hospice POC, and incomplete hospice calendars in the chart. Staff found that scheduled HA visits listed on the hospice calendar were not reflected in the record, and the ADON stated the hospice POC and hospice agreement were not followed.
A disposable yellow gown was found hanging on a washing machine after use instead of being discarded, and the LA said it had been forgotten while sorting dirty linens. The IP, LS, and DON stated disposable gowns are one-time use items and should be thrown away after use. In addition, multiple clean linen carts were observed covered with blue mesh material, and the IP and DON stated the mesh allowed visibility and could permit liquid or gas to pass through, leaving clean linens less protected from environmental contamination.
Failure to Maintain Privacy During ADL Care: A CNA left a privacy curtain partially open while providing morning ADL care to a dependent resident, exposing the resident to a neighboring resident. The resident had diagnoses including metabolic encephalopathy, UTI, and dysphagia, and was documented as lacking decision-making capacity and needing staff assistance with multiple ADLs. The CNA acknowledged the curtain should have been fully closed, and the DON stated privacy curtains are meant to protect resident privacy and dignity.
Unnecessary Psychotropic Medication Monitoring: A resident with schizoaffective disorder, major depressive disorder, and spina bifida received bupropion for depression manifested by feeling hopelessness. The MDSC, ADON, RN, and DON stated that feelings are not measurable behaviors and that the resident was not monitored for specific behavioral manifestations such as verbalization of hopelessness. The facility’s psychotropic medication policy required monitoring of behavioral triggers, episodes, and symptoms, but the resident’s record did not show that the medication was prescribed and monitored for specific measurable behaviors.
A resident with ESRD on dialysis and DM2 had an order for Insulin Aspart with sliding-scale coverage before meals and at bedtime, but the care plan did not include documented, comprehensive person-centered interventions for insulin use. RN confirmed there was no insulin care plan, and the DON stated the care plan should identify the problem and specific interventions; facility policy required measurable objectives and timeframes.
Wound Care Provided Without Physician Order: A resident with a sacral PI and diabetic foot and leg ulcers had wound care orders for Santyl, Mupirocin, therahoney, collagen powder, and DDs. During observation, an RN applied calcium alginate to the sacrococcyx wound as ordered, but also applied calcium alginate to the resident’s toe and posterior leg ulcers even though those wounds were ordered to receive only Santyl, Mupirocin, and DDs. The TN later stated the order had been confused, and the DON stated the treatment was not in accordance with the physician’s orders or facility P&P.
Unlabeled Urinal Bottle: A resident with MDRO/MRSA history, occasional incontinence, and toileting assistance needs was observed with an unlabeled urinal hanging at the bedside. The LVN, CNA, and DON all stated the urinal should be labeled with the date given, the resident’s initials, and room/bed number, and that unlabeled urinals could be interchanged between residents and lead to cross contamination.
A resident with HTN, HLD, CKD, and fluctuating capacity was involved in a medication error when an LVN left benazepril, aspirin, and fish oil at bedside during the med pass instead of directly supervising administration. The resident later had the meds on the floor and said he was not sure what he had taken. The LVN stated she did not watch him take the meds and could not determine whether benazepril was actually given, and the ADON and DON stated the facility med administration protocol was not followed.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A resident with DM, moderate persistent asthma, and a history of venous thrombosis and embolism twice reported shortness of breath, muscle tightening, and not getting enough air while on BiPAP. An LVN and an RN responded at the bedside, adjusted BiPAP settings, obtained vital signs, and provided a breathing treatment, but the RN did not initiate a Change of Condition process or notify the physician, contrary to facility policy requiring immediate consultation with the physician or NP for significant physical changes.
A resident admitted with diabetes mellitus and a documented personal history of venous thrombosis and embolism did not have a person-centered care plan developed to address DVT-related needs. Although the admission records and history and physical showed intact cognition and clearly listed the DVT/embolism history, facility staff, including those responsible for MDS and care planning, did not initiate a care plan for this condition. The DON confirmed that the care plan should have identified the DVT diagnosis and risk, and that the facility’s policy requires comprehensive care plans with measurable objectives and timetables for all medical and psychosocial needs, which was not followed in this case.
A resident with cognitive impairment, limited decision-making capacity, and Spanish as a preferred language received a STAT bilateral hip x-ray order related to prior hip fractures and leg pain, but neither the resident nor the responsible party was properly informed. An RN acknowledged there was no documentation of notification, and the resident later reported that a man was taking a picture of her. An LVN stated they explained the x-ray in English while accompanying the technician but did not speak Spanish and also confirmed there was no documentation of the explanation. This resulted in the resident and responsible party not being fully informed of the x-ray, in violation of the facility’s resident rights policy requiring notification and participation in care and treatment decisions.
A resident with severe cognitive impairment and multiple medical conditions experienced several falls and a change in condition, during which staff failed to maintain accurate and complete documentation. For one fall, the CIC recorded an incorrect physician notification time, and the RN who assessed the resident and called 911 did not document her interventions in the progress notes. For another fall, the CIC omitted where the resident was found and who found the resident first. In a separate change in condition, the date and time of family notification were left blank, contrary to facility policy requiring complete, objective, and accurate charting of events, assessments, and notifications.
A resident with severe cognitive impairment, traumatic subdural hemorrhage, COPD, and muscle weakness had physician orders and a care plan for use of a bed alarm in bed, with checks of placement and function each shift. A family member provided informed consent for the device. Surveyors observed a bed alarm hanging on the side of the bed and an LVN reported it was used to alert staff when the resident attempted to get up. The DON identified the bed alarm as the least form of physical restraint and stated that residents on bed alarms must be monitored and that monitoring documented on the MAR. Review of the MAR showed no documented monitoring of the bed alarm over an extended period, despite facility restraint policy requiring frequent observation and detailed documentation when a restraint is used.
A resident with severe cognitive impairment, poor safety awareness, and multiple medical conditions had a fall-risk care plan that required placement in a room within direct line of sight of the nurse’s station and use of a wander guard. After admission, the resident was initially placed near the nurse’s station with a wander guard, but was later moved to a room farther away and the wander guard was discontinued by physician order. The care plan was not updated to reflect the room change or the discontinuation of the wander guard, even though the resident continued to ambulate independently in the new room. Staff interviews confirmed reliance on the outdated care plan, and facility policy required ongoing assessment and revision of care plans as resident conditions and circumstances changed.
A resident with intact decision-making capacity and an immunodeficiency diagnosis reported receiving a breakfast tray with a dirty spoon containing dried food residue. The spoon was visually confirmed as dirty by the Dietary Supervisor and Social Service Director. Interviews revealed that Dishwasher Staff, a Dietary Aide, and CNAs were each expected to check utensil cleanliness but failed to identify and remove the soiled spoon before it reached the resident, contrary to the facility’s sanitation policy requiring all utensils to be properly cleaned and sanitized.
A resident with severe cognitive impairment received double doses of famotidine due to unclarified physician orders and was also given guaifenesin and dextromethorphan-guaifenesin less than the prescribed six-hour interval. Nursing staff did not clarify conflicting orders or follow the facility's medication administration policy, resulting in medication errors.
Staff failed to follow enhanced barrier precautions by not wearing required PPE, including masks, gloves, and gowns, while providing high-contact care to two residents with indwelling devices and wounds. Despite clear signage and available supplies, nurses entered rooms and performed care activities without proper protection, in violation of facility policy and local health orders.
A resident with severe cognitive impairment and a recent diagnosis of legionnaires disease and pneumonia did not have a care plan developed for their infection or for the use of azithromycin until after treatment had begun or was completed. Staff confirmed that care plans were delayed, and facility policy requires timely, individualized care planning for all residents.
A resident with severe cognitive impairment experienced low oxygen saturation and received emergency oxygen therapy. Nursing staff documented that 15 liters of oxygen were given via face mask, but interviews revealed that a non-rebreather mask was actually used. The nurse later confirmed the documentation was incorrect, resulting in an inaccurate medical record that did not reflect the actual intervention provided.
A resident with severe cognitive impairment and multiple health conditions was prescribed azithromycin for pneumonia, but staff failed to document monitoring for antibiotic use and side effects as required by facility policy. Both the IP and DON confirmed that monitoring should have occurred every shift, but no such documentation was found in the resident's records.
Three residents with severe cognitive impairment and high care needs were found with their call lights out of reach, despite care plans requiring accessibility. Staff interviews confirmed the devices were not returned to proper placement after care, and the DON acknowledged this was against facility policy.
A resident with cognitive impairment and risk for skin breakdown had a care plan specifying a low air loss mattress (LALM) setting of 100-150 pounds, but staff were observed using a setting of 200 pounds, inconsistent with the care plan and the resident's weight. Interviews with the DON, treatment nurse, and DSD confirmed the importance of following the care plan and that the incorrect setting could reduce the mattress's effectiveness in preventing pressure injuries.
A resident with severe cognitive impairment and incontinence was not provided with proper pressure ulcer prevention when staff failed to ensure the low air loss mattress was functioning as ordered. The mattress was set above the resident's weight, had multiple warning indicators active, and the alarm was muted, contrary to the care plan and manufacturer instructions. Staff were aware of the malfunction but did not resolve it, resulting in care inconsistent with professional standards.
A resident with dementia and hypertension received blood pressure medications from an LVN despite a physician order to hold the medications if the diastolic blood pressure was below 60. The LVN administered the medications when the resident's blood pressure was 104/53, contrary to the order. Facility staff confirmed the order was not followed, and policy review showed that vital signs should be checked and medications held as directed.
A resident receiving anticoagulant therapy had multiple entries on the MAR indicating the presence of bleeding, but no clinical evidence or progress notes supported these findings. Interviews with the DON and nursing staff revealed that no signs of bleeding were actually observed and that the documentation was inaccurate due to misinterpretation of physician orders. This failure to maintain accurate and complete medical records had the potential to cause confusion in the resident's care.
A resident with cognitive impairments was physically abused by another resident in a LTC facility. The aggressor, who has a history of psychosis and confusion, struck the victim on the head without provocation, resulting in pain and the need for medication. Staff interviews confirmed the incident as abuse, despite the aggressor's confusion.
The facility failed to develop and implement comprehensive care plans for residents, leading to potential risks. A resident using side rails lacked a care plan, another on Pradaxa was not monitored for side effects, a third refused physical therapy without a care plan update, and a fourth's low air loss mattress was improperly managed. These deficiencies were acknowledged by the facility's DON.
A facility failed to rotate insulin injection sites for three residents, leading to a deficiency. One resident with type 2 diabetes and other health issues received repeated injections in the same areas, confirmed by an LVN and the DON. Another resident with congestive heart failure and diabetes also had injections without proper site rotation, as shown in their MAR. A third resident experienced similar issues, with insulin administered multiple times in the same arm. The DON confirmed these practices were against facility policy and manufacturer guidelines, posing risks of skin complications.
A facility failed to maintain a safe environment for residents by placing overbed tables on floor mats, compromising their integrity and stability, and leaving a resident's bed in a high position unattended, despite fall risk precautions. Staff were unaware of guidelines, leading to potential injury risks.
Incomplete Discharge Documentation for Resident with Dementia and Psychosis
Penalty
Summary
The facility failed to ensure Resident 1’s discharge record was complete and accurately reflected the resident’s clinical condition and care needs at the time of transfer to a boarding care facility. Resident 1’s record showed admission with diagnoses including heart failure and type 2 diabetes mellitus. The MDS dated 4/3/2026 indicated moderately impaired cognitive skills for daily decisions and need for supervision or touching assistance with several ADLs. Earlier records included an H&P stating the resident had capacity to understand and make decisions, while later physician and psychiatry progress notes documented dementia with psychosis, unspecified psychosis, insomnia, and dementia. The discharge summary dated 5/29/2026 stated the resident’s health had improved sufficiently and listed diagnoses including cerebral infarction, aphasia following cerebral infarction, heart failure, and type 2 diabetes, but it did not include dementia with psychosis. The SSD stated she sent the boarding care facility the face sheet, medication review, and H&P, and that dementia with psychosis was not included in the documents sent. The SSD stated she was not aware of that diagnosis and noted miscommunication between the MDs and facility staff. The DON stated the boarding care facility received the MAR, which included psychosis, and acknowledged the discharge summary and MDS failed to update the diagnosis of dementia for accuracy. The facility policy required documentation of all services provided and changes in medical, physical, functional, or psychosocial condition in the resident’s medical record.
Failure to Transcribe and Carry Out Ordered Wound Treatment
Penalty
Summary
The facility failed to ensure a physician-ordered treatment was transcribed to the Treatment Administration Record (TAR) and implemented for one resident. The resident was admitted with diagnoses including type 2 diabetes, history of falling, hypertension, and neurocognitive disorder. The Minimum Data Set dated 5/30/2026 indicated the resident’s cognitive functioning was severely impaired and that the resident required moderate assistance with oral hygiene, bathing, and dressing. An order dated 6/5/2026 directed staff to cleanse a skin irritation on the resident’s chin with Normal Saline, pat dry, apply triple antibiotic ointment, and leave it open to air for 14 days. During interview, the LVN stated a CNA reported a small abrasion on the resident’s chin while shaving the resident’s face, and the LVN notified the MD and received the treatment order. The LVN stated she provided the treatment after receiving the order, but the order was not carried out in the TAR. The DON reviewed the record and stated the treatment order was not in the TAR and that the LVN must not have carried out the order completely.
Failure to Update Elopement Care Plan
Penalty
Summary
The facility failed to update the care plan for a resident identified as being at risk for elopement. The resident was admitted with diagnoses including heart failure and type 2 diabetes mellitus. The resident’s MDS dated 4/03/2026 indicated moderately impaired cognitive skills for daily decisions and the need for supervision or touching assistance with ADLs. The resident’s H&P dated 5/14/2025 stated the resident had the capacity to understand and make decisions, and an elopement evaluation on the same date indicated the resident was not at risk for elopement. The care plan, initiated on 9/6/2025, identified the resident as at risk for elopement related to expressing a desire to leave the facility prematurely and cognitive loss/dementia, with interventions to monitor attempted elopement and adjust care delivery. Progress notes documented that the resident had been telling different CNAs he planned to leave the facility, that the wife requested a wander guard, and that the resident was transferred to a more secure unit after looking for exit doors and being aggressive toward staff. During interview, CNA 1 stated the resident frequently attempted to leave the facility and would try to leave at least once a week. RN 1 reviewed the care plan and stated it should have been revised to evaluate whether goals had been met and that the IDT is responsible for updating and revising the care plan after each meeting and at least quarterly or with a change in condition.
Inaccurate MDS Diagnosis Documentation
Penalty
Summary
The facility failed to ensure accurate medical records for one sampled resident when the MDS nurse did not document active diagnoses in Section I of the resident’s MDS. The resident’s record included diagnoses of heart failure and type 2 diabetes mellitus on the admission record, and the MDS dated 4/3/2026 showed moderately impaired cognitive skills for daily decisions and the need for supervision or touching assistance with ADLs. However, the resident’s psychiatry progress note dated 9/25/2025 documented diagnoses of unspecified psychosis, insomnia, and dementia, and these diagnoses were not captured in Section I of the MDS. During interview and record review, the MDS nurse stated the facility failed to capture psychosis and insomnia on the MDS and was not sure why those diagnoses were omitted. The MDS nurse also stated that medical records and the MDS nurse were responsible for capturing active diagnoses, and stated the resident did not have dementia, which was why dementia was not captured. The DON stated nursing staff who received the new psychiatry diagnosis should have informed the MDS nurse, and stated that insomnia, dementia, and psychosis should have been captured by the MDS nurse. The DON also stated the resident was being treated for psychosis and insomnia by the psychiatry doctor, and that the IDT should have captured the new diagnoses during quarterly medication review.
Improper Garbage and Dumpster Sanitation
Penalty
Summary
Improper disposal of garbage and refuse was identified in the kitchen and outside the facility. During observation, the grey garbage can near the trayline and dishwashing machine was not completely covered and was not in use. In interview, the Dietary Supervisor stated the garbage lid should be completely closed to prevent the smell of garbage from attracting flies and acknowledged that the can was not completely closed and was not acceptable due to infection control concerns. During a separate observation outside the facility, the dumpster area had littered paper and condiment wraps on the surrounding ground, and the dumpster body had dry brownish spills on it. The Dietary Supervisor stated it was not okay to have trash and spills on the dumpster because it could attract pests and needed to be cleaned for infection control. The Environmental Service Supervisor stated the dumpster area was swept twice daily and that maintenance oversaw power washing, and also stated there should not be any trash around the dumpster because it attracts flies and is an infection control concern.
Physical restraints used without required assessment and documentation
Penalty
Summary
The facility failed to ensure residents were free from physical restraints unless needed for medical treatment for four of five sampled residents reviewed for restraints. The report identified concerns involving bilateral foam wedge cushions placed under a resident’s fitted sheet, bed pad alarms used without a documented physical restraint assessment, a bed positioned against the wall, and a wheelchair lap tray used without the required restraint monitoring and release documentation. Facility staff and leadership acknowledged that these devices and positioning could be considered restraints when the resident could not remove them or when they limited movement. For one resident with diagnoses including dementia, seizures, major depressive disorder, and generalized muscle weakness, staff observed bilateral foam wedge cushions tucked under the fitted sheet on both sides of the resident while the resident lay in bed with a bed pad alarm in place. CNA and LVN staff saw the wedges remain under the sheet, and the IP later stated the wedges should not have been tucked under the sheet because they restricted mobility and were considered a restraint. The ADON and DON stated the wedges were used for positioning on top of the sheet, but when placed under the fitted sheet to prevent falls they became a restraint. The record also showed a physician order for the bed alarm, but the ADON and DON stated there was no documented physical restraint assessment completed before the bed pad alarm was used. For another resident with dementia, Alzheimer’s disease, and generalized muscle weakness, staff observed a bed pad alarm under the resident while in bed, and the device was found turned off until an LVN activated it. The ADON stated the physical restraint assessment for the bed pad alarm had not been done, although it should have been completed before use. For a third resident, the bed was positioned against the wall on one side; RN staff stated this limited the resident’s ability to move freely and may be considered a restraint. The resident stated it was not his preference, and RN staff found no physician order, informed consent, restraint assessment, or documentation that the resident requested the bed placement. For a fourth resident using a wheelchair lap tray, the order directed staff to remove it every two hours, but RN staff stated there was no documentation showing the restraint assessment or the required two-hour removal had been completed.
Failure to Rotate Insulin Injection Sites
Penalty
Summary
Licensed nursing staff failed to rotate subcutaneous insulin administration sites for two residents who were receiving insulin for diabetes management. The deficiency was identified during interview and record review for Residents 13 and 14, both of whom had diabetes diagnoses and intact cognitive skills for daily decision making. Resident 14 also had end stage renal disease, was dependent on renal dialysis, and required substantial to maximal assistance with several activities of daily living. Resident 13 had type II DM, pleural effusion, and generalized muscle weakness, and was dependent on staff for toileting hygiene, showering, lower body dressing, and footwear. For Resident 14, the order summary showed insulin aspart was ordered as sliding scale insulin before meals and at bedtime. The location of administration report showed repeated injections on the right arm on multiple occasions in May 2026. During concurrent interview and record review, RN 7 stated there were multiple instances where licensed staff did not rotate the insulin administration sites for Resident 14. RN 7 stated there was no documented care plan regarding insulin use and explained that rotating sites was important to prevent bruising, trauma, and lipodystrophy. For Resident 13, the order summary showed orders for Humalog, insulin aspart, and Lantus. The care plan identified diabetes: insulin dependent, but did not include an intervention to rotate injection sites regularly. The location of administration report showed repeated use of the abdomen, especially the left lower quadrant, for Humalog, insulin aspart, and Lantus, with additional injections also given in the right arm. During interview, the MDS Director stated there were multiple instances that licensed staff did not rotate the insulin administration sites and that the care plan did not address rotating insulin injection sites regularly. The DON also stated the staff did not follow the facility policy and manufacturer specifications for Aspart, Humalog, and Lispro.
Medications Left Unattended and Fall-Prevention Devices Not Properly Used
Penalty
Summary
The facility failed to keep the resident environment free of accident hazards and to provide adequate supervision when medications were left at the bedside for residents who were not assessed or authorized for self-administration. Resident 140 was admitted with HTN, HLD, CKD, and cataracts, and his record showed fluctuating capacity. During observation, two tablets and two clear capsules were found on the floor next to his bed after the LVN left his medications at bedside during breakfast and did not watch him take them. The resident stated the nurse left the medications there and that he thought he may have taken some, but was not sure. The LVN acknowledged she left the medications at bedside and did not follow the facility medication administration protocol. Resident 110 was admitted with liver cell carcinoma, cirrhosis, and cognitive communication deficit, and his medication self-administration evaluation indicated he was unable to demonstrate secure storage of medication and self-administration was not recommended. Despite that, a cup containing yellow liquid medication was observed on the bedside table, and the resident stated the nurse leaves the medication so he can take it whenever he wants. The LVN stated she gave the resident lactulose and then left the room without observing him take it. The ADON and DON stated the resident was not to self-administer medications and that medications should not be left at bedside, but the facility’s medication administration process was not followed. Resident 23, who was admitted with a left femur fracture, muscle weakness, and dependence on supplemental oxygen, was observed with diclofenac sodium topical gel placed on the table beside the bed. The resident stated the gel had been there for days and that she had been applying it herself to her right knee and leg. Staff stated she did not have an assessment or order for self-administration and that the medication should not have been in her possession. In addition, Resident 155, who had dementia, Alzheimer’s disease, and severe cognitive impairment, was found with a bed pad alarm in place but not powered on, and staff stated it was not working. Resident 9, who was at risk for falls and had floor mats in the care plan, was observed with a chair placed on top of the right floor mat, which staff stated should not have occurred.
Respiratory Care Not Provided as Ordered
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for three residents receiving oxygen therapy. During observations and record review, staff found that one resident’s oxygen nasal cannula tubing was not connected to the nose and the tubing was touching the bed and floor. Staff interviewed stated that oxygen tubing should not touch the floor and that the tubing should be placed in a bag when not in use. The DON also stated that tubing touching the floor was an infection control concern and a safety concern. For another resident, the oxygen concentrator humidifier was observed empty and without a date label. RN staff stated that the humidifier was empty, was not labeled with the date it was provided, and that oxygen was flowing at 4 LPM via nasal cannula. The resident’s order summary indicated oxygen was ordered at 3 LPM continuously, with weekly tubing changes and labeling of each component with the date and initials. RN staff stated the physician’s orders were not followed and that administering oxygen at 4 LPM placed the resident at potential risk for oxygen toxicity. For a third resident, the oxygen concentrator humidifier was observed without a date label, and RN staff stated it was not labeled with the date it was provided. The resident was receiving oxygen at 3 LPM via nasal cannula, while the order summary indicated oxygen was ordered at 2 LPM continuously to maintain oxygen saturation levels of 92% and above. RN staff stated the physician’s orders were not followed and that administering oxygen at 3 LPM placed the resident at potential risk for oxygen toxicity. The DON stated that oxygen tubing and humidifier bottles must be labeled with the date initiated, that humidifiers provide moisture to prevent mucosal dryness, and that failure to maintain a filled humidifier placed the resident at risk for nasal dryness, irritation, mucosal breakdown, and potential injury to the nasal passages.
PRN opioid given outside ordered pain parameters
Penalty
Summary
The facility failed to provide pain management consistent with the physician’s order and the resident’s assessed pain level for one resident who had diagnoses including schizoaffective disorder, major depressive disorder, and spina bifida. The resident’s assessment indicated he could understand others and make himself understood, but he was dependent on staff for toileting and showering, required substantial to maximal assistance with lower body dressing and personal hygiene, and needed partial to moderate assistance with moving from sitting to lying. His care plan directed staff to evaluate pain characteristics, medicate as ordered, and report to the physician as indicated. The resident had orders to document pain before, during, and after treatment and to give acetaminophen as needed for pain, as well as oxycodone with acetaminophen every six hours as needed for severe pain rated 8 to 10. Review of the MAR showed oxycodone with acetaminophen was administered for pain ratings below the ordered threshold, including pain levels of 6 on three occasions and 7 on one occasion. During interview, the MDSC stated there were no pain parameters for acetaminophen or any pain level below 8, and that the nurse should have clarified the order before administering the medication. The resident stated he received oxycodone with acetaminophen for pain and did not take other pain medications, and that it was not always effective. RN 5 stated she misread the order and thought it allowed administration for pain levels 6 to 10 because the writing was small. The ADON and DON both stated the medication should have been given only per the physician’s order, and the DON confirmed the facility’s pain medication policy was not followed.
Failure to Monitor and Care Plan Fluid Restriction for Dialysis Resident
Penalty
Summary
Resident 14, who had ESRD and dependence on renal dialysis, was ordered a 1200 cc daily fluid restriction. The resident’s record showed no physician order for intake and output monitoring, and the May 2026 MAR did not document the amount of fluid consumed. The care plan report also did not include a care plan addressing the 1200 cc fluid restriction. During observation, the resident had a water pitcher with clear liquid, a partially full bottle of Gatorade, and an unopened soda on the bedside table. CNA 4 stated she provided the resident with an 800 ml pitcher of water at the start of the shift and that the resident also received coffee, water or juice with lunch, water with medications, and additional juice between meals. CNA 4 stated the resident’s visitors brought Gatorade and soda, and that she repeatedly told the resident not to consume outside fluids because of the dialysis status and fluid restriction. CNA 4 also stated she was not instructed to document the actual amount of fluids consumed and only checked off completion of the task in the MAR, and she would not report the resident’s fluid intake to an LN. RN 4 stated that residents on fluid restriction should have a physician order for I&O and a care plan addressing the restriction, and that CNAs must be instructed to monitor and report intake. RN 4 reviewed the records and stated the MAR only showed task completion, not actual intake amounts, and that the care plan was not comprehensive or resident centered. RN 4 also stated there was no documentation that the physician was notified of the resident’s noncompliance with the fluid restriction, and there was no care plan addressing that noncompliance. The DON stated the resident’s noncompliance should have been communicated to the physician and care planned, and the facility policy required the interdisciplinary team to include renal precautions, fluid restrictions, and documentation of noncompliance.
Missing bed rail orders, consent, assessments, and care plans
Penalty
Summary
The facility failed to safely use half bed rails for four sampled residents by not completing required documentation and assessments tied to their use. During observation, each of the four residents was seen lying in bed with bilateral 1/2 bed rails elevated. Record review and staff interview showed that the facility did not have the required informed consent, physician's order, bed rail evaluation, or care plan documentation in place for all of the residents as applicable to each case. Resident 14 was admitted and readmitted with ESRD, dependence on renal dialysis, type 2 DM, and diabetic neuropathy. The MDS showed intact cognitive skills for daily decision making and substantial/maximal assistance with several activities of daily living. The resident was observed with bilateral 1/2 bed rails elevated. The OSR showed an order for bed rails as an enabler for turning and positioning, but the Bed Rail Evaluation indicated the resident or representative was not informed about the medical needs addressed by side rails, the benefits and potential side effects, or alternatives that had failed to meet the resident's needs. The MDS Director stated there was no documentation of bed rail informed consent and that the evaluation was incomplete. Resident 77 was admitted and readmitted with CAUTI, stage 4 CKD, and DM. The H&P stated the resident did not have capacity to understand and make decisions, while the MDS indicated intact cognitive skills and substantial/maximal assistance with several ADLs. The resident was observed with bilateral 1/2 bed rails elevated. The OSR had no physician's order for bed rail use, and the care plan had no documentation for bed rail use. Staff stated there was no physician's order, informed consent, or care plan documented for the bed rails. Resident 82 was admitted and readmitted with DM, hypertension, and hypothyroidism. The H&P stated the resident had capacity to understand and make decisions, while the MDS showed moderately impaired cognitive skills and dependence or partial/moderate assistance with several ADLs. The resident was observed with bilateral 1/2 bed rails elevated. The OSR had no physician's order, and the care plan had no documentation for bed rail use. Staff stated there was no physician's order, Bed Rail Evaluation, informed consent, or care plan documented. Resident 108 was admitted and readmitted with DM, depression, and dysphagia. The H&P stated the resident had fluctuating capacity, and the MDS showed moderately impaired cognitive skills with substantial/maximal assistance for several ADLs. The resident was observed with bilateral 1/2 bed rails elevated. The OSR had no physician's order, and the care plan had no documentation for bed rail use. Staff stated there was no physician's order or care plan documented, and the Bed Rail Evaluation was incomplete because the resident or representative was not informed about the medical needs addressed by side rails, the benefits and potential side effects, or alternatives attempted that failed to meet the resident's needs.
Medication Administration and Controlled Substance Count Errors
Penalty
Summary
Pharmaceutical services were not provided in accordance with physician orders and facility policy for one resident who had diagnoses including HTN, HLD, CKD, and cataracts. The resident’s orders included benazepril 10 mg twice daily for HTN, aspirin 81 mg daily for CVA prophylaxis, fish oil 1000 mg daily, and Refresh Tears eye drops three times daily for dry eyes. During a medication pass, the LVN left the benazepril, aspirin, and fish oil at the resident’s bedside for the resident to self-administer, even though the resident was not determined to be safe for self-administration. The resident stated the nurse left the medications during breakfast and they fell on the floor while he was eating, and the resident was not sure whether he took any of them. The LVN stated she did not watch the resident take the medications because she was called away to another resident. She also stated she documented the benazepril, aspirin, and fish oil as administered even though she had left them at the bedside and did not know whether the resident took them. The LVN further stated she had not yet administered the Refresh Tears eye drops, but she had already documented them as given in the MAR. The eye drops were then administered after 10 a.m., although the facility process required administration within one hour before or after the scheduled 9 a.m. time. The MAR therefore did not accurately reflect the actual administration time. A controlled substance count discrepancy was also identified for another resident. At one medication cart, the count on the controlled drug record did not match the medication remaining in the bubble packs for pregabalin and methadone. One pregabalin capsule and one methadone tablet were missing from the expected count, and the LVN stated he had administered methadone but had not signed the controlled drug record right away. The ADON stated the controlled drug record and bubble pack count should match and that failing to sign immediately can lead to an incorrect count. The facility policy required controlled substance inventories to be monitored and reconciled, with discrepancies reported.
Medication Storage and Labeling Deficiencies
Penalty
Summary
Drugs and biologicals were not stored and labeled in accordance with accepted professional principles in Med Room Station 1 and Med Cart Station 3. In the medication refrigerator in Med Room Station 1, a tuberculin PPD vial was observed opened and in use without an open date. The vial box indicated it was filled on 4/3/2026 and that once entered it should be discarded after 30 days. The LVN stated the vial should have an open date because it is only good for 30 days, and the ADON stated the vial is a multi-dose vial that should have an open date when first used. In Med Cart Station 3, Resident 112’s hydrocodone-acetaminophen 5-325 mg bubble pack slot #28 was observed with a broken seal and covered with tape. The LVN stated he did not know who placed the tape over it and had not noticed it before, and stated the tablet should not have been placed back inside or covered with tape. The resident’s physician order indicated hydrocodone-acetaminophen was prescribed as needed for moderate to severe pain, and the ADON stated that once a medication is removed from a bubble pack and not used or administered, it must be surrendered for destruction and may not be returned to the container. Also in Med Cart Station 3, Resident 29’s morphine sulfate oral solution was observed with a use-by date of 12/3/2025 while the resident remained ordered to receive morphine as needed for severe pain. The LVN stated the medication should have been removed and disposed of when it expired, and the ADON stated expired medications should be removed from the cart on the same day they expire. Resident 29 had diagnoses including Alzheimer’s disease, hypertension, and Parkinson’s disease.
Menu Portion Sizes Not Followed for Pork Roast
Penalty
Summary
The facility failed to follow its menu spreadsheet for residents on a regular texture diet when pork roast was served in portions that did not match the listed 3 oz serving size. The menu spreadsheet titled Spring 2026 indicated that the regular diet tray should include Pork Roast 3 oz, but during observation the roast pork was not uniform in size and some pieces were larger while some were smaller. A staff member stated the pork roast was cut from scratch and was not individually pre-portioned, and also stated the portions were not weighed. During a concurrent observation and interview, random portions of pork roast were weighed on the facility food scale and measured 2.52 oz, 3.7 oz, and 3.93 oz. The dietary supervisor stated the portion size needed to be weighed to ensure it was the right cut and portion and that the spreadsheet had to be followed so residents received the nutrition they were required to receive. The facility’s Menus policy stated menus would be planned in advance to meet residents’ nutritional needs and served as written, and the standardized recipe for Pork Roast/Gravy listed a suggested portion of 3 oz.
Food Not Served at Proper Temperature and Lacked Flavor
Penalty
Summary
The facility failed to prepare food by methods that conserved temperature and flavor when hot foods were not served hot and pork roast and seasoned black beans were not seasoned well and tasted bland. During a test tray observation, the Dietary Supervisor took temperatures of the regular diet tray and the puree diet tray and found pork roast with gravy at 104 F, seasoned black beans at 90 F, and smothered cabbage at 111 F on the regular tray, and pureed pork roast at 114 F, pureed seasoned black beans at 97 F, and pureed smothered cabbage at 105 F on the puree tray. The Dietary Supervisor stated the seasoned black beans needed to be more seasoned, the pork roast was bland, and the food temperature could be a little hotter. Resident 149 was admitted with diagnoses including GERD, anxiety disorder, and anemia, and the MDS indicated the resident understood others and made self-understood and required set-up and clean-up assistance when eating. The resident was ordered a regular diet with regular texture and thin liquids. During interview, Resident 149 stated the food products are substandard and gross and that the food is not good. Resident 34 was admitted with diagnoses including dysphagia, depression, and malignant neoplasm of the prostate, and the MDS indicated the resident understood others and made self-understood and required set-up and clean-up assistance when eating. Resident 34 was ordered a cardiac diet with bite size texture and thin consistency and stated the food does not taste good. Resident 50 was admitted with diagnoses including dysphagia, hyperlipidemia, and unspecified protein-calorie malnutrition, and the MDS indicated the resident understood others and made self-understood and needed set-up and clean-up assistance when eating. Resident 50 was ordered a cardiac diet, easy to chew, with thin consistency and stated the food does not taste good. Resident 163 was admitted with diagnoses including GERD, HTN, and type 2 diabetes mellitus, and the MDS indicated the resident understood others and made self-understood and required supervision or touching assistance when eating. Resident 163 was ordered a carbohydrate controlled, no added salt, regular texture, thin consistency diet and stated meals are very bland, with no seasoning and no flavor.
Puree Diet Foods Not Prepared to IDDSI Texture Standards
Penalty
Summary
The facility failed to prepare puree foods in a form designed to meet individual needs for residents on a puree/IDDSI Level 4 diet. During a concurrent test tray observation with the Dietary Supervisor, the puree smothered cabbage did not hold its shape and was flat on the plate, causing it to touch the other food items. The puree corn bread was also observed to be sticky and took time to fall off the spoon during the spoon tilt test, requiring pressure while tilting before it released. The Dietary Supervisor stated that sticky puree food could make it hard for residents to swallow and could cause choking, and that puree food that is flat and does not hold its shape could also cause residents to choke. The Registered Dietitian stated that sticky puree food could create difficulty swallowing and that puree foods flat on the plate would not be presentable and would not be pleasant for residents to eat. The facility's diet manual and IDDSI guidance both stated that puree foods should be smooth, not sticky, hold their shape, and fall off a spoon intact.
Late Lunch Service
Penalty
Summary
The facility failed to provide meals at regular times scheduled in accordance with resident needs, preferences, and requests when lunch was served late on 5/18/2026. Resident 163 was admitted on 5/1/2026 with diagnoses including GERD, essential HTN, and type 2 diabetes mellitus. The resident’s order summary dated 5/1/2026 indicated a carbohydrate controlled, no added salt, regular texture, thin consistency diet, and the MDS dated 5/8/2026 indicated the resident understood others, could make self-understood, and needed supervision or touching assistance when eating. Resident 163 stated during interview that food is often up to two hours late and that lunch was late that day. Resident council minutes dated 2/12/2026 noted that sometimes the food cart comes out late. On 5/18/2026, kitchen staff were observed taking temperatures of food on the steamtable at 11:53 a.m., and the Dietary Supervisor stated lunch is at 12:00 p.m. and trayline service finishes around 1:00 p.m. to 1:15 p.m. However, the last meal cart was observed arriving at Station 3 at 1:55 p.m., and nursing staff passed the last meal tray to residents in Station 3 at 2:03 p.m. The Dietary Supervisor later stated the facility was behind because staff were nervous and needed to double check food textures, and acknowledged that residents sometimes complain of late meal service.
Unsafe Food Storage and Preparation Practices
Penalty
Summary
The kitchen and storage areas were observed to be unclean and not maintained in sanitary condition. In the walk-in refrigerator, the shelves had dry white dirt residue, and the floor contained vegetables, tape, paper trash, and dried lettuce. In the dry storage area, white particles identified as cream of wheat debris were observed on the floor. The Dietary Supervisor stated the walk-in refrigerator floor had been cleaned and mopped shortly before the observation, but still contained debris, and stated the dry storage floor needed to be cleaned to prevent pests. Multiple food storage and food-contact surfaces were observed to be damaged, rusted, or otherwise not cleanable. In the walk-in freezer, racks used for food storage had rust and amber discoloration. In the dry storage area, metal racks had cracks, rust, and peeling paint. All 66 resident trays were observed to have cracks, chips, and scratches. In the dishwashing area, three drying racks were rusted. The Dietary Supervisor stated the damaged racks and trays could not be cleaned properly and could contribute to bacterial growth and cross contamination. Food handling and storage practices were also observed to be inconsistent with sanitary procedures. In the dry storage area, foods were mislabeled with use-by dates that did not match the product labels, and one dented can was stored with non-dented cans. There was no thermometer in the dry storage area, and the Dietary Supervisor stated the area was not being monitored for temperature. During food preparation, a soiled towel was hanging near chopped cabbage and lettuce, and the same chopping board and knife used for chicken tenders were then used to slice bread. Staff were also observed wearing dangling earrings, bracelets, watches, and nail polish during food preparation, despite the Dietary Supervisor stating that only a plain wedding band was allowed and that nail polish and dangling jewelry were not permitted.
Incomplete psychotropic consent and MAR documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents reviewed for medication administration tasks. For one resident with diagnoses including cerebral infarction, depression, and muscle weakness, the record showed admission on 4/17/2026, a hospital history and physical dated 3/28/2026 indicating the resident had capacity to understand and make decisions, and an MDS dated 4/23/2026 indicating the resident was cognitively intact. The physician ordered trazodone 50 mg, 0.5 tablet at bedtime, and venlafaxine ER 75 mg daily for depression. During interview, the resident stated she was familiar with her medications but did not recall signing any papers regarding psychotropic medications and had never spoken to a physician about psychotropic medication since admission. RN 2 stated that consent must be obtained before giving psychotropic medications and that the physician is required to personally examine the resident, explain the proposed treatment, and ensure follow-up within 72 hours. RN 2 also stated the resident was not properly consented because the documentation was incomplete and there was no progress note showing that the physician explained the reasons for taking psychotropic medications. The DON stated that psychotropic medications are high-risk medications, residents must have continuous monitoring, the Psychotropic Medication Administration Disclosure form must be completed within 72 hours, and the physician should communicate with the resident about the purpose of treatment and potential side effects before the resident signs the consent form. The facility policy required documentation in the medical record to be complete and accurate and to include medications administered, and the psychotropic informed consent policy required the prescribing practitioner to document the discussion, understanding, and consent or refusal in the medical record. For the second resident, the record showed diagnoses including Parkinson's disease, anxiety disorder, and asthma, with an MDS dated 5/17/2026 indicating the resident could make self understood, understand others, and was cognitively intact. The physician orders included multiple scheduled medications, including carbidopa-levodopa, docusate sodium, entacapone, Entresto, escitalopram, gabapentin, lorazepam, omega 3, and tizanidine. During review of the MAR, the ADON stated LVN 7 did not sign off on multiple ordered medications on 5/19/2026, and RN 5 did not sign off on entacapone on 5/16/2026. The ADON stated medication documentation is done right after administration, that if licensed nurses do not document the medication they administer there is no way of knowing if it was given, and that the standard of practice is to document once done because if it is not documented then it was not done. The facility policy stated that all medications administered are to be documented on the MAR immediately after they are given.
Missing Hospice Documentation and Unfollowed Aide Visit Schedule
Penalty
Summary
The facility failed to ensure necessary hospice care was consistently documented and carried out for one resident receiving hospice services for terminal lung cancer. The resident’s record showed diagnoses including malignant neoplasm of the bronchus or lung, palliative care, acute respiratory failure, and COPD with acute exacerbation. The resident’s H&P indicated the resident had the capacity to understand and make decisions, and the MDS showed the resident could make self understood, understand others, and had moderately impaired cognition. The resident was dependent on staff for ADLs and mobility, and hospice care was being provided while the resident lived in the facility. During record review, the resident’s medical record did not include CHHA visit notes, the hospice plan of care after the initial plan dated 10/24/2025, or the hospice calendar for some months reviewed. Staff identified that the last hospice aide visit was 1/15/2026, while the hospice calendars showed scheduled HA visits on multiple dates in 1/2026 and 2/2026. The ADON stated there was no documentation for 4/2026 and 5/2026 regarding scheduled CHHA visits, and that the hospice plan of care was not followed up until 5/20/2026. The ADON also stated the hospice plan of care was not followed and the hospice agreement was not followed.
Infection Control Lapses With Disposable Gown Disposal and Linen Cart Coverage
Penalty
Summary
The facility failed to maintain its infection prevention and control program when a disposable yellow gown was observed hanging on the washing machine in the laundry area after it had already been used. During the observation, the Laundry Aide stated the gown had been used while sorting dirty linens and had been forgotten instead of being thrown away. The Laundry Supervisor, Infection Preventionist, and DON each stated that disposable gowns are one-time use items and should be discarded after use; the DON stated the gown should have been removed and thrown away once used. The facility policy on Standard Precautions stated that gowns are not reused and soiled gowns are removed as promptly as possible to avoid transfer of microorganisms. The facility also failed to ensure clean linen carts were covered with permeable mesh material as observed during the infection control task. Multiple linen carts on the units were observed with blue loosely woven mesh covers, and the Infection Preventionist stated that the mesh allowed liquid or gas to pass through and that the linens inside were visible from the outside. The IP further stated that the inside was not well protected from microorganisms and that anyone could see and potentially access the linens. The DON stated that the LS and IP were responsible for maintaining the linen carts and acknowledged that mesh-covered carts could allow spills or bacteria to penetrate through the cover. The facility policy for laundry and linen stated that clean linen should remain hygienically clean through measures designed to protect it from environmental contamination, such as covering clean linen carts.
Failure to Maintain Resident Privacy During ADL Care
Penalty
Summary
Certified Nurse Assistant 3 failed to maintain privacy for Resident 161 while providing ADL morning care. During a concurrent observation and interview on 5/18/2026 at 12:56 p.m., CNA 3 was observed inside the resident’s room leaving the privacy curtain partially open on the right side, where the curtain was shared between two residents, while providing care to Resident 161. This left the resident exposed to the neighboring resident. CNA 3 stated that the privacy curtain should remain completely closed at all times during ADL care and acknowledged that leaving the resident exposed violated privacy and could cause embarrassment. Resident 161 was originally admitted on 6/16/2023 and readmitted on [DATE], with diagnoses including metabolic encephalopathy, UTI, and dysphagia. The H&P dated 1/22/2026 indicated the resident did not have the capacity to understand and make decisions. The MDS dated 4/28/2026 indicated the resident was dependent on staff for eating, toileting hygiene, showering, lower body dressing, and putting on/taking off footwear. The DON stated that privacy curtains are intended to provide residents with privacy and dignity and must be kept fully closed during ADL/morning care. The facility’s Dignity policy stated that residents are treated with dignity and respect at all times and that staff promote, maintain, and protect resident privacy, including bodily privacy during personal care and treatment procedures.
Unnecessary Psychotropic Medication Monitoring
Penalty
Summary
The facility failed to ensure that one resident was free from unnecessary psychotropic medication use when bupropion was prescribed and monitored for depression manifested by feeling hopelessness, rather than for specific, measurable behavioral manifestations. Resident 4 had diagnoses including schizoaffective disorder, major depressive disorder, and spina bifida. The resident’s MDS indicated he was able to understand others and make himself understood, but required assistance with toileting, showering, lower body dressing, personal hygiene, and moving from sitting to lying. The MDS also identified antidepressant use as a high-risk drug class. Resident 4’s OSR included an order for bupropion extended release 100 mg daily for depression manifested by feeling hopelessness, along with orders to monitor episodes of depression manifested by feeling hopelessness every shift and to monitor for side effects related to bupropion every shift. The care plan for psychotropic drug use, initiated after admission, included a goal for the resident to have the smallest most effective dose without side effects and interventions to monitor for continued need of medication as related to behavior and mood. During interview, the MDSC stated psychotropic medications require informed consent and are prescribed for behaviors that are monitored and measured with a goal to taper or discontinue the medication. During interviews and record review, the MDSC, ADON, RN 5, and DON stated that feelings are not measurable behaviors and that Resident 4 should have been monitored for specific behavioral manifestations such as verbalization of hopelessness. The ADON stated psychotropic medications should be monitored by tallying behaviors daily and measuring them monthly to determine whether a GDR was possible. The DON stated the facility’s psychotropic medication policy was not followed and that the resident was not monitored for verbalization of hopelessness, which potentially resulted in unnecessary administration of a psychotropic medication.
Missing Comprehensive Care Plan for Insulin Use
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with ESRD on renal dialysis and type 2 DM with diabetic neuropathy who had an order for Insulin Aspart injection solution. The resident’s admission record showed the resident was originally admitted on 6/6/2024 and later readmitted, and the MDS dated 3/12/2026 indicated intact cognitive skills for daily decision making, substantial/maximal assistance with toileting hygiene, showering, lower body dressing, and putting on/taking off footwear, and use of a high-risk hypoglycemic medication class. The resident’s OSR included an order dated 5/2/2026 for Insulin Aspart 100 units/ml before meals and at bedtime using a sliding scale with specific blood glucose parameters and actions for low or high blood sugar. Review of the care plans showed no documented comprehensive care plan with goal-directed, person-centered interventions addressing the resident’s insulin use. During interview, RN 7 stated there was no documented care plan regarding insulin use and explained that insulin required clear nursing interventions and guidance based on blood glucose levels. The DON stated the care plan was needed to identify the problem and create specific interventions to achieve the goal of the problem, and the facility policy required a comprehensive person-centered care plan with measurable objectives and timeframes.
Wound Care Provided Without Physician Order
Penalty
Summary
The facility failed to provide wound treatment and care according to physician orders and the resident’s care plan for a resident with a sacral Stage 4 pressure injury, diabetes mellitus, major depressive disorder, and adult failure to thrive. The resident’s record showed skin issues including diabetic foot ulcers and a need for wound treatments with ointments, medications, and dressings. The care plan directed staff to provide wound treatment as ordered for the left toe diabetic ulcer, left posterior leg diabetic ulcer, and sacrococcyx pressure injury. The physician’s orders specified Santyl ointment with Mupirocin ointment and a dry dressing for the left big toe diabetic ulcer and the left posterior leg diabetic ulcer. For the sacrococcyx pressure injury extending to the buttocks, the order directed staff to cleanse the wound, apply therahoney gel and collagen powder, then cover with calcium alginate and a secondary dry dressing. During wound care observation, one treatment nurse applied calcium alginate to the sacrococcyx wound as ordered, but calcium alginate was also applied directly to the resident’s left toe diabetic ulcer and left posterior leg diabetic ulcer even though those wounds did not have an order for calcium alginate. Immediately after the treatment, the treatment nurse stated there was no physician’s order to apply calcium alginate to the left toe and posterior leg, and that the dressing had been confused with the sacrococcyx order. The assistant director of nursing stated calcium alginate requires a physician’s order and that the left toe and leg should only have had dry dressings applied. The director of nursing stated physician orders should be followed when wound care is provided and that applying calcium alginate without an order was outside the treatment nurse’s scope of practice and did not follow facility policy.
Unlabeled Urinal Bottle
Penalty
Summary
The facility failed to ensure proper care and services for one sampled resident by not labeling the resident’s urinal bottle with the date it was given, the resident’s initials, and the room number. Resident 171 was admitted with diagnoses including cellulitis of the abdominal wall, cirrhosis of the liver, and depression. The MDS dated 5/15/2026 indicated the resident could make self-understood and understand others, needed supervision with eating and oral hygiene, partial/moderate assistance with toileting hygiene, and was occasionally incontinent. The care plan for the resident’s history of MDRO/MRSA included handling soiled linen as infectious, cleaning and disinfecting resident care equipment according to facility protocol, and monitoring for signs and symptoms of infection. During a concurrent observation and interview, the resident’s unlabeled urinal was observed at the side of the bed hanging by the bedrail. The LVN stated the urinal should have been labeled with the date it was given, the resident’s initials, and the room number, and that an unlabeled urinal could be interchanged with another resident and result in cross contamination. A CNA stated urinal bottles are for residents’ own use and should be labeled before being provided, and that unlabeled urinals can be interchanged with other residents, causing cross contamination. The DON stated urinals must have a date when given and bed number, and that if the urinal is not labeled it could potentially lead to infection due to cross contamination; the DON also stated that no date of change in the urinal can cause bacterial growth which can possibly lead to UTI.
Medication left at bedside and not verified as administered
Penalty
Summary
The facility failed to ensure that a resident was free from a significant medication error when LVN 7 did not administer benazepril as ordered during the routine medication pass. Resident 140 was admitted with diagnoses including HTN, HLD, CKD, and age-related nuclear cataract. The resident’s MDS indicated he could make himself understood and understand others, and his H&P noted fluctuating capacity. The physician’s orders included benazepril HCl 10 mg by mouth twice daily for HTN, with instructions to hold for SBP less than 100 mmHg, along with fish oil and aspirin. During a concurrent observation and interview, the resident was found in bed with two tablets and two clear capsules on the floor next to him. The resident stated the nurse had left his medications during breakfast and they fell on the floor while he was eating, and he thought he may have taken some but was not sure. LVN 7 stated she had left the medications at bedside for the resident to self-administer and did not watch him take them because she was called away to another resident. LVN 7 also stated medications should not be left at bedside for self-administration and that the nurse should watch the resident take the medication before documenting it. The ADON and LVN 7 later compared the medications found on the floor with the resident’s bubble packs and identified them as benazepril, aspirin, and fish oil. LVN 7 stated she did not administer the benazepril because she could not determine whether the medications on the floor were the same ones she had left at bedside and did not want to give additional doses if she was not sure. The ADON, LVN 7, and DON stated the facility protocol for medication administration was not followed, that the resident was not safe to self-administer medications, and that it was a medication error when LVN 7 did not know whether the resident received benazepril.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Failure to Notify Physician of Resident’s Significant Change in Respiratory Status
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of a significant change in condition for one of three sampled residents. The resident was admitted with diagnoses including diabetes mellitus, moderate persistent asthma, and a history of venous thrombosis and embolism, and had intact cognitive function. On the evening in question, the resident experienced shortness of breath while on BiPAP at 7 p.m. An LVN reported that an RN came to the bedside, adjusted the BiPAP settings, and obtained vital signs, including an oxygen saturation of 97%. Later that evening at 10 p.m., the resident again reported difficulty breathing, muscle tightening, and not getting enough air, and the RN was again called to the bedside, where the resident received a breathing treatment. During subsequent interviews and record reviews, the RN acknowledged that he failed to initiate and implement a Change of Condition (COC) for the resident’s shortness of breath and did not report the resident’s symptoms to the medical doctor. The DON confirmed that staff failed to initiate a COC despite the resident’s complaints of not getting enough air and muscle tightening, and stated it was the RN’s responsibility to complete a COC and notify the physician. Review of the facility’s policy, “Change in Condition: Notification of,” indicated the facility must immediately consult with the resident’s physician or NP when there is a significant change in the resident’s physical condition and ensure all pertinent information is provided. This failure to follow policy and notify the physician constituted the cited deficiency.
Failure to Care Plan for Resident With History of DVT and Embolism
Penalty
Summary
Surveyors identified that the facility failed to develop and implement a comprehensive, person-centered care plan for a resident with a documented personal history of other venous thrombosis and embolism. The resident’s face sheet showed admission with diagnoses including diabetes mellitus and a personal history of venous thrombosis and embolism, and the history and physical documented that the resident’s cognitive functioning was intact. Despite this information being available in the admission records, there was no care plan initiated to address the resident’s diagnosis and history of deep vein thrombosis (DVT) and embolism. During an interview and concurrent record review with the DON, it was confirmed that licensed staff or the MDS Coordinator were responsible for initiating the care plan upon admission and that this had not been done for the resident’s DVT condition. The DON acknowledged that the care plan should have addressed the resident’s DVT diagnosis and risk for developing DVT, and that the care plan serves as a guide for necessary interventions. The facility’s own policy on comprehensive, person-centered care plans required development of a care plan with measurable objectives and timetables to meet each resident’s medical, physical, mental, and psychosocial needs, and to reflect recognized standards of practice for identified problem areas and conditions, which was not followed in this case.
Failure to Inform Resident and Responsible Party of STAT Hip X-Ray Order
Penalty
Summary
The facility failed to follow its resident rights policy requiring that residents and/or their responsible parties be notified of their medical condition, changes in condition, and treatments. A resident admitted with multiple diagnoses, including displaced intertrochanteric fracture of the right femur, displaced fracture of the epiphysis, anxiety disorder, and major depressive disorder, had documented limited decision-making capacity and moderate cognitive impairment. The resident required assistance with toileting, bathing, and lower body dressing, and the MDS indicated Spanish as the preferred language with a need for an interpreter to communicate with medical staff. A physician’s order was entered for a STAT bilateral hip x-ray due to the resident’s condition. During interviews and record review, the RN acknowledged that although the resident was alert to name and able to express basic needs, it would be better to inform the responsible party because the resident would not remember, and confirmed there was no documentation that either the resident or responsible party had been informed of the x-ray order. The RN stated the resident later alleged that a man was taking a picture of her and admitted the failure to notify and document notification of the procedure. An LVN reported being present with the x-ray technician and explaining to the resident, in English, that the x-rays were being taken due to leg pain, but the LVN did not speak Spanish and confirmed there was no documentation that the order and procedure were explained to the resident. This sequence of events resulted in the resident and responsible party not being fully informed or able to understand and participate in decisions regarding the x-ray, contrary to the facility’s written resident rights policy.
Incomplete and Inaccurate Documentation of Falls and Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate, complete, and objective medical records for a cognitively impaired resident with multiple diagnoses, including traumatic subdural hemorrhage, COPD, and muscle weakness. The resident’s MDS showed severely impaired cognitive skills and a need for staff supervision with hygiene, showering, dressing, transfers, and walking. On one fall incident dated 1/10/2026, the eInteract Change in Condition Evaluation (CIC) documented that the physician was notified at 12 midnight, even though the fall occurred at 7:15 a.m. and the nurse later stated she actually notified the physician around 7:20–7:30 a.m. Both the LVN involved and the DON confirmed that the documented time of physician notification was inaccurate. The facility also failed to document the interventions of an RN who responded to the same 1/10/2026 fall. The LVN reported that she called an RN, who assessed the resident and called 911 and the physician, but a review of the resident’s progress notes for that date showed no documentation by the RN. The DON confirmed that the medical record did not show that the RN had been notified, had performed a head-to-toe assessment, or had called 911, leaving the record without evidence of the RN’s involvement or actions related to the fall. Additional documentation gaps were identified for prior incidents. For a fall on 11/13/2025, the CIC noted that the resident was found on the floor holding the left side of the head and face and complaining of left hip pain, but did not indicate where the resident was found or who found the resident first; the DON stated this CIC was incomplete. For a change in condition on 5/16/2023, the CIC left blank the date and time of responsible party (family) notification. The facility’s own charting and documentation policy required that all services, changes in condition, events, incidents, and notifications be documented in an objective, complete, and accurate manner, including date, time, person providing care, assessment data, and notifications, which was not followed in these instances.
Failure to Monitor and Document Bed Alarm Use as a Physical Restraint
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from physical restraint by not monitoring the use of a bed alarm device as ordered and care planned. The resident was initially admitted in 2022 and readmitted in 2026 with diagnoses including traumatic subdural hemorrhage, unspecified COPD, and muscle weakness. An MDS dated 10/31/2025 documented that the resident’s cognitive skills for daily decision-making were severely impaired and that the resident required staff supervision for hygiene, showering, dressing, transfers, and walking. A physician’s order dated 1/13/2026 authorized the use of a bed alarm device, and a device informed consent dated the same day showed that a family member gave permission for the alarm while the resident was in bed. The resident’s care plan, also dated 1/13/2026, identified fall risk and included an intervention to apply a bed alarm when the resident was in bed and to check its placement and function every shift. A subsequent physician order dated 1/14/2026 reiterated that the resident may use a bed alarm in bed and that staff should check placement and function every shift. The resident’s H&P dated 1/15/2026 documented that the resident did not have capacity to understand and make decisions. On 1/27/2026, during an observation and interview in the resident’s room, a bed alarm device was seen hanging on the left side of the bed, and an LVN stated the resident used the bed alarm in bed to alert staff when the resident got up. On 1/28/2026, during an interview and record review with the DON, the DON confirmed that the resident had been on a bed alarm since 1/13/2026 and described the bed alarm as the least form of physical restraint. The DON stated that residents on bed alarms should be monitored for placement and function of the alarm and that this monitoring should be documented on the MAR. Review of the MAR for January 2026 showed no documented monitoring from 1/16/2026 to 1/27/2026. The DON stated that monitoring and documentation were needed to ensure the bed alarm device was effective for the resident in preventing falls. The facility’s restraint policy, last reviewed on 1/14/2026, required that restraints be used only for safety and well-being after alternatives were tried, that the least restrictive alternative be used for the least amount of time, that ongoing re-evaluation be documented, and that a resident placed in a restraint be observed at least every 30 minutes with an account of the resident’s condition recorded in the medical record, along with detailed documentation of the restraint episode and monitoring. These policy requirements were not met for this resident’s bed alarm use.
Failure to Revise Fall-Risk Care Plan After Room Change and Wander Guard Discontinuation
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for a resident with severe cognitive impairment and multiple medical diagnoses, including traumatic subdural hemorrhage, COPD, and muscle weakness. The resident’s MDS dated 10/31/2025 showed severely impaired cognitive skills for daily decisions and a need for staff supervision with hygiene, showering, dressing, transfers, and walking. On 1/10/2026, an eInteract Change in Condition Evaluation documented that an LVN heard a loud sound and found the resident lying on his right side on the hallway floor between his room and the shower room, moaning, with eyes closed and unable to talk, after which the physician ordered transfer to a general acute care hospital. The resident’s care plan for fall risk, dated 1/13/2026, included interventions that the resident be in a room with direct line of sight to the nurse’s station and have a wander guard due to poor safety awareness. Subsequently, the resident was moved from a room near the nurse’s station (room A) to a previous room farther away (room B) and the wander guard was discontinued by physician order on 1/16/2026, but the care plan was not revised to reflect these changes. Observation on 1/27/2026 showed the resident ambulating back and forth in his room without assistance, with the room located seven rooms away from the nurse’s station. Interviews with nursing staff confirmed that the written care plan still indicated the resident should be in direct line of sight of the nurse’s station and have a wander guard, despite the room change and discontinuation of the device. The DON stated that the care plan serves as the nurses’ guideline for resident care and interventions and acknowledged that it should have been updated when the room change occurred and the wander guard was discontinued. The facility’s care plan policy required that care plans incorporate identified problem areas, include measurable goals and timetables, and be reviewed and revised as resident information and condition change, which did not occur in this case.
Failure to Ensure Clean and Sanitized Eating Utensils
Penalty
Summary
The deficiency involves the facility’s failure to implement infection control measures by not ensuring clean and sanitary eating utensils for a resident. The resident, admitted with diagnoses including unspecified epilepsy, immunodeficiency, and essential hypertension, had intact cognitive skills and was independent with eating. The resident reported receiving a breakfast tray with a dirty spoon that had dried food residue on it and stated that the spoon appeared used and not properly washed. The resident expressed concern about the possibility of acquiring a bacterial infection from using the dirty spoon and reported the issue to the Social Service Director. Interviews and record review confirmed that the dirty spoon was observed by both the Dietary Supervisor and the Social Service Director, who each acknowledged seeing dried food residue on the utensil. The Dietary Supervisor stated that the Dishwasher Staff should have checked the utensils after washing, the Dietary Aide should have inspected the spoon before placing it on the tray, and the CNA distributing the tray should have checked the utensils before delivery. The DON stated that the CNA did not notice the spoon was dirty and reiterated that the Dietary Aide and CNAs were responsible for ensuring utensils were clean and for removing dirty utensils before providing them to residents. The facility’s sanitation policy required all utensils and food contact surfaces to be cleaned and sanitized, but this was not followed in this instance.
Failure to Clarify and Follow Physician Orders for Medication Administration
Penalty
Summary
The facility failed to ensure proper clarification and administration of physician orders for a resident with severe cognitive impairment and a history of neuropathy and falls. Specifically, licensed nurses did not clarify two separate physician orders for famotidine, resulting in the resident receiving double doses of the medication on multiple days. The orders included one for a daily dose and another for administration before breakfast, but both were administered without clarification, as confirmed by staff interviews and medication administration records. Additionally, the facility did not ensure that licensed nurses followed the physician's order for administering guaifenesin and dextromethorphan-guaifenesin. The orders specified that these medications should be given every six hours as needed, but the resident received doses of guaifenesin and dextromethorphan-guaifenesin only three hours apart. Staff interviews confirmed that these medications were considered the same and that the six-hour interval was not maintained. Review of facility policy indicated that medications are to be administered as prescribed and that any concerns about dosage or potential adverse consequences should be clarified with the prescriber. Despite this, the nurses did not clarify the orders or follow the prescribed administration intervals, leading to medication errors for the resident.
Failure to Implement Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to implement its infection prevention and control program for residents on enhanced barrier precautions (EBP). Specifically, staff did not adhere to required personal protective equipment (PPE) protocols when providing care to residents with indwelling devices and open wounds. Observations revealed that a registered nurse and two licensed vocational nurses entered the rooms of residents on EBP and performed high-contact care activities, such as disconnecting and flushing an IV line, checking blood pressure, and providing gastrostomy tube care, without wearing the mandated mask, gloves, and gown. Resident 2, who was admitted with diagnoses including acute osteomyelitis, dysphagia, and a chronic ulcer, was on EBP due to wounds and a midline catheter. Despite clear signage and availability of PPE outside the resident's room, staff were observed entering and providing care without donning the required protective equipment. Interviews with the involved staff confirmed that they were aware of the EBP requirements but failed to comply, citing reasons such as forgetting to wear a mask or not noticing the available supplies. The Director of Nursing and Infection Preventionist both acknowledged that the staff should have worn the appropriate PPE during these care activities. Similarly, Resident 6, who had a gastrostomy tube and required maximum assistance for activities of daily living, was also on EBP. An LVN was observed providing gastrostomy tube care at the bedside without wearing a gown, despite the presence of EBP signage and PPE supplies. The LVN admitted awareness of the EBP requirement but did not comply. Facility policies and local health orders reviewed by surveyors confirmed the necessity of PPE use during high-contact care and during respiratory virus season, yet these protocols were not followed during the observed incidents.
Failure to Timely Develop and Implement Care Plan for Infection and Antibiotic Use
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for a resident who returned to the facility with a presumptive positive test for legionnaires disease and an order for azithromycin to treat pneumonia. Upon review, it was found that the care plan addressing legionnaires disease was not created until several days after the resident's return, and the care plan for azithromycin was not developed until after the medication course had already been completed. The delay in care plan development was confirmed by both the registered nurse and the director of nursing, who acknowledged that the care plans should have been established at the time of the resident's return and initiation of treatment. The resident in question had a history of hereditary and idiopathic neuropathy, a history of falls, and was assessed as having severely impaired cognitive skills, requiring moderate assistance with daily activities. The resident was admitted with multifactorial pneumonia, including legionnaires disease, and was prescribed azithromycin for a three-day course. Despite these significant medical needs and the initiation of antibiotic therapy, the facility did not promptly create or update the resident's care plan to reflect these new diagnoses and treatments. Interviews with facility staff, including the infection preventionist, confirmed that the lack of timely care plan development could potentially delay necessary care and services. Review of facility policy indicated that comprehensive, individualized care plans with measurable objectives and timetables are required for each resident, and that these plans should be updated as the resident's condition changes. The failure to develop and implement appropriate care plans in a timely manner was a direct violation of these policies.
Failure to Accurately Document Oxygen Device Used During Resident Emergency
Penalty
Summary
The facility failed to maintain accurate and complete medical records for one resident by incorrectly documenting the type of oxygen device used during a critical event. The resident, who had severe cognitive impairment and required moderate assistance with daily activities, experienced desaturation and chest congestion. Documentation in both the Change in Condition Evaluation and Progress Notes indicated that 15 liters of oxygen were administered via a face mask. However, interviews with nursing staff and the Director of Staff Development revealed that a face mask can only deliver up to six liters of oxygen, and that 15 liters should be administered using a non-rebreather mask. The registered nurse involved later confirmed that she had used a non-rebreather mask but documented it incorrectly as a face mask. This inaccurate documentation was acknowledged by both the nurse and the Director of Nursing, who emphasized the importance of precise record-keeping to reflect the actual interventions provided during episodes of low oxygen saturation. The facility's policy on nursing documentation requires that records be concise, clear, pertinent, and accurate, but this standard was not met in this instance, resulting in a medical record that did not accurately communicate the care provided to the resident.
Failure to Monitor Antibiotic Use and Side Effects
Penalty
Summary
The facility failed to implement its antibiotic stewardship and infection prevention and control policies for one resident by not monitoring the use and adverse effects of azithromycin, an antibiotic prescribed for pneumonia. The resident, who had a history of hereditary and idiopathic neuropathy, a history of falls, and severely impaired cognitive skills, was admitted with significant care needs and lacked the capacity to make decisions. The resident received azithromycin over a three-day period, as documented in the Medication Administration Record. Despite facility policy requiring monitoring for antibiotic side effects every shift, there was no documentation in the resident's progress notes indicating that such monitoring occurred during the period the antibiotic was administered. Both the Infection Preventionist and the Director of Nursing confirmed during interviews that nurses are expected to monitor and document for side effects and adverse reactions to antibiotics every shift, but acknowledged that this was not done for this resident. A review of the facility's policies showed that antibiotic usage and outcomes are to be documented using an approved surveillance tracking form, and that all clinical infections treated with antibiotics should be reviewed by the Infection Preventionist or designee. The lack of documentation and monitoring for this resident was inconsistent with these established policies and procedures.
Failure to Ensure Call Lights Within Reach for Cognitively Impaired Residents
Penalty
Summary
The facility failed to ensure that call light devices were within reach for three residents with severe cognitive impairment and significant care needs. For each resident, care plans specifically required that the call light be accessible while in bed or in close proximity. However, during observations, surveyors found that the call lights were either hanging on the wall, on the floor, or otherwise out of reach for these residents. Staff interviews confirmed that the call lights were not accessible and that this was due to oversight or failure to return the device to the proper location after care was provided. Resident 1, who had diagnoses including chronic kidney disease, dementia, and hypertension, was admitted with severely impaired cognitive skills and required maximum assistance for daily activities. The resident was observed with the call light hanging on the wall, out of reach, and was unable to identify or use the device. Certified Nursing Assistant staff acknowledged forgetting to check the call light's placement and noted that nurses sometimes failed to return it to the resident's reach. Similarly, Resident 2, with dementia and dysphagia, and Resident 3, with Alzheimer's disease and atrial fibrillation, were both found with their call lights on the floor and out of reach. Both residents had care plans requiring the call light to be accessible, and staff confirmed during interviews that the residents could not reach the devices. The Director of Nursing stated that facility policy requires call lights to be within reach and acknowledged that failure to do so could delay care.
Failure to Follow Care Plan for Low Air Loss Mattress Settings
Penalty
Summary
A deficiency occurred when the facility failed to implement a person-centered care plan for a resident by not ensuring the prescribed settings for a low air loss mattress (LALM) were followed. The resident, who had diagnoses including chronic kidney disease, dementia, and hypertension, was assessed as having severely impaired cognitive skills and required maximum assistance for daily activities. The care plan specified that the LALM should be set between 100-150 pounds to match the resident's weight and prevent skin breakdown. However, during multiple observations, the LALM was found set at 200 pounds, which was inconsistent with both the care plan and the resident's actual weight of 111.8 pounds. Staff interviews confirmed that the LALM setting should have matched the care plan and that exceeding the recommended setting could compromise the mattress's effectiveness in protecting the resident's skin. The DON, treatment nurse, and DSD all acknowledged the importance of adhering to the care plan and the potential impact of not doing so. Facility policy required care plans to be individualized, measurable, and followed as written, but in this instance, the care plan was not implemented as intended for the resident at risk for skin breakdown.
Failure to Ensure Proper Functioning of Pressure-Relief Mattress for Pressure Ulcer Prevention
Penalty
Summary
A deficiency occurred when a resident, admitted with chronic kidney disease, dementia, and hypertension, was not provided with proper pressure ulcer prevention care as per professional standards. The resident was assessed as having severely impaired cognitive skills, required maximum assistance for daily activities, and was always incontinent. The care plan and physician orders specified the use of a low air loss mattress (LALM) with settings between 100-150 for skin maintenance and prevention of pressure ulcers. However, observations revealed that the LALM control unit at the resident's bedside had multiple cycle time indicators lit, the weight setting at 200 lbs (higher than the resident's actual weight of 111.8 lbs), the low pressure warning light on, and the mute button activated, which silenced the alarm for malfunctions. Staff interviews confirmed that the low pressure indicator had been on since the previous day and was reported to the treatment nurse, but the issue was not resolved. The LALM remained in a malfunctioning state, with incorrect settings and warning indicators active. The treatment nurse and other staff acknowledged that the LALM was not functioning as intended, and that the settings did not match the care plan or the resident's actual weight. The operator's manual for the LALM specified that the weight setting should correspond to the patient's weight and that the low pressure indicator signaled inadequate air pressure, which could compromise the mattress's effectiveness in preventing pressure ulcers. Despite staff awareness of the malfunction and the discrepancy in settings, the LALM was not promptly repaired or adjusted to meet the resident's needs as outlined in the care plan. The facility's policy did not specify procedures for timely repair of the LALM, and staff did not ensure the device was functioning according to manufacturer instructions. This failure to provide care consistent with professional standards placed the resident at risk for developing pressure ulcers.
Failure to Follow Physician Orders for Blood Pressure Medication Administration
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) administered carvedilol and losartan to a resident despite a physician order specifying to hold these medications if the resident's systolic blood pressure (SBP) was below 100 or diastolic blood pressure (DBP) was below 60. On the date in question, the resident's blood pressure was recorded as 104/53, but the LVN proceeded to give both medications. The resident had a history of dementia, essential hypertension, and dysphagia, and was assessed as having severely impaired cognitive skills and requiring moderate assistance with daily activities. Interviews with facility staff, including the LVN, Director of Staff Development (DSD), and Director of Nursing (DON), confirmed that the physician's order was not followed and that the LVN should have held the medications and clarified the order with the physician. Review of the facility's medication administration policy indicated that medications are to be administered in accordance with prescriber orders and that vital signs should be checked and verified prior to administration when necessary. The failure to follow these procedures resulted in the identified deficiency.
Inaccurate Documentation of Anticoagulant Monitoring
Penalty
Summary
The facility failed to maintain accurate and complete medical records for one of three sampled residents. The resident in question was admitted with diagnoses including unspecified dementia, essential hypertension, and dysphagia, and was receiving anticoagulant therapy. Physician orders required staff to monitor for specific signs of bleeding and to document findings on the Medication Administration Record (MAR) every shift, using 'Y' if no signs were observed and 'N' if any signs were present. A review of the MAR revealed that 'N' was documented on several dates and shifts, indicating the presence of bleeding. However, there was no corresponding documentation in the resident's progress notes to support that any signs of bleeding were observed or that the physician was notified, as required by facility policy and the physician's order. Interviews with the DON and nursing staff confirmed that no signs of bleeding had actually been observed, and that the documentation on the MAR was inaccurate due to misinterpretation of the order by nursing staff. The facility's policies on anticoagulant monitoring and nursing documentation require clear, accurate, and timely entries reflecting the resident's status and any interventions performed. The inaccurate documentation in the MAR, which was not supported by clinical findings or additional notes, had the potential to cause confusion regarding the resident's condition and care needs.
Resident-to-Resident Physical Abuse Incident
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident. On February 17, 2025, a Certified Nursing Assistant (CNA) witnessed one resident hitting another resident on the right side of the head with a closed fist. The incident resulted in the victim experiencing a pain level of 3 out of 10, for which acetaminophen was administered. The victim, who has a history of schizoaffective disorder, major depressive disorder, and hypertension, was admitted to the facility in April 2022 and has moderately impaired cognition, requiring assistance with daily activities. The aggressor, admitted in February 2020, has diagnoses including unspecified psychosis, hypertension, and major depressive disorder, with severely impaired cognition. The aggressor has a history of wandering into other residents' rooms and exhibiting confusion and agitation. On the day of the incident, the aggressor was walking with a CNA when he suddenly turned and struck the victim without any prior interaction or argument. Interviews with staff indicated that the aggressor's actions were considered abuse, despite his confusion, as the act of hitting was intentional and caused harm. The facility's policy on abuse prohibition defines abuse as the willful infliction of injury or punishment resulting in harm or mental anguish. Despite the aggressor's cognitive impairments, the incident was classified as abuse due to the physical harm inflicted. The facility's administrator acknowledged the incident as an altercation but was uncertain if it was intentional, given the suddenness and lack of prior interaction between the residents.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for several residents, leading to potential risks and inadequate care. For Resident 145, the facility did not create a care plan for the use of side rails, which were ordered as an enabler for turning and repositioning in bed. Despite the resident's dependency on staff for various activities and the presence of side rails, there was no care plan to ensure the resident's safety and to monitor for potential injuries related to side rail use. This oversight was acknowledged by the Director of Nursing, who confirmed that the facility's policy was not followed. Resident 141 was prescribed Pradaxa, an anticoagulant, for atrial fibrillation, but the facility failed to implement the care plan intervention to monitor for side effects of the medication. The Medication Administration Record for January 2025 lacked documentation of monitoring for bleeding, a critical aspect of managing anticoagulation therapy. The Director of Nursing admitted that the facility did not implement the care plan to reflect the resident's needs accurately, which could have led to unnoticed bleeding and potential harm. For Resident 147, the facility did not develop a care plan addressing the resident's repeated refusals of physical therapy treatments. Despite the resident's rehabilitation plan and good potential for recovery, multiple therapy sessions were missed due to refusals, which were not adequately documented or addressed in the care plan. Additionally, Resident 86's use of a low air loss mattress was not included in a care plan, and the mattress settings were improperly adjusted by a CNA without proper orders or documentation. This lack of a care plan and monitoring could have resulted in pressure ulcers, as the mattress settings were not correctly managed.
Failure to Rotate Insulin Injection Sites
Penalty
Summary
The facility failed to adhere to professional standards of care by not rotating subcutaneous insulin administration sites for three residents, leading to a deficiency. Resident 51, who was admitted with type 2 diabetes mellitus, chronic obstructive pulmonary disease, and generalized muscle weakness, received insulin injections repeatedly in the same areas, specifically the left upper quadrant of the abdomen and the left arm. This practice was confirmed by a Licensed Vocational Nurse (LVN) and the Director of Nursing (DON), who acknowledged that the insulin administration sites were not rotated as per the manufacturer's guidelines and standards of practice. Similarly, Resident 137, who had diagnoses including congestive heart failure and type 2 diabetes mellitus, also received insulin injections without proper site rotation. The resident's Medication Administration Record (MAR) showed repeated use of the same injection sites, such as the right arm and left upper quadrant of the abdomen. The LVN and DON confirmed the failure to rotate injection sites, which is contrary to the facility's policy and the manufacturer's guidelines, increasing the risk of complications like lipodystrophy and cutaneous amyloidosis. Resident 129, diagnosed with type 2 diabetes mellitus, also experienced the same issue with insulin administration. The MAR indicated that insulin was administered multiple times in the left arm without rotation. The DON reviewed the records and confirmed that the licensed nurses did not rotate the injection sites as required by the facility's policy and the manufacturer's guidelines. This oversight was identified as a significant medication error, potentially leading to skin abnormalities at the injection sites.
Failure to Maintain Safe Environment for Residents
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for several residents, leading to potential risks of injury. For Residents 94, 21, and 27, the facility did not maintain a clutter-free environment as required by their care plans. Observations revealed that overbed tables were placed on top of floor mats, which compromised the integrity of the mats and posed a risk of the tables becoming unstable and potentially falling on the residents. Staff members, including LVNs and CNAs, were unaware of the guidelines prohibiting the placement of furniture on floor mats, which could lead to indentations and instability. Resident 129's environment was also not adequately supervised, as the resident's bed was left in a high position while unattended by staff. This oversight occurred despite the resident being identified as a fall risk, with care plans and orders indicating the need for fall precautions, including keeping the bed in a low position. A CNA admitted to leaving the bed elevated after assisting the resident with breakfast, unaware of the resident's fall risk status. The Director of Staff Development confirmed that leaving beds in a high position unattended increases the risk of falls and injuries. The facility's policies and procedures regarding fall management and maintaining a safe environment were not followed, as evidenced by the placement of furniture on floor mats and the unattended elevated bed. The Director of Nursing acknowledged these deficiencies, noting that the facility's guidelines were not adhered to, which could lead to potential injuries for the residents involved.
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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) |
|---|---|---|---|---|
| The Meadows On Sunset Post Acute | 0 mi | ★★★★★ | 45 | 0 |
| Hollywood Presbyterian Medical Center D/p Snf | 0.6 mi | ★★★★★ | 22 | 0 |
| Fountain View Subacute And Nursing Center | 0.6 mi | ★★★★★ | 36 | 0 |
| Palazzo Post Acute | 0.6 mi | ★★★★★ | 23 | 0 |
| Hollywood Premier Healthcare Center | 0.6 mi | ★★★★★ | 6 | 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 October 2026) and official state health department websites.