Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at All Saints Healthcare Subacute during CMS and state inspections, most recent first.
Failure to Prevent and Treat Pressure Ulcers: A resident with MASD, incontinence, severe cognitive impairment, and dependence for turning developed a facility-acquired stage 2 pressure ulcer after staff did not complete weekly skin assessments, obtain wound treatment orders, notify the wound MD, document the wound in the care plan, or consistently reposition the resident every 2 hours. The facility also failed to provide ordered wound care for one resident, properly set LALMs for two residents, and apply heel protectors for another resident.
Failure to Document and Authorize Physical Restraints: Two residents were involved in restraint-related deficiencies. One resident had hand mittens ordered and used, but the restraint assessment did not document the device, least restrictive measures, or an IDT recommendation. Another resident’s bed was placed against the wall with all 4 side rails up, but the chart lacked a physician order, informed consent, restraint assessment, and care plan. The MP and DON both stated the required restraint documentation was missing.
A facility failed to ensure suprapubic catheters were secured and maintained properly for three residents. Observations showed the catheters lacked a leg strap or securement device, and one resident’s tubing also had loops or kinks. The residents had significant medical complexity, including impaired cognition, bladder dysfunction, respiratory failure, and CKD, while staff and facility policies stated the catheter tubing should be secured and kept free of kinks with the drainage bag below the bladder.
Tube feeding care was not consistently followed for several residents with GTs. A resident’s feeding bag and another resident’s water flush bag were observed without complete labels, and another resident’s EF bag lacked required identifying and feeding information. In addition, medication syringes used for two residents were observed with residual medication left on the tip and not rinsed properly. RN, LVN, MP, and DON statements, along with facility policies, confirmed the labeling and rinsing requirements.
A resident with a trach, ventilator dependence, and severe cognitive and functional impairment received trach care that did not follow the MD order or facility policy: the RT used NS instead of ordered H2O2, changed gloves without HH, and inserted the sterile inner cannula before cleaning the stoma. In addition, suction catheters for three residents were left without dates showing when they were last changed, and another resident’s HHN setup was found overdue for the ordered weekly change.
A facility failed to ensure nursing staff were competent in monitoring residents receiving antibiotics and in managing g-tube venting. For one resident on long-term erythromycin therapy, RN 2 documented only vague "no change" assessments and stated specific adverse-effect monitoring was not required, while other staff said nurses should document tolerance and specific reactions each shift. For another resident, a vent syringe with feeding formula was observed hanging open to air at the bedside; RN 1 and other staff stated the syringe was for venting only and that formula backflow into the open syringe created an infection concern. The DSD stated there was no specific training on gastric venting.
The facility failed to reconcile one eKIT containing narcotics at each shift change and failed to include required verifying signatures on two Controlled Drug Record accountability logs for narcotics awaiting disposal. RN 10 confirmed the eKIT labeled 13503 in Medication Storage Nursing Station 1 was not reconciled at every shift, and the DON acknowledged that two disposal logs lacked DON or RN verification signatures along with LVN signatures.
Failure to Monitor for Bleeding With Eliquis: A resident receiving Eliquis via GT for DVT prophylaxis did not have an order, care plan intervention, or MAR documentation for routine monitoring of signs and symptoms of bleeding. RN and MDS staff confirmed there was no order for shift-by-shift bleeding checks, despite facility policies requiring assessment for bruising, swelling, redness, and other anticoagulant adverse effects.
Medication error rate exceeded 5% after an LPN administered multiple ophthalmic drops back-to-back to a resident with glaucoma and dry eyes. The LPN gave brimonidine, dorzolamide, and refresh tears without waiting the required 3 to 5 minutes between eye medications, and both the LPN and DON confirmed this was a medication administration error under facility policy and manufacturer guidance.
Failure to Rotate Heparin Injection Sites: A resident receiving heparin injections had repeated subcutaneous doses administered in the same abdominal and arm sites instead of having sites rotated. RN and DON both confirmed the repeated sites and stated staff could see prior administration sites in the MAR. Facility policy and the heparin prescribing information both required rotating injection sites, and the DON stated the repeated sites could cause discomfort, irritation, bruising, or lipodystrophy.
Improper Medication Storage and Labeling: A medication storage area lacked a temperature monitoring log, an open levalbuterol inhalation solution pouch for a resident was not labeled with the date opened, and medication carts stored nasal sprays and eye drops together with oral tablets. RN and DON interviews confirmed the facility’s storage and labeling practices did not match policy, manufacturer guidance, or separation requirements for internal and external medications.
Food Storage and Utensil Contamination: Surveyors observed an opened bag of deli bread and an unopened bag of deli hot dog buns in the walk-in refrigerator past their best by date, with no open date on the opened bread. A spoodle hanging on the clean rack near the steam table also had butter residue on it. The DS/RD and DON stated the expired buns should not have been used and that contaminated utensils could lead to food-borne illness or GI infection.
Trash Bins Left Open and Overflowing: Facility trash bins were observed open and overflowing near the trash bin area, and a racoon was seen lurking nearby. The DS/RD stated the bins were not fully shut because there was too much trash and an extra bin had been requested but not yet delivered. The DON later reviewed photos showing the bins were not closed and overflowing, and the facility policy required outdoor trash bins to remain covered except when being emptied or filled.
Two residents receiving long-term ATB therapy did not have specific monitoring documented for adverse effects. One resident received erythromycin via g-tube for delayed gastric emptying, and another received metronidazole via g-tube for ethylmalonic encephalopathy; staff stated vague charting such as “no change in condition” was used instead of documenting specific reactions or tolerance. RNs, the MP, DON, and IP all acknowledged that antibiotic orders should include and reflect monitoring for adverse effects, but the records reviewed did not show that this occurred.
Two residents with chronic respiratory failure, tracheostomies, and gastrostomy tubes, both lacking decision-making capacity and dependent for ADLs, were not properly screened for or offered updated pneumococcal vaccines despite prior PCV13 or PPSV23 immunization and current CDC/ACIP recommendations. One resident was missing entirely from the facility’s flu, pneumonia, and COVID consent tracker, while the other was marked as completed for pneumonia vaccine without supporting documentation of updated vaccination, consent, refusal, or contraindication in the medical record, contrary to facility policies requiring admission assessment of vaccination status and documented consent/declination.
A resident with chronic respiratory failure, tracheostomy, G-tube, and ventilator dependence, who lacked decision-making capacity and required total assistance with ADLs, was admitted without being assessed for COVID-19 vaccination status. Review of the immunization record and the facility’s vaccine consent tracker showed no evidence that the COVID-19 vaccine was offered, administered, or declined. An LVN confirmed there was no related documentation in the clinical record, and the DON acknowledged this was not consistent with the facility’s vaccination policy, which requires admission screening and consent/declination documentation for all vaccines.
A resident with chronic respiratory failure, convulsions, and cerebral palsy was found cognitively intact and able to communicate and understand others, yet Housekeeping entered the room with a large gray bin and crashed it into the foot of the resident’s bed and overbed table after not moving the resident’s wheelchair to make space. The resident also reported being awakened in the morning by banging from housekeeping equipment while the room was being cleaned, and the DON stated the resident should be treated with respect and dignity.
Call Light Not Kept Within Reach: A resident with ventilator dependence, tracheostomy, type 2 DM, intact cognition, and limited upper and lower extremity mobility was found in bed with the pad call light placed at the foot of the bed instead of within reach. The care plan directed staff to keep the call light within reach, and RNs confirmed the resident could slightly move the hands and should have had the adaptive call light positioned near the hand to request assistance.
A resident with respiratory failure, a tracheostomy, ventilator dependence, and impaired cognition had a significant change in condition when staff observed rectal bleeding and bleeding in the trachea during suctioning. The NP ordered transfer to the ER via paramedics, but the discharge summary and SBAR did not show that the resident’s representative was notified of the change in condition or the hospital transfer, despite facility policy requiring timely notification of the family/responsible party and physician.
A resident was readmitted with a ventilator dependence, tracheostomy, and DM2, but the baseline care plan was not developed and implemented within 48 hours. RN and MDSC both confirmed the care plan was started after the required timeframe, despite the facility policy requiring an initial baseline CP upon admission to guide immediate care needs, including PT, fall risk, blood sugar concerns, anticoagulant therapy, and oxygen therapy.
The facility failed to develop complete CPs for two residents. One resident receiving Eliquis via GT for DVT prophylaxis did not have bleeding monitoring included in the CP, even though RN and MDSC stated it should have been there. Another resident with MASD on the buttock and risk for pressure injuries had no CP for the skin issue, despite documentation of impaired cognition, dependence for bed mobility, and staff statements that the wound-related CP should have been created when the skin problem was identified.
Care plan not updated for left buttock stage 2 pressure ulcer: A resident with severe cognitive impairment, dependence for bed mobility, and risk for pressure ulcers developed a left buttock wound that progressed from an open blister to a stage 2 pressure ulcer with drainage. The TN stated the wound management care plan did not include the stage 2 ulcer and should have been added when identified; the DON stated the care plan should have been updated to reflect current approaches.
Two residents did not receive care as ordered. One resident with severe neurologic impairment had an order for SCDs to be applied to both lower extremities at all times for DVT prophylaxis, but the SCD machine was off and the sleeves were not on the resident; staff said the resident refused, and there was no refusal care plan in the record. Another resident with a g-tube had an order for 400 cc water flushes with gavage via g-tube if unable to finish PO, but staff administered the flush via pump instead of as ordered. The DON stated the order was not followed as written.
A resident had a used mupirocin cream cup left on the bedside stand after treatment, even though the RN stated it should not have been left there and the DON said residual topical medication should never remain at bedside. In a separate finding, another resident had Vicks Vapor Rub, an aerosol air freshener, and arthritis pain relief spray on the bedside table without a MD order or self-administration assessment, and the DON stated staff did not know the items were there.
A RT failed to perform trach care per physician orders and facility policy for a resident with trach and ventilator dependence. During observed care, the RT changed gloves multiple times without HH between changes, attempted double gloving, used NS instead of ordered H2O2 to clean the stoma, and inserted the sterile inner cannula before cleaning the stoma area. The RTM and DON stated the care did not follow the ordered procedure or infection control expectations.
A facility failed to follow its infection control program when a resident with a trach, vent dependence, and suctioning orders had an unlabeled suction canister, and when another resident with a GT had a vent syringe hanging open to air with formula backflow in it. Staff, including RN, RT, RTM, MP, and DON, stated the suction canister should have been labeled and changed per policy, and that the open vent syringe with formula could lead to infection because it was not a closed system and was exposed to contaminants.
A resident with chronic respiratory failure, tracheostomy, ventilator dependence, and anoxic brain injury experienced tachycardia and tachypnea, leading an NP to issue a STAT chest x‑ray order by phone. The RN did not complete required Change of Condition documentation or clearly record physician notification, leaving the reason for the STAT order and communication with the MD undocumented. The NP did not enter a timely progress note explaining the clinical indications for the STAT chest x‑ray or confirming MD notification, instead documenting several days later in a way that did not clearly link the tachycardia and ventilator changes to the date of the STAT order. These actions and omissions did not follow facility policies on reporting changes in condition and documentation principles.
A resident with chronic respiratory failure, tracheostomy, ventilator dependence, and anoxic brain injury experienced a change in condition that led an NP to issue a STAT chest x-ray order by phone. However, the RN did not complete required COC documentation describing the resident’s signs and symptoms, and the only contemporaneous entry was a respiratory therapy note indicating tachycardia and tachypnea. The NP did not enter a timely progress note explaining the clinical rationale for the STAT x-ray or whether the attending physician was notified, instead documenting six days later in a way that did not clearly link the tachycardia and ventilator setting changes to the date of the STAT order. These omissions resulted in an incomplete and unclear medical record that did not meet the facility’s documentation standards for accuracy, timeliness, and detail.
A pediatric resident with severe cognitive impairment and high fall risk was left unattended on an adult-sized shower bed with large gaps in the side rails. The CNA turned away to retrieve a sheet, and the resident slipped through the gap and fell, sustaining a facial bruise. The facility had not assessed the safety of using adult-sized shower beds for pediatric residents, did not provide size-appropriate equipment, and failed to update the resident's fall risk assessment after the incident.
Business Office Staff did not inform resident representatives of their right to rescind a binding arbitration agreement within 30 days, as required by facility policy. This occurred for three residents with severe cognitive impairment who were dependent on medical interventions, and staff interviews revealed a lack of knowledge and communication about the rescission period.
Three staff members, including an LVN and two RNs, did not wear masks in resident care areas during respiratory virus season, despite facility policy and posted signage requiring masking. Staff interviews revealed confusion about the updated policy and lack of awareness due to communication gaps and use of alternate entrances. Facility leadership confirmed that hallways are resident care areas and that masking was mandatory, but staff non-compliance was observed and acknowledged.
The facility's assessment failed to accurately document the use of pediatric shower beds and the implementation of electronic health records (EHR), despite these resources being in use and necessary for the care of pediatric and adult subacute residents. Interviews with the ADM and DON confirmed that the assessment was incomplete, omitting essential equipment and not reflecting the transition to EHR, which had the potential to delay necessary care and services.
A resident with complex medical needs did not have timely documentation of a critical immunosuppressive medication administration, as the MAR was left blank and the responsible RN did not document at the time of service. Additionally, the resident's Baseline Care Plan inaccurately reflected cognitive status as intact, despite assessments and staff statements confirming severe cognitive impairment. These failures resulted in incomplete and inaccurate medical records.
A resident with severe cognitive impairment and complex medical needs was involved in an alleged abuse incident where a CNA was reported to have yelled at them. Although the initial abuse report was submitted, the facility did not provide the SSA with the final written findings of its internal investigation within the required five business days, as mandated by facility policy.
A CNA performed oral suctioning on a resident with chronic respiratory failure and a tracheostomy, despite facility policy and the resident's care plan specifying that only licensed staff should perform this procedure. The CNA was not trained for oral suctioning, and the DON confirmed that CNAs are not permitted to perform this task, indicating a failure to provide care by qualified persons as required.
A resident, who was cognitively intact and dependent on staff for daily care, reported to the SW that a CNA had touched him inappropriately about a year earlier. Although the allegation was promptly documented and communicated internally, the facility did not report the abuse to the SSA within the required two-hour timeframe, instead submitting the report the following day. This delay was attributed to the absence of injury, despite policy requiring immediate reporting of abuse allegations.
A resident with chronic respiratory failure and ventilator dependence experienced tachycardia and a low-grade temperature, leading to a hospital transfer. Facility staff did not complete a Change of Condition form or notify the physician as required by policy, resulting in a gap in communication regarding the resident's status.
A resident alleged physical abuse by a staff member, but the facility failed to investigate or report the incident to the California Department of Public Health as required. Despite the resident's intact cognitive skills, the facility did not follow its policy for immediate reporting and investigation, leaving the Administrator unaware of the incident and unable to provide necessary documentation.
A resident in a persistent vegetative state with chronic respiratory failure and hypotension experienced significant medication errors when the facility failed to follow physician's orders for midodrine administration. The medication was improperly administered six times despite high blood pressure and omitted once when needed. The facility's policies emphasized checking parameters like blood pressure, but these were not followed, leading to the errors.
A facility failed to maintain an effective infection prevention and control program when an RN did not follow Enhanced Barrier Precautions during gastrostomy care for a resident and neglected hand hygiene before medication preparation for another resident. The RN did not wear a gown as required and failed to sanitize hands after glove removal, risking cross-contamination. The facility's policy mandates protective attire during high-risk tasks to prevent the spread of infections.
A resident with chronic conditions and impaired cognitive skills did not receive a prescribed dose of hydralazine for hypertension, as the medication record was left blank. Interviews confirmed that a blank record indicates the medication was not given, contrary to the facility's policy requiring documentation after administration.
A resident with severe cognitive impairment and multiple health conditions experienced a medication administration issue due to incomplete medical records. Despite receiving medications for high blood pressure, the LVN failed to document the administration, leading to potential medication errors. The DON confirmed that unsigned records imply non-administration, highlighting the importance of accurate documentation.
The facility failed to ensure that call lights were within reach for four residents, potentially delaying necessary care. A resident with a tracheostomy had their call light placed on a ventilator, while another with spastic quadriplegia cerebral palsy had theirs on a pulse oximeter machine. Two other residents had their call lights out of reach, contrary to the facility's policy requiring call lights to be accessible and monitored.
The facility failed to protect resident PHI by not properly disposing of medication labels. Two residents' medication bubble packs with intact labels were found in a waste container, exposing their PHI. Interviews revealed inconsistent adherence to HIPAA guidelines, as staff did not consistently remove, shred, or cover labels before disposal. Despite education on HIPAA compliance, the facility did not consistently safeguard resident privacy.
The facility failed to ensure residents were free from physical restraints without proper assessments, physician orders, or informed consent. Several residents were subjected to restraints, such as bedrails and mittens, without quarterly evaluations or care plans, contrary to facility policy. Staff interviews confirmed these deficiencies, highlighting a lack of compliance with established protocols.
The facility failed to develop and implement comprehensive care plans for three residents, leading to potential delays in care. A resident with chronic respiratory failure had no care plan for the use of a right-hand mitten, another resident's bed was placed against the wall without a care plan, and a third resident had no care plan for the use of full side rails. These oversights risked delays in care and safety issues.
A resident with type 2 diabetes and severely impaired cognition did not receive proper insulin administration due to the facility's failure to rotate injection sites. The MAR showed repeated use of the same areas for insulin injections, contrary to professional standards and manufacturer's guidelines. This oversight was confirmed by both RN 2 and the DON, who acknowledged the risk of skin complications and improper insulin absorption due to this practice.
A facility failed to adhere to physician orders for ROM devices for three residents, leading to potential risks of skin irritation and contractures. One resident wore hand splints longer than ordered, another had improperly placed hand rolls, and a third was found without required hand rolls and heel protectors. Staff acknowledged the discrepancies, which were against facility policy.
A facility failed to maintain a safe environment for residents by leaving medications at the bedside, improperly using fall mats, and not adjusting bed heights. A resident's medications were left accessible, risking overdose, while another's fall mat was compromised by furniture placement. Additionally, a resident's bed was left in a high position, increasing fall risk. These actions violated facility policies on medication safety and fall prevention.
A facility failed to provide proper catheter care for residents, leading to potential UTI risks. A resident with a suprapubic catheter lacked a securement device, increasing infection risk. Two residents had coiled catheter tubing, impeding urine flow and raising infection potential. Facility policy emphasized proper catheter management, but guidelines were not consistently followed.
Failure to Prevent and Treat Pressure Ulcers
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and to prevent new ulcers from developing for a resident who was admitted with chronic respiratory failure, prior intracerebral hemorrhage, dysphagia after cerebral infarction, and hydrocephalus. The resident’s MDS showed severe cognitive impairment, dependence on staff for bed mobility, and risk for pressure ulcers. On readmission, the resident had left buttock MASD documented on the CAS form, but the record and staff interviews showed no weekly skin assessments were completed for the MASD before 1/20/2026, and no treatment orders were in place for the left buttock skin breakdown during that period. Staff interviews showed breakdowns in communication and follow-through. TN 1 stated the resident’s MASD on the left buttock was not monitored weekly, no treatment orders were obtained when the MASD was identified, and no care plan was developed for the MASD. TN 1 also stated the resident’s later left buttock stage 2 pressure ulcer was not added to the wound care plan. RN 8, TN 2, LVN 4, and the DON each described that the wound care physician should have been notified, but the DON stated the communication did not occur and the wound was not documented. The DON also stated the facility’s Decubitus Ulcer Prevention policy was not followed for this resident. The resident also required repositioning every two hours and as needed, but the facility’s position records showed repeated periods where the resident remained on the left side or back for more than two hours on multiple days in January 2026. CNA 2 stated repositioning sometimes did not occur every two hours and that turning required two people. By 1/20/2026, the wound care physician identified a left buttock open blister, and by 1/27/2026 the wound was documented as a stage 2 pressure ulcer on the left buttock. The DON stated the pressure ulcer was avoidable and that this was the first time the resident had a pressure ulcer of this type. The facility also failed to provide pressure ulcer care for other at-risk residents. For one resident, wound care treatment was not administered and documented on two dates in September 2025. For two residents, low air loss mattresses were not set according to weight and physician orders. For another resident, bilateral heel protectors were not applied while the resident was off AFOs. These residents were all described as at risk for pressure ulcer development, dependent on staff for turning, and incontinent of bowel and bladder.
Failure to Document and Authorize Physical Restraints
Penalty
Summary
The facility failed to ensure two residents were free from the use of physical restraints unless needed for medical treatment. For one resident, the record showed a physician’s order for hand mittens as needed to prevent self-inflicted injury, and informed consent was obtained by phone from the responsible party. However, the restraint assessment did not document the use of the hand mittens, did not identify any least restrictive measures attempted before use, and did not reflect an interdisciplinary team recommendation for the mittens. The resident had diagnoses including congenital malformation, tracheostomy, and gastrostomy, and the H&P stated the resident did not have the capacity to understand and make decisions. The MDS indicated severely impaired cognition and dependence for all ADLs. During observation, the resident was seen with a mitten on one hand, and a CNA stated the mitten was released every two hours for circulation checks. In interview, the MDSC stated the restraint assessment should have documented least restrictive measures attempted first and should have reflected the IDT recommendation to apply the mittens. The DON stated restraint assessments are completed prior to application of restraints or any device and that the assessment should have reflected that least restrictive measures were attempted and ineffective before the mittens were used. For the second resident, the bed was observed placed against the wall on one side with all four side rails up. The MP stated that placing the bed against the wall is a restraint and requires a physician’s order, informed consent, a restraint assessment, and a care plan. Review of the chart found no physician’s order, informed consent, restraint assessment, or care plan for the bed placement. The resident had diagnoses including convulsions, cortical blindness, and fracture of femur, and the H&P described the resident as delayed, spastic with upper extremity flexion contracture, and non-verbal. The DON stated licensed staff should have obtained the required order, consent, assessment, and care plan for the restraint bed placement against the wall.
Suprapubic Catheters Not Secured or Properly Maintained
Penalty
Summary
The facility failed to ensure that residents with suprapubic catheters had the catheter tubing secured and maintained in a manner consistent with the facility’s own orders and policies. For Resident 42, the record showed diagnoses including chronic respiratory failure, tracheostomy, and dependence on respirator status, with the resident described as alert but intermittently opening eyes and later as having severely impaired cognition and being dependent for mobility and ADLs. The care plan and orders directed staff to keep the suprapubic catheter tubing free from coils and to bolster the catheter at all times, yet during observation the resident’s suprapubic catheter was seen without a leg strap or securement device in place. For Resident 43, the record showed diagnoses including neuromuscular dysfunction of the bladder, chronic kidney disease stage three, and UTI, with the resident described as having global disability, no purposeful response, and severely impaired cognition. The resident’s care plan also directed staff to keep the suprapubic catheter tubing free from coils and to keep the dignity bag in place at all times, and the order summary included instructions to bolster the suprapubic catheter every 12 hours. During observation, the resident’s suprapubic catheter was also seen without a leg strap or securement device in place. For Resident 3, the report states that the resident’s suprapubic catheter likewise lacked a leg strap or securement device, and the tubing was not free of loops or kinks. Staff interviews stated that the catheter should have a securement device to prevent tugging and dislodgement, and that the tubing should be checked for loops or kinks with the drainage bag kept below the bladder. The facility’s catheterization and CAUTI policies also directed staff to secure catheters, keep the drainage system free of kinks, and maintain gravity drainage.
Tube Feeding Bags and Medication Syringes Not Properly Labeled or Rinsed
Penalty
Summary
Staff failed to follow the facility’s tube-feeding labeling and syringe-rinsing protocols for four residents who had feeding tubes. The report states that the facility did not ensure staff providing care to residents with feeding tubes were aware of, competent in, and using the facility’s protocols regarding feeding tube nutrition and care. The deficiencies were identified during observation, interview, and record review for Residents 42, 3, 105, and 41. For Resident 42, the record showed the resident had a gastrostomy tube and was receiving enteral feeding by pump five times daily. During a concurrent observation and interview, the resident’s feeding bag was observed without the complete resident name, the infusion rate, or the initials of the licensed nurse who hung it. RN 3 stated the bag should have been labeled with the resident’s complete name, the infusion rate, and the nurse’s initials. The MP and DON also stated the bag should have included the resident’s name, formula name, date and time hung, rate of infusion, and nurse initials. The facility’s policy required tube feeding formulas and water flush sets to be labeled with the patient’s name, room and bed number, time started, and rate. For Resident 3, the record showed the resident had a gastrostomy tube and was ordered continuous water flushes. During observation, the resident’s water flush bag was not labeled with the complete resident name, the infusion rate, or the initials of the nurse who hung it. RN 4 stated the bag should have included the resident’s complete name, the solution name, the date and time it was hung, the rate of infusion, and the nurse’s initials. The MP and DON gave similar statements, and the facility’s labeling policy again required tube feeding and water flush sets to be labeled with identifying information and the rate. For Resident 105, the record showed the resident had a gastrostomy tube and received bolus enteral feeding and water flushes. During observation, the EF bag was not labeled with the resident’s name, room number, start date and time, and administration rate, and the medication syringe had residual medication left on the tip and was not rinsed properly. LVN 1, RN 7, and the DON each stated the bag should have been labeled with the resident’s identifying information and feeding details, and that the syringe should have been rinsed after use. For Resident 41, the record showed the resident had a gastrostomy tube and received bolus feeding and water flushes. During observation, the medication syringe was also found not rinsed properly with residuals left on the tip. LVN 1, RN 7, and the DON stated the syringe should have been rinsed thoroughly after each use, and the facility’s infection control policy required a safe, sanitary environment to help prevent disease and infection.
Tracheostomy Care, Respiratory Equipment, and HHN Setup Not Per Orders
Penalty
Summary
Respiratory care was not provided according to physician orders and facility procedure during tracheostomy care for a resident with chronic respiratory failure, a tracheostomy, ventilator dependence, and severe functional dependence. During observation, the respiratory therapist suctioned the resident’s mouth, changed gloves multiple times without performing hand hygiene between glove changes, and attempted to double glove. The therapist then suctioned the trach and inserted the sterile inner cannula before cleaning the neck and stoma area. The therapist used normal saline to clean around the stoma instead of the ordered hydrogen peroxide and normal saline, and later stated she did not use hydrogen peroxide because she had been told to use only normal saline. The resident’s record showed orders for tracheostomy care every shift and as needed, including cleansing the stoma with hydrogen peroxide and rinsing with normal saline, and changing the inner cannula daily. The facility’s tracheostomy care policy required cleaning around the stoma with normal saline and hydrogen peroxide, then changing to sterile gloves and inserting the new inner cannula. During interviews, the RT manager and DON stated the resident’s order required hydrogen peroxide, that hand hygiene should be performed between glove changes, and that the cleaning of the stoma should occur before insertion of the sterile inner cannula. They stated the therapist did not follow the physician’s order or the facility procedure during the observed care. The facility also failed to ensure suction catheters were dated for three residents who required suctioning. For each of the three residents, the suction catheter was observed in a plastic storage bag without the date it was last changed. Staff stated the catheters were supposed to be changed regularly and should indicate the date they were changed so staff would know they were clean. In addition, a resident with a tracheostomy and ventilator dependence had a hand held nebulization setup that was dated far beyond the ordered weekly change schedule. Staff observed the setup was dated 10/6/2025 on the medication instillation barrel and 1/3/2026 on the plastic bag, while the order required weekly and PRN changes. Staff stated the setup should have been changed per the physician’s order.
Inadequate Competency in Antibiotic Monitoring and G-Tube Venting
Penalty
Summary
The facility failed to assure that nursing staff had the competencies and skill sets needed to safely provide care for residents receiving antibiotics and gastrostomy tube services. For one resident, the record showed an order for erythromycin ethyl succinate via g-tube every six hours for delayed gastric emptying and gastric motility, and the care plan identified the resident as at risk for adverse effects due to long-term antibiotic therapy. During interview and record review, RN 2 stated there was no physician order to monitor for adverse effects, and the progress notes and nursing assessments from the reviewed period did not show specific monitoring for adverse effects of the antibiotic. RN 2 stated that documenting "no change of condition" was sufficient and that it was acceptable to be vague when documenting antibiotic monitoring. For the same resident, staff interviews showed that RN 9 expected the licensed nurse receiving the order to clarify with the physician what adverse effects should be monitored and to document the resident’s tolerance or adverse effects. The MP stated that licensed staff should document every shift what antibiotic was given and whether the resident tolerated it or had an adverse effect, and that the staff were not asking physicians what adverse effects to monitor. The DON stated staff should verify the indication, duration, and adverse effects to monitor for safe use. The DSD reviewed RN 2’s annual skills list and stated it did not indicate specific competency for antibiotic administration and adverse effects monitoring. For another resident, the record showed an order to vent the g-tube continuously every shift, and the care plan addressed infection risk related to the g-tube site. During observation, a 60-cc syringe labeled for venting was hanging at the resident’s headboard without a plunger and open to air with feeding formula in it. RN 1 stated the feeding should have been on a closed system and that leaving the syringe open to air could lead to gastric infection. RN 2 stated the formula in the open syringe could result in GI infection if introduced to the g-tube and that RN 1 should have ensured there was no backflow of feeding formula. The MP and DON both stated the syringe was for manual venting, not feeding, and that the formula exposed to air could cause infection. The DSD stated there was no specific training or in-service regarding gastric venting and that staff learned it on the floor.
Missing narcotic reconciliation and disposal log signatures
Penalty
Summary
The facility failed to reconcile one medication eKIT containing narcotics in Medication Storage Nursing Station 1 for January 2026. During an observation and concurrent interview with RN 10, the eKIT stored in the refrigerator and labeled 13503 was found to contain narcotics without an accountability log showing narcotic inventory reconciliation at every shift change for that month. RN 10 stated that all narcotics, including medication eKITs containing narcotics, should be reconciled at every shift and acknowledged that the eKIT had not been reconciled at every shift in January 2026. The facility also failed to include verifying signatures of either the DON or an RN along with an LVN on two Controlled Drug Record accountability logs for narcotics awaiting final disposition in the locked cabinet. During observation and record review in the DON office, the two logs did not contain the required verifying signatures. The DON acknowledged the missing signatures and stated the DON and LVNs failed to sign the accountability logs upon receipt of the narcotics from the LVNs, although the DON counts the narcotics with the LVN upon receipt of the log.
Failure to Monitor for Bleeding With Eliquis
Penalty
Summary
The facility failed to ensure that Resident 97’s drug regimen was free from unnecessary drugs by not monitoring the resident for signs and symptoms of bleeding while the resident was receiving Eliquis (apixaban) for DVT prophylaxis. Resident 97 was admitted with diagnoses including GT, depression, and HTN, and the H&P stated the resident did not have the capacity to understand and make decisions. The MDS later indicated intact cognition, ability to make needs known, total assistance with ADLs, and receipt of an anticoagulant. The resident’s Order Summary Report showed a physician’s order for Eliquis 2.5 mg via GT every 12 hours, but it did not include monitoring for signs and symptoms of bleeding. The care plan titled Potential for injury or bleeding also did not include monitoring for signs and symptoms of bleeding as an intervention for Eliquis use. During interviews and record review, RN 7 stated there was no physician’s order to monitor for bleeding, that monitoring should occur every shift and be documented in the MAR, and that the MAR did not contain documentation for bleeding or bruising monitoring. The MDS Coordinator similarly stated there was no order to monitor for signs and symptoms of bleeding every shift. The facility policy titled Monitoring of Anticoagulant Therapy stated that patients receiving anticoagulation therapy should be assessed for bruising, swelling, and/or redness every shift and as needed, with the physician notified immediately for abnormalities. The policy titled Anticoagulant Therapy stated patients shall be assessed for signs and symptoms of adverse effects including unusual bruising or bleeding, hematuria, bleeding gums, sudden headache, dizziness, weakness, shortness of breath or chest pain, and swelling at the injection site. These monitoring elements were not reflected in the resident’s orders, care plan, or MAR documentation reviewed by surveyors.
Medication Error Rate Exceeded 5% Due to Improper Eye Drop Administration
Penalty
Summary
The facility failed to ensure that its medication error rate remained below 5 percent. Surveyors identified 3 medication errors out of 30 total opportunities, resulting in a 10% medication error rate and affecting one of two residents observed during medication administration, Resident 61. During an observation in the medication cart area, an LVN administered brimonidine eye drops to both eyes, immediately followed by dorzolamide to the left eye, and then refresh tears to both eyes without waiting between the medications. During interview, the LVN acknowledged administering the eye drops back-to-back and stated the directions required waiting 3 to 5 minutes between drops to the same eye so the medication could be absorbed. The LVN stated the failure to wait likely flushed out each drop and did not allow full absorption. The DON also stated that manufacturer guidelines and facility policy required a 3 to 5 minute lapse between more than one eye drop or eye medication to each eye, and confirmed the LVN failed to wait between brimonidine, dorzolamide, and refresh tears. Resident 61’s record showed diagnoses including hypertension, and the MAR showed prescriptions for brimonidine, dorzolamide, and refresh tears for glaucoma and dry eyes.
Failure to Rotate Heparin Injection Sites
Penalty
Summary
The facility failed to ensure that a resident receiving heparin injections was free from significant medication errors when subcutaneous injection sites were not rotated. Resident 6 was admitted with diagnoses including ventilator dependence, tracheostomy, and type 2 diabetes mellitus, and the record showed the resident had intact cognition and required total assistance with ADLs. The physician ordered heparin sodium injection 5000 units/ml, 1 ml subcutaneously every 12 hours for DVT prophylaxis. The Location of Administration Report showed repeated heparin injections given in the same sites on multiple occasions, including the right lower quadrant of the abdomen on two administrations, the left lower quadrant of the abdomen on two administrations, and the left arm on two administrations. During the concurrent interview and record review, RN 7 stated there were multiple instances where licensed nurses did not rotate the subcutaneous heparin injection sites and that sites should be rotated according to standards of practice and the manufacturer's guideline. The DON stated she was aware of the repeated injection sites and confirmed staff could see prior administration sites in the MAR and were supposed to rotate them. The DON stated there should be no reason to repeat the same subcutaneous injection sites and that Resident 6's heparin site should have been rotated because repeated use can cause discomfort or irritation, excessive bruising, or lipodystrophy. Facility policy also stated approved subcutaneous sites include the abdomen and upper outer arms, with sites to be rotated to prevent tissue damage, and the heparin prescribing information stated a different site should be used for each injection to prevent massive hematoma.
Improper Medication Storage and Labeling
Penalty
Summary
Medication storage practices were not followed in Nursing Station 1 because the room temperature monitoring log for January 2026 was not available. During observation and interview, RN 10 stated the medication storage area contained medication bottles for facility stock and residents, and that the temperature should be monitored and documented every day during all shifts to ensure medications remain within an acceptable range. The DON later stated the temperature of medication storage areas should be monitored and documented twice daily, and acknowledged that the Nursing Station 1 medication storage area did not have a temperature monitoring log for January 2026. In Medication Cart room [ROOM NUMBER], an open levalbuterol inhalation solution foil pouch for Resident 79 was found stored at room temperature without a date showing when the pouch was opened. LVN 7 stated the pouch was not labeled with an open date and that multi-dose products such as inhalation solutions should be labeled with the date first opened. The DON stated levalbuterol inhalation solutions expire within two weeks of opening the foil pouch and acknowledged the facility failed to label the pouch with the date when first opened for Resident 79. Medication carts were also observed with external-use medications stored together with oral medications in the same bin or compartment. In Medication Cart 3, fluticasone nasal spray and azelastine nasal spray were stored with a melatonin oral tablet bottle. In Medication Cart 2, fluticasone nasal spray and Refresh Tears eye drops were stored with a Tylenol oral tablet bottle. RN 11 and LVN 8 stated nasal sprays and eye drops should be stored separately from oral medications, and the DON stated internally and externally administered medications should be stored separately to prevent wrong route administration, infections, and contaminations. Facility policies reviewed during the survey required multiple-use medications to be labeled with the date opened, medications to be stored according to manufacturer recommendations, and internal and external medications to be stored separately.
Food Storage and Utensil Contamination
Penalty
Summary
The facility failed to store, prepare, and serve food in accordance with professional standards for food service safety for 19 of 109 residents. During a concurrent observation and interview with the Dietary Supervisor/Registered Dietician, surveyors found inside the walk-in refrigerator a bag of opened deli bread with a best by date of 1/20/2026 and no open date, as well as an unopened bag of deli hot dog buns with the same best by date of 1/20/2026. The Dietary Supervisor/Registered Dietician stated it was the responsibility of kitchen staff to ensure food products were not used after their best by date and that food items should have delivery and open dates to prevent use past expiration. Surveyors also observed a spoodle hanging on the clean rack near the steam table with butter residues on it. The Dietary Supervisor/Registered Dietician stated the utensil should not have any butter residues because it was contaminated and could cause food-borne illnesses if used to stir or prepare food. The DON stated the buns should have been discarded because they were past their best by dates, and that kitchen utensils such as the spoodle should be free from food residues because contamination could cause GI infections to residents. Facility policy on food storage and labeling indicated proper storage procedures were to be followed and newly opened food items were to be closed and labeled with an open date and use by date according to manufacturer guidance.
Trash Bins Left Open and Overflowing
Penalty
Summary
The facility failed to ensure garbage and refuse were disposed of properly. During an observation near the facility's trash bin area, a racoon was seen lurking around the trash bins. In a concurrent observation and interview, multiple black and blue trash bins were observed opened and overflowing with trash and could not be shut closed. The Dietary Supervisor/Registered Dietician stated the bins were not totally shut because they were not enough to hold the amount of trash and an extra bin had been requested but not yet delivered. The DS/RD also stated it was not appropriate to leave the trash bins open because it attracts pests such as rats and rodents that can carry diseases to residents. In a later interview and record review, the DON reviewed pictures of the trash bins and stated the bins were not closed and were overflowing, and that this was not acceptable because it can attract pests, rodents, and rats that carry diseases causing residents to get sick. The facility policy for Grounds stated outdoor trash bins will remain covered at all times unless being emptied or filled.
Failure to Monitor Long-Term Antibiotic Therapy
Penalty
Summary
The facility failed to implement its antibiotic stewardship program for two residents who were receiving long-term antibiotic therapy. Resident 39 was admitted and later readmitted with diagnoses including chronic respiratory failure, acute tracheitis, and gastrostomy, and was described as delayed, spastic with upper extremity flexion contractures, non-verbal, and dependent for mobility and ADLs. The resident had an order for Erythromycin Ethyl succinate 70 mg via g-tube every 6 hours for delayed gastric emptying and gastric motility for 6 months, and the care plan identified the resident as at risk for adverse effects due to long-term antibiotic therapy. During interview and record review, RN 2 stated there was no physician order to monitor for adverse effects from Erythromycin Ethyl succinate and that progress notes and nursing assessments from 12/2025 to 1/2026 did not show specific monitoring for antibiotic adverse effects. RN 2 stated that documenting no change in condition meant the antibiotic effects were monitored, and that it was acceptable to be vague in documenting monitoring. RN 9 stated staff should verify the indication, end date, and specified adverse-effect monitoring when antibiotics are administered, and that the licensed nurse receiving the order should clarify with the physician what adverse effects to monitor. The MP, DON, and IP all stated that staff should monitor and document specific adverse effects of antibiotics, including when used prophylactically, and that the lack of specific monitoring could contribute to antibiotic resistance. Resident 71 was admitted and later readmitted with diagnoses including acute upper respiratory tract infection, gastrostomy, and otitis media, and was described as well nourished, in no acute distress, non-verbal, with spasticity, hypertonicity, and clonus bilaterally. The resident had severely impaired cognition and an order for Metronidazole 187 mg via g-tube every 8 hours for ethylmalonic encephalopathy for 6 months, with a care plan intervention to assess for signs and symptoms of adverse reactions and report to the MD. RN 2 again stated there was no physician order to monitor for adverse effects and that the charting did not show specific monitoring, while RN 9, the MP, the DON, and the IP stated that antibiotic therapy required specific adverse-effect monitoring and documentation. The facility’s antibiotic stewardship policy and the pharmacist job description both referenced reducing unnecessary antibiotic use and identifying medications requiring special study based on adverse drug reactions, but the records reviewed for these two residents did not show the required specific monitoring for adverse effects.
Failure to Screen and Document Pneumococcal Vaccination for Two Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s implementation of its pneumococcal vaccination policies for two residents reviewed under the infection control task. Resident 85 was admitted with chronic respiratory failure, a tracheostomy, a gastrostomy tube, and ventilator dependence, and was documented in the H&P and MDS as lacking capacity to understand or make decisions and being dependent on staff for all ADLs. The immunization record for this resident showed receipt of Prevnar 13 on 12/27/2012, but there was no documentation that the resident was screened for, offered, administered, or refused an updated pneumococcal vaccine, nor was there documentation of a medical contraindication. Additionally, the facility’s 2025–2026 flu, pneumonia, and COVID consent tracker did not list this resident at all. Resident 41 was admitted with chronic respiratory failure, a tracheostomy, a gastrostomy tube, and cerebral palsy, and the H&P and MDS documented that the resident lacked capacity to understand or make decisions and was dependent on staff for all ADLs. The immunization record indicated Pneumovax 23 was administered on 5/9/2003, but there was no documentation that the resident was screened for, offered, administered, or refused an updated pneumococcal vaccine, nor any documentation of a medical contraindication. The facility’s consent tracker listed this resident as completed for the pneumonia vaccine despite the absence of documentation of updated vaccination, consent, or declination in the medical record. The Infection Preventionist stated that, per current CDC and ACIP adult immunization guidelines, both residents were eligible for and recommended to receive updated pneumococcal conjugate vaccines, and the DON acknowledged that not offering vaccines upon admission was not aligned with the facility’s policies, which require all new residents to be assessed for vaccination status and offered the pneumococcal pneumonia vaccine with consent or refusal documented in the record.
Failure to Assess and Document COVID-19 Vaccination Status on Admission
Penalty
Summary
Surveyors identified a deficiency in the facility’s process for assessing and documenting COVID-19 vaccination status upon admission. One sampled resident, admitted with chronic respiratory failure, a tracheostomy, a gastrostomy tube, and ventilator dependence, was found to lack capacity to understand and make decisions per the admission History and Physical and the MDS assessment. Review of this resident’s immunization record showed no documentation that the COVID-19 vaccine was offered, administered, or declined. The facility’s 2025–2026 flu, pneumonia, and COVID consent tracker also did not list this resident. During interviews, an LVN who assisted the Infection Prevention Nurse with vaccine data entry confirmed there was no documentation in the clinical record that the resident was offered, declined, or received the COVID-19 vaccine upon admission. The DON stated that not offering vaccines to residents upon admission was not aligned with the facility’s vaccination policy and that each resident should be screened by the Infection Preventionist upon admission. Review of the facility’s vaccination policy, last reviewed in January 2025, indicated that all new residents must be assessed for current vaccination status upon admission and that all vaccinations require consent or declination, with any refusal documented in the medical record. These required assessments and documentation were not completed for this resident.
Failure to Protect Resident Dignity During Housekeeping Activity
Penalty
Summary
The facility failed to provide care in a manner that promoted dignity and respect for one sampled resident, Resident 23, when Housekeeping 1 brought a large gray bin into the resident’s room without moving the resident’s wheelchair to create adequate space. During the event observed on 1/28/2026, Resident 23 was asleep in bed, and Housekeeping 1 entered the room with the gray bin, opened the restroom door, and crashed the bin into the foot of Resident 23’s bed and the overbed table before placing the bin in the restroom and leaving the room. Housekeeping 1 later stated that the wheelchair was in the way and that she did not move it because her gloves were dirty and she was touching the barrel. Resident 23’s record showed admission and readmission with diagnoses including chronic respiratory failure, convulsions, and cerebral palsy. The H&P dated 10/16/2025 indicated Resident 23 had the ability to understand and make decisions, and the MDS dated 1/21/2026 indicated clear speech, adequate vision, ability to make self understood, ability to understand others, and cognitive intactness. In interview, Resident 23 stated Housekeeping 1 wakes her in the morning by banging the bed with the broom and mop while cleaning her room, and that she has lost sleep in the morning. The DON stated Housekeeping 1 should have been careful and apologized to the resident, and that residents are to be treated with respect because it is their home and their rights.
Call Light Not Kept Within Reach
Penalty
Summary
The facility failed to reasonably accommodate a resident’s needs and preferences by not ensuring a pad call light was within reach for a resident with limited mobility. Resident 6 was admitted with diagnoses including ventilator dependence, tracheostomy, and type 2 diabetes mellitus, and the record indicated the resident had the capacity to understand and make decisions. The MDS showed intact cognition, the ability to make needs known, impairment of both upper and lower extremities, and a need for total assistance with all ADLs. The resident was also identified as high risk for falls. The care plan for potential falls and injury directed staff to place the call light within reach. During observation, the resident was lying in bed asleep, and the pad call light was found at the foot of the bed on the left side. The RN stated the call light should have been within reach, near the resident’s hand, because the resident could slightly move the hands and use the pad call light to request assistance. Another RN later confirmed the resident’s call light should have been placed within reach and not by the foot of the bed, noting the resident could slightly move both hands but could not move both lower extremities. The facility policy also stated that call lights are to be placed within residents’ reach and monitored for positioning.
Failure to Notify Responsible Party of Hospital Transfer
Penalty
Summary
The facility failed to notify the primary physician and the resident’s responsible party of a significant change in condition for one sampled resident when the resident was transferred to the hospital. Resident 13 was admitted with diagnoses including respiratory failure, tracheostomy, and dependence on a ventilator, and the H&P indicated the resident did not have the capacity to understand and make decisions. The MDS also showed moderately impaired cognition, total dependence for ADLs, and a need for suctioning. On 9/10/2025, during routine care, staff observed a large amount of blood from the rectum and bleeding in the trachea during suctioning of secretions. The nurse practitioner was notified and ordered the resident transferred to the nearest ER via paramedics. The discharge summary notes and the eINTERACT SBAR Summary form documented the bleeding and transfer, but neither document indicated that the resident’s representative was notified of the change in condition or the transfer. During interview and record review, the MDS Coordinator stated the resident was transferred to the ER for bleeding on the rectum and trachea and that the records did not indicate the family was notified. The DON stated licensed staff are supposed to complete the SBAR form to include notification of the resident’s representative of changes in condition and that resident representatives have the right to be notified. The facility policy also stated that the family or responsible party and physician or nurse practitioner shall be notified of a resident’s change in condition, and that nursing staff will report changes in a timely manner and document the notification in the nurse’s notes.
Delayed Baseline Care Plan for Readmitted Resident
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of Resident 6’s readmission on 5/31/2025. Resident 6’s admission record showed the resident was originally admitted on 1/21/2025 and readmitted on 5/31/2025 with diagnoses including dependence on a ventilator, tracheostomy, and type 2 diabetes mellitus. The H&P dated 5/31/2025 indicated the resident had the capacity to understand and make decisions, and the MDS dated 10/29/2025 indicated intact cognition, ability to make needs known, impairment of both upper and lower extremities, and total assistance needed with all ADLs. The baseline care plans for Resident 6 were not initiated until 6/3/2025. The care plans reviewed included PT care plan, potential for falls and injury related to impaired cognition and balance, potential for hypoglycemia or hyperglycemia related to DM 2, DM 2, anticoagulant therapy, and oxygen therapy. During interviews, RN 7 and the MDSC both stated that baseline care plans are supposed to be initiated upon admission or within 48 hours, and both stated Resident 6’s baseline care plans were not initiated and implemented timely. The facility policy titled Baseline Care Plans, last reviewed on 1/21/2025, stated the IDT shall develop and implement a baseline care plan for each resident within 48 hours of admission and include the minimum healthcare information necessary to properly care for the resident immediately upon admission.
Incomplete care plans for anticoagulant therapy and skin breakdown
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident receiving Eliquis via gastrostomy tube for DVT prophylaxis. The resident’s record showed diagnoses including gastrostomy, depression, and hypertension, and the H&P stated the resident did not have the capacity to understand and make decisions, while the MDS later indicated intact cognition and total dependence for ADLs. The physician’s order for Eliquis 2.5 mg every 12 hours was present, and the resident’s care plan titled "Potential for injury or bleeding" was initiated, but it did not include monitoring for signs and symptoms of bleeding as an intervention for the anticoagulant therapy. During interview and record review, RN 7 stated the care plan should have included monitoring for signs and symptoms of bleeding so staff would know how to properly care for the resident and avoid delay in needed care and services. The MDS Coordinator also stated the care plan did not include monitoring for bleeding and that the care plan should have been comprehensive and person-centered with complete interventions. The facility policy required comprehensive care plans with measurable objectives and time frames to meet the resident’s medical, nursing, mental, and psychosocial needs, and to be reviewed and revised after assessments. The facility also failed to develop a care plan for a resident with MASD on the left buttock and risk for pressure injuries. The resident’s record showed diagnoses including chronic respiratory failure, nontraumatic intracerebral hemorrhage, dysphagia following cerebral infarction, and hydrocephalus. The admission screening identified MASD on the left buttock, and the resident was documented as having impaired cognition, dependence for bed mobility, and risk for pressure ulcers. The record also showed ADUP scores indicating risk for pressure ulcer development. During interview, TN 1 stated there was no care plan developed for the MASD on the left buttock and said it should have been added the day it was identified. RN 8 stated the resident should have had a care plan addressing the MASD and treatment orders placed. TN 2 stated the charge nurse or primary nurse documented skin issues and that she did not call the wound doctor on the day the MASD was identified. The DON stated TN 2 was responsible for developing the care plan upon identification of skin issues, that the care plan should have been developed right away and followed through, and that because it was not developed, the wound doctor was not notified and the resident’s wounds were not followed through.
Care plan not updated for left buttock stage 2 pressure ulcer
Penalty
Summary
The facility failed to revise Resident 18’s care plan to reflect current interventions for a left buttock stage 2 pressure ulcer. Resident 18 was admitted with diagnoses including chronic respiratory failure, nontraumatic intracerebral hemorrhage, dysphagia following cerebral infarction, and hydrocephalus. The resident’s MDS indicated severe cognitive impairment, dependence on staff for bed mobility, and risk for pressure ulcers. The admission screening documents also noted left buttock MASD, and the resident’s ADUP scores were 23 and 25, indicating risk for developing pressure ulcers. On 1/19/2026, a physician order was written for treatment of a left buttock open blister, and on 1/20/2026 the wound care note documented the wound as a left buttock open blister measuring 1.6 cm by 1.5 cm by 0.1 cm with small serous drainage. A new physician order on 1/20/2026 continued wound treatment for 14 days. By 1/27/2026, the wound care note documented the wound as a left buttock stage 2 pressure ulcer measuring 1.2 cm by 0.8 cm by 0.2 cm with moderate serous drainage and a wound bed of 76 to 100 percent. During interview and record review, the Treatment Nurse stated the wound management care plan, revised on 1/20/2026, did not include the stage 2 pressure ulcer on the left buttock and that it should have been added when identified. The DON stated the TN is responsible for developing the care plan upon identification and that the care plan should have been updated to reflect current approaches. The facility’s policy stated residents admitted with a pressure sore should have immediate and appropriate action, and the care plan policy stated care plans are to be updated and revised as new diagnoses arise and are identified.
Failure to Follow SCD and G-Tube Water Flush Orders
Penalty
Summary
Resident 65 had orders for bilateral sequential compression devices (SCDs) to be applied to the lower extremities at all times for DVT prophylaxis. The resident’s record showed diagnoses including chronic respiratory failure, spastic quadriplegic cerebral palsy, and hydrocephalus, and the H&P indicated the resident did not have the capacity to understand and make decisions. During observation, the SCD machine was turned off and the sleeves were not applied to the resident’s bilateral lower extremities. RN 4 reviewed the record and stated the resident refused the SCDs, but there was no care plan in the electronic record for refusal. RN 4, the MP, and the DON all stated the SCDs should have been applied at all times per the physician’s order, and that refusal should have been brought to the IDT for care planning after explaining the risks and benefits. Resident 81 had diagnoses including gastrostomy, GERD, and constipation, and the H&P indicated the resident did not have the capacity to understand and make decisions. The resident’s record showed an order for enteral feed five times a day and to encourage oral water flush of 400 cc, with gavage via g-tube if the resident was not able to finish everything PO. The care plan included an intervention to give water flushes via tube as ordered. During observation, a water feeding flush bag was running at 195 ml/hour with 400 ml set at the feeding pump. RN 2 reviewed the order and stated the licensed staff did not follow the physician’s order because the water flush was given via pump. RN 4 stated staff should have clarified the order to prevent confusion. The DON stated the order should have been followed as written and that the feeding pump could not give a 400 cc bolus at one time, noting that infusing 400 cc by pump would take more than 2 hours. The facility policy on physician/FNP orders stated the primary nurse is responsible for carrying out orders with proper documentation.
Unattended Medications Left at Bedside
Penalty
Summary
The facility failed to ensure adequate supervision to prevent accidents when a used mupirocin calcium external cream cup was left unattended at the bedside of a resident with diagnoses including chronic respiratory failure, tracheostomy, anxiety disorder, and depression. The resident’s record showed the topical medication was ordered for daily application to the PEG stoma with supervised self-administration. During observation, the resident was sitting in bed with a clear plastic medication cup containing ointment placed on a stand next to the bed, and the resident stated it was cream for itching. The RN later stated she had applied the mupirocin cream that morning and forgot to dispose of the cup, leaving it on the resident’s stand with some cream remaining. The RN acknowledged the cup should not have been left at the bedside because anyone could grab it, and that the medication was prescribed only for that resident and should only be applied to that resident. The DON reviewed the facility’s medication administration and accident prevention policies and stated used medication cups containing residual medication should never be left at a resident’s bedside because the medication could be accidentally ingested by that resident or another resident. The DON stated the RN did not follow facility policy when the cup was left at the bedside. The facility also failed to ensure a resident’s medications were not left unattended on the bedside table without a physician’s order. A resident with chronic respiratory failure with ventilator dependence and morbid obesity was observed with Vicks Vapor Rub, Natural Breeze aerosol air freshener, and arthritis pain relief topical spray on the bedside table and overbed table. The resident stated her husband brought the items for her to use when needed. The DON stated the Vicks and arthritis spray should not have been at the bedside because the resident had no physician’s order for them and had not been assessed to self-administer medications, and staff did not know the medications were at the bedside.
Tracheostomy Care Not Performed Per Order and Policy
Penalty
Summary
Respiratory Therapist 4 failed to provide tracheostomy care to a resident with chronic respiratory failure, tracheostomy dependence, ventilator dependence, intracranial brain injury, and a history of sepsis in accordance with the physician’s orders and the facility’s tracheostomy care and hand hygiene policies. The resident’s record showed orders for tracheostomy care every shift and as needed, including cleansing the stoma with hydrogen peroxide and rinsing with normal saline, along with daily and as-needed inner cannula changes. The resident was dependent on staff for bathing, toileting, dressing, oral and personal hygiene, and mobility, and was unable to reliably understand others or make himself understood. During observation of tracheostomy care, RT 4 performed hand hygiene on entering the room, then used clean gloves for suctioning and changed gloves multiple times during the procedure without performing hand hygiene between glove changes. RT 4 attempted to double glove, then removed the gloves and continued care, again without hand hygiene between glove changes. RT 4 suctioned the resident’s trach and inserted the sterile inner cannula while wearing sterile gloves, then later cleaned the neck around the stoma with normal saline and applied a new dressing. RT 4 did not clean the stoma with hydrogen peroxide as ordered and performed the insertion of the sterile inner cannula before cleaning the area around the stoma. In interviews, RT 4 stated she usually double gloves for suctioning and inner cannula placement, but stopped after being told not to double glove. RT 4 also stated she only performs hand hygiene before and after resident care, not between glove changes, and acknowledged she did not use hydrogen peroxide to cleanse the stoma. The RTM and DON reviewed the care and stated the resident’s order required hydrogen peroxide, hand hygiene should have been performed between glove changes, and the facility’s tracheostomy care procedure required cleaning around the stoma before inserting the sterile inner cannula. The DON stated RT 4 had a competency issue and did not demonstrate professional standards of practice for trach care.
Infection Control Failures With Suction Canister and G-Tube Venting
Penalty
Summary
The facility failed to maintain its infection prevention and control program when a suction canister for a resident with chronic respiratory failure, a tracheostomy, ventilator dependence, and a history of sepsis was observed without a label showing the resident’s name or the date it was last changed. The resident’s record showed an order to suction tracheostomy secretions every two hours and as needed, and the care plan directed suctioning every two hours and as needed with a goal of remaining free from signs and symptoms of infection. During observation, the canister was mounted behind the resident’s bed and was not labeled, and the RN stated she did not know how long it had been there because it was not labeled. The RT stated suction canisters are changed twice a week and labeled with the resident’s name, room number, and date changed, and explained that labeling is important so the suction setup is not used on the wrong resident in a shared room and for sanitary reasons because secretions can grow organisms. The RT Manager and DON both reviewed the facility policy and stated suction canisters should be labeled with the date changed and the resident’s room number or name, and that the canisters should be changed twice weekly to prevent bacteria from growing and to prevent cross contamination. The facility policy titled Suction Canister and Tubing Changed required suction canisters to be changed twice per week and labeled with the resident’s name and the date changed. The facility also failed to maintain infection control during g-tube venting for a resident with a feeding tube, severe cognitive impairment, and dependence for mobility and ADLs. The resident’s order allowed the g-tube to be vented continuously every shift, and the care plan directed GT care as ordered every shift and PRN. During observation, a 60-cc syringe labeled for venting was hanging at the resident’s headboard without a plunger and open to air with 60 cc of formula in it. The RN stated the feeding should be on a closed system and that leaving the syringe open to air can lead to gastric infection. Another RN stated the syringe was meant for g-tube venting, that the formula in the open syringe could result in gastrointestinal infection when introduced to the g-tube, and that the purpose of venting is to release gas from the gut, not for feeding. The MP and DON also stated the syringe was for manual g-tube venting and that formula backflow into the open syringe could cause infection because it was exposed to environmental contaminants. The facility policy on Gastrostomy Tube Venting described venting as a method to alleviate abdominal distention and bloating and stated that after bolus feeding the GT should be clamped for the ordered duration.
Failure to Document and Communicate Change of Condition and STAT Diagnostic Order
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a ventilator‑dependent resident with chronic respiratory failure and an anoxic brain injury received care and documentation consistent with professional standards and facility policy during a change of condition. The resident, who required total care and constant supervision and was dependent for activities of daily living, experienced tachycardia and tachypnea on 12/30/2025. A STAT chest x‑ray was ordered by a nurse practitioner (NP) via phone at 6:08 p.m., and a respiratory therapist documented at 6:28 p.m. that the resident had tachycardia and tachypnea. However, there was no corresponding Change of Condition (COC) documentation by the responsible RN that described the signs and symptoms or the events that led to the STAT diagnostic order. The facility’s Director of Nursing (DON) and RN 1 both confirmed during record review that no COC form or nursing note was completed on that date to explain why the STAT chest x‑ray was ordered. RN 1 stated that tachycardia is a change of condition and that a STAT order is definitely a change of condition, and therefore should have been charted. The DON explained that a COC is any change from a resident’s baseline, such as abnormal vital signs or breathing, and that staff who observe a COC must report it to the primary nurse, who then notifies the charge nurse. The charge nurse is then responsible for assessing the resident, contacting the physician, and completing COC documentation, including documenting physician notification and any ordered care. Because no COC documentation was completed, it was unknown whether the resident’s physician was notified of the tachycardia, tachypnea, or the STAT chest x‑ray ordered by the NP. The NP’s documentation was also deficient. Although the NP stated that nurse practitioners function under a collaborative agreement with a physician, typically notify the attending physician of COCs and orders, and that physicians co‑sign NP orders, there was no timely progress note by the NP on or immediately after 12/30/2025 explaining the clinical indications for the STAT chest x‑ray or whether the attending physician was notified. A Medical Professional Note was entered six days later, on 1/05/2026, stating that the patient had tachycardia and was placed on backup ventilator settings due to work of breathing, but the note did not clearly specify whether these findings occurred on 12/30/2025 or 1/05/2026, nor did it document physician notification regarding the STAT order. The DON stated that, as a professional standard of practice, NPs should document in their progress notes when they notify the physician about a COC or when they give an order, and that verbal or phone orders should be supported by timely documentation explaining why the order was given. Facility policies on Reporting Changes in Condition and Documentation Principles required timely communication of significant changes to the attending physician and maintenance of a current, detailed health record consistent with good medical and professional practice, which did not occur in this case.
Failure to Document Change of Condition and NP Clinical Rationale for STAT Chest X-Ray
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for one resident by not documenting a clear change of condition (COC) and related medical decision-making. The resident was admitted with chronic respiratory failure, a tracheostomy, ventilator dependence, and an anoxic brain injury requiring total care and constant supervision. On the date in question, the order summary showed that a nurse practitioner (NP 1) gave a STAT chest x-ray order by phone at 6:08 p.m. However, there was no COC documentation by the responsible RN (RN 2) describing what occurred with the resident that led to this STAT order. The only contemporaneous entry was a respiratory therapy note at 6:28 p.m. indicating tachycardia and tachypnea, which RN 1 and the DON both identified as changes from baseline that should have been documented as a COC. The facility’s Director of Nursing (DON) confirmed that there was no COC documentation in the electronic medical record describing the signs or symptoms present on that date that prompted the STAT chest x-ray. The DON stated that a COC is anything that differs from a resident’s baseline, such as abnormal vital signs or breathing, and emphasized that timely COC documentation is important to communicate significant events and ordered care to subsequent shifts and to avoid duplicate orders. The facility’s policy on Documentation Principles required that health records be current, detailed, and consistent with good medical and professional practice, and that entries be accurate, timely, specific, concise, clear, and descriptive. The absence of a COC entry for this event meant the record did not meet these stated standards. In addition, the NP did not timely document a progress or medical note explaining the clinical indications for the STAT chest x-ray or whether the attending physician was notified. NP 1 stated that typically the attending physician is updated about a resident’s COC and that the physician completes progress notes, while NP 1 documents certain procedures and family conversations. Review of the resident’s record with RN 1 showed no NP progress note on the date of the STAT order or the following day. Instead, NP 1 entered a Medical Professional Note six days later stating the patient had tachycardia and was placed on backup ventilator settings due to work of breathing, without clearly specifying whether these findings occurred on the date of the STAT order or on the date of documentation, and without indicating if the attending physician had been informed. The DON stated that, as a professional standard, a nurse practitioner should document when contacted about a COC requiring medical interventions and that NP documentation must be clear, detailed, and separate from other nurses’ notes, reinforcing that if there is no documentation, it is considered not done.
Failure to Prevent Accident Due to Inadequate Supervision and Unsafe Equipment for Pediatric Resident
Penalty
Summary
A two-year-old pediatric resident with severely impaired cognition, chronic respiratory failure with tracheostomy, ventilator dependence, and a history of liver transplant was admitted to the facility. The resident was dependent on staff for all activities of daily living and had a documented high risk for falls, with care plans and assessments indicating the need for frequent visual checks and not being left unattended. Despite these documented needs, the facility failed to ensure the resident remained free from accident hazards during bathing. On the day of the incident, a Certified Nursing Assistant (CNA) transferred the resident from a crib to an adult-sized shower bed, which had significant gaps in the side rails. The CNA raised the side rails but then turned her back on the resident to retrieve a bed sheet, leaving the resident unattended. During this time, the resident slipped through the gap in the shower bed rail and fell to the floor, sustaining a bruise on the right cheek. The CNA did not request assistance from the Registered Nurse (RN) present in the room, nor did she maintain physical contact or line of sight with the resident as required by facility policy and the equipment manufacturer's instructions. The facility had not completed an assessment to determine the safety of using adult-sized shower beds for pediatric residents and did not provide size-appropriate equipment. The facility's annual assessment and relevant policies did not address the need for pediatric-sized shower beds, and the resident's fall risk assessment was not updated after the incident. Staff interviews confirmed that the use of adult-sized shower beds for pediatric residents was standard practice, and that the risks associated with the equipment had not been adequately addressed or mitigated.
Removal Plan
- RN 3 assessed Resident 1 for any injuries and transferred to the GACH for further evaluation and was readmitted back at the facility.
- The PNM and RN 2 provided an in-service to CNA 1 regarding Patient Safety Prevention of Falls During Shower and Bathing Procedures.
- The IP revised the P&P titled, Status Post Falls/ Accident, to require an immediate post-fall IDT meeting and a care plan/risk assessment revision within 24 hours of any fall.
- The PNM and SDC started an in-service regarding Shower Beds/ Flexi Bath/ Bed Baths/ Grooming/ Falls/ Infection Control Reminders to all pediatric clinical staff including CNA 1 to not leave residents unattended and ensure residents remain in line of sight when providing bath/shower.
- Use of size-appropriate pediatric shower bed for pediatric resident with weight of less than 50 pounds. The PNM and the Infection Preventionist (IP) approved the new pediatric shower bed to ensure appropriateness for pediatric use.
- The SDC provided in-services regarding Shower Beds/Flexi Bath/ Bed Baths/ Grooming/Falls/Infection Control Reminders for pediatric licensed nurses and CNAs. The in-services required that all pediatric residents must never be left unattended/out of line of sight during bathing/showering or while on assistive devices (pediatric shower beds). The in-services included the updated P&P titled, Use of Shower Bed, and hands-on competency validation for pediatric transfers and the proper use of the new pediatric shower beds. The PNM, RN 1 and RN 2 will perform the quality and safety checks when the new pediatric shower beds arrive. Any new pediatric staff and pediatric staff on leave will receive the in-services and policies regarding pediatric equipment and bathing safety prior to giving shift baths/showers.
- The facility stopped the use of standard-sized shower beds for pediatric residents under 50 lbs.
- The facility purchased size-appropriate pediatric shower beds to be used for all pediatric residents.
- RN 1 and RN 2 provided a mandatory re-education regarding the topic Bathing Safety and Demonstration and P&Ps titled, Falls Prevention, Precautions, and Assessment, and Use of Shower Bed, on proper bathing and safety.
- RN 1 and RN 2 verbally notified staff during the beginning of each shift huddles that no pediatric residents under 50 lbs. were bathed on the standard (adult) sized shower beds.
- The IP updated the P&P titled, Use of Shower Bed, to ensure residents below 50 lbs. are not bathed/showered in standard (adult) shower bed. Residents under 50 lbs. will be showered in the pediatric-sized shower beds when they arrive. Before the arrival of the pediatric-sized shower beds, all pediatric residents less than 50 lbs. are to be given bed baths in their respective beds.
- The facility's leadership team conducted a Root Cause Analysis (RCA) to determine the cause of the deficient practice.
- The IP updated the P&P titled, Use of Shower Bed to include Resident is to always stay in line of sight of the CNA performing bath/shower. If at any moment the CNA needs to leave the resident's side during bath/shower, the CNA is to ensure there is coverage by a clinical staff member.
- The SDC, the PNM, and RN 2 in-serviced CNA 2 regarding Bathing Safety Demonstration with a return demonstration.
- The Interdisciplinary Team (IDT) reviewed and revised Resident 1's comprehensive care plan and Fall Risk Assessment. The updated plan of care included:
- The DON and RN 2 evaluated all 33 pediatric residents for potential risk for falls from the adult size shower bed. Seven (Residents 1, 3, 4, 5, 6, 7, and 8) out of 33 residents were identified at risk for falls during bathing.
- The DON and RN 2 completed evaluations for potential risk for falls from a shower bed for all 33 pediatric residents that included: a review of each resident's current Fall Risk Assessment and comprehensive care plan to ensure bathing procedures are followed, supervision needs are met, and the required bathing equipment is used; the PNM and IP performing a physical inspection and assessment of all bathing equipment used for each pediatric resident to ensure proper sizing and safety; RN 1 and RN 2 completing care plan updates for any pediatric resident requiring changes to bathing procedures and bathing equipment.
- The SDC, the PNM, RN 1 and RN 2 will be responsible for daily unit supervision and monitoring effectiveness. The SDC or Unit Charge Nurses will conduct random observational audits to ensure: only size-appropriate equipment is used for pediatric residents; care-planned bathing procedures and supervision levels are consistently followed; no pediatric resident is left unattended on any assistive device; staff can verbalize understanding of the new and revised policies.
- The SDC will report audit findings to the DON weekly and to the Quality Assurance and Performance Improvement (QAPI) committee monthly. The QAPI committee will review the data, analyze trends, and make recommendations for further action as needed. The QAPI committee will monitor on an ongoing basis until sustained compliance is achieved for three consecutive months.
Failure to Inform Resident Representatives of Arbitration Agreement Rescission Rights
Penalty
Summary
The facility failed to ensure that Business Office Staff (BOS) were knowledgeable about the residents' and their representatives' rights to rescind a binding arbitration agreement within 30 days of signing. During interviews and record reviews, it was found that the BOS did not inform the resident representatives (RRs) for three sampled residents that they could rescind their signatures on the arbitration agreement. The BOS admitted to not reading the arbitration agreement and was unaware of the 30-day rescission period, as outlined in the facility's own policy and procedure. The sampled residents all had severe cognitive impairments and were dependent on medical interventions such as tracheostomies, ventilators, and gastrostomies. In each case, the arbitration agreement was signed by the RR and the BOS, but there was no documentation or evidence that the RRs were informed of their right to rescind the agreement within the specified timeframe. The facility's policy clearly states that residents or their representatives have 30 days after signing to cancel or rescind the agreement, but this information was not communicated to the RRs by the BOS. Further interviews with the Director of Nursing (DON) and the Administrator (ADM) confirmed that the facility's policy includes a 30-day rescission period and that the BOS was responsible for explaining this to the RRs. However, both the DON and BOS acknowledged gaps in their understanding and communication of the arbitration process, resulting in the RRs not being properly informed of their rights regarding the arbitration agreement.
Failure to Enforce Staff Masking Policy During Respiratory Virus Season
Penalty
Summary
During the respiratory virus season, the facility failed to implement its infection control measures as required by its own policy. Observations revealed that three out of five sampled staff members, including an LVN and two RNs, were not wearing masks while in the facility, despite posted signage and a policy indicating that masking was mandatory in all resident care areas starting from a specified date. The staff were seen in hallways and near resident rooms without masks, and one staff member assisted a surveyor without wearing a mask. Interviews with staff indicated confusion and lack of awareness regarding the updated masking policy, with one staff member stating she was not informed of the change and did not see the posted signage due to using a different entrance. Another staff member acknowledged forgetting to wear a mask, while others confirmed they had been informed of the policy but did not comply. Review of the facility's policy and procedure confirmed that all staff were required to wear masks in resident care areas, including hallways, during the respiratory virus season, regardless of vaccination status. Both the Infection Preventionist and the Director of Nursing affirmed that hallways are considered resident care areas and that the masking policy was in effect. The failure of staff to adhere to the masking policy was acknowledged by facility leadership, who recognized that non-compliance could contribute to the spread of respiratory illnesses among residents, staff, and visitors.
Incomplete Facility Assessment Omits Pediatric Equipment and EHR Implementation
Penalty
Summary
The facility failed to maintain an accurate and up-to-date facility-wide assessment regarding the resources necessary to care for its resident population, specifically omitting critical equipment and technology updates. The assessment did not reflect the use of pediatric shower beds and other pediatric-specific bathing equipment, despite the presence of 33 pediatric residents in the facility. Interviews with the Administrator and Director of Nursing revealed that the facility assessment only listed shower chairs, and did not include pediatric shower beds or gurneys, even though these were in use or had been requested by staff. The omission was confirmed during multiple record reviews and staff interviews, with the DON acknowledging that the assessment was incomplete and missing essential equipment details for the pediatric population. Additionally, the facility assessment failed to accurately document the transition to electronic health records (EHR). Although the facility began using EHR on April 1, 2025, the assessment continued to state that medical records were paper documents and only referenced a future transition to EHR. Both the Administrator and Staff Development Coordinator confirmed in interviews that the assessment was not updated to reflect the current use of EHR, and the DON also stated that the assessment was not complete or accurate in this regard. These deficiencies were identified through interviews and record reviews, which demonstrated that the facility's assessment did not accurately represent the resources and technology in use. The lack of accurate documentation in the facility assessment had the potential to delay necessary care and services for residents, particularly for the pediatric population and in the management of health information technology.
Failure to Accurately Document Medication Administration and Cognitive Status
Penalty
Summary
The facility failed to maintain accurate and complete medical records for a resident with complex medical needs, including a history of extreme prematurity, chronic respiratory failure with tracheostomy, ventilator dependence, and liver transplant status. On the date in question, the resident was scheduled to receive tacrolimus, a critical immunosuppressive medication, at 9 a.m. The Medication Administration Record (MAR) for that time was left blank, and there was no contemporaneous documentation by the Registered Nurse (RN) who administered the medication. Although a late entry was made nearly a month later by a Licensed Vocational Nurse (LVN) who witnessed the administration, facility policy required that the original staff member document medication administration at the time of service. Multiple staff interviews confirmed that if medication is not documented, it is considered not given, and the facility's policies emphasized the importance of timely and accurate documentation. Additionally, the resident's Baseline Care Plan inaccurately documented the resident's cognitive status as intact, despite multiple assessments and staff interviews indicating the resident had severely impaired cognition and was dependent on staff for activities of daily living. The inaccurate documentation in the care plan did not reflect the resident's true condition, as confirmed by the staff and the Minimum Data Set (MDS) assessment. These documentation failures were identified through interviews, record reviews, and policy reviews. The Director of Nursing (DON) and other staff acknowledged that documentation must be accurate and completed at the time care is rendered, and that inaccurate or missing documentation could lead to confusion in care and an inaccurate plan of care for the resident.
Failure to Timely Submit Written Abuse Investigation Findings to State Agency
Penalty
Summary
The facility failed to provide the State Survey Agency (SSA) with a written report of the findings from its internal investigation of an alleged abuse incident within five working days, as required by policy. The incident involved a resident with severe cognitive impairment and significant care needs, including dependence for eating, personal hygiene, and dressing, who was admitted with diagnoses such as hypertension, tracheostomy, and gastrostomy. The alleged abuse occurred when a Certified Nurse Assistant was reported to have yelled at the resident while providing care. The Infection Preventionist was assigned to conduct interviews and prepare the final investigation report, but as of the time of the survey, the report had not been submitted to the SSA within the required timeframe. The facility's own policy mandates that a thorough investigation be conducted and a final written report be submitted to the Department of Health Services within five business days. The Administrator confirmed that while the initial report of suspected abuse was submitted, the final written investigation findings were not provided within the mandated period.
Unqualified Staff Performed Oral Suctioning Against Care Plan and Policy
Penalty
Summary
A Certified Nurse Assistant (CNA) provided oral suctioning to a resident who had chronic respiratory failure, a tracheostomy, and a gastrostomy, despite not being trained or authorized to perform this procedure. The resident's care plan specified that oral suctioning was to be performed only by licensed staff such as Licensed Vocational Nurses (LVN), Registered Nurses (RN), or Respiratory Therapists (RT). The CNA used a Yankauer suction tip to remove secretions from the resident's mouth, during which the resident bit down on the device, and the CNA had to instruct the resident to open her mouth several times to remove it. Interviews with the CNA, another CNA present, and the Director of Nursing (DON) confirmed that CNAs are not trained or permitted to perform oral suctioning, and that the facility's policy restricts this procedure to licensed clinical staff. The DON acknowledged that the CNA should have called for licensed staff assistance instead of performing the procedure. The resident's care plan and facility policy were not followed, resulting in care being provided by an unqualified person.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse within the required two-hour timeframe to the State Survey Agency (SSA) after a resident disclosed to the Social Worker (SW) that a certified nursing assistant (CNA) had touched him inappropriately. The resident, who was cognitively intact and required maximal assistance with daily activities, reported the incident to the SW, stating it had occurred about a year prior while he was in the shower. The SW documented the allegation and notified the President of Operations, but the report to the SSA was not made until the following day, exceeding the mandated reporting window. Interviews and record reviews confirmed that the SW and the President of Operations were aware of the allegation on the day it was made, but delayed reporting to the SSA because the resident did not have any injuries. The facility's policy required allegations of abuse to be reported as soon as possible, but no later than 24 hours if there was no serious bodily injury, and within two hours if abuse was involved. The delay in reporting placed the resident at risk for further abuse.
Failure to Notify Physician of Significant Change in Resident Condition
Penalty
Summary
The facility failed to notify the attending physician when a significant change in condition occurred for one resident. The resident, who had a history of chronic respiratory failure, anxiety disorder, and dependence on a respiratory ventilator, was comatose and fully dependent on staff for care. On the date in question, the resident experienced tachycardia and a low-grade temperature, which constituted a change of condition. The resident was subsequently transferred to a general acute care hospital at the request of the responsible party, who was present and aware of the transfer. Upon review of the resident's records and interviews with facility staff, it was determined that no Change of Condition (COC) form was completed for this event, and there was no documented evidence that the physician was notified of the resident's change in status. The facility's policy requires immediate notification of the physician and responsible party in the event of a significant change in condition. The Director of Staff Development confirmed that the lack of a completed COC form could result in missed communication to required parties, and acknowledged that the physician had not been notified as required by policy.
Failure to Report Alleged Abuse
Penalty
Summary
The facility failed to implement its policy and procedure for reporting an allegation of abuse involving a resident who alleged being physically abused by an employee. Despite the resident's cognitive skills being intact, the facility did not investigate or report the allegation to the California Department of Public Health (CDPH) as required. The Director of Staff Development confirmed that all staff are mandated reporters and that abuse should be reported immediately or within two hours to the appropriate authorities, including the local police, Long-term Care Ombudsman, and CDPH. However, the facility did not adhere to these protocols. During interviews and record reviews, it was revealed that the allegation of abuse was documented in the resident's progress notes, and the abuse coordinator was informed. However, the Administrator was unaware of the allegation and could not provide an investigation report or evidence of attempts to contact external investigative agencies. The facility's policy requires that any employee witnessing or being informed of an abuse allegation must report it immediately, and a thorough investigation should be conducted. The policy also mandates contacting the Department of Health within two hours of the initial report, which was not done in this case.
Failure to Adhere to Physician's Orders for Midodrine Administration
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors by not adhering to the physician's orders regarding the administration of midodrine, a medication used to treat low blood pressure. The resident, who was admitted with diagnoses including unspecified chronic respiratory failure, unspecified hypotension, and Down syndrome, was dependent on staff for all activities of daily living and was in a persistent vegetative state. The physician's order specified that midodrine should be administered every 12 hours via gastrostomy tube and held if the systolic blood pressure exceeded 110 mmHg. The deficiency occurred when the facility administered midodrine to the resident on six occasions despite the resident's blood pressure being above the threshold specified in the physician's order. Additionally, there was a failure to administer the medication on one occasion when the resident's blood pressure was below the threshold, which was necessary for blood pressure support. These actions were confirmed during interviews and record reviews with the Director of Nursing, who acknowledged that the nurses should have followed the physician's order to prevent potential increases in the resident's blood pressure. The facility's policies and procedures, including the Ten Medication Rights and Medication Administration Techniques, were reviewed and indicated that nurses should read medication labels carefully and compare them with the physician's orders to prevent medication errors. The policies also emphasized the importance of checking necessary parameters such as blood pressure before administering medications. Despite these guidelines, the facility's failure to adhere to the physician's orders resulted in significant medication errors for the resident.
Infection Control Deficiency Due to Non-compliance with Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of Registered Nurse 4 (RN 4) during the care of two residents. RN 4 did not adhere to Enhanced Barrier Precautions (EBP) when providing gastrostomy (GT) care to Resident 5, who was comatose and dependent on staff for various activities. Despite the facility's policy requiring the use of gowns, gloves, goggles, and masks during high-contact tasks like GT care, RN 4 only wore gloves and a mask, neglecting to don a gown. Additionally, RN 4 did not perform hand hygiene after removing gloves and before preparing medication for Resident 6, who also had significant medical needs, including chronic respiratory failure. This lapse in protocol occurred after RN 4 accessed Resident 5's GT, potentially risking cross-contamination between residents. The facility's infection preventionist and Director of Nursing both acknowledged that RN 4 should have worn a gown and performed hand hygiene to prevent the transmission of microorganisms. The facility's policy on Enhanced Barrier Precautions, last reviewed in early 2024, clearly outlines the necessity of wearing appropriate protective attire during high-risk tasks to prevent the spread of multidrug-resistant organisms. The failure to follow these guidelines during the care of Residents 5 and 6 highlights a significant deficiency in the facility's infection control practices, as observed and documented by the surveyors.
Failure to Administer Medication as Ordered
Penalty
Summary
The facility failed to provide pharmaceutical services by not following the physician's orders for a resident, which had the potential to affect the resident's blood pressure management. The resident was admitted with chronic respiratory failure, end-stage renal disease, and diabetes mellitus, and was noted to have severely impaired cognitive skills. The care plan included an intervention to administer medication as ordered, specifically hydralazine for hypertension, to be given every eight hours via a gastrostomy tube. However, a review of the resident's medication record for October revealed that on one occasion, the administration of hydralazine was not documented, indicating the medication was not given. Interviews with a registered nurse and the Director of Nursing confirmed that if the medication record is left blank, it means the medication was not administered. This oversight was contrary to the facility's policy, which requires nurses to sign the medication record after administering medication to ensure accurate documentation and prevent medication errors.
Incomplete Medical Records and Medication Administration
Penalty
Summary
The facility failed to maintain accurate and complete medical records for a resident, which had the potential to cause confusion in care and delay the delivery of care. The resident was admitted with chronic respiratory failure, end-stage renal disease, and diabetes mellitus. The resident's cognitive skills for daily decisions were severely impaired. On a specific date, the resident's blood pressure was recorded as extremely high, and medications were administered by an LVN as instructed by an RN. However, the Medication Record for that day was incomplete, with lisinopril left blank and captopril recorded at an incorrect time. During interviews, the LVN admitted to administering the medications but forgetting to sign the Medication Record, acknowledging that such omissions could lead to medication errors. The DON confirmed that unsigned medication records imply that the medication was not given, emphasizing the importance of signing the Medication Record after administration. The facility's policy on Medication Error and Record Completion was reviewed, which mandates maintaining accurate and complete health records, and correcting deficiencies timely in accordance with professional standards.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that the pad call lights were within reach for four of the six sampled residents, which could potentially delay the provision of necessary care and services. Resident 463, who was admitted with a tracheostomy, gastrostomy, and nontraumatic intracranial hemorrhage, was observed with the pad call light placed on top of the ventilator, out of reach. The Director of Staff Development confirmed that the call light should be within reach to allow the resident to call for help when needed. The Director of Nursing also acknowledged that the failure to keep the call light within reach could result in the resident being unable to call for help and potentially falling while trying to reach it. Resident 75, diagnosed with chronic respiratory failure, tracheostomy, and spastic quadriplegia cerebral palsy, was observed with the call light placed on top of a pulse oximeter machine, not within reach. The Licensed Vocational Nurse verified that the call light should have been placed closer to the resident's cheek area to enable them to call for assistance. The facility's policy and procedure on call lights, which mandates that call lights be placed within reach and monitored for positioning, was not followed. Resident 18, with similar diagnoses and impairments as Resident 75, had their call light hanging between the mattress and the left upper siderail, out of reach. The Licensed Vocational Nurse confirmed that the call light should be within reach to allow the resident to ask for assistance. Similarly, Resident 4, diagnosed with cerebral palsy and gastrostomy, had their call light on the floor outside the bed frame enclosure. The Certified Nurse Assistant stated that the call light should be within reach to enable the resident to call for help. The Director of Nursing reiterated the importance of having the call light within reach to prevent delays in meeting the residents' needs.
Failure to Protect Resident PHI in Medication Disposal
Penalty
Summary
The facility failed to maintain the confidentiality of residents' protected health information (PHI) by not properly disposing of medication labels containing sensitive information. During an observation in the biohazard room, it was found that medication bubble packs for two residents had their pharmacy labels intact and visible through clear plastic bags in a waste container. This oversight exposed the residents' PHI, including their names, dates of birth, and medication details, to potential unauthorized access. Interviews with the Director of Nursing (DON) and Registered Nurse (RN) 3 revealed that the facility's process for disposing of medication labels was not consistently followed. The DON acknowledged that the labels should have been removed, shredded, or covered with an Identi-Hide label before disposal to protect resident confidentiality. RN 3 confirmed that the failure to cover or remove resident information from medication bubble packs was a violation of HIPAA guidelines, as it exposed PHI to third-party vendors responsible for waste disposal. The Director of Staff Development (DSD) and the Consultant Pharmacist (CP) both emphasized the importance of adhering to HIPAA guidelines, which require PHI to be shredded or covered before disposal. The facility's policy and procedures, as well as the in-service lesson plan, clearly outlined the need to protect resident information by shredding or covering it. Despite staff being educated on these guidelines, the facility did not consistently implement the necessary measures to safeguard resident privacy, resulting in a breach of confidentiality.
Inadequate Restraint Assessments and Consents
Penalty
Summary
The facility failed to ensure that residents were free from the use of physical restraints unless needed for medical treatment. This deficiency was observed in six residents who were subjected to physical restraints without proper assessments, physician orders, informed consent, or care plans. The facility did not perform the required Bedrail/side rail Use and Entrapment Risk Evaluation quarterly for several residents, including those with severe cognitive impairments and physical disabilities, which could lead to potential harm such as entrapment. For Resident 37, the facility did not obtain a physician's order, assess the need for the restraint, or obtain informed consent for the use of a restraint bed placed against the wall. Additionally, there was no care plan developed or implemented for this restraint. Similarly, Resident 71 was subjected to the use of a left-hand mitten without the necessary initial and quarterly restraint assessments or informed consent, and Resident 45 had a right-hand mitten applied without quarterly assessments. The facility's policies and procedures required evaluations and informed consent for the use of restraints, but these were not followed. Interviews with staff, including the Director of Nursing and the Minimum Data Set Coordinator, confirmed that the necessary assessments and consents were not completed as per facility policy. This lack of compliance with established protocols resulted in the inappropriate use of restraints, potentially restricting residents' freedom of movement and increasing the risk of physical harm.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for three residents, leading to potential delays in care and services. Resident 45, who was admitted with chronic respiratory failure, tracheostomy, and gastrostomy, had a physician's order for the application of a right-hand mitten to prevent pulling out life-sustaining tubes. Despite the order, no care plan was developed to address the use of the mitten, as confirmed by the Minimum Data Set Coordinator. This oversight meant that staff were not adequately informed of the resident's care needs, risking delays in care. Resident 37, admitted with chronic respiratory failure and dependence on a respirator, had their bed placed against the wall, which was considered a restraint. The resident required moderate assistance with mobility and activities of daily living. However, there was no care plan in place to address the bed's placement, as noted by Registered Nurse 6. The lack of a care plan for this restraint meant that the resident's safety and mobility needs were not formally documented or communicated to the care team. Resident 463, who had severe cognitive impairment and was dependent on mobility and activities of daily living, had an order for the use of full side rails for safety. Despite this, no care plan was developed to ensure the safe use of the bedrails, as observed by Registered Nurse 2. The absence of a care plan for the bedrails posed a risk of accidents such as entrapment, as the care team lacked formal guidance on managing this aspect of the resident's care.
Failure to Rotate Insulin Injection Sites
Penalty
Summary
The facility's licensed nursing staff failed to adhere to professional standards of care by not rotating the subcutaneous insulin administration sites for a resident, identified as Resident 81. This resident was admitted with chronic respiratory failure, a tracheostomy, and type 2 diabetes mellitus, and was noted to have severely impaired cognition, requiring total assistance with activities of daily living. The failure to rotate insulin injection sites was identified during a review of the resident's Medication Administration Record (MAR) for the months of August, September, and October 2024. The MAR indicated that both Humulin N and Regular insulin injections were repeatedly administered in the same areas, such as the left lower quadrant and right lower quadrant, without proper rotation. This practice was confirmed by Registered Nurse 2 (RN 2) and the Director of Nursing (DON), who both acknowledged that the insulin administration sites were not rotated as per the standards of practice and the manufacturer's guidelines. The facility's policy and procedure for insulin administration, as well as the manufacturer's guidelines, clearly stated the need for site rotation to prevent complications such as lipodystrophy and localized cutaneous amyloidosis. The DON verified that the nurses did not follow the manufacturer's guidelines, which emphasized the importance of changing injection sites to reduce the risk of skin complications and ensure proper medication absorption. The facility's policy also required the use of proper subcutaneous techniques, which were not adhered to in this case. This oversight in insulin administration practices had the potential to adversely affect the resident's health by causing skin lumps, bruising, and affecting insulin absorption.
Failure to Adhere to Physician Orders for ROM Devices
Penalty
Summary
The facility failed to provide appropriate services to prevent decline in joint range of motion (ROM) for three residents, as observed during a survey. Resident 15 was found to have been wearing hand splints for longer than the physician-ordered duration of one hour, which could potentially lead to skin irritation or lesions. The Restorative Nursing Aide (RNA) admitted to applying the splints for two hours instead of the prescribed one hour, and this discrepancy was confirmed by both the Registered Nurse (RN) and the Director of Rehabilitation. The facility's policy required adherence to physician orders regarding the duration of splint application, which was not followed in this case. Resident 93 was observed with hand rolls improperly placed around the wrists instead of inside the hands, contrary to the physician's order for them to be worn at all times. This improper application was noted by a Licensed Vocational Nurse (LVN), who corrected the placement. The RN and Director of Nursing (DON) confirmed that hand rolls are essential to prevent contractures and skin issues, and they should be applied correctly as per the orders. The facility's policy also emphasized the importance of following physician orders for hand roll application. Resident 94 was found without the required hand rolls and heel protectors, which were ordered to be worn at all times. An LVN observed the resident without these devices and proceeded to apply them, noting that their absence could lead to contractures and pressure injuries. The RN and DON reiterated the necessity of following orders for these protective devices to prevent skin breakdown and other complications. The facility's policy mandated that such orders be noted and carried out, which was not adhered to in this instance.
Failure to Maintain a Safe Environment for Residents
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for four residents. Resident 19's medications, Albuterol and Atrovent, were left at the bedside, posing a risk of accidental overdose. The resident, who lacked the capacity to understand and make decisions, was at risk due to the staff's failure to store medications safely. The facility's policy required an assessment and a physician's order for self-administration of medications, which was not followed in this case. Resident 35's bottle of milk of magnesia was also left at the bedside, despite the resident having the capacity to understand and make decisions. The staff did not adhere to the facility's policy of storing medications safely unless a physician's order and interdisciplinary team assessment deemed the resident capable of self-administration. This oversight could lead to accidental overdosing, as acknowledged by the Licensed Vocational Nurse and the Director of Nursing. Resident 100's fall mat was improperly used, with the bed's wheels resting on it, compromising its effectiveness in preventing injury from falls. The resident, who had impaired vision and required substantial assistance, was at risk due to the sitter's inattention to environmental hazards. Additionally, Resident 87's bed was left in a high position by an X-ray Tech, increasing the risk of falls for a resident with severely impaired cognition and high fall risk. The facility's policies on fall prevention and accident prevention were not followed, as staff failed to ensure the bed was returned to a safe position after the procedure.
Deficient Catheter Care Leads to Potential UTI Risks
Penalty
Summary
The facility failed to provide appropriate care for residents with urinary catheters, leading to potential risks of catheter-associated urinary tract infections (CAUTIs). Resident 80, who had a suprapubic catheter, was observed without a securement device or leg strap, which is necessary to prevent pulling and trauma to the stoma. This oversight was confirmed by both a Licensed Vocational Nurse (LVN) and the Director of Nursing (DON), who acknowledged that the absence of a securement device could lead to skin trauma and serve as a portal for infection. Residents 7 and 94 were found with coiled urinary catheter tubing, which can impede urine flow and increase the risk of infection. Resident 7, who had an indwelling catheter, was observed with coiled tubing below the bed, confirmed by an LVN who noted the potential for infection and catheter dislodgement. Similarly, Resident 94's catheter tubing was coiled, with visible sediment in the urine, indicating improper drainage. The DON confirmed that catheter tubing should be free of coils to ensure proper urine flow and prevent urinary retention, which can lead to UTIs. The facility's policy and procedure on catheter care, last reviewed in January 2024, emphasized the importance of securing catheter tubing to prevent kinks and loops. However, the observations and interviews revealed that these guidelines were not consistently followed, resulting in deficiencies in catheter care for the residents involved. These practices put the residents at risk for developing CAUTIs due to improper catheter management.
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Nursing homes near North Hollywood
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Valley Palms Care Center | 1.8 mi | ★★★★★ | 11 | 0 |
| Valley Vista Nursing And Transitional Care Llc | 2.2 mi | ★★★★★ | 22 | 0 |
| Villa Scalabrini Special Care | 2.2 mi | ★★★★★ | 10 | 0 |
| Valley Village Care Center | 2.3 mi | ★★★★★ | 27 | 0 |
| Pacifica Hospital Of The Valley Dp Snf | 2.3 mi | ★★★★★ | 22 | 0 |
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