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 Alvarado Care Center during CMS and state inspections, most recent first.
A resident with multiple complex diagnoses and generally intact cognition developed new left knee pain and swelling that prompted an X-ray order to rule out fracture, indicating a significant change in condition. Despite facility policy and leadership expectations that licensed nurses assess and document changes, report incidents such as falls, and update the care plan, there was no documented assessment of the knee swelling, no incident or fall investigation, no clear EMR documentation of the change in condition, and no care plan updates addressing pain, altered mobility, or risk for further injury.
A resident with liver disease, reduced mobility, cellulitis, thrombocytopenia, and muscle weakness developed new left knee pain and swelling, for which an X-ray was ordered to rule out fracture, indicating a significant change in condition. The resident later reported by voicemail that she had fallen, had left knee pain, and believed staff had not accurately documented the event or managed her care needs. Record review with the RN Supervisor showed there was no documented assessment of the knee swelling, no incident or investigation of a possible fall or injury, no clear documentation of the change in condition in the EMR, and no updated care plan addressing pain, impaired mobility, or risk for further injury, despite facility policy and the DON’s expectation that licensed nurses revise care plans when conditions change.
A resident with DM2, hypoglycemia, and osteoporosis with fracture, who required staff assistance for multiple ADLs, activated a call light that did not register at the nurse’s station, revealing a non-functioning call system. The resident reported delayed staff responses and that the call light sometimes did not work. A CNA confirmed the call light cable was not fully connected and admitted forgetting to check it during morning rounds. The DON stated department heads were expected to conduct daily rounds to verify call light functionality, and facility policy required a working call system or alternative bell with documented safety checks when the primary system was inoperable.
A facility failed to clearly link psychotropic meds to documented diagnoses and specific behaviors for two residents. One resident’s Risperdal use was tied to multiple diagnoses in the record, making the true indication unclear, while another resident’s Risperdal and Depakote orders cited vague disruptive and aggressive behaviors without specific examples, individualized nonpharmacologic approaches, or resident-centered goals. The same resident’s Cymbalta also lacked adverse-effect monitoring on the MAR, and the DON stated the behavior descriptions were too vague and that psychotropics must be monitored for side effects.
Inaccurate MDS Section I Diagnoses: The facility failed to accurately record active psychiatric diagnoses for two residents. One resident’s record included dementia, schizoaffective disorder, and later bipolar disorder treatment with Risperdal, but the MDS omitted the psychiatric diagnoses. Another resident’s record included schizophrenia and treatment with sertraline for depression, but the MDS did not list depression. The DON stated the MDS assessments were inaccurate because they did not reflect the clinical record.
The facility failed to create individualized care plans for a resident at high risk for falls, a resident who required supervision or touch assistance with meals due to severe vision loss, and a resident receiving Depakote and Risperdal for aggressive or disruptive behaviors. Records and staff interviews confirmed the fall risk was not care planned after actual falls, meal assistance needs were not addressed despite assessments showing the resident needed help, and behavioral care plans lacked specific target behaviors, non-pharmacologic interventions, and resident-centered goals.
A resident with dementia had a care plan that was not personalized and contained only one generic cognition intervention despite severe cognitive impairment and total dependence for many ADLs. Another resident identified as high risk for falls was removed from the Falling Star Program even though the quarterly assessment still showed fall risk, and the fall care plan was not followed. A third resident who smoked required supervision and was not a safe smoker, but the smoking care plan was not documented as implemented; the resident was observed smoking without a smoking apron and handling ashes with contracted hands.
A resident with impaired hand function and smoking supervision needs was observed smoking without the required smoking apron, while staff could not show documentation that the apron was offered or refused, and the care plan interventions were not documented as carried out. Another resident with Huntington’s disease, an unsteady gait, and high fall risk had falls with no documented post-fall assessment for one event, no 72-hour neuro checks for either event, and no timely IDT review or care plan revision after the later fall.
A resident with ADHD and major depressive disorder missed five scheduled doses of Adderall after the facility ran out of the medication and the refill was not obtained in time. The MAR and nurse notes showed a partial dose followed by multiple missed doses while the pharmacy refill was pending, and the DON stated refill requests should be made several days in advance for controlled meds. The resident said repeated medication delays made her feel overwhelmed and anxious.
Expired meds and an unlabeled inhaler were found during survey in medication storage areas. An opened insulin aspart pen for a resident was past its 28-day use period, two vials of injectable lidocaine and one vial of injectable haloperidol in the E-kit were expired, and an opened Arnuity Ellipta inhaler for another resident was missing the required open date.
Diet orders were not followed during tray line service when a dietary aide failed to communicate allergy information from meal tickets to the cooks. A resident on a gluten free pureed diet received pureed country fried steak with gravy instead of a hamburger and baked potato, and a resident on a lactose intolerance diet received potato au gratin containing milk. The DS verified the wrong foods were served, and staff stated the meal tickets, resident preference list, and menu were not followed.
Minced and moist meals were served in the wrong texture when a cook chopped breaded beef patties into inconsistent, sometimes 1-inch pieces instead of mincing them to IDDSI Level 5 size, and the potato au gratin was also not minced. During tray line observation, the country fried steak appeared dry and overcooked, and staff acknowledged the food should fit through fork prongs and be prepared to the facility’s minced and moist standard for residents on this diet.
Unsafe Food Storage and Labeling Practices: Clean resident trays and cups were stored next to a handwashing sink in the splash zone, the dry storage floor was dirty with debris and trash, and expired or improperly stored food items were found in storage areas. Nutrition shakes were kept without thaw dates despite instructions to use within 14 days of thawing, and food in a resident refrigerator was left unlabeled or expired, including open deli items and expired yogurt smoothies.
A resident with schizophrenia and documented decision-making capacity was started on Cymbalta for phantom limb pain without documented informed consent. The record contained no evidence that the resident or a responsible party was educated on the risks and benefits before the psychotropic medication was initiated, and the DON stated the facility was unaware consent was needed because the drug was not being used for behavioral management.
Failure to Provide Meal Assistance for a Blind Resident: A resident with severe vision loss, dementia, dysphagia, and cognitive deficits was observed eating lunch without staff assistance even though records showed she needed supervision or maximum assist with meals. Speech therapy and dietary documentation noted she was blind and needed verbal cues and help locating food, but no staff member assisted her during the meal. The IP, RN, and DON stated there was no IDT care plan for meal assistance, no documentation that she refused help, and another resident should not have been assisting her.
Failure to complete PASRR for a resident with bipolar disorder and schizophrenia. The DON reviewed the EMR and PASRR website and could not locate a PASRR for the resident, and the ADM also could not provide proof that one had been completed before admission or transfer. The facility policy required PASRR Level I screening prior to admission for all applicants.
A resident with cerebral palsy, DM, malnutrition, intellectual disabilities, heart failure, schizophrenia, and a large upper back wound had a low air loss mattress observed set for 300 to 350 pounds despite weighing 79 pounds. LVNs and an RN stated the mattress setting should have matched the resident’s weight, and the DON confirmed the resident could not verbalize comfort and that the mattress dial is adjustable to weight and comfort.
A resident with an indwelling foley, DM, ESRD on dialysis, and BPH had cloudy urine, pain at the penile shaft, foul-smelling urine, and recurrent UTIs, including ESBL in the urine and a complicated UTI requiring IV ABX. The record showed no ongoing assessment of catheter use/removal, no urine output monitoring order, and no care plan revision or IDT review after the UTIs and change in condition.
A resident with HIV did not receive the prescribed medication Biktarvy for six consecutive days due to lack of supply, with incomplete documentation for the missed doses. The resident expressed concern about the missed medication and related health issues, while an LVN confirmed the medication was unavailable and that proper protocol was not followed. The DON acknowledged the facility's failure to ensure medication availability and proper documentation.
A resident with HIV did not receive the prescribed medication Biktarvy for six consecutive days due to lack of supply, with incomplete documentation and follow-up by nursing staff. The resident expressed concern about missed doses and experienced symptoms, while staff interviews confirmed lapses in medication management and adherence to facility policy.
A resident with multiple health conditions and high fall risk was admitted without a comprehensive care plan addressing fall prevention. Despite facility policy and assessment findings, no individualized fall risk interventions were documented, as confirmed by the DON during record review.
A resident with multiple health conditions and impaired cognition experienced two falls. Although documentation indicated the care plan was updated, review showed the care plan was not revised until days after the incidents, contrary to facility policy requiring timely updates and new interventions after falls.
A resident with multiple health conditions, including diabetes and dysphagia, repeatedly refused meals over several days. Despite care plan requirements and facility policy mandating notification of the physician and RD after such refusals, there was no documentation that these notifications occurred, resulting in the resident not receiving timely nutritional interventions.
A resident with multiple health conditions and impaired cognition had fall risk assessments that failed to indicate their correct fall risk status and inaccurately documented their fall history. The assessments did not specify whether the resident was at low or high risk for falls, and one assessment incorrectly stated there was no history of falls, despite evidence to the contrary. These documentation errors resulted in an incomplete and inaccurate medical record.
A resident with multiple medical conditions, including cognitive impairment and a history of falls, sustained a right femur fracture after a witnessed fall. The facility did not report this major accident to the State Agency, as required by regulations, due to an outdated policy and staff misunderstanding of reporting requirements.
A resident with dementia and impaired decision-making capacity was scheduled for an MRI without the POA being notified, despite facility policy requiring representative involvement in care decisions. Both the LVN and DON confirmed the POA should have been informed, and the POA stated she always accompanies the resident to appointments due to the resident's inability to self-advocate.
A resident with a sacrococcyx pressure injury was found lying on a chux placed on a low air loss (LAL) mattress, contrary to physician orders, manufacturer instructions, and facility policy. Staff interviews confirmed that the chux should not have been used with the LAL mattress, as it could interfere with the mattress's function and the resident's comfort and healing.
A resident with dementia, hypertension, and depression did not have multiple prescribed medications properly documented as administered, with several doses not signed for on the MAR and no reasons recorded for missed doses. The DON confirmed that the MAR should be signed immediately after administration, and the facility's policy requires this documentation. This failure resulted in uncertainty about whether medications were given and did not meet the resident's needs.
The facility failed to create individualized care plans for three residents, leading to potential delays in care. A resident with pressure ulcers lacked a care plan for ulcer management, another resident on Lexapro did not have a timely care plan for medication use, and a third resident refusing tube feedings had no care plan to address this issue. These deficiencies were confirmed by facility staff.
The facility failed to monitor behaviors and side effects of antipsychotic medications for two residents, leading to potential risks of unnecessary medication and adverse effects. One resident was prescribed Risperdal for bipolar disorder without monitoring for behaviors or side effects. Another resident, with multiple diagnoses, was prescribed Risperidone and Valproic acid, but there was no documentation of monitoring for side effects or behavioral episodes. The facility's policy required daily monitoring, which was not followed, as confirmed by nursing staff and the DON.
The facility failed to ensure proper food storage practices in the kitchen, with unlabeled and undated frozen food items found in the freezer, and personal items improperly stored in the dry food storage area. These actions were against the facility's policies, which require all food to be labeled and dated and personal belongings to be kept in designated areas.
The facility did not follow its policy for labeling and storing food brought in by visitors, as several items in the residents' refrigerator were found without labels indicating the resident's name or the date of arrival. This oversight was confirmed by an RN and the DON, who emphasized the importance of labeling to ensure dietary compatibility and prevent spoilage.
A facility failed to comprehensively assess a resident's oral health upon admission, leading to an oversight of missing upper teeth. Despite the resident's intact cognition and need for assistance with daily activities, the MDS did not report any denture issues. The oversight was confirmed during an interview, and the DON acknowledged potential health deterioration due to the inaccurate assessment.
A facility failed to conduct a quarterly Braden scale assessment for a resident at high risk for pressure ulcers. The resident, with a stage 3 pressure ulcer, was last assessed in August, missing the required assessment in November. Interviews with the RN and DON confirmed the lapse, which could lead to a worsening of the resident's condition due to unidentified necessary interventions.
A facility failed to transmit a resident's MDS assessment to CMS within the required timeframe, as confirmed by the facility's VP of Clinical Services and MDS Resource. The resident, with diagnoses including dementia and diabetes, had severely impaired cognitive skills and was dependent on staff for daily activities. The MDS was submitted and accepted beyond the 14-day requirement, contrary to the facility's policy.
A resident at risk for pressure ulcers had their Low Air Loss Mattress (LALM) set incorrectly at 120 pounds instead of their actual weight of 99 pounds. Despite a physician order discontinuing the LALM, it remained in use, potentially causing discomfort and hindering skin condition improvement. The facility's policy on pressure ulcer prevention was not followed, as confirmed by staff interviews and record reviews.
A resident with multiple diagnoses and a history of falls did not have their fall care plan revised after certain falls, and their fall risk was inaccurately assessed as low. This led to a lack of appropriate interventions to prevent further falls. Facility staff confirmed these deficiencies, acknowledging that care plans were not revised post-fall and fall risk assessments were incorrect.
A facility failed to store latanoprost eye drops, used for treating glaucoma, in the refrigerator as required by the manufacturer. An unopened bottle was found at room temperature in a medication cart. The LVN and DON acknowledged the error, noting that improper storage could reduce the medication's effectiveness.
A facility failed to follow its infection control policy when an LVN did not perform hand hygiene between administering eye drops to a resident's eyes, risking cross-contamination. The resident had chronic conditions and required assistance with daily activities. Interviews revealed a lack of awareness of the policy among staff.
Two residents did not receive prescribed ROM exercises on specific dates, as the facility failed to ensure restorative nursing assistants performed the exercises. Additionally, care plans addressing the residents' restorative needs were not created, contrary to facility policy. This oversight involved residents with conditions requiring consistent ROM exercises, such as a fracture and Huntington's disease.
A resident with severe cognitive impairment alleged that someone entered their room and placed a hand over their mouth. Despite the incident being reported and the resident's inability to provide details, the facility failed to create a care plan addressing the allegations. The resident required substantial assistance with daily activities and had multiple diagnoses, including cerebrovascular disease and anxiety disorder. The facility's policies mandated care plan updates for changes in condition, but this was not followed.
A resident with severe cognitive impairment and multiple diagnoses reported an incident where someone allegedly entered her room and placed a hand over her mouth. The social service designee filed a grievance report but failed to document further services provided, contrary to facility policy requiring documentation of psychosocial evaluations upon a change of condition.
A resident with severe cognitive impairment alleged that someone entered their room and placed a hand over their mouth. The incident was inaccurately documented by a registered nurse supervisor as a physical assault by a staff member, contrary to the facility's policy on maintaining clear and accurate medical records.
A resident with a history of aggressive behavior hit another resident, causing harm, due to inadequate care planning and monitoring. Despite known behavioral issues, the facility failed to update the care plan and prevent the altercation, resulting in the victim being transferred to a hospital for evaluation.
A facility failed to develop a care plan for a resident prescribed psychotropic medications, including Paxil, Seroquel, and Risperdal, despite the resident's diagnoses of psychosis, schizoaffective disorder, and depression. Interviews confirmed the absence of a care plan, which is required to ensure appropriate care and monitoring of potential side effects.
A facility failed to obtain informed consent for a resident's increased dosage of Fluvoxamine Maleate, a medication for depression. The resident initially consented to 50 mg, but the dosage was increased to 100 mg without a new consent, contrary to the facility's policy. This was confirmed by the RN Supervisor and Administrator, highlighting a lapse in following the required procedure for medication changes.
A resident with dementia and major depressive disorder made significant financial withdrawals without the knowledge of her Durable Power of Attorney (POA), despite her medical condition indicating a lack of decision-making capacity. Facility staff believed the resident could make her own decisions, leading to a violation of the resident's rights and placing her at risk.
Two residents experienced disturbances due to a roommate playing loud music and TV late at night, disrupting their sleep. Despite complaints to staff, no care plan was developed to address the noise issue, violating the facility's policy for a homelike environment.
The facility failed to implement a comprehensive care plan for three residents, leading to sleep disturbances for two residents due to their roommate's nighttime noise. Despite multiple complaints and staff awareness, no care plan was developed to address the situation.
A resident with nicotine dependence, COPD, and other health issues was not properly assessed for smoking safety, leading to potential fire hazards. The facility's policy required a safe smoking assessment and care plan, which were not implemented, despite the resident's family and physician advising against smoking.
Failure to Assess, Document, and Care Plan Resident’s Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to appropriately assess, report, document, and care plan a significant change in condition for one of three sampled residents. The resident was admitted with hepatic encephalopathy, cirrhosis of the liver, reduced mobility, cellulitis of the left leg, thrombocytopenia, and muscle weakness, and had intact cognitive skills and mostly independent or supervised ADL function per the MDS dated 3/15/2026. On 2/17/2026, the resident developed pain and swelling in the left knee, and a physician order was obtained for an X-ray to rule out fracture, indicating a significant change in condition. The facility’s process, as described by the RN Supervisor, required CNAs to report unusual circumstances to licensed nurses, document them in a Change of Condition Binder, and for licensed nurses to review the binder and complete prompt assessments. Record review showed there was no documented assessment identifying the cause of the knee swelling, no documented incident or investigation related to a possible fall or injury, no evidence of notification or clear documentation of the change in condition in the EMR, and no updated or revised care plan addressing pain, altered mobility, or risk for further injury. The DON stated that licensed nurses are responsible for assessing and documenting changes in condition, reporting and documenting incidents such as falls, and updating the care plan in the EMR to reflect current needs, goals, and interventions, as also outlined in the facility’s Change of Condition Notification policy dated October 1, 2023. Despite these stated responsibilities and policy requirements, the resident’s left knee pain and swelling were not properly assessed, reported, documented, or incorporated into the comprehensive care plan.
Failure to Update Care Plan After Significant Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement an updated, person-centered care plan following a significant change in condition for one of three sampled residents. The resident was admitted with hepatic encephalopathy, cirrhosis of the liver, reduced mobility, cellulitis of the left leg, thrombocytopenia, and muscle weakness. An MDS assessment showed the resident had intact cognitive skills and was largely independent with most ADLs, requiring only supervision or setup assistance for some tasks. On a later date, the facility received a voicemail from the resident reporting that she had experienced a fall, had left knee pain, and believed the nurse did not accurately document the event. The resident also expressed dissatisfaction with staff not managing her care needs, though further clarification could not be obtained because she had already been discharged and could not be reached by phone. Record review with the RN Supervisor showed that on a specific date the resident developed pain and swelling in the left knee, and a physician order was obtained for an X-ray to rule out fracture, which constituted a significant change in condition. However, the medical record contained no documented assessment identifying the cause of the knee swelling, no incident report or investigation related to a possible fall or injury, and no evidence of notification or clear documentation of the change in condition in the EMR. There was also no updated or revised care plan addressing the resident’s pain, altered mobility, or risk for further injury. The DON stated that licensed nurses are responsible for documenting changes in condition, completing appropriate assessments, and updating the care plan in the EMR, and the facility’s care planning policy required the interdisciplinary team to revise the care plan as needed to address changes in behavior and care and changes in the resident’s condition.
Failure to Ensure Functioning Call Light System and Verification Rounds
Penalty
Summary
The deficiency involves the facility’s failure to ensure that the resident call light system in a resident’s room functioned properly and was consistently checked by staff. A resident with diagnoses including type 2 diabetes, hypoglycemia, and osteoporosis with fracture required varying levels of staff assistance for activities of daily living such as toileting, showering, dressing, and transfers, as documented on the MDS. During an observation and interview in the resident’s room while the resident was eating lunch, the resident activated the call light, but the call light failed to illuminate at the nurse’s station, demonstrating that the system was not functioning properly. The resident reported that staff response times were sometimes delayed and that at times the call light did not work, which contributed to delays in assistance. During an interview immediately following the observation, a CNA confirmed that the call light cable in the resident’s room was not fully connected and acknowledged that she had forgotten to check the call light connection during morning rounds. In a separate interview, the DON stated that department heads were expected to conduct daily rounds to ensure call lights were functioning properly to support timely response to resident needs and prevent delays in care. Review of the facility’s “Communication – Call System” policy indicated the facility would provide a call system to enable residents to alert nursing staff from beds and toileting facilities, and that if the primary call system became inoperable, a bell would be provided for each resident room with hourly resident safety check rounds documented until the primary system was operable again. The observed non-functioning call light and missed verification of its connection were inconsistent with these expectations and policy provisions.
Psychotropic Medication Orders Lacked Clear Diagnoses, Behavior Definitions, and Adverse-Effect Monitoring
Penalty
Summary
The facility failed to ensure psychotropic medication use was tied to clearly documented diagnoses and specific behaviors for two residents. For one resident, Risperdal was ordered for bipolar disorder, but the record also referenced dementia, schizophrenia, and schizoaffective disorder, and the DON stated the diagnosis related to the medication was unclear. The resident’s H&P indicated the resident had capacity to understand and make medical decisions, and the psychiatric follow-up note identified schizoaffective disorder as the diagnosis related to Risperdal use. The facility’s policy required psychotherapeutic medication orders to include the diagnosis and the indications and manifestations of the disorder treated. For another resident, the record showed diagnoses including schizophrenia and orders for Risperdal and Depakote for disruptive and aggressive behavior, but the psychiatric note did not describe specific problematic behaviors or examples. The available care plans did not address disruptive or aggressive behavior related to schizophrenia, and the care plans for Risperdal and Depakote did not include specific examples of the resident’s behaviors, individualized non-pharmacological approaches, or resident-centered therapeutic goals for reducing those behaviors. The DON stated the behaviors were vague and should have been defined more specifically so nursing staff could monitor them appropriately. The same resident also had Cymbalta ordered for phantom limb pain, but the January 2026 MAR did not show monitoring for adverse effects related to Cymbalta. The DON stated psychotropics must be monitored for adverse effects to ensure the benefits outweigh the risks, and that the facility failed to monitor adverse effects related to Cymbalta. The report states that failing to define behaviors and monitor adverse effects could result in the resident being on psychotropic medications longer than necessary and experiencing more adverse effects than necessary.
Inaccurate MDS Section I Diagnoses
Penalty
Summary
The facility failed to accurately complete MDS Section I, active diagnoses, for two residents by omitting psychiatric diagnoses documented in the medical record. For one resident, the admission record listed dementia, the H&P stated the resident had capacity to understand and make decisions, and a psychiatric follow-up note identified schizoaffective disorder related to Risperdal use. The resident’s MDS dated 12/28/2025 did not include schizophrenia, schizoaffective disorder, or bipolar disorder in Section I, even though the order summary later showed Risperdal 1.5 mg daily for bipolar disorder manifested by throwing objects and fighting with staff, and the care plan had been updated to bipolar disorder. For the second resident, the admission record listed schizophrenia and the H&P stated the resident had capacity to understand and make medical decisions, but the MDS Section I dated 10/14/2025 did not include depression. The care plan related to sertraline identified depression manifested by excessive crying for her husband, and the order summary showed sertraline 25 mg daily for depression manifested by uncontrollable crying for husband. In interviews, the DON stated the MDS assessments were inaccurate because they did not reflect the psychiatric diagnoses and treatment documented in the clinical record.
Failure to Develop Individualized Care Plans for Falls, Meal Assistance, and Behavioral Needs
Penalty
Summary
The facility failed to develop and implement individualized, person-centered care plans for multiple identified needs. For Resident 54, the record showed the resident was re-admitted with diagnoses including lack of coordination, muscle weakness, cognitive communication deficit, gait and mobility abnormalities, and dementia. A fall risk assessment dated 11/11/2025 showed a score of 80, indicating high fall risk, and the change in condition evaluation documented that the resident fell in the hallway, lost balance, landed on his bottom, and hit his back on a closed door, with mild pain to the back and sacrum. Although the care plan report later documented actual falls on 11/11/2025 and 1/9/2026, the active care plans did not include a specific at-risk-for-falls care plan. During interviews, the LVN, RN, and DON all verified that the resident was high risk for falls and that no at-risk-for-falls care plan had been created. For Resident 69, the admission record and assessments showed severe visual impairment, dementia, dysphagia, cognitive communication deficit, and need for supervision or touching assistance with eating. Speech therapy noted the resident required set-up and intermittent cues to identify food items on the tray because of legal blindness and benefited from verbal cues and finger foods. The dietary profile indicated the resident was blind and able to feed self with supervision and maximum assist. During observation in the dining room, the resident was eating without staff assistance while another resident was seen helping with the meal. The IP, CNA, RN, and DON all confirmed there was no care plan for supervision or touch assistance with meals, and staff stated another resident should not have been assisting with the meal. Resident 69 also had physician orders for Depakote and Risperdal for schizophrenia manifested by aggressive and disruptive behavior, but the active care plans did not address specific aggressive or disruptive behaviors related to those medications. The record review found no care plans with specific examples of the behaviors, no individualized non-pharmacological interventions, and no resident-centered therapeutic goals for reducing the behaviors. The DON stated the facility failed to care plan target behaviors and non-pharmacological interventions related to the psychotropic medications, and the facility policy required individualized interventions with measurable goals, timetables, and specific behavioral management strategies.
Care plans not revised for dementia, falls, and smoking needs
Penalty
Summary
The facility failed to revise the comprehensive care plan for a resident with dementia and severe cognitive impairment. The resident was re-admitted with a diagnosis of dementia, and the MDS showed severe cognitive impairment with dependence for eating, oral hygiene, toileting hygiene, bathing, dressing, footwear, and personal hygiene. The care plan dated 12/10/2025 identified impaired cognitive function related to dementia and included goals for communication, decision-making, and orientation, but it contained only one intervention: that the resident could remember one/two/three instructions, find the room, read, sit, and participate in activities of choice. During interviews, the LVN, RN, and DON all stated the care plan was not appropriate, was not personalized to the resident’s needs, and should have included additional individualized interventions. The facility also failed to revise the care plan for a resident identified as high risk for falls. The resident was re-admitted with diagnoses including a lumbar compression fracture, unsteadiness on feet, and generalized muscle weakness. The DON stated the resident had been removed from the Falling Star Program because the resident had not fallen in three months, but the quarterly assessment still identified the resident as high risk for falls. The resident’s care plan, dated 10/30/25, listed risk for falls related to confusion, gait/balance, and history of falls, with an intervention to follow the facility fall protocol. The DON stated the resident should not have been taken off the fall precautions and acknowledged that the care plan was not followed when the resident was removed from the program. The facility also failed to revise the care plan for a resident who smoked and required supervision. The resident was re-admitted with diagnoses including hereditary idiopathic neuropathy, type 2 DM with polyneuropathy, lack of coordination, reduced mobility, and schizophrenia, and the H&P noted contractures of both hands and that the resident was a smoker. The smoking assessment showed the resident required supervision, was not a safe smoker, and could not independently hold or safely use a smoking device or dispose of ashes. The care plan dated 1/2/2026 included smoking apron offered during smoking time and supervised smoking at all times, but progress notes did not document that a smoking apron was offered or refused. During observation, the resident smoked without a smoking apron and used contracted fingers to wipe ashes from the cigarette, with ashes falling directly on the resident. Staff interviews confirmed the resident was not able to safely dispose of ashes, that a smoking apron was recommended, and that no PT/OT evaluation for safe smoking was found.
Unsafe Smoking Practices and Incomplete Post-Fall Assessment
Penalty
Summary
The facility failed to ensure safe smoking precautions for a resident with hereditary idiopathic neuropathy, type 2 DM with polyneuropathy, lack of coordination, reduced mobility, schizophrenia, and contractures of both hands. The resident’s admission assessment indicated he required supervision for smoking and was not able to hold a smoking device, light or smoke safely, or dispose of ashes safely. His care plan identified him as at risk for injury related to smoking and included interventions for a smoking apron and supervised smoking at all times. During observation in the designated smoking area, the resident was seen smoking without a smoking apron and using his contracted hand and fingers to wipe excess ashes from his cigarette, with ashes falling directly on him. Staff interviews confirmed the resident could burn himself if he could not hold the cigarette safely and if ashes fell on him without a smoking apron. Record review showed no documentation that staff offered the smoking apron or that the resident refused it, and staff stated there was no documentation of interventions from the smoking care plan being carried out. The facility’s smoking policy required residents who are not safe smokers to wear a smoking apron and indicated residents who cannot smoke independently and safely are to be accompanied by staff while smoking. The facility also failed to complete required post-fall assessments and neurological monitoring and failed to have the interdisciplinary team meet, review, and revise the care plan after falls for another resident with Huntington’s disease, extrapyramidal and movement disorder, schizophrenia, moderately impaired cognitive skills, and dependence for multiple ADLs. Records showed falls on two occasions, including one unwitnessed fall and one fall in which the resident lost balance while walking in the hallway. Staff documented that the resident was high risk for falls, had an unsteady gait, used a wheelchair for locomotion, and was unable to use the call light. RN and DON interviews confirmed there was no documentation of a post-fall assessment for one fall, no 72-hour neurological assessment documentation for either fall, and no timely IDT review after the later fall. The DON also stated the reassessment and care plan update were not completed after the later fall, and the facility’s fall policy required a post-fall assessment, investigation, and neurological flow sheet monitoring for 72 hours after applicable falls.
Failure to Administer Scheduled Adderall Doses
Penalty
Summary
The facility failed to administer five doses of Adderall for one resident, who had diagnoses of major depressive disorder and ADHD and was documented as having the capacity to understand and make decisions. On 1/21/2026, surveyors observed an empty bubble pack for the resident’s Adderall in the locked medication cart compartment, and the controlled drug record showed the last dose from that pack was given on 1/19/2026 at 2:00 PM. The physician’s order summary showed Adderall ER 15 mg, two capsules by mouth twice daily for ADHD. The MAR and nurse progress notes showed missed or partial doses on 1/19/2026, 1/20/2026, and 1/21/2026. The notes documented that a refill was requested from the pharmacy on 1/19/2026, that the resident received only half a dose that afternoon, and that the medication was out of stock on 1/20/2026 and again on 1/21/2026 while awaiting pharmacy delivery or authorization. One note also stated the resident was out at an appointment on 1/21/2026 in the afternoon. During interview, the LVN stated the afternoon dose on 1/21/2026 was missed because the resident was out of the facility and the medication had not yet been delivered, and that the progress notes were incomplete. The DON stated there were administrative hurdles obtaining approval for the refill and that refills should be requested at least three to five days in advance, possibly longer for controlled medications, to maintain continuity of care. The resident stated the facility had only half the dose available on 1/19/2026 and then missed two doses on 1/20/2026 and two doses on 1/21/2026, and that repeated delays in refilling medications caused her to feel overwhelmed and anxious.
Expired and Unlabeled Medications Found in Carts and E-kit
Penalty
Summary
Expired and improperly labeled medications were found in two medication carts and an emergency kit during observation and interview. In Station 1 Medication Cart, one opened insulin aspart pen for Resident 67 was found with an open date of 12/16/2025, and LVN 4 stated it was expired because insulin aspart pens are only good for 28 days after opening. In the Medication Room, two vials of injectable lidocaine and one vial of injectable haloperidol were found in the E-kit with manufacturer expiration dates of 12/2025, and LVN 4 stated these medications had expired last month. The facility policy titled Medication Storage in the Facility, revised January 2025, stated that medications and biologicals are to be stored safely, securely, and properly according to manufacturer recommendations and that outdated, contaminated, or deteriorated medications are to be immediately removed from stock. During observation of Station 2 Medication Cart, one opened Arnuity Ellipta inhaler for Resident 83 was found without an open date. LVN 3 stated the inhaler had been opened but not labeled with an open date, and that it expires six weeks after opening per the manufacturer’s requirements. The report also noted that the product labeling for Arnuity Ellipta requires use or discard within six weeks of removal from the protective foil pouch.
Diet Orders Not Followed During Lunch Service
Penalty
Summary
The facility failed to ensure the lunch menu was followed for residents on gluten free and lactose intolerance diets during tray line service. One dietary aide did not communicate the allergies listed on the meal tickets to the cooks, and the meal tickets for the gluten free pureed diet and the lactose intolerant diet were not followed. The gluten free meal ticket indicated a hamburger and baked potato should be served instead of country fried steak and potato au gratin, and the lactose intolerant meal ticket indicated the potato au gratin should be eliminated. During the lunch service observation, the tray for the resident on the gluten free pureed diet received pureed country fried steak with gravy, and the tray for the resident on the lactose intolerance diet received potato au gratin. The dietary supervisor verified the cooks served the wrong food to residents on the gluten free diet and stated the dietary aide did not follow the resident preference list, diet orders, and menu when calling out the diets to be served. The cooks stated the hamburger was not prepared for the gluten free diet, the facility did not have gluten free bread or dinner rolls, and the potato au gratin contained milk.
Minced and Moist Diet Foods Served in Incorrect Texture
Penalty
Summary
The facility failed to ensure that residents on a minced and moist diet received food prepared in the correct IDDSI Level 5 texture. During kitchen observation, a cook removed baked breaded beef patties from the oven and cut them into pieces of varying sizes, including pieces about 1 inch, stating the food was being prepared for the minced and moist diet. The cook said the patties would be chopped into small pieces and served with gravy for moistness, and that the kitchen did not use a food processor because it made the food mushy and sticky. During tray line service, the minced and moist country fried steak appeared dry and overcooked, with brown breading edges, and was chopped into inconsistent sizes rather than minced. The potato au gratin was also served without being minced. In a concurrent interview and test tray observation, the dietary supervisor and cooks stated the food should have been very small and fit through the gaps of fork prongs; one cook acknowledged the patties were chopped and not minced, were too large, and were dry. Facility recipes and the diet manual stated minced and moist foods should be minced to about 4 mm, tested with a fork, and served with gravy, and the report identified ten residents on the minced and moist diet.
Unsafe Food Storage and Labeling Practices
Penalty
Summary
Safe and sanitary food storage and preparation practices were not maintained in the kitchen. During observation, clean and sanitized resident trays and cups were stored on the dishwashing counter next to the handwashing sink and within the splash zone. The Dietary Supervisor confirmed the items had been washed and left to air dry there, and acknowledged there was potential for splash contamination. The Maintenance Supervisor and Dietary Supervisor later agreed the dishes were in the splash zone and should have been covered to prevent cross contamination. The dry storage area was observed to have a dirty floor with food debris, a hair net, a lighter, condiment packages, and plastic wrappers on the floor. Expired and improperly stored food items were also present, including an unsealed bag of chocolate chips with no date, an opened bag of powdered graham crackers with a received date of 8/30/2024, a container of Worcestershire sauce with a use-by date of 3/21/2025, and a container of sesame oil with a use-by date of 11/20/2025. The Dietary Supervisor stated the powdered graham crackers were expired and not sealed, and that the seasonings were expired and would be discarded. The facility policy required opened products to be stored in tight-fitting containers, labeled and dated, with stock rotated. Nutrition shakes stored in the kitchen refrigerator and walk-in refrigerator were not monitored for thaw dates even though the manufacturer instructed they be stored frozen and used within 14 days of thawing. The Dietary Supervisor did not know when the shakes were removed from the freezer and stated they should have been dated. In the resident refrigerator at the nurse’s station, open deli meat and sliced cheese were stored without a resident name, along with a Subway sandwich and a bag of tamales and taco brought in on 1/19/26, and four expired yogurt smoothies with manufacturer expiration dates of 10/11/2025. The Infection Prevention nurse and RN confirmed outside food should be labeled, dated, and discarded according to policy, and both verified the smoothies were expired.
Failure to Obtain Informed Consent for Cymbalta
Penalty
Summary
The facility failed to obtain informed consent before initiating Cymbalta for Resident 69. Resident 69 was admitted with a diagnosis of schizophrenia, and the admission H&P dated 4/10/2025 indicated that she had capacity to understand and make medical decisions. The order summary showed that on 5/7/2025 the attending physician prescribed Cymbalta 30 mg by mouth at bedtime for phantom limb pain. A review of the available informed consent documentation and clinical record found no documentation that Resident 69 or a responsible party received education regarding the risks and benefits of Cymbalta before it was started. During interview, the DON stated the facility failed to obtain informed consent for the medication and was unaware that Cymbalta required informed consent because it was not being used for behavioral management. The facility policy on psychotherapeutic drug management stated that when obtaining consent for psychotherapeutic drugs, the resident will be informed of the risks and benefits of these medications.
Failure to Provide Meal Assistance for a Blind Resident
Penalty
Summary
The facility failed to provide feeding assistance during meals for one sampled resident who had severe vision loss, dementia, dysphagia, and cognitive communication deficits. The resident was admitted with diagnoses including unqualified visual loss in both eyes, unspecified dementia, dysphagia, and other coordination and communication deficits. The resident’s records also showed severely impaired vision, no use of corrective lenses, and a need for supervision or touching assistance with eating. The resident’s speech therapy note stated the resident required set up and intermittent verbal cues to locate food items on the meal tray because of legal blindness and benefited from verbal cues and finger foods. The dietary profile stated the resident was blind and able to feed self with supervision and maximum assist. During an observation in the dining room, the resident was seen eating lunch unassisted by staff while another resident intermittently scooped food into mounds on the plate and the resident continued eating. A CNA was present at the table assisting another resident and did not assist this resident. During interview, the resident stated she could not see, only saw light, had cataracts, and needed help but no one had assisted her. The IP stated any staff member in the dining area could have assisted the resident, but no one helped her that day, and the resident usually refused assistance; however, there was no documentation of refusal. The IP, RN, and DON all stated there was no IDT care planning done for the resident’s meal assistance needs, no care plan for supervision or touch assistance with meals, and it was not appropriate for another resident to help with the meal. Facility policies for care planning and accommodation of needs stated the IDT would develop care plans and staff would accommodate residents’ physical or sensory limitations.
Failure to Complete PASRR for Resident With Mental Illness
Penalty
Summary
The facility failed to ensure that a PASRR was completed for one of five sampled residents, Resident 42, who had diagnoses of bipolar disorder and schizophrenia prior to admission. The admission record showed Resident 42 was admitted on 8/18/2025 with additional diagnoses of ESRD, HTN, and hyperlipidemia. A review of the MDS dated 11/25/2025 indicated Resident 42 had the ability to make himself understood and to understand others. During a concurrent interview and record review on 1/21/2026, the DON reviewed Resident 42's EMR and stated he could not locate a PASRR in the record. The DON also logged onto the PASRR website and stated he could not locate a PASRR for Resident 42. The facility's P&P required PASRR Level I screening prior to admission for all individuals seeking admission, and the DON stated there was no proof a PASRR was done for Resident 42. During a later interview, the Administrator stated she would investigate whether the GACH had completed a PASRR before transfer, but she was not able to provide proof that Resident 42 had a PASRR.
LALM Set Incorrectly for Resident With Back Wound
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not ensured for one sampled resident. Resident 79 was admitted and later readmitted with diagnoses including cerebral palsy, type 2 DM, unspecified protein-calorie malnutrition, unspecified intellectual disabilities, unspecified convulsions, heart failure, and schizophrenia. The MDS dated 12/25/2025 indicated the resident rarely or never could make himself understood or understand others and was dependent for oral hygiene, toileting, bathing, dressing, personal hygiene, rolling, transferring from chair to bed, and going to the toilet. The resident’s dietary profile dated 1/16/2026 showed a weight of 79 pounds. A progress note from the same date documented a left middle back surgical wound measuring 12 cm x 18 cm x utd and described the resident’s skin as fragile. The H&P dated 1/18/2026 documented that the resident did not have the capacity to understand and make decisions, had a large ulcer on the upper back, and had stiffness and contraction on the back and extremities. During observation and interview on 1/20/2026, the resident’s low air loss mattress was observed set for a weight between 300 and 350 pounds even though the resident weighed 79 pounds. LVN 3 stated the LVNs were responsible for checking that the mattress settings were correct and stated the setting was too high and should have been based on the resident’s weight. RN 1 also stated the mattress settings should be based on the resident’s weight. The order summary dated 1/21/2026 indicated the resident was to have a LALM for wound management and that the mattress should match the resident’s weight. The DON reviewed the facility’s Med-Aire 8 user manual, which stated the pressure dial is adjustable to the patient’s weight and comfort, and stated staff would not be able to tell what setting was comfortable because the resident could not verbalize it.
Failure to Assess Foley Catheter Use and Address Recurrent UTIs
Penalty
Summary
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections was not ensured for one sampled resident with an indwelling foley catheter. The resident was admitted with diagnoses including type II DM, ESRD with dependence on renal dialysis, and BPH. The MDS dated 11/20/2025 indicated the resident’s cognitive skills for daily decisions were intact, required maximal assistance with ADLs, and had an indwelling foley catheter. During observation on 1/20/2026, the resident had a foley catheter with yellow, cloudy urine in the tubing and stated he had had the catheter for over a year without knowing why. The record showed no ongoing assessment of the use and removal of the foley catheter, and LVN 4 stated there was no order for monitoring urine output. The resident had a urine culture on 3/24/2025 showing ESBL in the urine, and the Infection Preventionist documented HAI contact isolation for ESBL in the urine, pain around the shaft of the penis, foul-smelling urine, and that the MD was notified and ordered urinalysis with culture and sensitivity. The resident continued to have recurrent UTIs. Records from the hospital on 9/13/2025 showed admission for a missed dialysis session and a complicated UTI requiring IV antibiotics, with urinalysis showing TNTC white cells and many bacteria. The report also states the facility failed to review and revise the individualized care plan after the UTIs on 3/24/2025 and 09/15/2025 and failed to initiate an IDT review after those UTIs and after a change of condition on 11/30/2025.
Failure to Provide and Administer HIV Medication as Ordered
Penalty
Summary
The facility failed to ensure that a necessary medication, Biktarvy, used to treat HIV, was available and administered as ordered by the physician for a resident over six consecutive days. The resident was admitted with a diagnosis of HIV and had an active physician order for daily administration of Biktarvy. Review of the Medication Administration Record (MAR) showed that the medication was not administered on six specific dates, with incomplete documentation regarding the reason for omission on most of those days. Nursing progress notes only documented that the pharmacy had been contacted for a refill on the first day of omission, with no further explanation for the subsequent missed doses. During interviews, the resident expressed concern about not receiving the medication, reporting that staff informed him it was not in stock and expressing worry about the impact on his health. The resident also reported experiencing diarrhea and concern about infection, as well as uncertainty about when he would see his physician for a prescription refill. An LVN confirmed that the medication was not administered due to lack of supply and stated that the facility protocol would be to notify the physician and arrange for an appointment to ensure continued access to the medication. The LVN also noted that the turnaround time for obtaining the medication from the pharmacy is typically one to two days, emphasizing the importance of timely refills to prevent treatment interruption. The Director of Nursing verified the omission of the medication and acknowledged that the omissions should have been documented and explained by licensed nurses. The DON stated that it was the facility's responsibility to ensure medications are available for each resident and confirmed that the facility failed to have Biktarvy available for the resident on the dates in question. Review of the facility's pharmacy services policy indicated that staff should be educated on pharmacy services, and that drug regimens and medication distribution errors should be reviewed and updated regularly.
Failure to Provide and Administer Prescribed HIV Medication
Penalty
Summary
The facility failed to ensure that a necessary medication, Biktarvy, prescribed for the treatment of HIV, was available and administered as ordered for a resident. The resident was admitted with a diagnosis of HIV and had a physician's order for daily administration of Biktarvy. Despite this, the resident did not receive the medication for six consecutive days, as documented in the Medication Administration Record (MAR), with the reason for omission noted only on the first day and no further documentation for the subsequent days. Review of the resident's medical chart and nursing progress notes revealed that the medication was not administered due to a lack of supply, and the nurse had contacted the pharmacy regarding a refill. However, there was no documentation explaining the omissions for the remaining days, nor evidence of ongoing assessment or follow-up as required by facility policy. The resident expressed concern about missing doses and reported symptoms of diarrhea, as well as anxiety about the interruption in treatment. Interviews with facility staff confirmed that the medication was not available due to issues with insurance coverage and the need for a physician appointment to obtain a refill. The Director of Nursing verified the omissions and acknowledged that the medication should have been administered as ordered, and that omissions should have been properly documented and communicated. Facility policy required immediate assessment and documentation of any medication omissions, which was not followed in this case.
Failure to Develop Fall Risk Care Plan for High-Risk Resident
Penalty
Summary
The facility failed to develop a comprehensive care plan to address the fall risk for a resident who was assessed as high risk for falls upon admission. Despite the resident's complex medical history, including diabetes, dysphagia, lack of coordination, and an above-knee amputation, there was no documented care plan targeting fall prevention. The Minimum Data Set assessment indicated the resident had moderately impaired cognition and required varying levels of assistance with activities of daily living, further underscoring the need for individualized fall prevention strategies. During a review of the resident's records and an interview with the DON, it was confirmed that the fall risk assessment identified the resident as high risk, but no corresponding care plan was found in the medical record. Facility policy requires that admission assessments be used to create an initial baseline care plan, and that fall risk assessments inform individualized plans of care. The absence of a fall risk care plan for this resident constituted a failure to meet these requirements.
Failure to Timely Update Care Plan After Resident Falls
Penalty
Summary
The facility failed to update and revise the care plan for a resident following two separate falls. The resident, who was admitted with diagnoses including diabetes, dysphagia, lack of coordination, and an above-knee amputation, was assessed as having moderately impaired cognition and required significant assistance with activities of daily living. The resident experienced falls on two occasions, once in the smoking patio and once beside the bed, as documented in the Change of Condition and Post Fall Assessment records. Although the post-fall documentation indicated that the care plan was updated, review of the actual care plan and interviews with the registered nurse supervisor revealed that the care plan was not created or revised until several days after the falls occurred. Facility policy required that the care plan be reviewed and revised after a fall, with new interventions implemented as appropriate. However, the care plan addressing falls was not initiated or updated in a timely manner following the resident's incidents. This resulted in a failure to develop and implement new interventions to prevent future falls, as required by the facility's Fall Management Program policy.
Failure to Intervene After Resident Meal Refusals
Penalty
Summary
The facility failed to ensure that a resident received adequate nutrition by not providing appropriate interventions when the resident refused multiple meals. The resident, who had diagnoses including diabetes, dysphagia, lack of coordination, and an above-knee amputation, was admitted with a care plan that identified a risk for nutritional problems and required a mechanical soft, carbohydrate-controlled, no added salt diet. The care plan specified that the resident should maintain adequate nutritional status by consuming at least 75% of three meals daily, and included interventions for the registered dietitian to evaluate and make dietary recommendations as needed. Despite these care plan requirements, documentation showed that the resident refused to eat dinner on one day and refused all meals on two other days. There was no evidence that the physician or registered dietitian were notified of these refusals, as required by facility policy. The DON confirmed during interview and record review that there was no documentation of such notifications, and acknowledged that the physician and RD should have been informed immediately to provide recommendations. Facility policy required notification of the physician and responsible party in cases of resident refusal of care or services, but this was not followed.
Inaccurate Fall Risk Assessments and Incomplete Medical Record
Penalty
Summary
The facility failed to maintain accurate and complete medical records for a resident, specifically regarding fall risk assessments. The fall risk assessments dated 8/18/25 and 8/30/25 did not indicate whether the resident was at low or high risk for falls. Additionally, one of the fall risk assessments inaccurately documented that the resident had no history of falls, despite the resident having a previous fall history. These inaccuracies were confirmed during a review of the records with the registered nurse supervisor, who acknowledged that the assessments did not properly reflect the resident's fall risk status or history. The resident involved had multiple diagnoses, including diabetes, dysphagia, lack of coordination, and an above-knee amputation of the right leg. The Minimum Data Set assessment indicated the resident had moderately impaired cognition and required significant assistance with activities of daily living. The facility's policy required nursing documentation to be concise, clear, pertinent, and accurate, but the fall risk assessments did not meet these standards, resulting in an incomplete and inaccurate medical record for the resident.
Failure to Report Major Accidental Fall with Injury
Penalty
Summary
The facility failed to ensure its policy for Unusual Occurrence Reporting included major accidents and did not follow state and federal regulations to report a major accidental fall with injury. A resident with a history of unsteadiness, repeated falls, Parkinson's disease, osteoarthritis, and cognitive impairment experienced a witnessed fall while attempting to use a walker, resulting in a right femur fracture. The resident was transferred to the hospital for treatment and later readmitted to the facility. Despite the severity of the injury, the incident was not reported to the State Agency as required. Review of the facility's policy revealed it did not specify major accidents as reportable events, and both the DON and Administrator stated they did not consider the incident reportable because the fall was witnessed and the cause was known. However, state regulations require reporting of major accidents, regardless of whether the cause is known. The facility's outdated policy and misunderstanding of reporting requirements led to the failure to report the incident in accordance with applicable laws.
Failure to Notify POA of Resident's MRI Appointment
Penalty
Summary
The facility failed to notify a resident's Power of Attorney (POA) about a scheduled MRI appointment, despite the resident having diagnoses including dementia, hypertension, and depression, and being assessed as lacking capacity to make decisions. The resident was dependent on staff for most activities of daily living and had moderately impaired cognitive function, as documented in the Minimum Data Set. The physician had ordered an MRI to evaluate confusion, and the appointment was scheduled accordingly. Interviews revealed that the POA was not informed of the MRI appointment, even though she routinely accompanied the resident to medical appointments due to the resident's inability to advocate for herself. Both the LVN who arranged the appointment and the Director of Nursing acknowledged that the POA should have been notified, in accordance with the facility's policy on resident rights, which includes involving representatives in care decisions and ensuring residents and their representatives are fully informed and able to participate in treatment decisions.
Improper Use of Low Air Loss Mattress for Pressure Injury Care
Penalty
Summary
The facility failed to ensure that a low air loss (LAL) mattress was used according to professional standards of practice for a resident with a sacrococcyx pressure injury. During observation, the resident was found lying on a blue reusable pad (chux) placed on top of the LAL mattress. The resident's care plan included interventions to follow facility protocols for pressure injury treatment, and a physician's order specified the use of the LAL mattress with daily monitoring for proper setting, functioning, and placement. The LAL mattress operator's manual instructed that only a cotton sheet should be used to cover the mattress to avoid direct contact and improve comfort. Interviews with facility staff, including a CNA, LVN, and the DON, confirmed that the chux should not have been used with the LAL mattress, as it could interfere with the mattress's function and potentially affect the resident's comfort and healing. The facility's policy required that all residents receive care and services in accordance with evidence-based and accepted professional clinical standards. The use of the chux on the LAL mattress was inconsistent with these standards and the manufacturer's instructions.
Failure to Document and Administer Medications as Ordered
Penalty
Summary
The facility failed to ensure that medications were administered as ordered by the physician and that medication administration was properly documented for a resident with multiple diagnoses, including dementia, hypertension, and depression. Review of the Medication Administration Record (MAR) revealed that several prescribed medications, such as ascorbic acid, famotidine, ferrous sulfate, folic acid, lisinopril, multiple vitamins, zinc sulfate, docusate sodium, and prostat oral liquid, were not signed as given on multiple occasions. The MAR lacked documentation indicating whether these medications were administered or, if not, the reasons for omission. The facility's policy requires that the licensed nurse chart the drug, time administered, and initial their name with each medication administration, which was not followed in these instances. During an interview, the DON confirmed that the MAR should be signed immediately after medication administration and agreed that unsigned entries indicate the medications were not given. The resident involved was noted to have moderately impaired cognitive function and required significant assistance with daily activities, making accurate medication administration and documentation particularly important. The failure to document medication administration as required resulted in the facility being unable to determine if the medications were given, as well as failing to prevent potential medication errors, duplication, or delays in care.
Failure to Develop Individualized Care Plans for Residents
Penalty
Summary
The facility failed to develop individualized person-centered care plans for three residents, leading to potential delays and inadequacies in care delivery. Resident 25, admitted with a displaced fracture, difficulty walking, and anemia, was at risk for pressure ulcers. Despite having a stage 3 pressure ulcer on the right knee, the resident's care plan lacked goals and interventions for pressure ulcer management, as confirmed by RN 2. This oversight could lead to the worsening of the resident's condition. Resident 28, diagnosed with major depressive disorder, bipolar disorder, and paranoid schizophrenia, was prescribed Lexapro for depression. However, a care plan addressing the use of Lexapro was not initiated until several months after admission. The Director of Nursing acknowledged that a care plan should have been developed upon the medication's prescription to ensure adequate care and monitoring, highlighting a gap in the facility's care planning process. Resident 45, with a gastrostomy and schizophrenia, frequently refused bolus tube feedings, as noted in the Medication Administration Record. Despite this, no care plan was developed to address the refusal of feedings, which could lead to weight loss. RN 2 and the Director of Nursing confirmed the absence of a care plan, emphasizing the need for interventions to manage the resident's nutritional needs effectively.
Failure to Monitor Antipsychotic Medication Side Effects and Behaviors
Penalty
Summary
The facility failed to monitor behaviors and side effects of antipsychotic medications for two residents, leading to potential risks of unnecessary medication and adverse effects. Resident 8, who was readmitted with a diagnosis of bipolar disorder, was prescribed Risperdal for excessive talking and screaming. However, there were no physician orders to monitor for these behaviors or the side effects of Risperdal. The Medication Administration Record (MAR) for December 2024 did not indicate any monitoring for behaviors or side effects. Both the Registered Nurse (RN) and the Director of Nursing (DON) confirmed the lack of monitoring, acknowledging the potential for worsening side effects if not monitored properly. Resident 23, admitted with diagnoses including sepsis, metabolic encephalopathy, and chronic kidney disease, was prescribed Risperidone and Valproic acid for mood disorders. The physician orders included monitoring for side effects and behavioral episodes, but there was no documentation of such monitoring on specific dates in December 2024. RN 1 could not provide evidence of monitoring, and the DON emphasized the importance of monitoring to adjust dosages and report adverse effects to the physician. The facility's policy on psychotherapeutic drug management required daily monitoring of psychotropic drug use and target behaviors, with documentation of adverse effects and behavioral presence. However, the facility failed to adhere to this policy, as evidenced by the lack of monitoring for the two residents. This deficiency was confirmed through interviews and record reviews with the nursing staff and DON.
Deficient Food Storage Practices in Kitchen
Penalty
Summary
The facility failed to maintain safe and sanitary food storage practices in the kitchen, as observed during a survey. A bag of frozen carrots and a bag of frozen corn were found in the freezer without labels and dates, which is against the facility's policy that requires all food items to be labeled and dated. This oversight was acknowledged by a staff member who removed the items from the freezer. Additionally, personal items such as a plastic bag full of clothing and shoes were found stored in the dry food storage area, which is not permitted according to the facility's policy. The staff member responsible for the kitchen confirmed that personal belongings should not be stored in the food storage areas. Further observations revealed that a staff member's jacket and hat were hanging on a shelf in the dry storage area, which was also against the facility's policy. The Dietary Supervisor confirmed that personal items are not allowed in the dry food storage area and removed the clothing. The facility's policies, reviewed during the survey, clearly state that personal belongings of dietary staff should be kept in designated areas only, and that food storage areas should be maintained in a manner that prevents cross-contamination and ensures food safety.
Failure to Label and Store Visitor-Brought Food Properly
Penalty
Summary
The facility failed to adhere to its policy regarding the labeling and storage of food items brought in by visitors for residents. During an observation and interview, it was noted that several food items, including cartons of Almond Breeze, a plastic container of string cheese, a plastic bottle of Gatorade, a carton of Ensure original, and a plastic container of clover honey, were stored in the designated residents' refrigerator without being labeled with the resident's name or the date they were brought in. This was confirmed by a Registered Nurse (RN 1), who acknowledged that labeling is crucial to ensure compatibility with the attending physician's diet order and to prevent spoilage. The Director of Nursing (DON) further confirmed that the facility's policy requires food from outside sources to be stored in sealed containers with the resident's name and the date it was brought in. The policy also states that perishable food requiring refrigeration should be discarded after 48 hours. The lack of labeling could lead to food spoilage, which the facility aims to prevent. The facility's policy and procedure titled "Food brought in by visitors," last reviewed in November 2023, clearly outlines these requirements.
Failure to Assess Resident's Oral Health
Penalty
Summary
The facility failed to comprehensively assess the oral health status of a resident, identified as Resident 40, upon admission and during subsequent evaluations. Resident 40 was admitted with several medical conditions, including acute kidney failure, atrial fibrillation, and anemia. The Minimum Data Set (MDS) indicated that the resident had intact cognition and required supervision for eating, along with moderate-to-maximal assistance for other activities of daily living. However, the MDS did not report any issues with dentures, despite the resident having missing upper teeth as noted in the History and Physical Examination. During an observation and interview, Resident 40 confirmed the loss of upper dentures prior to admission. A review of the Initial Nutritional Assessment by a registered nurse revealed that the assessment failed to document the missing teeth, which could lead to nutritional problems. The Director of Nursing acknowledged that an inaccurate assessment of the resident's oral health could result in further health deterioration. The facility's policy on nursing assessment, which requires comprehensive evaluation through observation and communication, was not adhered to in this case.
Failure to Conduct Quarterly Braden Scale Assessment for High-Risk Resident
Penalty
Summary
The facility failed to ensure that a resident, who was at high risk for pressure ulcers, was assessed quarterly using the Braden scale assessment. The resident, admitted with a displaced fracture, difficulty walking, and anemia, had a stage 3 pressure ulcer and was receiving care for it. The Minimum Data Set (MDS) indicated the resident was at risk for pressure ulcers, and the Braden scale assessment showed a high risk with a score of 12. However, the last Braden scale assessment was performed on 8/9/2024, and the next one was due in 11/2024 but was not completed. Interviews with the RN and the DON confirmed the oversight, acknowledging that the Braden scale assessments are crucial for identifying the resident's risk level for developing pressure ulcers. The facility's policy required these assessments to be done quarterly, but this was not adhered to, leading to a potential risk of worsening the resident's pressure ulcer. The DON emphasized that without the assessment, necessary interventions might not be identified, which could lead to deterioration in the resident's condition.
Failure to Timely Transmit MDS Assessment
Penalty
Summary
The facility failed to ensure the timely transmission of the Minimum Data Set (MDS) for a resident to the Centers for Medicare and Medicaid Services (CMS) system. The deficiency was identified during a review of the resident's admission record and MDS assessment. The resident, who was originally admitted in 2005 and readmitted later, had diagnoses including dementia, type two diabetes mellitus, and major depressive disorder. The MDS assessment indicated that the resident had severely impaired cognitive skills and was dependent on staff for various daily activities. The MDS dated a specific date was not transmitted to CMS within the required 14-day period, as it was submitted on December 11, 2024, and accepted on December 12, 2024, which was beyond the stipulated timeframe. During an interview and record review, the facility's Vice President of Clinical Services and the MDS Resource confirmed that the MDS was not transmitted timely, constituting a deficient practice. The facility's policy and procedure manual, dated October 1, 2023, outlined the requirement for timely transmission of MDS assessments in accordance with CMS guidelines. The failure to transmit the MDS within the required timeframe resulted in the potential for CMS not having the most updated resident information, which could delay services for the resident.
Incorrect LALM Setting for Resident at Risk of Pressure Ulcers
Penalty
Summary
The facility failed to set a Low Air Loss Mattress (LALM) to the correct setting for a resident, identified as Resident 23, who was at risk for pressure ulcers. The resident, who was admitted and later readmitted to the facility, had diagnoses including idiopathic neuropathy, major depression, and anxiety, and was totally dependent on staff for all activities of daily living. The resident's Minimum Data Set indicated moderately impaired cognition, and the resident lacked the capacity to understand and make decisions. A physician order dated 3/27/2024 required the LALM to be set according to the resident's weight and monitored every shift. However, during an observation, the LALM was set to 120 pounds instead of the resident's weight of 99 pounds, as confirmed by Treatment Nurse 1. Further investigation revealed that the physician order for the LALM had been discontinued on 7/7/2024, yet the mattress was still in use. Registered Nurse 1 confirmed the absence of a current physician order for the LALM and acknowledged that using the mattress without an order and at an incorrect setting could cause discomfort and hinder the resident's skin condition improvement. The Director of Nursing emphasized the importance of following physician orders for LALM settings to prevent further skin injuries. The facility's policy on pressure ulcer prevention, last reviewed in 2023, stated the need to identify residents at risk and provide appropriate care to prevent pressure ulcers, which was not adhered to in this case.
Failure to Revise Fall Care Plan and Assess Fall Risk
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 35, received the necessary care and services to prevent accidents and falls. The resident, who was admitted with diagnoses including depression, lack of coordination, reduced mobility, and unsteadiness on feet, experienced multiple falls on specific dates. Despite these incidents, the facility did not revise the resident's fall care plan after falls on two occasions, which is contrary to the facility's policy that requires care plan revisions after each fall to identify and implement appropriate interventions. The facility also failed to accurately assess the resident's fall risk. The fall risk assessments conducted on certain dates incorrectly indicated that the resident had a low risk for falling, despite having a history of falls and multiple diagnoses. This incorrect assessment led to the resident not being considered a high risk for falls, and as a result, appropriate interventions were not implemented to prevent further falls. Interviews with the facility's staff, including a Registered Nurse and the Director of Nursing, confirmed these deficiencies. The staff acknowledged that the resident's care plan was not revised after each fall and that the fall risk assessments were not completed correctly. The facility's policies and procedures require that fall risk assessments be conducted upon admission, quarterly, and with any significant change in condition, and that care plans be reviewed and revised post-fall to ensure adequate supervision and assistance to prevent accidents.
Improper Storage of Latanoprost Eye Drops
Penalty
Summary
The facility failed to ensure that latanoprost eye drops, a medication requiring refrigeration, were stored according to the manufacturer's guidelines. During an observation of Medication Cart 1, an unopened bottle of latanoprost eye drops intended for a resident with glaucoma was found stored at room temperature instead of being refrigerated. The Licensed Vocational Nurse (LVN 1) acknowledged that the medication was new and unopened, and therefore should have been stored in the refrigerator until needed. The LVN noted that improper storage could render the medication less effective. The Director of Nursing (DON) confirmed that latanoprost should be refrigerated until opened, as per the manufacturer's guidelines. The manufacturer's product labeling from December 2022 specified that unopened bottles should be stored under refrigeration at 2 to 8 degrees Celsius (36 to 46 degrees Fahrenheit). The failure to adhere to these storage requirements could potentially compromise the effectiveness of the medication in treating the resident's eye condition.
Failure in Hand Hygiene During Eye Drop Administration
Penalty
Summary
The facility failed to implement its infection prevention and control program as per its policy titled 'Installation of Eye Drops.' During a medication administration observation, a Licensed Vocational Nurse (LVN) did not wash and dry her hands thoroughly between administering eye drops to each eye of a resident. The LVN sanitized her hands with an Alcohol Based Hand Sanitizer before administering the eye drops to the resident's right eye but did not remove her gloves or sanitize her hands before administering the drops to the left eye. This practice was contrary to the facility's policy, which requires hand hygiene between administering eye drops to each eye to prevent cross-contamination. The resident involved had been admitted with diagnoses including chronic systolic heart failure, essential hypertension, and schizophrenia. The resident's Minimum Data Set indicated mildly impaired cognition and a need for moderate-to-maximal assistance with daily activities. Interviews with the LVN, the Infection Preventionist, and the Director of Nursing revealed a lack of awareness and adherence to the facility's policy regarding hand hygiene during eye drop administration. The Director of Nursing acknowledged that the failure to perform proper hand hygiene could have led to cross-contamination or infection between the resident's eyes.
Failure to Provide Ordered ROM Exercises and Care Plans
Penalty
Summary
The facility failed to provide range of motion (ROM) exercises as ordered by the physician for two residents, Resident 2 and Resident 3. The restorative nursing assistants (RNA) did not perform the prescribed ROM exercises on specific dates, namely 11/5/24, 11/7/24, and 11/12/24. This omission was identified during a review of the Restorative Administration Record (RAR), which showed that these dates were not signed off, indicating that the exercises were not conducted as required. Resident 2 was admitted with diagnoses including a fracture of the right fibula, lack of coordination, and difficulty in walking. The physician had ordered passive and active ROM exercises for Resident 2's extremities to be performed daily, five times a week. Similarly, Resident 3, who was admitted with Huntington's disease and a movement disorder, had a physician order for active ROM exercises for the upper extremities. Both residents had recommendations for an RNA program from physical therapy, but the facility failed to ensure these exercises were consistently provided. Additionally, the facility did not create care plans addressing the restorative needs of Resident 2 and Resident 3. The registered nurse supervisor confirmed the absence of such care plans, which are essential for outlining the interventions required to meet the residents' restorative needs. The facility's policy mandates that the interdisciplinary care plan should reflect the written plan of care, including problems, measurable goals, and individualized approaches, but this was not adhered to in the cases of Resident 2 and Resident 3.
Failure to Develop Care Plan After Resident's Allegation
Penalty
Summary
The facility failed to develop a person-centered care plan following a change in condition for a resident who alleged that someone entered their room and placed a hand over their mouth. This incident was reported by the resident during a phone conversation with a family member, which was overheard by a licensed vocational nurse. Despite the resident's severe cognitive impairment and inability to provide detailed information about the incident, the facility did not create a care plan to address the resident's allegations or outline the necessary interventions and services. The resident, who was admitted with diagnoses including cerebrovascular disease with hemiplegia and hemiparesis, diabetes, and anxiety disorder, was assessed with severe cognitive impairment and required substantial assistance with daily activities. The facility's policies required that care plans be updated to reflect changes in a resident's condition, but this was not done in this case. Both the registered nurse supervisor and the director of staff development confirmed the absence of a care plan addressing the resident's allegations, which was a deviation from the facility's established procedures.
Failure to Provide Necessary Social Services After Allegation
Penalty
Summary
The facility failed to provide necessary social services for a resident who made an allegation of an incident involving a person entering her room and placing a hand over her mouth. The resident, who was admitted with diagnoses including cerebrovascular disease with hemiplegia and hemiparesis, diabetes, and anxiety disorder, reported the incident to a family member during a phone call. The licensed vocational nurse documented the conversation in the nurse progress notes, noting that the resident was unable to provide detailed information about the incident and had no visible injuries. The social service designee (SSD) was informed of the incident and spoke with the resident, filing a grievance report. However, the SSD did not document any additional services provided to the resident in the progress notes, as confirmed by the director of staff development. The facility's policy requires the director of social services to evaluate and document the resident's psychosocial status upon a change of condition, which was not adhered to in this case.
Inaccurate Documentation of Resident Allegation
Penalty
Summary
The facility failed to maintain accurate and concise medical records for a resident who alleged physical assault by a staff member. The incident was first noted when a licensed vocational nurse overheard the resident telling a family member over the phone that someone had entered their room and placed a hand over their mouth. Despite the resident's severe cognitive impairment and inability to provide detailed information about the incident, the registered nurse supervisor later documented in the Nurse Progress Notes that the resident alleged a staff member physically assaulted them. This documentation was later deemed inaccurate by the registered nurse supervisor. The resident involved had been admitted to the facility with diagnoses including cerebrovascular disease with hemiplegia and hemiparesis, diabetes, and an anxiety disorder. The Minimum Data Set indicated the resident had severe cognitive impairment and required substantial assistance with daily activities. The facility's policy on nursing documentation emphasized the need for concise, clear, pertinent, and accurate records, which was not adhered to in this case, resulting in an inaccurate medical record for the resident.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident, resulting in harm. On June 26, 2024, Resident 2, who had a history of aggressive behavior, hit Resident 1 on the nose, causing pain and redness. Resident 2 had been admitted with diagnoses including Parkinson's disease, psychosis, and anxiety disorder, and had a documented history of sudden outbursts of anger and physical aggression towards staff. Despite these known behaviors, the facility did not adequately update or implement a care plan to prevent such incidents. Prior to the altercation, Resident 2's care plan included interventions to assist in developing appropriate coping methods and positive interactions. However, the care plan was not updated to reflect Resident 2's behavior of grabbing and spitting at staff, as noted in a Change of Condition form dated May 14, 2024. Additionally, Resident 2's Minimum Data Set assessment did not accurately reflect the resident's behavioral symptoms, indicating a discrepancy in the documentation of Resident 2's condition and behavior. Resident 1, who was admitted with schizoaffective disorder and depression, had previously reported not getting along with Resident 2. Despite this, both residents refused a room change. On the day of the incident, Resident 2 became angry and hit Resident 1, who was subsequently transferred to a hospital for further evaluation. The facility's policy on abuse prevention and resident altercations was not effectively implemented, as evidenced by the failure to prevent the altercation and protect Resident 1 from harm.
Failure to Develop Care Plan for Psychotropic Medications
Penalty
Summary
The facility failed to develop a care plan for a resident who was prescribed psychotropic medications, including Paxil, Seroquel, and Risperdal. The resident, admitted with diagnoses of unspecified psychosis, schizoaffective disorder, and depression, was receiving these medications as per the physician's orders. However, upon review, it was found that no care plan had been initiated for these medications, which is a requirement to ensure appropriate care and monitoring of potential side effects. Interviews with the Registered Nurse Supervisor and the Administrator confirmed the absence of a care plan for the psychotropic medications prescribed to the resident. The facility's policy mandates that a comprehensive care plan be developed for each resident, including measurable objectives and timetables to meet their medical, nursing, mental, and psychosocial needs. The lack of a care plan for the resident's psychotropic medications was identified as a deficiency, as it could potentially lead to the resident not receiving appropriate care and monitoring for adverse side effects.
Failure to Obtain Informed Consent for Medication Dosage Increase
Penalty
Summary
The facility failed to obtain informed consent for an increase in the dosage of Fluvoxamine Maleate for a resident diagnosed with depression. Initially, the resident consented to receive 50 mg of Fluvoxamine Maleate at bedtime, as documented in the Consent 3.0 document. However, following a psychiatric consultation, the dosage was increased to 100 mg without obtaining a new informed consent from the resident. This oversight was confirmed during interviews with the Registered Nurse Supervisor and the Administrator, who both acknowledged the absence of a consent form for the increased dosage. The facility's policy on Psychotherapeutic Drug Management requires informed consent for any changes in the dosage of psychotherapeutic medications, even if the change is within the same class of medication. Despite this policy, the resident received 20 doses of the increased medication without the necessary consent, potentially leaving the resident uninformed about the change and at risk of experiencing adverse side effects. The Director of Nursing was unavailable for comment during the investigation.
Failure to Inform POA of Resident's Financial Activities
Penalty
Summary
The facility failed to ensure that a resident's Durable Power of Attorney (POA) was informed of the resident's financial activities, despite the resident's medical condition indicating a lack of capacity to make informed decisions. The resident, diagnosed with unspecified dementia and major depressive disorder with psychotic symptoms, had a court-delegated POA responsible for financial decisions. However, the facility did not notify the POA of the resident's financial activities, including significant withdrawals from the resident's bank account. Interviews and record reviews revealed that the resident had a history of cognitive impairment and was admitted to a behavioral health care hospital for psychiatric evaluation. Despite this, the facility's staff, including the Social Services Director and Director of Nursing, believed the resident was capable of making her own decisions and did not consider the POA's authority necessary. This led to the resident making large financial withdrawals without the POA's knowledge, which raised concerns about the resident's safety and financial management. The facility's policy on informed consent and decision-making capacity was not adhered to, as it required the involvement of a surrogate decision-maker for residents without decision-making capacity. The facility's failure to notify the POA of the resident's financial activities was a violation of the resident's rights and placed the resident at risk of making uninformed decisions due to her medical condition.
Failure to Maintain Comfortable Sound Levels in Resident Rooms
Penalty
Summary
The facility failed to provide a safe, comfortable, and homelike environment for two residents, identified as Resident 5 and Resident 6, by not maintaining comfortable sound levels in their shared room. Resident 5 and Resident 6 experienced disturbances due to their roommate, Resident 1, who played music and watched TV loudly late at night. This noise disrupted their sleep and caused discomfort, which was reported to the facility staff multiple times. Resident 5 was admitted with diagnoses including type 2 diabetes mellitus and depression, requiring maximal assistance for activities of daily living. Resident 6, admitted with diagnoses including diabetes, congestive heart failure, and insomnia, was totally dependent on staff for daily activities. Both residents had intact cognition for daily decision-making. Despite their complaints about the noise and smoke smell from Resident 1, who accessed the smoking patio through their room's sliding door, no care plan was developed to address these issues. Interviews with facility staff, including a Licensed Vocational Nurse, a Certified Nursing Assistant, a Registered Nurse, and the Social Services Director, confirmed awareness of the complaints. However, the facility's policy to provide a pleasant environment with person-centered care plans was not followed, as no care plans were created to mitigate the noise disturbances caused by Resident 1.
Failure to Implement Comprehensive Care Plan for Residents
Penalty
Summary
The facility failed to implement a comprehensive care plan for three residents, leading to a deficiency in addressing their individual needs. Resident 5 and Resident 6 experienced sleep disturbances due to the noise created by their roommate, Resident 1, at night. Despite being aware of the situation, the facility did not develop a care plan to address the complaints of Residents 5 and 6 regarding the noise and disturbances caused by Resident 1. Resident 5 was admitted with diagnoses including type 2 diabetes mellitus and depression, requiring maximal assistance for activities of daily living. Resident 6 was admitted with diagnoses including diabetes mellitus, congestive heart failure, and insomnia, and was totally dependent on staff for activities of daily living. Both residents had intact cognition for daily decision-making. They complained about Resident 1's behavior, which included playing loud music, watching TV late at night, and allowing smoke to enter their room from the patio. Resident 1, who was admitted with chronic obstructive pulmonary disease, unspecified dementia, and major depressive disorder with psychotic symptoms, was independent in activities of daily living and was taking antipsychotic medications. Despite multiple complaints from Residents 5 and 6, and acknowledgment from staff including the Social Services Director, Licensed Vocational Nurse, Certified Nursing Assistant, and Registered Nurse, no care plan was developed to address Resident 1's nighttime behavior or the complaints of Residents 5 and 6.
Failure to Assess Smoking Safety for Resident
Penalty
Summary
The facility failed to ensure that a resident who was a smoker was properly assessed for their ability to smoke safely before being allowed to smoke independently. The resident, who was admitted with diagnoses including nicotine dependence, COPD, unspecified dementia, and major depressive disorder with psychotic symptoms, was not given a specific care plan regarding smoking safety. The Minimum Data Set indicated the resident had modified independence cognition and was independent in activities of daily living, but the smoking assessment completed by a registered nurse inaccurately stated that the resident did not smoke. The registered nurse admitted to not conducting a thorough and accurate assessment, which led to the resident being at risk of smoking-related accidents. Despite the facility's policy requiring a safe smoking assessment and care plan for residents who wish to smoke, this was not followed. The resident's family had informed the nurse that the resident should not smoke due to COPD and a physician's order, but this information was not accurately reflected in the assessment or care plan.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 6,996 citations issued within 25 miles in the last 12 months — including the 35 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Los Angeles
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Olympia Convalescent Hospital | 0.1 mi | ★★★★★ | 4 | 1 |
| Alden Terrace Convalescent Hospital | 0.1 mi | ★★★★★ | 14 | 0 |
| California Post Acute | 0.3 mi | ★★★★★ | 9 | 0 |
| Alta View Post Acute | 0.3 mi | ★★★★★ | 31 | 0 |
| Grand Park Convalescent Hospital | 0.4 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Alvarado Care Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.